 Good morning, everyone. Welcome to the Pediatric Ophthalmology Grand Rounds. We have a few cases to present for you today. And Lydia is going to start with the case of oculopoietal myoclonus and the difficulties in its treatment. Thank you very much. This is just a brief introduction to the case that Dr. Dries is going to present later on. And I kind of want to start with, if you suddenly saw the world differently out of nothing, how would that influence you and your daily life? And I just want us all to think about that if we would have one day where we wake up and suddenly we can't see single, we just have double vision. So with that, I want to start presenting a 30, 60-year-old man who had only a past medical history of hypertension, who suffered an acute hemorrhagic central pontine stroke in August of 2021. And he noticed afterwards that he had horizontal diplopia, which was worse when he was looking to the right or the left. He also had a lot of other issues amongst difficulty with speech and swallow, difficulty with ambulation, attacks, diminished sensation and weakness. And the horizontal diplopia would be kind of like that picture of the coffee cup on the lower right here. So he doesn't have any past medical history or past surgical history, aside from, as I said, hypertension. He was hospitalized after his stroke and then in rehab for two months. He doesn't have any family history of eye diseases or astrobusiness, and he is a former smoker, but he has quit. He has quit on CT imaging, and you can see how it's just calling through here. This is his initial scan from August of 2021. He had that very large hemorrhagic stroke in that pontine area. And here is another scan of his initial CT imaging, where we can also see that big area that is affected by the stroke. Prior to presenting to ophthalmology clinic, he also got an MRI imaging, which kind of showed that these old legions in the pontine area that was a couple months after his stroke, but nothing else that was abnormal. And here is, again, another view of the MRI scan from that same time. So in that area that is affected by his stroke, there are a lot of cranial nerves that kind of exit the brain to move towards the eye, including the sixth cranial nerve here. It's not a surprise that he demonstrated Trinidad ophthalmology clinic in December of 2021. He saw Dr. Warner and at that time his visual acuity was 2040. He had full issue color plates, his pressures were normal pupils were normal visual fields were full to confrontation, and he had a normal anterior and posterior segment exam. His posterior vision was completely gone. And he had a large isotopia of about 40 diopters with bilateral horizontal gaze palsy with this conjugate a deduction nystagmus of the right eye on left gaze, which is right I know, which corresponds to a pontine lesion. So the appendula and rotary vertical nystagmus that became large amplitude and down gaze, as well as a horizontal high frequency and low amplitude nystagmus of the left eye on left gaze, and his cranial nerve exam was otherwise unremarkable. So the options of possible strabismus surgery were discussed at that time, but the plan was to wait for at least six months and then to reevaluate and we measure the deviation. However, he presented sooner than six months in August in April of 2022, when his vision suddenly became a lot more blurrier and more overlapped so he said that the doubling would use but it was just more overlapped from the images. And his wife also noticed very severe vertical movements of the ice and MRI scan that he'd gotten in March showed an inferior olivary hypertrophy. His visual acuity on that visit was 2200 he was not able to perform any color or stereopsis testing his pupils was still normal, his visual field still full, and his lit lamp exam still normal. His eye movements had improved in horizontal gauge, but now he had this very rapid vertical oscillation with synchronous head bobbing, and he didn't have any pellet held tremor, which is something that is highlighted in this video that can sometimes be seen in this condition. This is his clinical exam just an image of the eye movements that he's had, which are very severe and probably even worse compared to the videos I showed in the beginning of just distorted vision because we could not measure anything or look at the funders at all, and he was severely affected by this. So let's talk about the syndrome a little bit ocular palatal myoclonus is an acquired syndrome that has includes continuous and rhythmic movements of the soft palate combined with pendulum stagmas and occurs after an injury of the brainstem or the cerebellar regions, and it's affecting the Dantatru ruple olivary tract, which is located in the valerian molare triangle, which is shown in the image right here. It's typically a delayed complication of a brain stem lesion, so it occurs between three weeks and 49 months after the initial insult, but typically within six to eight months, which is where our patient presented as well. The frequency, even