 Most of the ones that we see are bilateral, high, astigmatism or things like that, which can lead, if it's really high, but for the most part those bilateral ambiopia, bilateral ambiopes still fuse. Don't develop ambiopia. All right. What is this test that we use in our clinic? And how does it work? Each of those pictures shows the right and left eye with the glasses on a little bit of a different image and together makes a 3D-looking image. And then as you go from one to nine, the arcs difference in the two images that the person can perceive decreases. Exactly, they get closer together so they give us less of the feeling. So if you're looking at this one, this is actually a little different than this, but it's close enough that our brain can put it together. So yeah, you're looking at it through these polarized glasses and your brain kind of integrates it into one image. So if you have to see all nine of those, what kind of vernacular visual acuity do you have to have? Do you know? 2025. Yeah, exactly, exactly. I had a faker last week who could only count fingers but could get eight out of nine of these circles. So yeah, it's a good, it's something you can use to test for that. Yeah, and that was kind of what I just answered. What else, where else can this be useful and it can be useful and look some of those kids who are faking and to kind of reassure you that their vision actually is pretty good. So when I talk about vernacular vision with people they're strapped business with people and they are looking at that and seeing that their kid can't see those things pop up. Does a kid who doesn't see those things, do they still have depth perception? Yeah, they can have depth perception because they have like vernacular cues and a lot of different other things that can give them decent depth. Exactly, there are lots of people walking around with who don't have any stereo vision. So depth perception is not synonymous with stereopsis. Like you said, vernacular cues are also important. Object overlap, relative object size, highlights and shadows and perspective. Like we talked about stereopsis or being able to see those things as a vernacular sensation caused by that horizontal disparity that our brain integrates cortically into one. And that stereopsis is really only kind of helpful for the first 10 feet or so after that you're really mostly relying on vernacular cues. So I think probably you couldn't be a top baseball player Roger Federer or something without stereopsis because I do think it helps you somewhat but I think, I don't think it holds you back from a whole lot in sports otherwise. I think these shouldn't discourage kids without any, but not any stereo vision from doing sports. So, your eyes wire to give you good vernacular vision but which retinal fibers cross at the chiasm? nasal. Exactly. So the nasal ones cross and the temporal ones are stay on the side side there track back to the lateral genically nucleus and then back to the, you know, cortical or the visual cortex and what's conditioned do all the fibers cross? Obonism. Yeah, exactly. And how can we diagnose that? VEP. VEP. Yep. How else can you look for it? Physical exam. Yep. What if the physical exams kind of unclear? Can't totally tell. The macula and the phobia is underdeveloped. Exactly, yeah. You can try to get an OCT. Some of these kids have nystagmus that make it hard but some of them it's a pretty fine nystagmus when you're looking at some of those mild albinisms. It's pretty common, more common than you would think. I had a kid the other week that was followed for, yeah, a while for some kind of nystagmus and it looked like albinism to me but a lot of these kids, I used to send a lot more of them to Creole but he's has inconclusive so much of the time. It's pretty easy to get genetics to do it now. So I just send them to Emily Spoth. As far as visual development, is your vision normal right at birth? No. No. When do we start seeing nystagmus when kids who have like bilateral cataracts? You see that? About four months. We'll say it again. Four months, I think. Yeah, you can see it about two or three months. Yeah, you start to see it. So even kids who, yeah, that's when you start to see it. So yeah, their phobias aren't covered or are covered by multiple cell layers at birth, which is some of those kids that can be hard to tell whether they're hypoplastic when they're young, which I think is why the VEP sometimes doesn't work as well, but some of them it's hard to see that phobial dip in a squirmy kid, especially if there is some nystagmus and I think the phobias are a little underdeveloped and I think they take a little longer to develop in some of these kids anyway, but those redistributing over the first few months and years. What is amblyopia? When your brain doesn't learn to see. Exactly. So it's a brain issue. Families have a hard time understanding why the glasses still don't fix it. And you can kind of go around in circles on that one, but yeah, it's reduced vision that we can't attribute to any other structural abnormality. So it's something that's just brain. Everything else looks pretty normal. What causes amblyopia? There's a lot of different ones. You could have refractive or deprivation or stropismic. Those are, I think the main categories or maybe some, oh, anisometropic, I think too. Basically anything that has unequal input to the visual cortical pathways. Exactly. What about a really high astigmatism in both eyes? Yeah, that can be. Oh, that's like anisoconia, right? Anisoconia is more like when you have a different shape of things. We see that more in adults, like when you do cataract surgery and put them both plano and somebody who's been anisometropic for a long, long time or you see that a lot in. Yeah, it's more of a different size of image. Just a high refractive error in both can make it. So some of these kids, like we can never correct them to 20, 20 just because they didn't wear their glasses when they were young, when they're like four and five diopters of astigmatism. So yeah, strabismus and anisometropia are the big ones and those are the ones that we are really looking for with those vision screeners. Which kind of those is harder to treat? Strabismus is harder. Yeah, exactly. So anisometropia often, if you put the kids in glasses, it would just solve the problem totally. Whereas strabismus, you'd usually have to do some kind of patching and things because anisometropia, yeah, when you put the glasses on, you're kind of correcting them all the time. Strabismus, you still, some of them are still manifest even, you have to do some kind of patching or some kind of therapy. So it's always harder to treat the strabismic and then when they have a mix on top, that makes it even harder when they're strabismic and have anisometropic refractive error. And then high bilateral refractive error. So really high minuses, really high pluses or just or high astigmatism. So when do you give glasses to kids? This is, we all have differences of opinion even among the five of us about when to give glasses. And oftentimes I'll take kids out of glasses that optoms put them in, but this is a little diagram that's put together by the AAO. But in general, little kids can tolerate a little, little less than a year can tolerate a fair amount of refractive error without it causing bilateral amblyopia. Usually, and even if they do have some of those high errors, if you put them in glasses later and wait a little while, it's pretty easy to treat. So I sit on a lot of these refractive errors. I mean, less than a year, even if they have up to three, three and a half or all of diopters of astigmatism, I won't put them in glasses. Even if they do have a little bit of amblyopia from not being able to see things clearly enough, if you wait a year or two, it's usually pretty easy to treat. Even two or three year olds and a minus three, they don't think you need to give those. Hyperopia, I tolerate a lot more than that. Usually if they're straight, there is some thought that if you treat these kids with hyperopia, then they aren't accommodating as much and that's not gonna drive eye growth as much. Yeah, and these are what they recommend they kind of put as their sets, numbers on their vision screeners, but