 Our medical students, University of Utah will be kicking kicking it off. It's nice to see some suits and ties out there And and if you are a medical student not wearing a suit and tie, that is also very acceptable as well Our residents will be doing our introductions today. I believe it may be our 11 and dr. 11. I apologize if I'm mistaken Can can Ariana be unmuted? I just made her co-host so she can Okay, we've had a little change of schedule here, so let me Yeah organized Okay, I think that we have all University of Utah students this morning at our first Presentation will be Michael Sawyer. There's a fourth-year medical student presenting a nine-year-old female with corneal vascularization Go for it Michael Immuted how's that? Good perfect Good morning, everybody It is a pleasure to be here. I'm really excited for this presentation I have loved this ophthalmology rotation so far and it's just been a lot of fun The faculty have been excellent and it really is an honor to be at the Moran eye center It's also been a privilege to work with Sam and Taylor on this Rotation so far and I'm excited to hear their presentations this morning as well So I am presenting today on a nine-year-old female with corneal vascularization. This is a girl who came into our clinic My my Slides are not here we go. This is a girl who claim into our clinic as an outside optometry referral She has coronal opacities and coronal vascularization and she also has a three-year history of recurrence styes and blepharitis Mom reports that she's had some pain in her eyelids and swelling in her eyelids as well as eye crustiness And she's had a pretty significant decrease in her vision on in both eyes Some significant negatives through her histories that she does not get Cold sores or Lee and she does not have a history of glasses or contact lenses No surgical history and she also does not have any known recent trauma They've tried antibiotic eye drops for previously not sure which kind and they're trying to wash her lids daily at the moment On base eye exam her right eye is 2100 vision her left eye is 2,400 vision both eyes improve to Roughly's 2070 with pinhole. We're able to refract her right eye to 2080 with the negative point 75 sphere and The left eye we don't have any improvement With refraction for distal visual cutie. The rest of her exam is pretty normal No other No other abnormalities in the base eye exam Here's a slit lamp exam photo of her right eye Starting externally. We don't see any active signs of Currents die. However, looking at the eyelid margins. Would you see some mybilma and gland dysfunction here? mainly on the upper eyelid going to the country Tyva it is hyperemic and On the corner we see some opacities Some punctate keratitis Which we can see in the glare of the cornea and definitely some vascularization Mainly on the lower half of the cornea Here's another view of the same eye just to help us appreciate the opacities with the light at a different angle as well So appreciate the vascularization a little bit better looking at the left eye externally the lid does not have any Currents dies that we can see But there is again some mybilma and gland dysfunction I've indicated with the arrows here because it can be hard to see over the internet and Both on the upper and lower eyelid. We have a hyperemic country Tyva and as well as Corneal vascularization with opacities here looking at the nasal cornea. There might be a flictenol there that we see too Here's a slit lamp at a different angle here And this I thought was helpful because it shows that the vascularization May extend down into the stromal layer of the cornea on that nasal side in this area so differential diagnosis we have a Ninety-old patient with corneal vascularization and opacities Can be pretty wide. I split the differential into four main categories. I'm sure that there's a variety of ways to do this But we felt that from her history and physical exam that blepharoceridoconjunctivitis was the most likely diagnosis and decided to treat for that So we decided to treat right away since her significantly was impaired and She was given erythromycin drops in both eyes every night as well as toberdex four times a day and then just standard treatment for dry eye and Encouraging her to have eyelid scrubs on a daily basis. We scheduled a follow-up for three weeks in three weeks They come back mom has Noted some subjective improvement Her eyelids are not quite as crusty anymore, and they're pretty compliant with the treatment However, the patient is pretty resistant to the wait minutes at times Visual acuity has improved to 2050 bilaterally and her pressure is still looking pretty good at follow-up So lamp exam here's the right eye We see some very significant improvement a lot less vascularization and there was a few weeks ago still some opacities that look like they could be obstructing the visual axis and a little bit of vascularization still on the temporal cornea here the conjunctiva is Less distressed and it seems a few weeks ago as well Here's the right eye again just with the light a different angle to help us appreciate the opacities a little bit better Again, so pretty improved from last time Looking at the left eye we have Maybe some mild my boomy and gland dysfunction here in the upper eyelid that I've indicated with an arrow the Conjunctiva is looking better less inflamed and then the cornea does