among patients with brainstem stroke lesions is very, very low. So this is very uncommon. Here's the MRI imaging from our patient. And again, I'm not a neuro radiologist but I tried to find a scan that shows the olivary hypertrophy. And it was determined that he has that ocular palatal tremor as a late consequence of the pontine hemorrhage that is now dramatically worsened. So talking about that lesion in the Dantatru ruple olivary tract. It is associated with that enlargement of the inferior olivary nuclei. The other messages I have described here it originally originates in the cerebellar dentate nucleus, and then it goes via the superior cerebellar peduncle into the contralateral web nucleus, and to the ipsilateral olivary nucleus via the central tegmental tract and damage and that central trigmental tract area causes that enlargement of the inferior olive, which is believed to cause the syndrome. It can be bilateral in some cases, resulting then in bilateral ocular palatal myoclonus, and the bilateral form tends to show peduncular movements whereas the lateral unilateral form may have more rotary component. And the MI and ocular palatal myoclonus can help to confirm the diagnosis by showing this inferior olivary enlargement and patients with that syndrome as I mentioned before severely debilitated with and have poor mobility. So there are a lot of pharmacology agents that have been tried in this condition, and the success is very variable. And here's just a list of different options that were mentioned in studies that just the one there highlighted here which is a very good review article in this condition. There are dampening using contact lenses in conjunction with high plus power spectacles has been tried and botulina toxin injections into the muscles or into the retroboba space can also sometimes be a benefit. It can be performed to try to decrease nystagmus, but it's not really frequently used. And so, Dr Warner statement in the end of this visit was unfortunately there's no cure for this kind of abnormal eye movement, and the disorder tends to be very refractory to medication. However, he already had luckily an appointment set up with Dr Dries, which he was recommended to keep. And with that I'm going to hand the word over to Dr Dries. Thank you. Hi everybody and good morning. Acknowledgements. First of all, Julie Harman or thought this Julie I could not do this job without you. I'm so grateful for all the hard work you give us in our clinic. You're doing 50% of the work, at least, and then also really need to acknowledge Dr Steve Archer at the University of Michigan who's been extraordinarily generous with what to do and how to do it for multiple cases in my practice and And indeed, when this patient came to me, this is a new entity for me and a great challenge and I didn't formulate what I'm about to show you. I didn't know how to do it Steve Archer formulated the procedure, did it, figured out how to do it. He shared all that with me, and I'm excited to share it with you because I think this particular procedure seems to make significant progress for these patients. So I think there is some hope, these patients. Unfortunately, without treatment. It's pretty much just close your eyes and imagine the world bouncing with that abnormal eye movement. It'd be terrible. He also had ease atropia with this and some Diplopia but the main thing for him was the Ocelopsia that that nystagmus created now the literature on surgery is pretty dismal. Most of the reports say what we did didn't work well. Two procedures have been tried the first is just disinserting the superior and inferior recti and sewing teen ounce capsule over the stump in the hopes that they don't reattach to the globe. That was reported as not not much improvement, especially in the long term, and eventually botulinum into the muscle cone was offered and one patient to climb one patient did that but not much more follow up. The second was 11 millimeter recession of both vertical recti and I don't know the precise procedure that was done this was in 1980 had trouble getting that article for the details. In any case, here he is pre op. And then the center video is about two days post op he had to be admitted because of an aspiration ammonia. And so he looks about the same. In up gaze he can control it better. In about six months after his surgery. Here's the video and there's really a lot of improvement in in the abnormal eye movements, and he can voluntarily control it so he's starting to watch television and can look people in the eye much better. He still has some Diplopia but with prism that's that's improved. So what's this procedure that Steve Archer came up with and why am I presenting it well, I'm hopeful that this will be on the internet on Moran core for the world. Steve tried to publish this years ago with a case series of six cases but it was not published because he didn't have eye movement recordings he just said video. And the idea here is a super maximal recession of the superior rectus and the