I find these to be pretty different and sometimes much less than this. But like, yeah, these one year olds who come in with two diopters of astigmatism, so many kids have that. And I think that there's a thought that maybe if you put them in them and put them in the glasses, maybe they won't naturally outgrow it. So, but like a year old, you don't even recommend putting glasses until there's two and a half diopters of anisomatropia. So, yeah, a lot of these kids, we may be catching a lot of these things that are transitory and maybe we don't wanna mess with, but a lot of times optometrists will put kids in glasses that I will take them out of that don't seem to be necessary. So, ambliopia is caused by optical de-focus on one of the macules or both of the macules. It can be caused by anisomatropia, which has a later onset than a critical period in astro-byzmic ambliopia. Just saying that's just saying that it's easier to treat. You have a longer window there. This says, you don't even develop any kind of astigmatica ambliopia until during the first year and may not develop until age three. I sit on astigmatisms of three, 350, maybe even four in those early years of life. Strobismus is, you actually have a foveal disparity where the foveas are not lined up. They're not looking at the same thing. Also has some optical de-focus because they're not focused on those foveas, but this critical period's younger. So it's, this is why we operate early for strobismus is trying to prevent that ambliopia, trying to prevent that loss of fusion. So why do kids develop it? So they're largely trying to avoid diplopia, especially with strobismus, right? They're seeing through adaptation of the brain to get rid of a second image. And it can be facultative, suppression can be facultative, meaning you can come and go like intermittent exotropia. They're not always suppressing, but it can, you know, when they do go exotropic, then they start depressing. Depressing, sorry. Treating it, we like to treat it with put them in in glasses, treating with patching and atropine and, you know, trying to align their visual axes with surgery if we need to for those strobismus and ambliopia. What about adults who are suppressing? How do we treat them? In general, we don't like to stop them from suppressing because if we do, you know, you're not gonna get back binocularity usually, you know, and these people who are suppressing and sometimes when you start messing with it, you can get something that you can't get rid of. So you have to be, you know, really careful with some of these people, adults with strobismus, especially when they have an almost retinal correspondence and they're suppressing one eye, you know, sometimes they used to do some therapies to try to get them to unsuppress it and then they can't make it go away again. So you got to be pretty careful with those adults with the history of childhood strobismus. What is anomalous retinal correspondence? Center of the vision in one eye like is like offset from where you'd expect the pov yet to be. So the eyes are not aligned, but the images are. Exactly, you have kind of a, you know, an anomalous correspondence between the two eyes where the fove in one eye kind of makes a relationship with a peripheral element of element in the other eye. So it's an adaptation to have some kind of degree of macularity. How would this look in a kid in clinic or an adult? They could have a parent strobismus, but actually be fusing. Yeah, exactly. So it's when they're kind of Krinsky and their alternate prism doesn't match up, what they're kind of seeing and what you measure are not always the same. What's this test? Worth four dot. Yeah. So what, if you close your left eye, what do you see? You see just the red. Yeah, so you see two reds. You close your right eye, what do you see? Just the green. Yeah. So what does it mean when you see five? It means you're misaligned, but not suppressing. Exactly. So you're either, sometimes it can be that they're alternating between this. Like if they, it can be that they're like, they can be suppressed. Sometimes they'll answer that they see five, but they're really going back and forth. But if they really see five all the time, yes, it means that they're, they're deplopic. Dr. Young, when you, for the anomalous, retinal correspondence, I always get kind of confused. It's different than angle kappa, because angle kappa is when the phobia is actually in a different anatomical place. Exactly. So angle kappa, their phobias are actually looking at the same thing. They're actually kind of lined up, but, you know, their phobia can be dragged a little bit further. Like albino kids are always positive angle kappa. Kids with ROP can be positive angle kappa. Some people just are. There's just more space between their nerve and their retina. So, yeah, so like, they're actually, even though they're, I mean, I guess did I have a good image back here? If I ever have a good, where they're looking at the same thing. No, like, if you're, and I'm a horrible artist, but, and I don't know, these lights keep going off. So like, yeah, so like an image, I don't even know if you can see. You can see here that like, if you're looking at the same image, there's a lot of space there between your macula and your phobia, or sorry, your phobia and your nerve, but they're still lined up looking at the same image. Whereas if you have like a, yeah, and if they're less distance, yeah, and they should actually be, and I'm not a good, but the eyes will kind of be pointed out a little bit to get those maculas to line up here, but they're actually looking with the same part of their macula, whereas you have anomalous, it's gonna be like, that is actually lined up here. Right, so, but when you do cover on cover, there's not gonna be any movement, but when you look at them, or for anomalous retinal correspondence, yeah, there's not gonna be much movement, or it's not gonna line up with what your Krimski is. It's why it's important like in some, in people who have had many strabizma surgeries or things like that to do a cover on cover and then also do a Krimski to make sure it's the same. I got that one girl that's, if you shine a light at her eyes, she's clearly, it looks like she's exotropic in one eyes looking at the wall, but then when you have her look at the chart and do cover on cover, her eyes are actually coming, she has an aesophoria. So just what she's using for phobia or what her eyes are lining up, she doesn't have good vision in either eye and usually these people don't, often won't. But they can have an okay vision too, but yeah, the short answer to that is, yes, with the positive angle cap of their phobias are lined up, whereas with an anomalous retinal correspondence, it's a phobia in one eye and something that that's kind of corresponding as a phobia in the other eye, kind of like a para phobia or something that they're using, but it's not actually the phobia. Got it. And Dr. Yaren, correct me if I'm wrong, but I remember being, I think I was in clinic with you and you said that like positive angle cap is far, far, far, far, far more common than actual anomalous retinal correspondence, right? Correct, correct. Yeah, yes. Yeah, a lot of people like, I don't know, my husband always is on TV, like is that person exotropic? Like a lot of people just kind of have a little look of exotropia, especially when they're looking off to the side or things, but they aren't truly exotropic. You know, it's just that they're, how they're, where their phobia is, there's just, you know, a few microns more distance between their phobia and their optic nerve. And just to clarify, when you're examining the patient, like by Krusey and alternate cover, those two conditions should look pretty much the same. And you basically have to look at the macro to be like, to decide which of the two it is. Yeah, yeah. Or if they're, I mean, they should be pretty much the same, if they're not, you've got some kind of an issue and you have to be careful about it. Because if you just operate for that, you know, to line up what you think the phobia is, they may not like it. If you actually line up their phobia sometimes, like in an anomalous retinal correspondence, what they're