 Thank you so much, Elizabeth. Thanks for the great discussion. Our last presentation today is going to be by Heidi Dahl. She's visiting us from East Tennessee University. And interesting thing to know about Heidi is that in her past life, she was a professional runner for many years. And she's going to be presenting a very interesting case on a leukemic infiltrate of the iris. And I believe we may have some of our pediatric oncology folks here. Maybe not. OK, maybe not. But take it away, Heidi. There it is. OK. Hi, I'm Heidi. Thanks for having me. So I'm going to be presenting a case that came through the Peds Clinic. This happened back in April. But I was able to see this patient for a exam under anesthesia in the past two weeks. So the case is in April of 2019, a seven-year-old female with a past medical history of pre-B cell ALL in remission since August, presented to the Peds Clinic with a six-day history of left eye exotropia and a psychoria and blurred vision. I apologize for my voice. I've been battling a cold for what seems like forever. So anyways, the parents noticed a yellowish discoloration in her left eye for a week or so prior to this presentation. And of note, she was diagnosed with a left-sided seventh nerve palsy in February of 2019 with a concurrent dilated pupil. CT of her head was done at that time in an outside facility, and it was reportedly normal. This was treated by her primary care physician as a left-sided Bell's palsy with steroids and antibiotics to good effect. However, she was still having recurrence of it during times of illness. Prior to this, she had no history of glasses or patching and no family history of eye disease. So here's a picture of the patient in the clinic. She's already been dilated here, but you can notice that she's got a left-sided exotropia, and it's a little hard to appreciate, but that left eye has a little bit of a yellowish tinge compared to her blue right eye. So on exam pertinent positives are she does have some blurred vision bilaterally, although it's more blurry at distance on the right and more blurry at near on the left. And then her pupil exam, right side is relatively normal. The left side is slow with minimal reaction. And then her strip business exam, she's actually found to have a bilateral exotropia with a right eye preference, and she has difficulty adducting her eyes bilaterally. At the slit lamp, pertinent positives are she is noted to have a left-sided facial weakness. Her iris, her right iris is apparently uninvolved. However, on the left, she has a yellowish green discoloration and is diffusely thickened and mild at tropion mutia. And then the other pertinent positive here is her right optic nerve seems to have some super nasal blurring on the disc margin. And everything else was apparently normal. So here we are zoomed in. On the top is the right eye, which is apparently uninvolved. And then on the bottom is the left. And you can see that there's sort of this yellowish green, fluffy infiltrate that's obscuring the normal architecture of her iris and has completely obliterated the crypts of the iris. So our assessment here, we're really concerned that there might be a leukemic relapse here in the iris because of the thickening and heterochromia. The blurring of the disc margin is concerning for a possible optic nerve infiltration. And the strabismus and pupil exam are concerning for a bilateral third nerve palsy. So at this point, the patient was escorted downstairs to oncology and was admitted that day for an LP and MRI of the head. Her oncology workup, one more puncture showed numerous malignant cells consistent with blasts. And according to the attending oncologist too, I was able to talk to her CSF on that spinal tap was grossly turbid. And a normal positive CSF for a leukemic relapse has something in the order of hundreds of cells. And this patient had 10,000. So it was, according to the attending, the most positive CSF he had ever seen in his career. Also, she had a recurrence in her bone marrow. So she has a relapse both in bone marrow and CSF. So here's some of the imaging. That was done that day. On the left side, we have a fiesta scan. And on the right is a G2 weighted scan. These are both with contrast. I know these are showing essentially the same thing, but I feel like you just can appreciate some subtle differences between the two. But here you have all of her extraocular muscles are involved. And they're all thick and sort of symmetrically. And this symmetry is indicative of an increased cellularity throughout all of the muscles. On the left here, we have a diffusion weighted scan. And you can see that there's diffusion restriction in the muscle bellies bilaterally and that it's also fairly symmetrical. And this again is indicative of an increase in cellularity, which would be consistent with a process like leukemia or maybe lymphoma, which in this case would obviously be leukemia because of her history. And then over here, we have a T2 scan. And this is just showing that the optic nerve sheath on the right is enhancing, which I thought was interesting because the optic nerve itself is not involved, which based on the exam I would have expected. And over here, these are both fiesta scans. Right here, we have the fifth cranial nerve showing enhancement. And over here, we have cranial nerve seven and six. And they're all enhancing. And according to the radiologists that read these scans, she had enhancement basically throughout her brain stem and throughout the course of all her cranial nerves. And so in normal scans, cranial nerves don't enhance at all. So she pretty much had full involvement of her cranial nerves. Some considerations from this case. A study done in 1998 in Malaysia took about 80 kids diagnosed with leukemia. And they underwent a dilated eye exam within two days of diagnosis and prior to getting any kind of treatment. And out of these participants, 17% had eye findings prior to treatment, while only 3% had symptoms. And the most common finding was retinal hemorrhage. I just thought that was interesting because we think of eye involvement in leukemia as relatively rare. But based on this study that might not be completely accurate and also the mortality in the kids with the eye involvement was significantly higher. So further considerations, CNS involvement in a relapse is apparent in 5% to 10% of these patients. The most common symptoms are meninges and cranial nerve deficits. And the most common cranial nerve involved is the seventh nerve, which is interesting because this patient had a seventh nerve in palsy several months prior to this presentation. Infiltration of the anterior chamber is extremely rare. And it portends a very poor prognosis. It can present from anything to increased ocular pressure, corneal edema. It's been known to masquerade as uveitis. It can really look like just about anything. And the symptoms can be just as varied. However, most pertinent to this case, if anterior chamber infiltration is the only sign, like if this patient didn't have cranial nerve involvement, then you would need to get an anterior chamber paracentesis in a biopsy of the iris. And you would need to do this prior to giving any kind of steroids, topical or systemic because the steroids would decrease the cellular load in the anterior chamber and could possibly delay your diagnosis. So here are my references. The attending oncologist was maybe going to be able to make it. Has he been able to see out there anywhere? No. OK, in that case, does anyone have any questions for me? Thanks.