still have quite a few opacities Vascularization is quite a bit down although still present and if you were to see this slit lamp in person You'd be able to appreciate that this vessel here on the central cornea is still functioning and patent Based on the fact that we see red blood cells of flowing through This vessel which for me as a medical student seeing that for the first time was pretty exciting Not something that I get to see on a daily basis at this point in my training. So I Really love this slit lamp exam here Here's the same eye just with a light a different angle to help us see those opacities pretty well So our assessment is that the patient was Responding well to treatment her pressure looks good. She's tolerating the steroids well So we decided to continue the same treatment and have the patient follow up in six weeks This patient has blepharoceratoconjunctivitis Which is pretty common in pediatric ophthalmology clinics this review from Will's eye hospital in Philadelphia Showed that over a five-year period Blepharoceratoconjunctivitis, which I'll just call BKC turn out. It's a pretty big mouthful But it was actually the most common referral diagnosis for patients in their clinic so I The reason I chose this case out of all the cases I could have chosen Is because for me is someone who's relatively new to the field of ophthalmology It was really exciting to see a patient go from being essentially legally blind to being an almost driving vision within just a few weeks and On top of that the really fascinating physical exam findings seeing the coronal vascularization It's the cells running through the vessels made this a very memorable case for me and As I've told some people if this is considered a more common And routine case and ophthalmology than by all means this is a pretty exciting field So I think BKC is really worth talking about for a variety of reasons One being that coronal vascularization is not an uncommon thing It's estimated that there are about 1.4 million cases of coronal vascularization seen per year in clinics About 20% of coronal transplant specimens have some sort of vascularization on them And then with BKC as we've seen patients can have pretty rapid response to treatment However left untreated you can have very detrimental outcomes So it's absolutely crucial to have a timely and proper treatment for this condition, especially in children Where they can develop really deleterious complications if if it's left alone for too long we'll be talking about those in a second but BKC Essentially comes down to the stability of the tear film lipid layer and that can be caused by either mybomine gland dysfunction or by bacterial lipases in an infection that can further destabilize the lipid layer And our patient we saw probably saw a combination of both of these Pathophysiology is going on Once you have a destabilized tear film you get evaporative dry eye which causes inflammation Leading to vascularization in places where we don't want it and so that leads to the treatment We want to treat the underlying cause of the inflammation as well as the inflammation itself something I found interesting is that although BKC can be a fairly routine presentation in the clinic and there is a lot of research about the treatments for BKC There's not actually a standardized like official treatment regimen for the condition Here we see I just put the titles of two cocker reviews about BKC that done by similar groups of authors and Out of all the literature they reviewed they actually found that between these two studies only one study actually fit inclusion criteria for their study and Mainly because most studies don't have a proper Control treatment arm and other ones mixed children and adults in their treatments. And so they weren't actually able to make any Recommendations for treatment of BKC that being said the consensus is pretty wide throughout the field that topical steroids and topical antibiotics along with treatment with for dry eye is Pretty widely accepted So some additional treatments that are less common but Plausible is that for patients who are steroid responders or otherwise intolerant steroids a calcineur inhibitor could be used as a steroid sparing agent and As a treatment for sty something that's become more popular in the last few years is hypochlorous acid spray or the brand name Avenova. This is something that patients can buy over-the-counter and a lot of people tend to like it And then research is Showing increasing support for essential fatty acids in the diet They can have an anti-inflammatory effect and may help with dry eye and chronic blepharitis So recommending flax seed oil is certainly a possibility in a patient like this Similar presentations common things being common. We don't want to forget about HSV keratitis This is especially important since one of the main stages of treatment for BKC steroids We could obviously make HSV a lot worse by treating for BKC if it were concurrent or if it were the actual cause of this patient symptoms on the other hand some providers Maybe hesitant to treat for BKC out of concern that there is keratitis present So a good way to get around this is with concurrent steroids and acyclovir Basically treating each condition at once We decided not to give this patient acyclovir simply because her history and exam Were very indicative of BKC. We weren't as worried about keratitis