 No one said he's a tropic, sorry, lost on the list. No, that's okay. We only have a few minutes. So I'll just go through kind of quickly. I don't wanna delay anybody today. The patient that I'm presenting was a previously healthy two-year-old girl. She was born full-term, no prior medical problems, not a patient of our clinic previously. She was initially presenting to the pediatric ophthalmology clinics from the primary children's ER. And she was seen there after a chair fell on her head. And the chief complained in the ER, she had new right eye crossing with a face turn, and it was after this unwitness blunt trauma to the head. She did not lose consciousness. When she was evaluated in the ED, which was initially the day after her trauma, she was sent home without intervention. She then represented to the ER several days later because her parents were concerned that her eye was still crossing, her face was still turning, they didn't understand why this was the case. At that time, we were consulted, we documented a right esotropia, but a normal dilated exam, and the recommendation was made just to follow up as an outpatient. And so I saw this child six days after the initial injury in my clinic. And to highlight some of the pertinent parts of the exam, this was a two-year-old child, not reading the eye chart, but did have normal tracking abilities in each eye. But on her strabismus exam, you can hopefully see, it's a little small, I apologize. She has a right esotropia that is greater at distance, it's 25 at near, but 35 at distance. It's also incommitant on my exam, which is probably why she has at least a 30-degree head turn to get her eyes into the left gaze position where you can see she no longer has a right ET. And I did document aduction limitation. In the ER, our evaluation felt like there was no induction limitation, but she did have the face turn at that time, which is kind of a red flag for an incommitant esotropia or eye misalignment of any kind. Because generally, a new onset face turn, why would anyone do that to keep their eyes straight? And so that must mean there's some position where their eyes are straight. And by definition, that means it's not committant. Because in a committant deviation, the eye misalignment is the same in all directions of gaze. Therefore, there would not be a head position that would be advantageous, at least to give you binocular vision. So these things were concerning to me. The rest of her exam was fairly non-focal. She didn't have optic nerve edema. Her dilated exam, I agreed, was normal. And she really didn't have a significant refractive error. She wasn't a high hyperope. So I recommended that we scan her. And the radiologist read is gonna be most informative, more so than my impressions. But essentially, this is a computer, that the radiologist was coming to us. All right, so they found this, these flare hyperintensities that were bilateral. They had a specific pattern in the white matter. They didn't notice volume loss. But they really, they essentially called this a picture of leukomalacia, but they weren't quite sure. It didn't look like anything that they could call specifically from the MRI. But it wasn't normal. The other thing that was really interesting to me is that they didn't feel like it looked very acute. I mean, we were imaging her because this all happened after what I found out from the mom was that a chair that was sitting up on a table, she pulled it off onto herself in the kitchen. And so I expected to maybe see an acute finding. But this didn't seem acute. So it was really interesting and perplexing. I thought a neurologist would be better able to evaluate it. So I referred them to neurology and their findings, they did find a right six cranial nerve palsy, which is what prompted everything in the first place. She was maintaining her head position when she saw them in clinic. But they didn't notice any other neurologic deficits in their clinic. They were specifically looking, it sounds like for things like spasticity that they didn't find, they felt that they were in agreement with her pediatrician and her parents that she'd been meeting all of her developmental milestones. They really could find no clinical evidence that would coincide with her MRI findings. And they also said they can't tell if the white matter injury to her brain is old or new. So it was really kind of perplexing. Their plan was to watch her carefully. They're gonna repeat a brain MRI in three months. It has not yet been three months since this was done sooner if she develops any other motor deficits. And then they're also doing some blood analysis to look for things associated with different leukodistrophies because their main concern was this thing called vanishing white matter disease that I had not previously heard of. So we'll talk a little bit more about that. But I think the salient points and the reason I wanted to present this is that when we see new esotropia in a child, we never know if they had a tendency previously that was unrecognized and that their disease process has worsened and this is just a manifestation of something that was already present or if this is truly a new phenomenon. And it has implications for what the cause is and if we should image the child, if we should look for any concerning underlying etiologies. So some things to watch out for, if it's an incomitant esotropia, that's a