 All right, so we're gonna get started here. I'm just gonna introduce Dr. Julia Bird. She's one of my co-residents. We're in our first year of residency. Dr. Bird graduated from medical school at the University of New Mexico. We all heard about Dr. Bird's career as a child actress a few weeks ago when she was introduced. But she also has other talents. She is a former ballerina, which apparently makes you really good at rock climbing. We had a mini-resident retreat this past weekend, and Dr. Bird was the fastest person to make it up the more difficult route, beating out co-residents and a few faculty and staff guest stars. She's gonna give us a neuro-ophthalmology case of optic neuropathy. Thank you. Thank you. All right, so I'm gonna be going over a case we saw in the neuro-ophthalmology clinic. This is a patient who came in in February. He was referred for a history of NAION in the left side and some kind of continued vision loss. He's a 56-year-old man, and his kind of main complaint was decreasing vision or decreased vision in the left side for the past three years. You know, the story is a little unclear, but he said he remembered a cute onset of painless blurred vision, but that has progressed over time. He has some distortion, missing areas of vision in that left eye, and he's noticed that colors are definitely diminished and not quite as vivid in that eye. But over the past couple months, he's also noticed some changes in his right eye. You know, he can't describe it more than just kind of some blurry vision, distortion of vision. He's also in general had some increased glare and some floaters that are unchanged. So in 2013 he reports he saw an outside ophthalmologist who said he might have had a stroke in his left eye. We didn't have any records from this visit, but 2014 he said his vision continued to decrease to almost nothing, his count fingers in the left eye. Again, no records, this was just from his account. He's seen multiple ophthalmologists kind of since then, but finally got referred to the neuroophthalmology clinic. Past medical history, he's really quite a healthy gentleman. He had some headaches for the past few years that he kind of correlated with the onset of his blurry vision, but they're kind of in the nasal temporal region. They can radiate anywhere. They are variable for how long they last, either dull, achy pressure pain or a sharp pain, no associated photophobia, phonophobia, nausea, vomiting, no history of migraines in the past, no eye pain associated with this. He's just on allopurinol and albuterol. He lives in Idaho, he owns a general store, no cigarette use, a few occasional alcohol. Family history really is just significant for a father who had a blood vessel occlusion. We don't know exactly what happened, but when he was 83. Kind of a review of systems. The only positive that he was elicited or that was elicited was a erectile dysfunction, no history of steroid use. He's never had any imaging done. He's never used any phosphodiesterase inhibitors, no history of diabetes. He's had normal lipids. Neurologic exam was normal. And his eye examination when he presented his vision in the right eye was about 2020. Left eye was count fingers. He had a left ather and pupillary defect. Visual field to confrontation. He was recorded that he had a supronasal defect in the right eye and generalized constriction in the left eye. Color vision was actually decreased in both eyes. The right eye was four out of 10, but couldn't see any of the color plates in the left eye. And flicker fusion was also decreased in the right eye significantly, but he wasn't even able to see the light in the left eye. On his examination, the anterior segment was pretty unremarkable. And his posterior segment examination is generalized pallor in the left nerve. Possibly increased temporal pallor. The right nerve looked healthy and cup-to-disk ratios were slightly increased with the right being 0.6 and the left being 0.7. He had some, as noted, he had some AV nicking in both eyes. So here's a retinal nerve fibroler. He had actually come in with this test being done. So he had generalized thinning of the left eye and a little bit of inferior thinning of the red eye and some borderline, or sorry, that looks yellow there, but it's full superior nasally and temporally. So the interesting thing in this gentleman is if you just go by what we know at this point, he has a history of NAION reportedly. We don't have the records. And his exam potentially is consistent with NAION. Maybe it's kind of the things that are a little bit odd is that he still complains of decreasing vision loss in the right eye. We don't exactly know what's happening there, but he hadn't had a visual field done up until this point. And so this was his visual field, which shows temporal hemianopia and not completely symmetric, but pretty clearly demarcated. So of course, the next thing that he had done was imaging. And so the MRI showed this large mass, you could say here, we can see it here as well. And basically the radiologists felt that this was most consistent with a giant anterior communicating artery aneurysm, which is quite rare. So looking at the literature, there is one report of a giant anterior communicating artery aneurysm that produced by temporal hemianopsia. This was back in 1981, but just kind of a 10-year history of headache, vomiting, neck stiffness. We're lucky, this is their picture of the angiogram back then. So we definitely have a little bit better technology to help facilitate our diagnosis these days. But an interesting case of this fairly rare aneurysm causing the by temporal hemianopsia it kind of was thought to go over the optic chiasm and then push up the chiasm causing this visual field defect. So our patient had a diagnostic cerebral angiogram and they actually with this diagnosed him with a left internal carotid artery aneurysm and an ophthalmic artery, kind of