using, they kind of like, like in an adult. What they're using to correspond with their phobia in one eye and the other eye is kind of where they like to be. And sometimes if you put their phobias together, they won't like it just because their brain is not biphobia. Does that make sense? Yeah, that makes sense. I have one kid that is an albino that, he's an ocular albino and he came in with like a, six, you know, 50 XT. And I did surgery on him and he was still a little bit XT, but had diplopias that like all the, you know, that lasted for about six months and then finally went away. And I, you know, I couldn't, it was weird. I couldn't get, even when I put his eye back, he'd tell me he still had diplopia, still had diplopia. But if I just sat on it for a while, but yeah, that's, he had some kind of binocular problem and he was still exotropic. Like he should have still, he's not totally binocular, but I would have thought he would still be within some kind of a suppression scatoma, but just kind of weird. Some of those kids have weird adaptations that you can't totally figure out. He was also like 15 at the time. So it wasn't like he could rewire or things, but it did finally go away. Talked about the, oh, we're back here, sorry. We kind of talked, oh, so mono fixation syndrome is a condition where you have a central scatoma and peripheral fusion. These are people who have just, you know, sometimes they'll come in with just a little amblyopia, but you don't even really see much strabismus at all and you can't, and you dilate them and they don't have much refractive error in either eye. It can also be a good outcome of strabismus surgery for somebody with like congenital esotropia. That's what it says there on the bottom. These people can have amblyopia, you know, because they have just a tiny, a small misalignment. They have some stereo, but reduced stereo and they may or may not have a little manifest deviation. So how would you test for this? What do these people look like on worth four dot? So you do a worth far away, where the angle between the two eyes is pretty small and then you do a worth up close where you get outside of their scatoma. Yeah, and what do you see on those tests? So they'll only see like whatever eye they're suppressing at distance, so we'll see like two dots or three green and then up close, they'll be both. Correct, yeah, so they fuse it up close. Anyone know, they used to do these kinds of tests on the board, anyone know what this is? Amblyoscope. Exactly, so it's something that you can use to kind of really, it can be really helpful to look at big cyclo deviations. So people with a lot of torsion, they can really dial it in and see if they can fuse stuff together to figure out exactly what their deviation is or subjectively. And it can be helpful like in people with a lot of torsion who no matter what kind of prism you put up, they still can't fuse things because they've got so much torsion that can help to kind of figure that out. They can also use it to try to increase your fusional amplitudes. Sometimes that can be a problem if you start unmasking suppression though or I'm doing suppression. In clinic though, how do we usually measure torsion? Double Maddox rod. Exactly, or those bagelini lenses. They took a lot of this stuff out of your Pied's book, which is good because they haven't used to have a lot of superflips information, but yeah. So you put these rods on there, you have them turn the dials and then you kind of read them. And what they put them as is what you read them as. So this red one here would be X cyclotorted because they've twisted it out that way. What kinds of things do we see that cause torsion? Who do we come in complaining of torsion? What's the big one in adults that causes torsion? Fourth nerve. Yeah, exactly. So traumatic fourth nerves. Sometimes congenital fourth nerves that start unmasking later. Looking at this guy, what's his diagnosis? Is that a right cranial nerve for? Exactly, exactly. So if he has limited depression of his, of the right eye. Correct. And it's an inferior oblique is overacting. So in that upper right one, that's, you know he's overacting an adduction of that, of his right eye. You can also tell that he's got some esotropia and down gaze. Sometimes they have a little extra, you know they have a, you know, have a V pattern usually. And if they have bilateral, it can be much worse. So yeah, they can have a V pattern, esotropia. But yeah, if you look at that right eye looking to the, his right, it looks pretty normal when he starts looking to his left that right eye, you know, starts twisting up and much more in the up and left gaze. But yeah, and then he doesn't depress as well. Which are the following rules out of diagnosis of monofixation peripheral fusion? They have peripheral fusion in monofixation. They do. Yep. Do they have bimacular fusion? No. No. Do you see two lights at distance? Yes. Yeah, they do see that. And what about 60 arc seconds of stereo? Which mark? No. No. Yeah, they do not have that much stereo. They usually have much worse stereo than that. Why might you patch a kid with optic nerve hypoplasia? Because most of their vision loss is going to be from the hypoplasia, right? Well, we still might be able to improve their vision a little bit in the nerve with the eye with the hypoplasia. Yeah. To be used more. So they may have, you know, because of the hypoplasia they don't see as well, right? And so then they may get some stirbismus and then they may lose a little bit of additional vision from amblyopia. So you're trying to see if you can get their vision any better from any overlying amblyopia on top of optic nerve hypoplasia. Sometimes you can't. I mean, some of these kids, every time you patch them, they just, you know, go to sleep just telling you they get no vision at all out of that eye. So sometimes you can't, but I think it's always worth a try to see if you can. But that's why we patch them is from any additional vision they might lose from amblyopia. So this is a case, a six-month-old girl with the esotropia of 50. She has a psychopathic refraction of 1.5 diopters. Would you give glasses to that kid? No, that would be expected for that knee change. Yeah, I wouldn't give glasses to that kid. I mean, you could, but I don't, it's not gonna fix that ET of 50. This is not, you know, 150, you give glasses when they have more of an accommodated component. And then a six-month-old with that big of an ET looks more like a congenital esotropia. So in general, no, you wouldn't give glasses for that. I mean, if they had a higher one, you could try it and see, it probably won't change it much, but it's always worth trying. Yeah, if they had four or five, yeah, I would, they had three maybe, but for 150, I don't think so. I just do the surgery. And if they're still crossing a little bit after, you could give that to get rid of the last residual, but 150 is not usually gonna correct an ET of 50, especially in a six-month-old. What else might you see on exam and a kid with congenital esotropia? What else are you looking for? Alternating. Yeah, it's alternating. So because they're alternating, are they usually amblyopic or not? Not. Not, not. You can sometimes create amblyopia because then you do surgery and you leave them with a little ET and those kids are more likely to be amblyopic, but when they have a big angle like that, they usually use one eye to fixate one way and the other eye to fixate the other way. So no, they're not usually amblyopic. But what else do you see on exam? Sometimes it doesn't come up till later though. Latest agmas, then DVD. DVD, yep. Sometimes those don't come up until a little later, but what else is associated with those two things? Like a V pattern. A V pattern and yep, what causes that V pattern? Inferior oblique. Exactly. Overaction. Okay. So you're gonna operate on this ET of 50 and do a BMR. You just wanna know, should you also operate on those obliques at the same time? Is there any oblique overaction? Because if you do a BMR and then start to realize that you miss the obliques, you don't wanna have to go back. If they're already overacting, you should recess them now at the time. When would you operate? There's some discussion about this. I think