inferior rectus so the muscles go way back on the globe. In fact, think of it as taking the insertion of this pure rectus and the inferior rectus, and just putting it on the backside of the globe. And of course the the torque arm of rotation of the eyes very small and equal between those two muscles. And in addition to that, we think that the orbital muscle pulley causes the muscle to reflect backwards. It turns the superior rectus goes back like this on the eye, because of the orbital muscle police. Why does this help I don't know it must dampen the eye movements, but in a way I, I'd like to know why it works but doesn't matter to me it seems to help. I typically recess. Yeah. Yeah, right. Yeah, I'm getting a juice so the typical recession for a superior rectus is what's called a hangback recession. Look, if you're assessing the superior rectus five eight millimeters, you can't so into the globe because the superior bleak tendon is in the way. The superior rectus is over the superior bleak tenants so you cannot. So into the superior bleak tenant you'll you'll change the, the, the function of the of the superior bleak muscle if you do that. And so the solution to that is to throw scleral tunnels that the native insertion and just let the muscle hang back, but they can't be trusted because you don't know exactly where that's going to reattach to the globe. I think this is the procedure that's been done in the past in the superior rectus, but I don't know that for certain. So with a hangback you can see the suture just hangs back the spear rectus and this is a schematic of the same thing where the muscle will overlies the superior bleak and it scars down there and we get good results with that for vertical deviations and dissociated vertical deviation. So here's the thing with these larger sessions 12 millimeters way way back. You need to so the superior rectus down underneath the superior bleak tendon. That's what makes this so tricky. And that's why I'm presenting it so that Mimi and Srav and all of our younger partners, you know you might see this once in a career, so you can refer back to this for pearls and techniques. But this is where the superior rectus is going to go with an average insertion of the superior bleak underneath from behind. And if the superior bleak tendon is more anterior you end up sewing just behind that tendon. And if the superior bleak tendon is more poster you might be sewing in front of the tendon is one other important thing. The month the superior bleak pulls on a line from its native insertion of the globe to the orbital apex it does not pull directly posterior towards the posterior apex of the globe. And with these larger sessions if you go directly posterior, you're actually causing a kink in the muscle. So the superior rectus has to be nasally transposed by four to five millimeters while you do this. The inferior rectus of course is way less tricky, because the inferior bleaks normal anatomy just puts it out of the way for the surgery and the inferior rectus. Well as you can imagine this is really tricky to go back 12 millimeters on the superior rectus and then nasally transposing you're you're sewing right next to the vortex veins. They're very much in the way. If you need great exposure with an experienced assistant a headlamp because you're working in a pole. The superior rectus is the tricky one in particular need to dissect the frenulum that the fascia that is between the under surface of the superior rectus and the top surface of the superior bleak. So that when you do this recession you don't disturb the superior bleak need to dissect the superior rectus back very far, get all of its attachments off of it so you don't end up with a complication of a iatrogenic stravism. And but where the vortex veins they're right there. And once those lead it's usually kind of difficult. So I'll stop there. I just simply say this procedure, or whatever reason is improving this single patient Steve Archer has the same experience and it's not published. And, and I think what is published is kind of giving a dismal prognosis but maybe it's better than that. So I'll stop there. See if there's any question or discussion. Instead of, yeah. Maybe you could help with that Randy. Well, let me Steve's has six he's done video but he didn't have. I think at the time Steve tried to publish it the nystagmus I muscle surgery gurus really insisted on my movement recordings. And so that was the white didn't get published. I understand so Judith. Yeah. So, well, I think we could perhaps help them though the one somewhat cautionary note is I'd say that post up video is about six months out. Maybe we'll see it one year, two years. If it's, you know, stable or worsens. Do you mean the degree of excursion. No, I just have the video juice. Yeah, so, oh, I'm sorry, his range of motion. I, I don't have his Sturbismus exams up. I don't recall. I do know he had about Julie if you remember he had a like a prison doctor is a trophy left over and he liked prison and we put him in prison. No, I