However, based on my reading, I don't think it would be frowned upon To give a patient prophylactic acyclovir if they were in this situation So some important complications, especially in pediatric patients With the corneal involvement we can develop an irregular astigmatism Another cause of this is simply because of the eyelid issues with chronic chelasia Can also cause an irregular astigmatism And then with the obstruction of visual axis or with the astigmatism Pediatric patients commonly develop amblyopia from this condition And that's definitely something that we need to keep an eye out for this patient And of course for walking a fine line between Managing the inflammation in this patient's eye, but also making sure her eye pressure Doesn't get too high. So that's another important reason for regular follow-up With that in mind some considerations we have for this patient is to have corneal topography in the future To make sure to see whether this patient develops an astigmatism and of course keep her pressures in check Another thing to consider as we saw from the follow-up is that most children don't like things going in their eyes And that can lead to really difficult compliance in children. So although this is a very treatable condition Some patients may have deleterious outcomes simply because they're refusing treatment despite the best being parents Prognosis in BKC as I've hinted can be pretty good. Um, this is a study in 2007 by A group of researchers who Found that on average their patients ended up with 20 20 vision at the end of the study that being said 30 30 percent of patients did not have improvements in visual acuity And over half of the patients did develop amblyopia that required ongoing treatment So I think this shows that BKC while it is Um a relatively routine presentation in pediatric ophthalmology clinics does require Really prompt treatment and it's something that Either with misdiagnosis or delayed diagnosis can lead to really bad outcomes And uh I just really love this case. Um You know, they they say when at this point in my academic career When you're thinking about specialties Uh, think about the the common standard even mundane things about a specialty and imagine yourself doing that on a daily basis Um, and boy if this is uh an example of that in ophthalmology, then this is a pretty exciting field Uh, the zebras of every field I think are are fascinating and exciting Uh, but it's also nice to admire the glamorous beautiful horses Right in front of us and for me that was an example of that. So, uh, this was just a good opportunity to reflect on that Thank you so much for listening to my presentation special. Thanks to everyone on this slide Uh, I couldn't have Prepared this presentation without any of these uh people. So thank you. I'd be happy to answer any questions Thank you, michael This is dr. Olson, uh a few comments uh The corny has evolved to be fairly resistant to vascularization for obvious reasons because Uh vascularization is obviously bad for vision and bad for survival Yes, so uh, there is that there's a system that's been worked out and uh part of inflammation Is uh, almost always up regulation of vegef and it doesn't take much of that for cornyas To be vascularized, but there's a system called flip two Which uh, uh resist that So, uh, a couple of things with kids that are important as it's obvious that that when you breach that system, it can it can go Dramatically fast. I mean I I've I've seen cases where it was just early neovascularization They were lost to follow-up and a month later the cornyas were hugely vascularized So that's one reason why you got to get on top of kids very very fast And once they are vascularized you can look carefully and you'll see these ghost vessels that are still there And that's true for all of the different conditions, you know Zoster herpes you know Leuetic and interstitial keratitis and it takes very little New inflammation those open-ups you really got to watch these kids carefully and of course The secondary effect if you've got vascularized cornyas is that you'll end up getting scarring a lot of that white deeper stuff Is just you know, true scarring in the cornyas. It's now an altered architecture And so that's something that also needs to be watched very carefully, but The other side is is that um, it because kids are hard to check and they're hard to do with pressure We see an awful lot of kids who not only have steroid glaucoma and dexamethasone has been well shown to be the one most likely to lead to steroid you know, glaucoma but Easily lead to cataracts and we often see these in more of the allergic conditions Where people have been treated and they're not getting good control steroids are extremely effective For this condition and and then all of a sudden the next thing you know, you've got You know, you've got a steroid induced cataract, which is a Not reversible at that particular point and that can be a real problem So there even though we deal with blepharoconjunctivitis so commonly in adults and many of the things are going to be very very similar Kids are quite different. So I think you you raise those points But it's it's always a shame to let it get to the point where you know, you've got pretty profound Vascularization, but those are some of the things to think about with this tough condition Thank you, Dr. Olson All right, we'll save additional