Griffin sits on these sometimes. I think where he trained, he said they sometimes like to wait until they're a year old, but if they come in at three, I'll usually watch them till they're about five or six months, but I'd operate now because they've got a 50 ET, that's not consistent with binocularity. I just think the earlier the better on that. Sometimes it can get better and go away. Some of these ET's can be transient, but usually when they're up to 50, they're not. What kind of outcome would you expect? Do these kids usually get binocularity back? Good binocularity, good stereo vision? Yes. They usually don't get great stereo, but they can. Even if you just get like a mono fixation and gross stereo, you're pretty happy here, but it's hard to get binocularity in these guys. I mean, good stereo in these guys. You can get binocularity, but it's hard to get good stereo back in these kids who are born with congenital ET, but that's what you're hoping for, which is why I would operate sooner on this kiddo. That's what you're saying, Dr. Young, is that you would operate to hopefully to restore binocularity, not necessarily for amblyopia because they are not amblyopics. Correct. They're usually not amblyopic. They're much more likely to be amblyopic after you operate, because then you leave them usually with a small tropia or off a dew. You're operating more to get binocularity than stereo. Gotcha. And then do you just try to have that with the residual ET with like prism and... Glasses. I don't usually do prism. A lot of these kids, some of these kids are straight on for a while and sometimes slowly they drift a little exotropic, whether that's because the eye grows or the muscle slips back a little more or what, but sometimes you know that you do get a consecutive exotropiolator, even if they're pretty close to straight for many years, sometimes they still drift that way. Their brains just aren't as good at holding things as straight, but yeah, you're just trying to get some amount of binocularity. What outcome you would expect that, I mean, I'm just saying, the answer to that question is, yeah, even if you're gonna get a monofixation syndrome, that's some kind of fusion and it's better than nothing. So yeah, it's better to operate early and try to get something, some amount of binocularity that will keep them straight in the long run. Gotcha, thank you. Is the argument to not, to like wait till a year or so, would that be so that you decrease the risk of like creating amblyopia? I don't know what the total argument is. I know some people argue that a lot of these go away or some of them go away. So, you know, some of this business can be transient in this age group. I don't know. I was kind of surprised when he came here and said that that's what they do at Indian often. So, but usually the big argument is that it can't be transitory. But yeah, I mean, yes, another argument would be that, yeah, they aren't usually amblyopaths. Thank you. I just feel like that clock is ticking on binocularity, but I guess some people don't have that same opinion. So, a two-year-old girl comes in with this prescription. What else would you like to know? That's what her failed screening. Would you give glasses to that kid? Is she straight? Is she straight, exactly. If she's crossing, yeah, for sure I would. If she's not crossing, no, I wouldn't. You can also just look at their retinoscopy before you dilate them and see if they're focusing all three diopters, but usually a two-year-old with three diopters will be focusing. So, do they neutralize it near with the retinoscopy? Usually a three, they will. It starts to be more of a question when kids have like six, seven, something like that. We kind of talked about this. Why is it important to get Krimski an alternate prism, because they're testing in adults because yeah, because they can have ARC or anomalous retinal correspondence. Or some kind of funky-fusional thing. I had a lady last week who had a congenital fourth nerve palsy and you would do an alternate prism cover and she would go up to 16, but then when you give her 16, she'd tell you she could see two screens and only two screens, like they were so far apart. So, she had something fusional that she only liked about four diopters at prism. But she really could build up to about 16. Adults are just harder because they usually have some amount of binocularity whereas kids often don't or they're remold after you do surgery. They're much more forgiving. So, you just have to be a lot more careful in adults. This was a patient that I had who came to see me from Amy Lin. So, a 35-year-old comes in for a Lasik Eval. He's got a psychopathic refraction that looks kind of like that. Now, he's getting to be 35 and he can't focus that 150 up close and he wants to do a clear lens exchange. But he feels like he gets double with his new glasses. Just these people with anti-Semitropia and hyperopia and a little E.T. can be kind of tricky. So, the teaching point, this guy, when I gave him his full prescription, he was diplopic. So, if she had done surgery or clear lens exchange to make him plano in both eyes, he would have been really unhappy because that left eye, he liked to not wear glasses and let that left eye be blurry and then he could suppress it. But when he corrected his vision in that I really didn't like it and he'd just been for years and years that way. And his vision was actually pretty good, corrected like 20, 25. But so, I think she ended up just doing an exchange on his right eye. But some of these people, yeah, it can be a little bit tricky. So, if it doesn't totally make sense to you, it's often good to send them to business people to kind of take a look. This one was kind of a weird one, but I think if she had corrected him, it's plain on both eyes, he would have been unhappy. So, he's happily suppressing, but if right now, because he's keeping that left eye blurred, but if you unblur it, he may not be so happy. Do you think it's possible that he could have been unhappy in the short term and then like gotten the ability to refuse because it's so small? Or do you think it's like, man, he, because you know how they say like, adults have a little plasticity they can sort of adapt or think he would have just been totally. It's a good question. It's a good question. He may have been like that late. And I tried to have this discussion with Dr. Hoffman recently, like that lady that I have that actually is a 16. Like, I think if you operate for the 16, she'll be miserable for a while, but I feel like some of her problem is just a fusional problem. And she probably would settle into it because I actually, she had stereo. So, I think her phobias do like to be lined up, but it's some kind of a thing. So, I think she would have been miserable for a while, but actually would have kind of probably slowly gone into it over time. This guy, I'm not so sure, but it is a good question if they could have, it's like that kid I had who had double vision for six months and then it finally went away. If you actually kind of make him better, maybe, but maybe not. I don't know that he would have, if he would have been able to, because I think he's just totally turning it off when it's blurred, but when you make it clear, he has a hard time turning it off. And I don't know if that would have gotten better at time or if he would have actually started to kind of rewire, it's a good question. Yeah, it makes sense, especially in this population who's coming in wanting a good result, I would say straight clear. Did he have any stereo? Let's go. I can't remember that. I bet he did not, because I think he was kind of, he was like, I think he was suppressing and blurred up close. I think he was mostly always suppressing that left eye. I think he's kind of like a mono fixation and he's in that suppression scatoma, when you started to make his vision more clear, he pulled out that ET a little bit and got out of his suppression scatoma. So I can't remember if he had stereo. I was trying to remember what his name was because I was gonna look up his chart, I was just pulling this from my memory and I can't remember his name either. But my guess is no, he didn't have stereo. Yes, he could. He clearly had an ET, so if he had stereo, it would have been a very reduced stereo. All right, the other part of my lecture is, and to your segment. And while I'm pulling that up, I was just gonna tell the junior residents that at AUPO, the AO, like AO basically did this like OCAP kind of update and they said that mono fixation syndrome is one of the most missed topics on OCAPs. So glad that we're covering it here. Yeah, they like to test on peeds because nobody likes to think about those. Oh. What's the diameter of a newborn's cornea? 