 by my two fellow co-chief residents who I'll introduce in just a second. First, I just wanted to give a public shout out to Alicia Dawson, I don't know. Probably most of us were included on her email and I was very sad to hear that she's going to be leaving us after many years of dedicated service. Alicia has done an outstanding job with the residents and with medical students. Her job gets harder every year and she's been able to manage it flawlessly. She can analyze with a smile on her face and we really appreciate her service. So quickly I'll give her a round of applause. So our grand round today is going to be presented by first Dr. Brian Stagg, who's going to talk about an 86-year-old lady with black and long glands swelling. Dr. Stagg, we're followed by Dr. Russell Swan, who will talk about Susak syndrome. So will you guys be starting? Okay, thank you Adam. I feel like, so Russell and I are in our last year of residency, I feel like things have gotten a lot more intense for grand rounds. Now we've got this big light in front of us and I'm hooked up to microphones and so things have changed over the last few years in terms of grand rounds. I'm really glad to be here. I also wanted to take just a quick second. I normally wouldn't talk about something really personal at grand rounds, but I thought I just really need to thank people so I thought I'd take a quick second. Most of you know my wife was pregnant and went into pre-term labor last week and our baby survived only a few minutes and it was pretty tough. I just wanted to thank everyone here for so much support from my co-residents and from my attendings, from the academic team and just from the Moran in general. We received some beautiful flowers and it really makes a big difference when you have something hard happen just to have such a great support system and I really feel fortunate to be here at the Moran Eye Center where it really does feel like a family and we really have the support of, like I said, really amazing co-residents too. So thank you all for that. And also just kind of introducing our topics for me and Russell. So as residents we're required to do three neuro-ophthalmology grand rounds and it pretty frequently happens that we get to our last year of residency and there's still at least one left and so today Russell and I are both doing a neuro-ophthalmology presentation. It's one that I prepared with Dr. Patel's help for the oculoplastics grand rounds and so we ran out of time that day to give so I'm also giving that presentation. So my first presentation is my neuro-ophthalmology presentation. So red eye and double vision presenting to triage clinic and I title it this way. I think that one of the most difficult jobs at the Moran Eye Center is the triage clinic where anything can walk in the door and you're not sure what it's going to be. Most of the time it's something really simple and then sometimes it can be something bad. So I really respect all of our doctors that work in triage. So a 71-year-old man with red right eye and double vision and symptoms started three to four days earlier. His right eye redness, so just first notice the right eye redness and swelling and then a little bit of pain when he'd look to the right and he'd have binocular vertical and horizontal diplopia that was worse in right gaze. So I thought we could just start, we've got OCAPs coming up this week, I thought we could just start with one of our PGY2 residents and just kind of talk through, I know it's really early for a differential but I feel like in triage clinic it's important to be able to put together a quick differential early to be efficient. So I don't know, Rhys? Just kind of what are you thinking, how are you going to approach this patient? Nice. So those are kind of some of the more concerning things you might be worried about. Anything you can think of that might be less concerning that probably comes up a lot in triage too. Right, exactly. But I think those like dry eye or conjunctivitis or things are always, you see them so often in triage that those probably are running through your head too. Or how to kind of sort that out. So in triage clinic an on-call history ends up becoming really important. So past ocular history was hit in the right eye at age 10. He was really concerned about that. He wanted to talk about, that was the biggest thing he wanted to talk about. Past medical history, he has multiple myeloma. He was diagnosed in 2007, had a bone marrow transplant and has active disease. He restarted chemotherapy in January. He had a compression fracture of his spine, reflux disease, chronic kidney disease. And then he's a non-smoker and had a father with CLL. And so on exam his vision was great. His pressure, no issues with pressure, no afferent peoplery defect, color vision was normal, but he was proptotic on that right side. So then exam he had a little bit of edema on that right side and