just told him let's see what we can do about the Ocelopsia and then go back on the horizontals worrying about answer segment ischemia. In my view. I don't think anyone knows the answer to that question. I think the surgery is not don't it's not a try this at home kind of procedure. You know, I think I, I probably, my blood pressure was probably 155 over 100 during that case because you have your way back there deep in a hole before text means the optic nerve is right there. I mean, I mean like boopy might feel a little bit better with this optic nerve sheath and the illustrations but for me, I'm like, oh, so I think pulling in the, the, the experienced team of surgeons is the way to go and at least that's how I view it. But anyway, okay. So in, in the interest of time I'll go through this case quickly so Mimi has sufficient time. This patient is an Iraqi interpreter who came to the United States thinking that I'm out of Iraq. Thank God. But unfortunately had a bad complication after bilateral maxillary and ethmoid sinus surgery that was done endoscopically where there was on the left the the surgeon went through the orbital wall and and orbital hemorrhage occurred interoperatively there was proptosis of the ENT surgeon did a lateral canthotomy and cantholysis and then went back and tried to tamponade and I think cauterize to stop the hemorrhage. But unfortunately, postoperatively, he had Diplopia he had Mediorectis paralysis. And this photo is when I saw him weeks later. So he looked worse than this initially two days after that procedure. An orbital surgeon and the ENT surgeon went back and attempted to repair of what they thought was a transected Mediorectis. And with that surgery, the patient said his binocular horizontal Diplopia didn't change, but origin was added. His surgeries also were complicated by optic atrophy in a branch retinal artery collusion past medical histories just is type two diabetes so he may have been a vascular path. In any case, here's his true business exam. He can, he can bring this exotropy together a great effort in extreme left gaze, but you can see, he does not adduct the sidewall at all. And he's got extortion in his left eye. But there's no vertical deviation here, but there's extortion. So, here's a video of his floating saccades. So when he looks towards his nose, I kind of floats over, it doesn't go briskly over and that's a sign that it's a peretic muscle, but he does have some Mediorectis function. So at this point, you know, what surgical approach do we have for the least unhappy ending. It's kind of hard to get a very happy ending here. And I want to bring up repeat orbitotomy. We ENT surgeons I think rush to try to repair this but maybe that's not the best course and I asked Bupi to come to just kind of address that because he helped me with this case as well and thank you Bupi for helping me with this case. Bupi, could you talk about this case? What your impression. Visually QT was quite good in 2025. Yeah, he did have some feel loss from his ranch right now, artery occlusion. Yeah. We see these ones every double of years, it's not a common complication but it's a dramatic complication. And I remember is not to go into the orbit acutely because the injuries not to the muscle only but the optic nerve the vessels and more importantly the nerve to the mediurectis when you try and reattach the muscle you cause secondary trauma and you get a super oblique involvement, you get the optic nerve involvement so it's best to quieten these down, and about 50% of them will show some spontaneous improvement if the muscle is not completely transacted. So these days we do a dynamic MRI to see if there are any attachments between the proximal and the distal so called cut part of the muscle and frequently there will be a continuity of the muscle and there is then you wait at least three to four months, and all attempts at reattaching this muscle so far. I did another review last night including our six patients that we initially tried to repair have been unsuccessful. So you do not try and reattach is now. You try and do a hang back to try and get some degree of some degree of medial stability, and there you can also do a fixation to the bone itself to hold the eye in a deduction. As far as the types of injuries, the commonest is a partial transaction of the mediurectis. The next is a complete transaction, and the majority of them will also have involvement of the optic nerve. So this gentleman had a partial transaction and I think further exploration just leads to more risk. Thank you Dr Patel. So, I muscle surgeon comes in and the question is what I muscle surgery to do and I can tell you what what I did. But the the main decision point is whether to do a recession recession of the lateral rectus and the media rectus thinking that there's enough media rectus function that if you're resected it'll actually get the eye midline. And with that floating saccade that really tells us that there's significant paralysis to the muscle and probably a transposition