9.5 to 10.5. Exactly. It gets to adult size by about age two, but usually just a little bit smaller. What's our diagnosis for kids with enlarged corneas? Bocoma. Yeah, make a little cornea, but the big one is Bocoma. That's the one you're worried about. I have never seen this, but it's an excellent, recessive disorder, vagal ophthalmos. They have an increased risk of Bocoma. It's non-progressive. Kind of a hard picture to read, but anybody have any idea what this is? Keredoglobus. Yeah, exactly. Where do we see that in? Like what other disorder? Yeah, or what can be associated with? Is it like Aelish namas? Yeah, exactly. So, Keredoglobus is when the entire cornea is thin. I have a really deep anterior chamber. What do we worry about in these guys? Perforation. Yes. So I saw my saddest case in residency of a guy with this. He was an attorney in San Francisco. When he was a kid, he had been hit in one eye with a baseball. So it was monocular. And then his wife rolled over and elbowed him in bed one night and opened his globe. And he went from being a very functioning attorney to blind who was really thin. Oh my God. But yeah, it can be associated with Aelish dandlos, but just eye protection is the big thing in these guys and preventing open globe. What disorder might you encounter in a Down syndrome patient who rubs her eyes? Keredoglobus. Yeah, exactly. Keredogonus is a progressive thinning and bulging of the paracentral or centricornia often presents and progresses during adolescence can be associated with Down syndrome. In kids, you just start seeing like a rapidly progressive often astigmatism in teenage years can treat them with RGPs, corneal transplants. What causes high drops in these patients? What's the anatomic thing that happens that causes it? You rubbed your decimates. Right, yep. Yeah, and then they come in with eyes like this, but yeah, kids with Down syndrome certainly get it more commonly. It can be painful, look like this. Little difficult to treat. Microcornea we see sometimes can be associated with other problems. Big thing in these kids is just trying to get them appropriate refractive correction treat associated amblyopia with disorders this. Is that sclerocornia? Yeah, exactly. These kids, it's non-progressive. They have a central cornea that's clearer which is in contrast to Peter's anomaly. Sometimes they don't look quite as I have one kid that doesn't look quite as bad as this. Can be sporadic or hereditary, usually bilateral. Can't really treat them with a corneal transplant because they'll just erode again or vascularize again. Usually just kind of try to treat their amblyopia. What is this disorder? Peter's. Yeah, exactly. What does it look like underneath? There's no endothelium, but there's also adhesions to either the lens or the virus. Yeah, how do they progress with time usually? Stay the same, get worse, get better. I'm honestly sure someone has to help me out here. They usually kind of clear over time. They get more clear, which is kind of funny. How do we treat these guys? Can do a PK. Can do a PK. Some people also just cut a whole lot of the iris and make an iridectomy so it's bigger. Can also just try to dilate the people around it to get good vision. I've seen a few of these that are kind of like very mild, where it's just, can you see if I move my mouse here or no? Yes. Oh yeah, you can't see that. Yeah, so they'll be just like a little bit here and they're often infernasal, just like colobomas, but they will just have a little bit of haze here. So not quite as bad up here. And they often are very, they're often asymmetric, unilateral, and they're often very anti-symmetropic. So they can be very, I've got several where they're like plus five and one eye and plus nothing in the other eye. But you can actually end up getting pretty good vision because usually you get them in refractive correction early because they come in because they have this, some haze on their cornea. So I have some with pretty good vision actually. But yeah, some people will do optical iridectomies, but the big thing is that, yeah, they kind of clear, they get a little bit more clear over time. What do we see here? Here am I? Yeah, what do we see it in? Golden heart, golden heart. Exactly, what happens when you take it off? Or what do you usually see when you dilate these people, when you refract them? They usually have a bunch of astigmatism and it's usually kind of like that, like this one would be like 60 or something or like 70, they'll kind of just be almost parallel to that. But when they take it off, it often does nothing to the astigmatism, but they sure look a heck of a lot better. So yeah, and usually cornea doesn't like to do it until they're a little bit older, like school age, just because there's more cornea to deal with, but sometimes they'll do like a lamellar graft in there. Sometimes they'll just shave it off, but I've seen some really nice things done with them, but it doesn't usually change their fraction. So there's not a whole lot of visual benefit to doing it early, you know, and the cosmetic benefit isn't usually until they're a little later anyway, just cause kids don't care what kids look like until they've done some studies looking at kids. And it's like five years old that they start realizing that other kids have crossed eyes and things like that. So in general, yes, we just wait on these. They kind of already went over all that. What do you suspect here? Kid who comes in with a cornea looking like that, lots of little crystals in it. Cystiasis. Yeah, exactly. I have a couple of these kids and they're all on, that's these drops that you're supposed to use six times a day, which is not so possible in little kids, but they say they get photophobia, but for the kids I've seen, I do not think they get any photophobia. The big thing is kind of renal failure. All the kids I've seen have come in already with it, diagnosed, but these drops, they have to get them and keep them in their fridge and use them like six times a day. And sometimes they still progress, but I've got at least a couple of little guys with this. Sometimes they smell funny because they're on other medications or something like the people smell interesting. What's the diagnosis here? Herbs. Yeah, exactly. You guys probably see this a lot on call. We don't like to put steroids on it. We don't see this so much in kids. They usually don't come into dendrites. They usually come into stromal disease, but most resolve on their own. Some people put them on antivirals. What do you guys do here these days? Just oral antiviral. You do orals. Yeah, do you debrief them at all or no? I don't. I've never seen that done. No, I haven't seen that. What we see more commonly as kid is stromal keratitis. So these are kids who I had one once that was a orbital cellulitis that didn't go away for six weeks. Yeah, that's not a orbital cellulitis. But it's usually pretty easy to tell, right? When you put a, you know, you often can't get these kids to a slit lamp. You know, especially in their acute phase, you know, they're usually little scared. But if you throw up a retinoscope, you can see that they're, you know, they don't have a bright reflex that there's something funny going on there. They can be pretty aggressively get neovascularization, but it can also go away pretty nicely as well. The big thing is putting these kids on a cycle of air for a while to try to prevent it recurrences. But any kid who comes in with, especially unilateral painful eye or eye that they won't open, it's always something you need to think about, especially in kids with any kind of a immune. I've got one girl with pretty bad disease like this and she's got some kind of immune problem. So yeah, any kind of a