 Hey guys, I'm Tom Olberg. We've got eight minutes, but we can do this. So, Samantha's a little girl that's upstairs that hopefully everybody got a chance to see this morning. She's a three-year-old girl who, about the time she was one, her parents noted that her left eye was not fully elevating and it was sort of intermittent but became progressively more restricted. They went to see an ophthalmologist who then referred them down here to primary. And then at that time she had no pastematical history, surgical history. She was full-term, uncomplicated delivery. She crawled at seven, she walked at 15, which is a little late, but that's also when her older sister walked. So in September, she was seen, this is the extraculum was of her left eye. So you note that she had a difficult time with elevation, more market when the eye was adducted. And she was diagnosed with likely Brown syndrome and continued to do very well. And then three months later, mom and dad noted that her pupils didn't seem to be acting quite regular. And when we really pushed them, they said, I think the left is usually smaller than the right and that's pretty consistent. And then she also started to develop some left upper lidtosis. Again, that was intermittent in the beginning and became more progressive and pronounced. So they represented back to primaries in August. Again, she had the difficulty with extracular movements, but now she also had a problem with adduction and depression. And then you can see at her pupil exam, the right eye was four millimeters in light and the left was two millimeters in light. And then the dark, the right dilated to six and the left barely budged to three. She was orthotropic at that time. And she did have this ptosis that was seen. So the thought was that this was some sort of weird now coroner syndrome with a third nerve palsy and MRI was ordered and obtained and read as normal. And then she was referred to her neurophthalmology for further workup. We saw her in September and her vision was excellent. Her color was great. You can see her stereo was pretty abnormal. She was only four out of nine on the circles. And then the parents also said that she was starting to act a little clumsy. She was walking into things and they were getting worried. So there's a question of whether or not there was another neurologic component or this is just from the decreased stereopsis that was making her clumsy. And we checked her pupils, same sort of picture. The right eye and the light was six. The left eye was three and a half. In the dark, the right eye dilated to seven. The left eye stayed at three and a half but occasionally dilated up to 5.5 sort of mimicking a dilation light. But that wasn't always present. And her near reflexes were excellent. She did not have an APD and she was a 10 prison bathroom of exotopia. There was no vertical component. And on our extracurricular motility exam, she had difficulty with elevation, depression and her ADduction. She was either full and could bring in very nicely or she could be very limited and was unable to bring in at all. And then her left pupil was also occasionally constricting with ADduction and sometimes dilating with ABduction. But again, this was very variable and it was really hard to pinpoint because the exam was changing and if you met her this morning, she's a very highly energetic young lady. So here is the extracurricular motility pictures. The center is primary gaze. You can see that left upper lidtosis. You can see that meiosis. And then you see she has a difficult time elevating, depressing. Her ADduction looks pretty good there. It's hard to appreciate if the pupil has changed at all with ADduction but then when she ABducks, you can sort of appreciate that her pupil on the left side seems to have dilated a little bit. And here's her pupil photos. So this top left corner is a room light and far which should be very similar to the center picture here which is basically also a room light and far. And you can see how different that is just between these two sets of pictures. So the center picture there and the top left picture there are the same gaze and the same lighting conditions. And then you see she does have a nice consensual response to light in the top right picture. And then at the bottom right picture is a room light and dark. And you see she's a little more tautic and that pupil seemed to have constricted a little bit more. So we were thinking this is maybe an aberrant regeneration of the third versus a cyclical third nerve palsy. More likely than a hornet or a brown or anything else like a dewayne. Does anybody have any other input that saw her today? So that's a really good question. So typically with a cyclical third nerve palsy you would expect there to be the background of a third nerve palsy which would be a dilated pupil. But in the case reports you get all kinds of weird variations and the whole mechanism and theory based on it isn't really well understood but one of the prominent theories is that there's efferent destruction and you get retrograde destruction up to the nuclei and then you get aberrant regeneration plus weird connections so that you can have maybe constant input to the pupil that's trying to make the lid raise and trying to move the muscles so that their pupil function might be better spared. Yes, but hers was not. Right. Yeah. I mean her pupil changes a lot. I mean we didn't do cocaine tests. We did repeat the MRI with contrast and that was again read as normal but again with her pupil and there's one more thing that really wasn't very obvious when we first examined her but then today when she first came in she was bouncing off the walls and running around and her lid was smacked way up high and it was occasionally twitching. So I think that we really didn't think there is much role for a whore so we didn't do any testing. Yeah, so it's very old and more defined. She sees neurology in January. Oh, she didn't. She didn't. That's where she was on. She's your mom. Thanks, everybody. Okay.