procedures needed. And so the initial procedure that I did and this is a rocky road that this guy went through going going back to the operating room, a couple times but eventually we got the least unhappy ending. And here's the procedure it's partial. Well, let me back up. So, the media rectus, presumably was transected enough that there's no blood supply to the answer segment from the media rectus. So you've already got one muscle gone to maintain blood flow the answer segments you're already worried about answer segment is scheming with cataract and there's atrophy problems. So a partial vertical rectus transposition rather than a full vertical rectus transposition of both the superior and inferior recti is is what I did and when you're transposing to the media rectus you really have to resect some muscle. There's not enough adducting mechanical force without resecting muscles so four millimeter resection and then bringing those muscle halves down here. Now, presumably, this does not help his torsion, presumably. So, I did a her out of ego procedure moving part of the spirit leak tended down to the lateral rectus to bring that left eye and crank it to in toward that I. And here he was. So, his alignment is really a lot better in primary gaze he still has an adduction deficit with a bit better adduction still has an AB and has an abduction deficit by the way the lateral rectus was recess nine millimeters I should have added that I apologize. That's why he's got an abduction deficit here because it is super maximal recession the lateral. But, oh dear. He went to 20 degrees of in torsion. So his left eye went from here. See here. Oh dear. So, I took him back to the operating room and recess the her out of ego by nine millimeters. And we got some improvement, but not a lot right away, but not a lot. And so I took him back to the operating room again. I reposition the right of you to back where it came from because apparently he didn't need that. And I recessed the inferior rectus partial vertical transposition a bit. If you think about that that'll give you a less in torsion right. You take that muscle put it back that is going to extort a little. And before that procedure, he looked up at me and he said, you know, Dr. Dries, I think you've got it this time. I think it's going to work. And he was right. So that's a patient who got partial improvement taking back over and over again to the OR. And I guess the reason I'm presenting it is just pearls. You may not see this in your career, you know, or you may not very often but here the pearls. And this happens. Loading saccades and or for first generations in the clinic tell you if you need a transposition. Interestingly, to me I really learned something that if you transpose vertical recti that apparently takes care of torsion for you. That kind of locks in the I word supposed to be with regard to torsion, apparently. So I see about forced actions trying to make sure that the forced actions for torsion or equal. And, but nonetheless he had to reverse the some of these procedures. And I'll stop there. Thank you. Thank you Dave. So I learned the most from the cases that don't turn out so well. And I'm going to share two of those with you today. This is a 73 year old woman who came in with constant double vision. She's had it for the last seven years. She tried using a Fresnel Prism but it didn't really help how it blurred her vision so she's just been walking around with a patch on the cause of her double vision is thought to be from Neuro sarcoid. She had been referred by neuro ophthalmology. She had a biopsy in Singapore previously, and had been followed by MRI. She was three weeks prior to me seeing her, and she'd been treated with immunosuppression for this neuro sarcoid. It had caused some optic atrophy, especially in that left eye. And she had a little mild APD. She was a little bit near sighted and had an isotropia with some limited movement on the left. She had a pretty similar distance and near had no stereo. Color vision was normal, but as you can see I can't even get that left eye to midline. When she's trying to look in. Also doesn't fully seem to. Yeah. Can't pull that. Can't pull that I out sorry. Also can't pull it all the way in so she's just got some limited motility. So I thought was her isotropia. So I decided that I was going to treat that with a right. Sorry, that should say left but I was in this position as well as a medial rectus recession on an adjustable suture so I was going to move that superior rectus all the way over towards her lateral to try to get that left eye to move it. That should be say left sorry get that left eye to move out and just and then also recess that medial on an adjustable. While I was in the case I went after the medial first and hooked to the medial and thought wow this really isn't that tight. And handed it to the assistant that wow that's kind of got a lot of give on it. And all of a sudden she pulls the hook up and it was into. So this was the medial, not the lateral, which was the parietic muscle. And this is something that I've seen in fellowship but hadn't since then what we call pulled into muscle cold into syndrome. So this is where the rectus muscle is pulled in two pieces and it's usually where the tendon attaches to the muscle. So this is a this is an article looking at pulled into syndrome that was done by David granted at UCSD and he found that most patients have a preexisting condition. Either a previous surgery or a cranial nerve palsy were the most common but can also be seen in thyroid disease. So it was pretty much previous surgery and to had no underlying conditions so our patient did fit into that category of having a cranial nerve palsy or having some kind of other disease. 