kid with kind of immune disease or anyone that's on chemo or any kind of immunosuppressants, you wanna think about herpes. I usually do somewhere in like this range and divide it TID for the acute phase and then go down to BID for maintenance for six months or a year. They often come back. The big thing is they often get some funky astigmatism afterwards as a result of the scarring or just the changes in the cornea. I've got one kid that's got like four diopters of against the rural cell in the eye that you don't got nothing in the other eye but he had this when he was like two. So he had them in glasses right away and his vision's 20, 25. So they can get a lot of astigmatism. So it's just important that post infection or whenever you just have somebody retinoscopy to make sure you're figuring out what that is. I have one girl with this who also has a bunch of astigmatism, has a lot of central clouding. Her best correct division's about 2040, 2030 now in that eye and then I've been following her for 10 years and she started to get an intermittent nexotropia like last year, like nine years in, which is just weird but can happen. She doesn't ever like to wear her glasses that correct that sill. So I think she sits at like 2080, 20 hundred. I'm not worried about amblyopia but it probably in some way contributed to now the fact that she's got an intermittent nexotropia. So what is this? Staff Marshall. Yeah, or? Vernal. It's Vernal, yeah. What are those white dots called? Limbo follicles. They are limbo follicles but. Horner tronti. Yeah, exactly. And what are they? Kind of cells, are they? Epithelial. Yeah, they're eosinophils. So it's collections of eosinophils. They look pretty robust like this but they go right away with a little bit of steroids. So they're pretty easy to treat right away but getting them to stay away is always hard because you don't want to stay on steroids for a long period of time and they really need to be on some kind of maintenance therapy. This kind of Vernal is much more common in African-American kids. Males, more than females, usually resolved by puberty. Yeah, it's more common with these horner trannous dots in African-Americans. Whereas this you see more in the Caucasian kids where they get those really robust you know, things under there when you flip their lid. They can rub on their, these I don't, you don't want to call them, I don't think they call them GPC, right? What do they call those? I can't remember. Just those huge papilla under their lids. They can rub on their cornea and cause some haze and drop their vision a little bit. I have seen some people who, some cornea guys that will inject their upper lid with steroid, but the big thing is to get them on Claritin, AzurTech. I usually put them on Patinol and then just try, you know, use them steroids for the acute phase but it's hard because kids don't like to stay on that Patinol and the steroids usually work a whole lot better but can just be kind of a chronic relapsing or a mening disease till they, you know, till they outgrow it. And it sometimes can't drop their vision. They can get some ptosis in the eye that's worse and it's often, you know, often like bilateral but much worse in one eye than the other and I don't really know why that is but yeah, it could be tricky to treat that you see these kids over and over and over again. What's this? We see these pretty commonly in kids. Fluctenual? Yeah, exactly. So these are flictenuals. They're a white thing. They often have, you know, pretty robust vessels going right up to it and a day or two of steroids will get rid of it. I don't know why you can't see my notes here but yeah, usually just a short little course of I usually just do maxotrol because it's cheaper than topodax but it's a type four hypersensitivity reaction for the boards. They always worry about tuberculosis in these people which I've never seen but it's just because kids have really sensitive immune systems but they just have this white dot that sometimes is that the limbus isn't always that the limbus can be back from the limbus a little bit but if you just put a little steroid on it it will go away really pretty quickly but we see these pretty commonly. What's this line called? By this line, I mean this one here. Both your embryo toxin? Yeah, exactly. So it's a thickening and displacement of Schwalbe's line about 15% of normal individuals have it can also be associated with Aksenfeld's anomaly which is these little projections up here to the scleral spur can be associated with some of these mutations. Some of them 50% can develop glaucoma inherited in an almost dominant fashion can be associated with Reiger's anomaly here. Oh my slides didn't turn out so well. This is Reiger's syndrome, the anomaly with some systemic abnormalities and this facial appearance. I haven't seen too many of these kids. Doesn't seem too prevalent in this genetic rule here. What do you see here on exam? Aniridia? Yeah, exactly. So in kids with aniridia and you're trying to get a glasses prescription would you still cycle PGM? Yeah, because they still have some iris. Exactly and they still accommodate. They can still usually, even though they don't have an iris or they might not have an iris they can still usually accommodate and what we're doing when we usually the biggest reason we dilate kids is so they cannot focus. They cannot accommodate so we can figure out what their glasses prescription is. So these kids still accommodate. So yes. It's kind of funny people forget that. I had somebody that hard night was falling a few months ago that she put on atropine for dilation. It's like, no, that cycle pleases them. It does more. So that's gonna make their embryo be a worse. But yeah, the big reason we dilate people is to cycle PGM. Aniridia, these kids have foveal hypoplasia which is the cause of their vision loss. They have pendulum nystagmus. They can't have corneal panis due to stem cell deficiency. I haven't seen that much in kids. I think that gets worse as they get a little bit older. They can have some non-progressive cataracts, optic nerve hypoplasia and they can have much more likely to have glaucoma so every time we see and we check their pressure but the big thing we're worried about in these kids is somebody comes into your, what? Wager. Yeah, exactly. So the kid comes into you with aniridia and you got to be worried about this, yeah, Wilms tumor, why they have it. If it's hereditary and it's associated with the PAC-6 we don't have to worry about it but if it's a new sporadic case you've got to make sure you get them worked up for this and some of these kids need or repeat ulcer sounds to look for Wilms tumor. Treating these kids, they like tinted glasses just make sure you are correct their refraction. Sometimes they have a fair amount of cell, limb stem cell transplant sometimes if that panna starts overgrowing and affecting their vision too much watch for glaucoma and refer them to low vision services. Why do you always see colobomas infranasally? That's where embryologically it fuses last. That's exactly. So these can involve the cell, everybody, coroid, retina, optic nerve depending on how much they involve their vision corresponds with that. They can be surgically repaired and some people they are a little bit more light sensitive in those eyes. I have seen, these kids often can have, even when their pupils pulled pretty low down they can still have pretty good vision. In general, like pupillary anomalies often don't cause vision problems. I have one kid whose pupils pulled way up and she's got 20, 20 vision. So the kids can use those eccentric pupils especially when they're born with them in these colobomas sometimes even when the top of their iris is pulled down to midline or lower oftentimes they still have pretty good vision. So I don't worry so much about that. The bigger issue is how extensive is the coloboma? What's your biggest concern in this patient? First of all, what are those? Yeah. And so what do we see those in? Neurofibromatosis. Exactly. And what do kids with neurofibromatosis get? That we worry about. Optically almost. Exactly. So, yeah. Geez, I screwed up some of these slides pretty bad. Yeah, they can, you know, usually we get these kids referred to us