questions or comments until the end of the presentations to make sure that each presenter has Enough time. So thank you so much Michael. Our next presenter is Samuel Wilkinson another fourth year medical student Who will be presenting ocular syphilis as our speakers speak. You can also place questions in the chat Okay, good morning. Can everyone hear me? Okay Yes, you're good. All right, perfect. Well, good morning, everyone And thank you for the opportunity to be here. My name is Sam Wilkinson And I'm a fourth year medical student here at the University of Utah Today, we're going to present a case of ocular syphilis seen in Dr. Law Rochelle's uveitis clinic This particular patient was a 64 year old female with no significant ocular history Who presented to the brand triage clinic with two months of a worsting black spot in the center of her vision of her left eye She also reported intermittent flashing lights as well as blurred vision in her left eye That did not have any symptoms in her right eye Her past ocular and medical history is non-contributory Her family history is significant for a father who lost vision from age-related macular degeneration And no family history of autoimmune disease Social history is significant for a history of incarceration, but otherwise low risk Current positives and negatives from review of systems includes hip pain and muscle aches Patient also reported occasional urinary urgency and diarrhea Patient denies any rash or genital sores Vision in the affected eye was decreased to 2200 without improving with binhole And pupils and pressure were normal The right eye had a cataract, but was otherwise normal The affected eye had findings of mild anterior chamber reactivity with posterior sneaky eye and a few pigmented cells in the vitreous Here's an optosphoto of the right eye As you can see here the right eye is significant for a small nevus Just outside the super temp super temporal arcade And this is an optosphoto of the left eye It is remarkable for a placoid yellowish lesion in the posterior pole Notably on our fundus exam. There was a cluster of punched out spots inferiorly that cannot be visualized with this image Here we see a fundus autochoresis imaging of the left eye And in that same location on the posterior pole, there's this placoid hyperintensity The top image here is a macro CT from the right eye As you can see it is normal and the bottom image shows the left eye Right here. There's loss of the ellipsoid zone See here as well as retinal pigment epithelium irregularities It's in here and here Next we have fluorescein angiography of the left eye This image is of the earlier arteriovanus phase. Initially it is relatively normal But if we move forward to a later phase it shows hyper fluorescence in the area of the placoid lesion As well as staining of the overlying vessels And weight leakage peripherally Here we have a mid phase icg of the left eye These are there are a few hypo fluoresce spots In the posterior pole At this point we describe this as a subacute unilateral pan uveitis Due to the anterior chamber reactivity Pigmented vitreous cell and macular lesion Our differential at this point was placoid syphilis Versus non-infectious or inflammatory posterior uveitis An initial laboratory workup returned two days later With a positive RPR titer and positive FDA ABS No other abnormalities were found on lab work Patient was admitted to the hospital for IV penicillin Infectious disease consult and a neurosyphilis workup Due to the ocular involvement She completed a two week course of IV penicillin A lumbar puncture was remarkable for elevated white blood cells And notably the VDRL of the CSF was negative Regardless this is still treated as neurosyphilis due to ocular involvement Additionally the elevated white blood cells do raise suspicion And notably she was HIV negative Patient had to follow up ophthalmology appointment one month after the initial presentation And had that follow up her exam Her visual acuity improved from 2200 to 2050 And here are opto-color photos of the left eye from the initial visit on the left And then right next to it is the one month follow up As you can see the placoid lesion that we originally saw Is resolving This difference in color between the photographs is just an artifact And this is fundus autofluorescence of the left eye Similarly there's near resolution of the hyper fluorescent Placoid lesion seen here as well And an OCT of the left eye shows that the photoreceptors have returned And there's been some normalization of the retinal pigment epithelium So the final diagnosis is acute syphilitic posterior placoid choreo retinitis Or ASPPC Patient will follow up with ophthalmology as well as infectious disease to ensure Definitive treatment of this patient's syphilis As syphilis can present in the eye in a wide variety of ways Of all the presentations uveitis is the most common This particular presentation of ASPPC was first described by dr. Donald gas in 1990 And the key clinical findings of ASPPC are a yellowish placoid lesion within the macula Patchy disruption of the ellipsoid zone And a hyper reflective nodule lesions in the retinal pigment epithelium Is more commonly seen in immunocompromised individuals Although still possible in immunocompetent patients as seen in today's case In uveitis patients with suspected ASPPC The workup should include a high specificity test such as