big red flag that this should be imaged. And it can be difficult in a two-year-old child to ensure that all of their ductions are completely full, especially in an ER setting. And so some things that can, it's certainly aduction limitation is going to help you determine if it's incomitant, but a new head posture, as we discussed earlier, is also a sign even if you can't fully evaluate the ductions or feel like you might not be getting a true picture, if they have a new gaze position, a preferred gaze position, that is a red flag. In the setting of imus alignment, it's a red flag for an incomitant. I, misalignment. But if there is no imus alignment but they still have a new gaze preference, that's still worrisome, they could have a new homonymous hemianopsia or something like that. So anytime a child has a new head posture, it should be a cause for concern. And especially in the setting of trauma, even if you feel like the parents are poor historians, they don't know what they're talking about, this probably has been going on forever. In the setting of a trauma, you have to give the benefit of the doubt to the parents, I think. And so what if this was actually a incomitant esotropias I think was initially thought? Well, there's some guidelines for this which we don't need to go into in depth but people have studied this and even a new onset incomitant esotropia can be cause for concern. And they found in their study that out of these 48 children that presented with an acute, comitant esotropia that about 6% did have an intracranial process that would account for that. And the things that were red flags in a comitant deviation were larger angle at distance than near, which really suggests possibly a cranial nerve six, etiology that's really a notice because that pattern because the lateral rectus muscles which are innervated by the six cranial nerve are more important distance and have more activity we think. So common because it's bilateral? Comitant meaning it's the same in all these directions. The reason why a six would be common is because you've got. I think it might have been missed. If there's truly a distance near disparity it may be a missed six. And they may be calling it comitant when it might be, yeah. But obviously if the child has neurologic sign symptoms they included optic nerve and demonness. If they have recurrence like it gets better and then it comes back or if they're older than six years of age at the time they present those are the things that correlated in their study with intracranial pathology causing the deviation. So even in a comitant esotropia that's new there can be a reason to image those kids and those are some of the things to look for. So what do we know about vanishing white matter disease and why would that be causing this six nerve palsy and how is it related to the chair falling on her head? Well we don't know for certain that she has this but I think the reason neurology suspects it is that it is a stress induced leukomalacia and the MRI was substantiating the fact that this child had a leukomalacia. The chair they feel like could have been the stress that caused this chain of events you can see here that there is we won't go into detail but there is a molecular rationale for why stress could potentiate this disease process but essentially these children like our patient if this is an early childhood onset form of the disease they do tend to develop normally. They may have some mild motor or speech delays but they can be completely normal until you see evidence after a trauma of something like any neurologic deficit and ours it was the six nerve but it can be ataxia or spasticity. And you can see that there is some concern for life expectancy. It's an awful disease, you should read that. Yeah, we won't go, it is an awful disease and it's really hard to fathom considering that she's a cute normal two year old right now and so for me this is a conundrum because how do I treat her? Her head is like this and so that is not sustainable, you know. For long term but it is allowing her to maintain binocularity which is one of our goals so I like that. I don't know how she would respond to strabismus surgery for a couple of reasons would strabismus surgery stress her in a way that could potentiate her disease progression? Otherwise I don't know and I wouldn't want and it might not just be relative to the eyes it could potentiate other manifestations of the disease which I would not want to do. I mean she's currently binocular even though she's got this giant head turn. I don't want to make things worse for her and then would she respond normally to our traditional strabismus dosing and techniques because her neurologic system is not normal and that's what's causing this. You know often in our accommodative esotropes or partially accommodative esotropes if we're doing surgery on them we feel like the innervation is fairly normal the muscles are fairly normal so we have some framework to believe that they're gonna predictably or somewhat predictably respond to our surgical dosage but in circumstances where the muscles are abnormal the innervation is abnormal they don't respond as reliably and would a surgery be able to allow her to maintain a straight eye position? Would it be worth it to do that? I don't know. So we're kind of working through this now with neurology and with the family but any thoughts would be appreciated.