70 were over 50 years of age so it tends to go with a little bit older age. They looked at it and thought it was a little more likely to happen with a green hook than the Stevens hook and that's a picture of a green hook there and I don't know if that's just use green hooks or or not but Stevens hook is that small little hook. Most of the time. It's possible to retrieve that proximal and so that the you know the end on the other side and reattach it however in this series 30% couldn't be retrieved. And some ended up undergoing a transposition later, but a large number of them didn't need any re operation which is pretty remarkable. Most of the time it happens to the medial or inferior rectus. And I've also listed here where where most of those points of insertion are points of rupture from assertion. And they kind of line up with where that 10 you know how long that tendon is and where it attaches to the muscle there so it's usually at that same, that same spot because the medial rectus has a four and a half millimeter length of a tendon and goes right in that space of four to six millimeter so it really does rupture right there where the medial where the tendon meets the muscle. From this study they anticipated that there they conjecture, you know that most people who are doing a lot of stir business surgery are going to have one case and one case of this every 10 years or so. So, after the case. Just thinking a little bit more about it. I so after that muscle pulled into I called Bob and he came and we together were able to find the end of the muscle and pull it back and reattach it. It was for it seemed a little bit further back than where I would have expected you know within that four and a half millimeters to where I would have expected that it to pull from the tendon to the muscle. And I just was curious more about her neuro starcoid disease which I hadn't fully researched prior to the surgery and went back and looked and found that this is her MRI looking at her inferior. She had some thickening of the inferior rectus and the medial rectus right near the orbital apex there. And I don't have as good of images as you can see that they're pretty thickened back here so we have some abnormal muscles to begin with and I think that that probably contributed somewhat to them being weak. And I think it ruptured more posteriorly than that where the tendon inserts because of this inflammation that was still you know still happening and this was the memory that was just a few weeks prior to me doing surgery. And I had some serious enhancement there right before it. The muscles get a meat in the muscle cone. So, after that, after that happened I didn't end up transposing this superior rectus because I was just a little bit traumatized by losing that muscle. And I saw her a few weeks later she was as you recall was an ET of about 40 prior to surgery after she was about 30. She can still fuse if she gets a pretty big head turn, but not a whole lot better. So I did take her back to the OR a few weeks later and did that transposition. After her photos afterwards, you can see that she is still, you know, somewhat limited, you know, still has some limited adduction here, but she's looking much straighter than 40 prism diopters of esotropia. And she's still quite limited here, you know, she can't get to midline now before she had was a minus six so couldn't completely get to midline. But now can you can also see that she's, you know, somewhat limited on her up and down gaze here. And about one month after her surgery she was down to about an ET of 10 confused with just a little bit of head movement, and looking more at her vertical movements I hadn't concentrated so much on those before but I think. Yeah, she still has some limited up and down gaze there, which I probably missed before because I was more just concerned about her ET and hadn't really looked as much as her up and down gaze. But this is probably somewhat limited by that thick inferior rectus muscle. So in thinking about more about this case. I mean, I didn't review the scan before I just kind of thought she would you know she'd been stable for many years she had had the same esotropia for many years. She hadn't changed for her report, and I didn't fully go back and look at that scan and if I had I might be a little bit more