 Good morning, thank you all for being here this is I'm just going to start this morning's grand rounds with a neuro ophthalmology case presentation and then Derek will do our main course Our patient was a 64 year old right-handed and an engineer He came to the neuro ophthalmology clinic because he was complaining of episodic flickering of vision His story began with sinus disease. He said he'd had this sinus disease for about 40 years And it had been slowly getting worse For the last year and a half. He had been experiencing this popping noise in his right ear and with the popping noise He had post nasal drip and a cough and he also had his associated visual symptoms at that time He was a very observant person if he he stated that if he closed his left eye He had the movement of everything in his vision with that right eye But if he closed his right eye and was just looking at the world with his left eye everything was normal We had another patient in clinic who described What they saw as the old black and white movies the way it would flicker on the screen He just described he was very descriptive It was vertical and rotational and every object in the visual field of his right eye moved this way He said that occur numerous times throughout the day and it lasted for approximately 15 to 20 minutes He also noted that he could sometimes trigger it by looking to the right and then back to center Interestingly he had surgery done in June of 2010 for his sinus disease and that improved his sinus symptoms And he was also free of his visual symptoms for approximately three weeks And then as his sinus symptoms returned his visual symptoms started to recur His ocular history did have myopia and presbyopia were glasses for this and he had a history of chemical burn in both eyes from wood preservative His medications he wasn't on anything that would cause nystagmus and the remainder of his history was really non-contributory On exam his vision was good his color and stereo vision as well as visual fields to confrontation were normal He didn't have any proptosis His pupillary exam was normal and extracular movements were normal He did have a minuscule left hyper that was worse in right gaze with Maddox rod testing But only with the Maddox rod could you pick that up on anterior segment exam He did have a linear Infratemporal scar in his left eye, but otherwise normal and his dilated fundoscopic exam as well as his neuro exam was normal So his diagnosis was right superior oblique myocymia based on his clinical history It was helpful in this instance because he had been to an outside ophthalmologist who had observed the eye movements at the time that they were occurring And a diagnosed him with superior oblique myocymia But had referred him to NeuroAuth clinics for a second opinion as well as for management Now there have been no on on literature review There have been no case reports that show that sinusitis can cause superior oblique myocymia but in his case it did seem to be very associated with the symptoms and You know dr. Warner and I were talking about and she was wondering if maybe it was some irritation of a superior oblique muscle through the ethmoid air cells however on MRI he only it's only showed mild sinus disease and the lamina perprecia was Normal He has trochlear nerves were also normal So for him his treatment since his symptoms were so associated with sinus disease was to control the sinuses if his symptoms ever become Dissociated or he has worsening of his visual symptoms He can return to the NeuroAuth demology clinic and at that point we would probably offer him Neurantin or Tegretol Superior oblique myocymia was first described by Alexander Dwayne in 1906 He described it as a unilateral rotary nystagmus after he'd seen a 24-year-old healthy girl that had this nystagmus and no other problems could be found Hoyt and Keen later had five patients with episodic monocular and torsion. The nystagmus was high frequency and low amplitude And patients also described the same sensation of jiggling and ocelopsia and They introduced the term superior superior oblique myocymia So what exactly is it? It's a rare recurring motility disorder It's typically unilateral as mentioned before the nystagmus is high frequency and low amplitude and patients will describe an intermittent vertical or torsional ocelopsia and It's due to contraction of the superior oblique muscle But what causes that contraction of the superior oblique muscle isn't really known It's typically lasts for seconds, but it can last longer and the severity ranges from mildly annoying to incapacitating And it depends on how frequently it occurs and how long it lasts Often patients note that it's more noticeable to them when they do tasks that require near vision And if you get tonic contraction of the superior oblique they can get double vision So this is just a video to show you what the eye movements look like You can see the movement best over here So as I mentioned before the etiology is unknown Microbascular compression has been proposed as well as intercranial lesions or trauma that results in aberrant regeneration of the fourth cranial nerve There are a few case reports showing association with multiple sclerosis or posterior fossil tumors, but it's only an association The prognosis is good. It's a variable to benign course patients often have spontaneous remissions and Relapses, but the good news is they don't typically have any associated neurological or muscular disorders Most patients should be imaged with MRI to make sure that there's not a secondary etiology causing this in one study using six patients they looked at high-res MRI and Looking at that they found that there were neuro vascular contacts with the root exit zone In 100% of the affected eye and there was 0% of this contact in the normal eye Medications are typically used if the symptoms are bothersome to the patient Typical medications are Tegretol or Neurontin in one retrospective study looking at approximately 20 patients 16 of the 20 they were all on a different combination of these medications But they had improvement in there of their symptoms and this was over a long-term follow-up of approximately six years Surgery can also be done if it's severely Abling to the patient Techniques used include the superior oblique tonotomy or tenectomy with weakening of the if salateral Imperial bleak or you can do my myctomy of the superior bleak with recession of the trochlea The problem with surgery is that there is a 50% recurrence and depending on How much you do to the superior oblique you can get superior oblique palsy and these are my references any questions