FDA ABS And non-specific tests such as RPR and BDRL Are negative in about one third of ocular syphilis cases The prognosis is variable Spontaneous resolution is possible However, loss of retinal function is also possible when left untreated Patients do respond well to treatment as seen in today's case Treatment typically includes IV penicillin G 24 million units daily for 10 to 14 days And syphilis has been rising the past decade The U.S. has had the highest number of new syphilis cases since 1991 So this is an important diagnosis to keep in in your mind with any uveitis patient But especially with these characteristic findings I just want to say a special thank you to Dr. La Rochelle For help on this presentation as well as for all of her mentorship And for introducing me to clinical ophthalmology And a thank you to Dr. Abigail Jevarage for helping me obtain some of these photos And if there are any questions, happy to answer those Great. Thank you, Sam. We probably do have time for one question before we move on if someone has one Otherwise as you're thinking of questions and putting them in the chat Our third presenter is Taylor Brady A fourth year medical student who will be presenting an otherwise healthy newborn with an anterior segment lesion Thank you, Ariana I think back up here So, um, appreciate the time. I'm going to talk about an otherwise healthy Newborn with an anterior segment lesion Michael and Sam. Thank you for your presentations. They were great I have no disclosures for this presentation. So let's jump into it Just to first cover the patient specifically she's now two years old but Presented at two months old. She was otherwise healthy Born at full term She had this irregular iris border in her left eye that you can see here in this image This clear kind of inferior nasal lesion with a tropion uba that you can see here She also had lens coloboma Which you can't see in this particular image because it's posterior to the iris Didn't have any pertinent family history and our Initial differential diagnosis includes a ciliary body or iris cyst or neoplasm Or a coloboma phpv aniridia Trauma or nat Or potentially a juvenile xanthogranuloma This was concerning. So she was sent for An e way and ultrasound. Here's actually an a scan and a b scan Similar to what our patient received She at primary children's got an a and b scan with With dr. Harry and unfortunately we went over there to retrieve those images and the The ultrasound machine at primary children's is broken. So we weren't able to pull them off But this is a very similar presentation in another patient You see in the a scan this increased signaling Behind the cornea in the iris suggesting location of this lesion, which is in the ciliary body And in the b scan you can see the location actually located in the ciliary body It's important to know that this particular b scan is taken at a very steep angle So it makes the posterior chamber Look a lot more shallow than it actually is And if you look at the lesion closely, you can note that there's the solid consistency of the mass And when you compare that to other ciliary body gross, they're typically more cystic in nature and appearance And so that's something to note when you see these types of presentations This was concerning for medullo epithelioma And so this patient was referred to ocular oncology dr. Jonathan kim Who's a great ocular oncologist at usc? He actually diagnosed her with medullo epithelioma after his own ultrasound and examiner anesthesia And that's actually the best method to diagnose these tumors. We don't want to biopsy at them Because there's a large risk of re of seeding or causing a hemorrhage Now our patient had a fairly typical presentation for medullo epithelioma when it does show up The typical presentation includes a lens coloboma, which you can see in this image here And this actually arises interestingly because of congenital absence of the zonule in the area of the ciliary body where the tumor is located And the tumor actually is typically Inferotemporal although in our particular patient. It was infero nasal You can see a clear to flesh tone mass arising from the ciliary body There's often small clear cysts that are present within the mass And sort of like retinoblastoma. It can also have these calcifications depending on Any embryonic tissue that's contained in the tumor and and kind of depending on its histopathologic characteristics It's often covered in the cyclic membrane There can be secondary glaucoma resulting from Incl closure, there can be lens subluxation if the mass is actually pressing into the lens and ectropion uva as we can see in our patient They can also have leukocorio, which is one of the main reasons It's important to differentiate these tumors from retinoblastoma And you know, one of the concerns is that oftentimes patients undergo a workup for Cataract or glaucoma something else that's secondary to the medullo epithelioma And they get treated for that. Maybe there's even been cases of people having surgery for glaucoma surgery for On the vitreous surgery for cataracts Things like that and then having a medullo epithelioma found incidentally during the surgery Here's an image that shows leukocoria in a five-year-old female with medullo epithelioma You can also note with this arrow the neobascularization of the neoplastic cyclic membrane. So that's that's a good image And here's