carotid ophthalmic artery aneurysm was fairly large. And so we can see the picture here of this large aneurysm. So just a quick review of the vascular anatomy. We're talking about his aneurysm is basically, it's on the left, but at this junction of the ophthalmic artery and the internal carotid. And you can see the close proximity of course to the optic chiasm. So the carotid ophthalmic aneurysms most are intradural, which present if they're presenting they could present as a subarachnoid hemorrhage and of course visual field defects that we saw and I'll talk about. But there's a few that are extradural and then in that case they could present as a carotid cavernous sinus vascular or a subdural hematoma. And looking at these there is a kind of a large study of 2,000, about a little over 2,000 intracranial aneurysms looked at in 1966 by 0.4% of them were carotid ophthalmic. So not too common. They're more common in women, at least reportedly and then more frequent on the left, which is kind of interesting. But and then also associated with other intracranial aneurysms. Some other reports of these aneurysms that were kind of interesting. There were three reports of aneurysms actually penetrating through the optic nerve or chiasm and then other manifestations that you can have a subarachnoid hemorrhage which would damage the neural structures around the, you know, where the blood is, the vision loss. You can get emboli from within the aneurysm that would cause vision loss and then compression of course from any of the visual structures. And so this was the report of aneurysm. This is the aneurysm here. This is the artist's rendition, but the optic nerve is just being kind of split in half by this large aneurysm. And this gentleman interestingly had acute loss of right vision or acute loss of vision in the right eye after a severe headache. But, you know, it's clear that aneurysm had been there for a while. So they weren't exactly sure why it was, I think they thought he had a sentinel bleed and then kind of had this vision loss, but there's the other report of this ophthalmic artery aneurysm splitting the nerve that's patient had no visual symptoms and no changes in her vision, which is kind of amazing. So there's kind of, you could pretty much see any visual field defect with these. The ophthalmic artery can emanate in different orientations from the optic chiasm. So depending on where that is and where the aneurysm happens, it can produce different things. But, and then the aneurysm, depending on where it expands, could of course also produce different types of visual field defects that expands anteriorly. You could have, you could compress optic nerve and have a unilateral optic neuropathy. Superiorly, same reports of either kind of a slow, monocular vision loss or acute, painful associated with the central scatoma and ipsilateral APD, which could mimic Richard Bulbar optic neuritis. If it expands posteriorly and superiorly, there's a, you could have an optic chiasm or tract syndrome and then expand, if it expands laterally, it can compress the lateral aspect of the optic nerve, chiasm or tract, and then you can have a nasal hemianopsia and the ipsilateral eye. Which they, you see a fair amount with them. Just looking at a few other kind of case series. In 1989, Drake looked at 103 crotodoxymic aneurysms and out of his series, there were only eight males to presented with subarachnoid hemorrhage. And then interestingly, 48 eyes already had vision of 2,200 or worse. And just the slowly progressive loss of vision, which is just kind of interesting that they go on for so long with this giant aneurysm and don't get diagnosed until their vision is so poor. Very talked about some of the visual field defects, but the most common that he saw were just unilateral or bilateral temporal defects. So unfortunately with these aneurysms, the treatment is also not necessarily going to preserve the vision in that, especially in the side that they have the aneurysm is due to direct damage from the optic nerve or the blood supply of the nerve being disrupted or interrupted in the process of clipping the aneurysm and then any post-operative vasospad and you're just the blood source for the nerve can be a problem. So for our patient, he did undergo left craniotomy and had clipping of his ophthalmic aneurysm or crowded ophthalmic aneurysm. He unfortunately, his post-operative course was complicated by an intraventricular hemorrhage with acute obstructive hydrocephalus and they went in and evacuated his epidural hematoma and he did well after that systemically. But on his post-op eye exam, so he reported that immediately post-op he didn't have any vision in the left eye. No one evaluated him from ophthalmology, so we don't know exactly how bad it was, but he said after a few weeks his vision returned but it was still blurry. The right eye, he thought was completely resolved pretty much right after the surgery. There was no more of this visual disturbance, no more blurriness. And the right eye is seeing great, 2015. Left eye is still poor vision, count fingers. The APD was measured as a little bit higher post-operatively. Color vision in the right eye is almost normal. Left eye still doesn't see any color. And then visual field from his post-op. The right eye is definitely improved, but the left eye there's more generalized defects and is worse. Luckily, subjectively, he doesn't think the left eye is worse and he's happy with the right eye. But I wanted to present this case because I think it's another good case and kind of a scary case of when going on kind of our anchoring biases or the diagnosis that a patient comes in with can really be life-threatening in this case. And visual fields are such a easy and non-invasive test that it's just, if there's any doubt, I think you're doing them can save a life, so. Any questions or comments? All right. I think we have three stuff next.