 Okay, so I just wanted to talk about a patient that I saw in the neuro-optimology clinic with Dr. Katz. This is a patient that saw her physician because of some migraines and she was referred to neuro-optimology because during the exam she was told that her left optic nerve was swollen. She's 14 years old. These migraines have been going on for about three years and review of systems was negative except for that whenever she had migraines, she would also get blurry vision. Her past medical history and family history were non-contributory. On exam, almost everything was very normal. Her acuity, tenometry, there's no afferent pupillary defect. Visual fields and extraocular movements were fold bilaterally. External exam and slit lamp exam were also normal. The abnormalities though became apparent on the funnest exam. The right eye, everything looked very normal. In the left eye though, there was some nasal elevation of the optic disc and there was what appeared to be some anomalous branching of the vessels within the optic disc. This is her right eye and left eye on a funnoscopic exam as you can see, you know, a pretty normal looking optic disc over here and then some nasal elevation over here. Some asymmetry between the vessel branching patterns between the left and right eye. And so the referring physician thought that she had papillodema from increased intracranial pressure and so when looking at someone who might have papillodema or say an anomalous optic nerve, as far as symptoms go, there's no other disease process going on. The patient should be asymptomatic whereas someone has increased intracranial pressure. Most all of them have headache. Some of the very common symptoms are transient visual obscurations, pulse synchronous tinnitus, dyphelopia. On exam, someone has papillodema, they'll frequently have a central cut that is maintained throughout the disease until the disease becomes very chronic, very long standing. Vest sole branching pattern is normal in papillodema whereas it frequently is abnormal in someone with an anomalous optic nerve. They may have loops, trafications, and just increased branching. The optic nerve margins in papillodema frequently are blurred and so if someone has very, very crisp optic nerve margins, it's unlikely that they have papillodema. So it's thought that this patient might have some kind of anomalous optic nerve. So these are just some examples of different types of anomalous nerves compared with papillodema, morning glory, congenital tilted optic nerve, myelinated nerve fibers, optic nerve hypoplasia, optic nerve coloboma, and optic nerve drusen. And currently it's thought that this patient has bilateral optic nerve drusen. And so further workup in a patient with a suspected optic nerve head drusen. D-mode ultrasound scan is very good at showing the drusen because of scheduling and timing. That has not yet happened with this particular patient, although she has scheduled to have a B-scan ultrasound. OCT can be used to quantify optic nerve swelling if there is any. And it can identify some of the more superficial optic nerve head drusen, but it doesn't penetrate as deep as some of the other imaging modalities. And so it's hard to see some of the deeper drusen or maybe the posterior surface of any drusen. Allofluorescence, drusen are very positively allofluorescent, and so they typically show up on that. And then EDI-OCT, in addition to identifying optic nerve drusen because it penetrates deeper, you can see the structure of the drusen itself and see both the anterior and posterior surface of the optic nerve head drusen. And so this is just an example of not the specific patient, but someone with optic nerve head drusen identified on B-scan ultrasound. And so you see the drusen right here with the shadow behind it and the same thing over here. Again, we don't yet have the results of this patient's ultrasound. Someone with optic nerve head drusen identified on allofluorescence. Pretty obvious all of these bright spots right here are the optic nerve head drusen. This patient's allofluorescent, definitely not as obvious, nothing nearly as obvious or apparent as in this example right here. On the patient's right, there's these little areas of lightness right here that might be something, but definitely nothing real definitive. This is an example of EDI-OCT showing optic nerve head drusen on this mass right here. So it'll be lighter, I guess, on the image. In this patient's EDI-OCT, the patient's right eye, the patient's left eye, nowhere near as obvious as that previous example. Here on the patient's left, you can see the tilting of the optic nerve. You can see over here what might look like some optic nerve head drusen. So we're waiting again for the ultrasound to confirm the suspected diagnosis. So assuming that this patient does, in fact, have bilateral optic nerve head drusen and no other intracranial or ophthalmic pathology going on, we would continue to follow her. We would examine her fundus at each visit and compare what it looks like in the present visit with any previous visits and see if there's any changes. And then, similar thing, we would continue to monitor her optic nerve function with visual acuity, perimetry, and other tests of that sort and see if there's any changes, see if there's any deterioration, then might point towards some kind of pathologic process going on that is starting to pick up. That's that. I just wanted to say thank you very much to everyone. As I rotate here, you've been very helpful in specifically Dr. Katz, Dr. Warner, Dr. Crumb, and Dr. Joss in neuro-optimology. I've been very helpful in patienting, explaining these things to me and helping me out with neuro-optimology. Any questions about this patient?