a growth gross pathology specimen It's a example of a large medullo epithelioma after enucleation and you can notice the lens subluxation And then all this retinal detachment that's happened. So this can be an incredibly morbid disease Histopathology, I think is really interesting in these tumors They typically arise from the non-pigmented epithelium of the ciliary body And they're classified into teratoid versus non-teratoid and also benign versus malignant The majority of them are malignant or have malignant potential regardless of whether they're teratoid or non-teratoid And they're classification there The non-teratoid here or there another another name An older nomenclature you may know them as is a dictioma It has this characteristic kind of net like proliferation of these neoplastic cells And then the teratoid medullo epitheliomas can have a bunch of diverse cell origin seed here is actually a really distinct focus of highland cartilage That you can see within those tumors. There's a couple other examples here Couple other histology images and these are both from teratoid medullo epitheliomas as well The image on the left resembles skeletal muscle And and malignancies that can be found in in skeletal muscles such as a rhabdomyosarcoma And the image on the on the right resembles neural or brain tissue Some of the complications of malignant Medullo epithelioma can include extra ocular extension and orbital invasion Which typically cause significantly increased morbidity for these patients regional lymph node extension does occur and is Most common if there's extra ocular extension Distant metastases are pretty rare cns extension is also really rare But if we encounter a patient that has this metastases or cns extension that is Almost always fatal unfortunately So in discussing this presentation with dr. Dardeen something that he brought up and I think is a really really Prudent way to approach these cases And and applies to most of general oncology as well Is to take kind of this stepwise approach You know, we're mostly Foremost concerned about the patient and their survival We want them to be able to live secondly, we want to preserve their eye And then we want to preserve their vision and you know in a lot of pediatric tumors intraocular tumors The fourth step here is to preserve their binocularity if we can so we approach this in a stepwise fashion And I think this is a great method of thinking through the treatment of these tumors So for preservation of life, I think it's appropriate to kind of compare medullo epithelioma to retinoblastoma Which is a tumor we're all much more familiar with From an epidemiologic standpoint medullo epithelioma is incredibly rare I spoke with dr. Hoffman and dr. Harry Dr. Hoffman says he's seen maybe five to six cases of this in his career. Dr. Harry said he's seen about 12 of them Whereas with retinoblastoma There's two to 300 new cases per year in the united states Medullo epithelioma Manifests in the first decade of life almost always and retinoblastoma before the age of five For metastatic risk medullo epithelioma has a low metastatic risk, but the challenge is that it's uncommon And there's often a delay in diagnosis because well for a couple of reasons one is we're just not looking for it as much The other is that it's It's easy to miss if you know if it's in the ciliary body, it's posterior to the iris. It can be difficult to see there But when it's caught early, it is really it does have a lower metastatic risk In contrast retinoblastoma has a higher metastatic risk, but you know family medicine doctors Pediatricians, we're all trained to look for this And catch it really easy really early when we see leukocoria in a in a kid Um, and so it's typically caught early Survival rates are are pretty similar in a recent study for medullo epithelioma on medullo epithelioma post a nucleation There was a 90 to 95 5 year survival if the extension was just in the globe And with retinoblastoma it was 96 5 year 5 year survival There's some risk for other cancers in medullo epithelioma. Most of these are non hereditary but there is a 5% risk of a specific genetic mutation That contributes to several other tumors or cancers that can happen In that patient's life, but that's pretty rare. It's a rare rare mutation in an already rare cancer And then of course we know about germline rb1 mutations associated with pineal and bone tumors and patients with retinoblastoma So the next step in that stepwise approach is preservation of the eye. So the big question is can we avoid a nucleation? With medullo epithelioma sometimes we can but it's really important to catch it early if we want to give the patient a chance Unfortunately a nucleation is still currently the standard of care for advanced medullo epithelioma because it's often caught so late If it's large, if there's glaucoma, if there's significant global involvement Almost always have to have a nucleation And if there's any orbital involvement you need to get even more more bed and move on to exentration Which can be often for these patients Luckily in our patient, she had this relatively small lesion. It was about three clock hours It was no no significant involvement of the globe. It wasn't causing any other complications Like glaucoma or Wendt subluxation And she was able to be treated with plaque radiotherapy Placement of the plaque for her with Dr. Kim was an inferior