to look for lesion modules to help with the diagnosis cause they have a few cafe LA spots. But usually we don't see these starting in kids until seven, eight, nine. So they, you know, they'll send you 18 months old. I get 18 months old referred to me all the time to look for these, which they don't have but doesn't mean that they won't get them later. They don't usually cause a vision problem. Those optic gliomas are pretty common in these kids. I just had a kid about a year ago that I did an ET, you know, I did a BMR on and I was kind of talking to the family and saying, well, it's always possible they could have a glioma that's causing this, but I don't think so. And we ended up getting an MRI and just showing thickening of one optic nerve. Maybe it's a glioma, maybe it's just thickening, hasn't changed at all. A lot of these don't change over time. When they do change, they can be pretty aggressive. I have had some gliomas that just push on the back of the eye and cause anti-symmetropia. So any of these kids who have NF and come in with anti-symmetropia or if they have NF and they come in with any kind of strabismus, you have to kind of wonder a little bit more if they've got a glioma. How do we follow these gliomas? They're kind of hard to follow. You know, these kids, you can't really get visual fields on them. Usually if they're rapidly progressive enough to drop their vision, you know, you, we can follow that, that sometimes we will follow them with OCTs of the RNFL in some of these kids where we, you know, are only following with MRI. So, you know, oftentimes they're young and can't come in and complete visual vision testing even. So sometimes they can be a little bit difficult to follow over time, but in general, most of the ones you see are non-progressive. But... And that are young, how do you tell like a leash nodule? Like basically a hematoma. I'm distinguishing it from just like an iris nebis or just like, you know, an ice syndrome. So I guess the system is way more common than ice. They're usually a little bit orangish. They usually have multiple. They're not just one, especially in an adult. But I think sometimes they can be a little bit difficult to tell, especially when they're young and there's maybe only one or two in the eye. And usually the kids I'm looking at with these are coming already with CAFE LA, so your suspicion's high. But distinguishing it from a nebis, they're a little more orange color, I think. Not as dark. And they're usually multiple. Cool. I mean, I haven't seen any ice since residency. Just don't see that in kids very often. But, you know, adults with NF still have these. So yeah, it can be something you guys see too. When do we take out cataracts in kids? Think if unilateral four weeks and bilateral six. Close. So when I started training, I was more aggressive about taking these out. Now I watch some of them. Why? Because keeping that accommodation is nice and sometimes helps preserve their vision. Sometimes when you take these out and the people, if they're not gonna patch, if they're not gonna, especially the infants, they're not gonna patch. Sometimes it's like, why did you take the cataract out to begin with? So certainly anything that's over three millimeters, you start to worry. If they're two to three millimeters and in the back of the lens, oftentimes I'll just follow them. And if people are good patching, they end up with good vision in the eye. But you really kind of wanna balance a lot of the risk, minimize the risk of general anesthesia. If they could glaucoma is always something we worry about. So in terms of timing and kids who are born with one cataract in one eye, this big study suggests that we should, take them out less than six weeks. So yeah, four to six weeks. Like you said, Arianna, if you take them out after six weeks, their vision starts to drop precipitously. So their visions can be pretty good before that time. If you take it out after it starts, after the six weeks time, their vision really starts to drop. So in general, we like taking them out about six weeks. The longer you wait from birth, probably the less likely they are to develop a fake glaucoma. So we really like to kind of wait on that five to six weeks time frame. They've done studies looking at kittens that can also kind of help with how we understand binocular vision development. In kids who were they, so just one eye shut, all the neurons were driven by the non-deprived eye and this persisted when they opened the eyes for 14 months. But in the kids who had both eyes, so shut a third were binocular, a third were driven by one eye and a third were unresponsive. And 14 months after the number was the same. So this is just kind of telling you that the window is a little bit longer for binocular-deprived kittens and adults too, sorry, and humans as well. So we have a little bit more time with kids who have bilateral cataracts. And this is a big study done by Ed Wilson, which is where Leah trained and Scott Lambert, who is now at Stanford, but he's kind of the one who has been doing a lot of these IAT studies and they think that for these kids with bilateral cataracts, you can usually wait until about 10 weeks. And I really try to kind of wait until that time because I think their risk of glaucoma is less and you just have a little, and I just think the longer you wait, the less risk of anesthesia and everything else like that. When do we leave the posture capsule? If you can, I guess. Or when they're old enough to be able to tolerate a Yag, I think, because PCO happens a lot, right? Yeah, exactly. So yeah, usually we like five years, I take it usually until about four or five years old. After that, you can leave it and try to Yag it later. I've seen Craig will sometimes leave these sooner or leave these earlier, but I think in general in the Peds world, they almost always so pacified, so it's better to take them right away. So surgery on these kids, their anterior lens capsule is more elastic. So for the really young kids, especially the ones less than a year, we just usually don't tear our axis, we just use the cutter to make a retractor axis. They have a really high rate of posterior capsule of pacification. Usually I think people take the posture capsule until about four or five years old. You also wanna take some of that anterior vitreous because it can be a scaffold for lens epithelial cells to regrow and regrow more membranes. And you want to leave that posture opening slightly smaller than the anterior capsular opening, but you kinda wanna read them pretty big because a lot of these kids grow back membranes. Afterwards, we treat them with contact lenses, those silicone lenses are really nice, although we've had a trouble lately because they couldn't get the stoppers for these caps from supply chain issues. And so they applied to the FDA to get a new approval for a new way to sell these devices just in this bottle and it's taken like a year. So they haven't been making these contact lenses purely because the FDA can't get back to them on whether to approve this new kind of packaging. So sometimes some people have been treating more with rigid gas permeables if they couldn't get these, we're kind of getting more of them now again, but we changed them as the eye grows. So we wanna over-plus these kids. So these contact lenses only come in certain powers. They start at 32 and then they jump to 29, 26, 23, 20, and then they come in one diopters. So you wanna make sure that you give them more power to make them minus, because what you want to do is put them in focus up close. So it's like looking through the bottom part of a bifocal. So if they're minus three, minus four, something like that, that's pretty great. If you leave this kid plaino, it's not great because they're not in focus up close. They can't focus anymore, they can't accommodate. Some of these kids though, even in a plus 32, they're still underdone. And if they're really young, three, six months old, sometimes we'll just leave them that way and they should grow into it. But sometimes we have to put glasses on top of the contact lenses to get them clear enough at near for normal visual development. So the hard part of these kids is not taking the cataracts out because that's not