gentle or I've thought a little about the case a little bit different. Knowing that I also had a brand new tech who wasn't familiar in the OR and just kind of handed her the muscle like she knew what she was doing and I think she pulled a little bit harder than she should have. You know, ultimately I'm the one who's responsible there but just all of these all of these things kind of led together to me pulling that muscle into. But these are the cases that I end up, you know you think about and go back and kind of reevaluate and realize the mistakes you made and anyone have any thoughts on that. The other interesting thing to me was that, and I'm just trying to go back here but a fair amount of these are the of the people with cranial nerve policies three were the peretic muscle and three were the antagonist muscle and I thought that was interesting because I would have thought that the one I would pull into would be that would be that you know would be the peretic lateral. So it's often them and I don't know if you're pulling harder because it's a tight muscle or if it's an abnormal muscle or, but a fair amount of time it's the it's the one that's tight that you're pulling into I thought that was interesting. But hers was likely related to her inflammation there but also just, you know, you have a new scrub tech, you don't, you know, sometimes I don't always communicate as well with them. These guys aren't always trained to hold the muscle they're more, you know, they do a lot more cataract surgery than they do these muscle cases and I just, you know, that second before I thought that muscle is kind of loose. Grab that muscle that happens. Yeah. Well yeah because sometimes they're like moving the muscle things and it doesn't matter most of the time but here it did. So, yeah, because you don't always know how hard you're pulling if you're and they don't always know because they haven't done that many of these but I have one other quick case here, I have time I don't even know what time it is. So this is a 22 year old girl who came in with an intermittent nexotropia so she was getting some intermittent double vision didn't like it had had it since high school recently got married and just wanted to fix. For example, she's 2020 has good stereo just has this intermittent nexotropia run of the meal, a little bit more at year, but pretty not that poorly controlled great vision. So I took her to the OR and did what I usually do which is a bilateral outer reception recession for these so I moved that muscle back so that I can come in a little bit more. So I usually in adults will do these as an adjustable suture so I put that little noose not there and can move it post up. If I need to if they're a little bit under corrected on day one they're going to be a lot of under corrected in a couple months so it's kind of nice to have this and some of them are controlling better than others and so, especially these young women, not so young women can sit and in the office will let you adjust them so I, you know, past the sutures at the insertion did my adjustable new news not everything seemed fine. No concerns at all. She said she had some soreness when using your peripheral vision had a little bit of XT which I didn't adjust but thought it would be okay. She said she's a little light sensitive but nothing to run of the mill. And then about a week after you know after surgery she called in and talked to the on call resident. She had a little bit of increased bruising and she has some more floaters. You know, the resident told her maybe she should come up she lived in Provo didn't really want to drive up. And I actually and so I saw her the next day in clinic which seemed appropriate to me because I haven't had too many of these problems and usually these young people complaining of problems don't have them. On her dilated exam she did have a little bit of vitreous hemorrhage and a little bit of temporal corridor whitening and a little elevation of the corridor pigment in that left eye. So was 2020. You know she was probably just getting a few of a little bit of that vitreous hemorrhage in the middle where she was, you know, moving a little bit where she was seeing a little bit of blurry vision but I remember about the options she lived in Provo she had been to see you know in the same office was referred to us as one of the retina dark down there so follow it up down there. He saw, oh, talk a little bit about this so clearly I perforated the, you know, the I passed a deep suture. How often does this happen. More than we think. This is difficult to determine because we don't look at every patient, and most of them don't have problems so we don't worry about it. If you look at a lot of these kids who you've done surgery on sometimes you'll see a little bit of a pigment or little things temporarily you're on some of your post ops but you know this clearly I didn't go through the retina but I, you know penetrated enough to cause some some bleeding there. There's a study that looked at 300 cases where they