then chemosis and it was described as straw colored fluid. He had some punctate staining and then otherwise pretty normal exam. So here's his motility. So left hyper with a little bit of exo-phoria was documented as. So at all times when you see a left hyper, does anyone kind of want to talk through what you're thinking about when you see a hypertropia? Maybe just expand the differential a little bit now. Eileen, do you want to do it? Great. So kind of talk through the differential. So what next steps are you going to do for this patient? Chris Conradti, do you want to kind of talk about what you'd... Oh, sorry. I couldn't see you back there. Yeah. So what imaging do you want to do, Eileen? Yeah. So we did. So triage clinic, Dr. Tabin ordered an MRI and did so a mass. So there are multiple new enhancing right intra-orbital masses. There was a larger intra-conal mass and then a few other masses. So one near the cavernous sinus and then one between the temporalis muscle and the lateral pterygoid muscle. So just by the maxillary sinus. And so he was admitted to the hematology oncology service treated with decadron and they did a PET CT and the PET CT showed a number of other lesions throughout his body. And so we saw him back in follow-up in the ophthalmology clinic. I think Dr. Joe saw him in follow-up. He still had the diplopia, but his visual function remained normal. He still didn't have an afferent pupillary defect, still normal color vision. And so treatment plan, he was evaluated. So what this looked like and what the hemonc service thought it was because it was throughout and just the appearance of it felt like it was recurrence of his multiple myeloma and multiple myeloma affecting the orbit. And so they recommended that he see radiation oncology and continuous chemotherapy. He actually did see radiation oncology and they did recommend some treatment but he wasn't interested in it at that time. But he's still receiving chemotherapy. And so just a, as I mentioned, these kind of shorter presentations today because there are three of them, just a quick review on an interesting, the best paper I found about multiple myeloma involving the orbit. I had never seen that before. So this was their case series. So let me see, laser pointer. So this was their case series. They had 34 patients with orbital myeloma. So 34 of them ended up being multiple myeloma. 13 ended up being a plasma cytoma and 5 ended up being primary extra-medulary plasma cytoma. So 65% of those patients had been diagnosed beforehand, which is similar to our patient. And so a number of them, the ones that had prior diagnosis, the average was 17.6 months. Maximum was eight years. The patient was diagnosed in 2007, so would be right at the edge of that limit in their case series. Interestingly, and I think something just to keep in mind with differential diagnosis is that a number of those, that was their, the orbital findings were their initial presentation for multiple myeloma. And then proptosis was the most common. 23% of them had decreased vision, which fortunately our patient didn't. And then 23% had the diplopia, which was the biggest thing that our patient had. And a small percentage of them were bilateral. And so this was just interesting, just going through their imaging, 84. So most of them had CTs, some of them had MRIs. So this was just interesting that intraconal was less common than the other things. If you remember, our patient had several extra-conal, but then one very large intraconal mass. And this paper only had survival data on 17 patients, and the mean survival was 23 months. So poor prognosis, but that's actually close to in line with what you'd expect from multiple myeloma with recurrences. So, and just thank you. I think, so I saw the patient with Dr. Feist when he was on the consult service. I think it was staffed with Dr. Crumb, and then Dr. Joss also saw the patient in follow-up. So any discussion about, yeah, Dr. Crumb? From a cost-effectiveness standpoint. Yeah, makes sense. Thank you, Dr. Crumb, for that. Any other thoughts? No, it was just that way. It didn't really change much. I think if maybe radiation oncology would have pushed more and there had been visual compromise or things like that, but he wasn't really interested in radiation and probably reasonable. Right, yeah. No, no, sorry, I should have shown the visual fields, but his visual function was completely normal, which was kind of surprising with how what the mass looked like. And correct, yeah, don't worry, Dr. Crumb's watching the visual fields. So he had the MRI and went home, and then I think, correct me if I'm wrong, Rhys, but I think you got paged about that on call, and they said we have a patient from triage that had this imaging and so ended up calling him and getting him to come in to be admitted to Hemonk eventually. So it was good working together with the Hemonk team as well. So a nice job, Rhys.