nasal area In proximity to her tumor And this patient is a great example of how early detection can contribute to preservation of the eye and avoidance of the nucleation So some complications she had with plaque radiotherapy With plaque radiotherapy, she had two muscles moved in order to have the plaque placed And her inferior rectus of the left eye was not resuscitated to the insertion She developed worsening strabismus over time and keep in mind this is two years ago that she started she was uh diagnosed Um, she also developed a radiation induced cataract in that same eye She started to develop amyliopia. Their thought is that this is a multifactorial cause, you know, she's got a tuner She's got strabismus. She's got a cataract. She's been undergoing radiation Her parents have been patching her two to three hours a day for the past two years But unfortunately hasn't been incredibly effective to this point She's also developed this strabismus, which is exacerbated by the surgery she's had Exasperated by the plaque radiotherapy and the movement of those muscles She's had to undergo two strabismus surgeries with dr. Jardine And the question about what caused the strabismus is is Is difficult to quantify unfortunately and and also the question how much is it actually contributing to her amyliopia at this point Is it a congenital cause? Is there a sensor? Is it a sensory cause because of her cataract? Because of the radiation or their their permanent damage to the muscles that's causing it and My thought and our thought is that it's most likely max multifactorial as well So here's an image that you can see of this eye During our most recent eua. You can actually make out the cataract here faintly And you can see that it's more of this flesh toned. It's it's it looks like it's evolved I'm not sure if this is because of evolution of the tumor or because of Just the the differences in the camera differences in the in the picture quality But the measurements are actually about the same here and the main thing to do With these particular tumors is to ensure that they're not continuing to grow And the measurements have been the same. They've been stable. And so that's the main goal Especially with this patient Next steps for her are cataract surgery And you know, that's concerning looking at that tumor. We're going to enter the eye with that Neovascularization. It's that's quite a worry. It's something that Dr. Jardin and I have talked quite a bit about There's a big worry for a neovascular hemorrhage within her orbit Considering also doing some of Aston treatment in our anterior chamber before the operation And then the other thing is to monitor these for reoccurrence It's unfortunate, but oftentimes people who have Local resection or other Non and nucleation surgeries for these tumors end up needing an enucleation anyway because of recurrence So that's something we really need to watch Thank you for the time. I feel very You know, I feel very lucky that I actually got to see a patient with such a rare cancer that Is not often seen in just the last couple weeks A special thank you to dr. Jardin dr. Harry dr. Hoffman and dr Who have helped me out so much with this. Thank you for your time Great. Thank you. Taylor. We did have a question come into the chat The question is whether a scan or b scan is more helpful or whether it's a combination in cases like these Taylor, you're welcome to answer and I think we also have dr. Harry in here as well Yeah, so dr. Harry could probably answer this better than me But I think that a combination of the two is typically the way that the air these are diagnosed Can you hear me? Am I unmuted? Okay. Very nice presentation. Taylor Um, yeah, the question a and b scan a scan is really superior in the poster segment for melanomas Anything posteriorly it really is more information in the b scan. I use them both But I depend on the a scan more the anterior segment is different just because of Angle usually size of trimmer or smaller. You don't get internal reflectivity Patterns as well. So I depend more on the b scan the anterior segment And unfortunately because the machine was sent out for repair. Like you said, we didn't have the images from this case, but The immersion high frequency ultrasound is very helpful too This case shows a regular 10 megahertz b scan that The picture you show is just a regular 10 megahertz. You can see the tumor but to really see detail the high frequency machine is better But for residents going into practice if you have access to an ultrasound machine without the high frequency You can still use the 10 megahertz. You have to use immersion scan of some kind I use a little square old shell. You can put a tonal pen cover on the tip You can use a cut a glove tip off and use that To make an immersion and visualize the enter segment But that's pretty important and just one comment about Dictiomas they can be masquerade kinds of lesions. I saw a case years ago with paul's emerman We thought was par's planitis But as we looked at it Again carefully with immersion ultrasound. It was a tumor ended up being a dictioma. So they can fool you sometimes So anyway, very nice job on the presentation Great. Thank you. I think that's it for today. Great job to all of the medical students I think that they're still in their rotations for a little while. So say hi and if you have questions, let them know Thanks, everybody