found 13 penetrations and six perforations this is a UCLA and probably a little bit more because I think a lot of the fair amount of these are done by residents so. But they didn't have any real complications happened a little bit more in recession than reception which would mean that that more when they were passing that suture further back, a little more likely to happen with horizontal muscles but we also do those more and more likely with that as 24 needle a little bit bigger needle. Of these people and none of them had retinal detachments if they were followed for a year know I'm depth on my desk. One maybe had a little bit of a skatoma caused by some cryo that was maybe it was done at the time. Some had some retinal edema. A little bit more likely when they were doing a posterior fixation suture putting a suture into the square far back. This is another study that was done in Saudi Arabia looking at 4000 surgeries they have 15 perforations pretty low percent. And not many, no loss of best corrective visual acuity. Most of them are treated with laser there's, you know, one of them was a kid with high myopia who needed this girl patch crash somewhere more likely with the sharp West Cots. So, so it happens more than we think doesn't usually have you know too many devastating consequences but certainly something to be aware of. So she went down my patient back to my patients she went down to that group of Provo they saw a little bit of a cradle hemorrhage temporarily did not think she had a retinal detachment didn't think that that any couldn't see any abnormality in the retinal didn't have any submetal fluid they put a little laser in there just to protect her. And I didn't think about it much. And then about a month later I got a call from that retina group again saying that her vision was down to count fingers. And she had a big enough cradle hemorrhage in there that she had not that it had now broken through into the vitreous and she was. So they recommended and it didn't clear for another month. She was still count fingers so they decided to do of attract me so he did a 25 gauge retract me. So she was set up had her stroke cars at the top and infusion at the bottom post update one she was 2060 came back to see me a month after that which was three months after her initial surgery. And I just like to point out our alignments. We fixed exotopia, but she's pretty bothered by this. She's 2040 now and was 2020. I don't know if it's better to correct her better but now she's got some astigmatism and it's bugging her because she's never needed glasses and she feels like now that I blurry and so I don't know why that is and I kind of look through the literature. We do get it and strabizma surgery for sure right after and then most of these cases they show some changes in refraction. And the most of the series that they've done are similar to this where right after surgery yes there are changes and this one had a significant difference in refractive error axiolength and corneal stigmatism at post op day one but it all cleared by post op month one. I know this because I had a patient that I didn't big R&R on a month ago and he was beside himself because he's a stargazer and I induced some astigmatism and now he's got a halo. And it will go away and it did go away but I don't know why after after 25 gauge protect me that they didn't suit her I don't know why she's got or I don't know what happened but she's. And this is just more of a study saying that one day after surgery there are some changes but a month after there aren't. Any thoughts on that. Now, and I looked through it sounds like it doesn't happen so much so maybe it will settle hopefully will settle but. Now she's mad because her insurance is fighting the cost of her surgery but these are the cases that I learned the most from and think about the most from and. I think it's hard to share your complications and I. Where I trained we did a lot of that and. It's always hard to admit that you screwed up but I think, or the things didn't go as you had planned or you had hoped but I think that talking together and and I'd hope to present these at M&M but my surgery schedule is always kind of hard. Those are the ways you learn the best and support each other and and and grow from them. Dave. He had another comment there at the back. Yeah, none. Yeah, none that I could see. Yeah. Yeah, she wasn't happy. Yeah, I'd haven't know. That's a good thought I could. Yeah, I don't always jump to thinking that because we don't have one that I saw I see her at Riverton but yeah it would be and it would be interesting. Yeah, and I always think about, yeah. We see I see it after a business surgery all the time, like that stargazer guy and they get, and it goes and it goes away, but it's noticeable and then it can make a it can make your amblyopia worse if you do an R&R and a kid so I think about it a lot with strabismus but I hadn't. Yeah. She could be she could be growing cataract I didn't notice it then but she'll be thrilled. Thank you everybody.