the hard part. You just suck those cataracts out. They're not the most difficult cataracts to do, but the hard part is like following them after, figuring out what kind of contacts, what kind of glasses, and then when to put in IOLs. The AFAKE Spectacles, you can have some induced ionisoconia, especially if the eyes are different. And I prefer contact lenses because the optical center is better. If you put these kids in AFAKE Spectacles, their clear optical zone is pretty small through the center of those glasses. And once they start looking off the center, it starts degrading their image pretty quickly. So we like them in contact lenses, but sometimes that could be hard if they have a different prescription in each because they only come in three day after jumps. These contacts are nice because I usually just have people leave them in for a week even after surgery. I don't have them take them out for a month. I think it's just better to have it in all the time than taking it out at night. They do get protein deposits on them. Balshamlam does not recommend you clean them with anything. Some people will clean them with the gas permeable solution cleaner, which can't get some of those off, but they just start accumulating a lot of proteins on them. But I think it's better to have proteins and have them wear them all the time and have good prescription in there than have them taken them out all the time. IOLs, yeah, usually there are lots of issues in terms of choosing powers and figuring out when to put them in. Does anyone have any idea how we do choose a power? There's a really simple way of thinking about it in that like your numbers should add up to eight in terms of like, if you're putting it in a two-year-old, you add their age with the power to be about eight. So a two-year-old you put in in like a plus six, four-year-old, you'd put in like a plus four, an eight-year-old you put in about a plano. People do something kind of similar to that in general to put in those powers. But a lot of it is guessing. We don't know how these eyes are gonna grow. They're not usually normalized to begin with. So they just grow a little bit different. I used to kind of wait longer on putting these lenses in with the Silsoft shortage. I've been putting more in now just after their year-old kids who lose their contacts all the time. After about a year, I'll put in the lens just to have them have some correction. Yeah, it's better to wait till longer because you have a better idea of what kind of lens to put in, but it's better to have them wear it some of the time and then keep losing these contacts with them, you have to order them in and it takes a few weeks. And then they've been a few weeks without a lens which can cause permanent amblyopia. So yeah, usually we use half-requeues because they're good for small eyes. It's difficult to predict the growth. So yeah, some of these formulas aren't so good. I usually kind of look at the eight and some of these eyes tend to grow a lot. They've done a recent study. They haven't published yet with PDeg. They really kind of found out that these eyes kind of grew to whatever lens they had put in them as a two. So ended up a little bit better than they thought than they might be. When do we leave kids a fake? And when do we put in an IOL? Do you have any idea when we do put them in usually? Usually it's about a year. So this big IAT study which Scott Lambert did was a big randomized multi-center study. They looked at IOLs versus a fake with a contact lens. Yeah. So they did a little bit less than these little little kids on target refraction but somewhere between six and eight. At a year they found no significant difference in vision but they did find that 63% versus 12% underwent an additional intraocular operation meaning that the kids that they put an IOL in were much more likely to regrow a new membrane versus the other kids. So usually people do it about a year. They'll start putting contact lenses in, I don't know, nine months to a year. I think people are putting more contacts in and they're finding that some of these kids do better with contacts. I mean with IOLs then they do with contacts. Especially looking at your patient population too. If you feel like this family is gonna have a hard time with contacts it's probably better when they're coming with cataract at nine months to put in a lens. Sorry. So this is my niece who kind of got me into ophthalmology. She had served by Dr. Hoffman when she was two weeks old and her irises are different colors. Do you guys know why that is? Could be that she got infigate glaucoma and is on Montana Prost. Yeah, that's a very good thought. It's very similar. So these kids almost all in unilateral cataracts so she had cataract surgery in her right eye and that's the darker eye. They think it's because at the time of surgery that they released so many intraocular prostaglandins that their irises change color. So almost always in these kids with congenital cataracts their irises are different colors before, I mean, are the same color before surgery and after surgery, the surgery, the surgeries eye turns a little bit darker. So kind of just an, but it probably is, yeah, same mechanism, prostaglandin. But she also could be on have a fake glaucoma, exactly. But almost all kids with cataracts, infantile cataracts have either two eyes that are kind of that color, that greenish, brownish color or the eye that's operated on as that is a little bit darker. Can I go briefly through congenital glaucoma? I don't know how much Craig covers, but usually seen in the first year of life can be familial. Symptoms we commonly think of, tearing, photophobia, blinking, eye rubbing. Usually these kids come in with cloudy corneas, high intraocular pressure. Unlike other glaucomas, adult glaucomas where it's always like, what pressure is good for this patient? And when we're talking congenital glaucoma, we're always talking high pressures. We're not ever talking normal pressures. Glaucoma, we're just talking that they either, that they can't drain the fluid that they've got building up higher pressures can be associated with, like we said, aniridia, kids who have ROP and treated with laser are more likely that can be associated with anterior segment disorders, can be associated with lots of other syndromes. Lows is the big one, which is we see in boys with alter a little bit of mental delay. Certainly see a lot of Sturge Weber kids. And we just follow them over time because their glaucoma can't come up later. It's always present right when we diagnose it. We're diagnosing this, yes. We're just looking for a high pressure. Their gonioscopy can be a little bit difficult to assess because they can have these membranes covering their trabecular mesh work. Big thing is you wanna look at their refraction and treat any associated amblyopia. Usually they come in with cloudy corneas like this. Oftentimes can't get a view of their angle or anything even under anesthesia. Often have to put them on drops or diamox. Just wanna watch for associated electrolyte imbalances that can come with those. Also topical blader blockers are good. In general, in kids, we like to avoid any alpha-2 agonists. They can have some CNS depression, can have some changes in behavior and things. I see this pretty commonly in kids. The few we've tried on it because they have congenital glaucoma that have failed other therapies. Then we try them on this. It seems pretty common that they have issues with the alpha-2 agonists. I don't have any kids who have been able to tolerate it. We treat these with either a goniotomy which requires a clear cornea where they be in size through the trabecular mesh work under direct visualization means you have to have a clear cornea. Either have to often have to have them on diamox for a little while to let those corneas clear. Can also treat them with a trabeculotomy where you can feed this device through Schlem's canal and then kind of tear it inwards. Afterwards, they develop a hyphema but just to try to open that drainage up, you can also use these trabectomes or sorry, this trabectome, but they use these catheters that often have a blinking light on the end and thread them around and pull it through. This is one of those. If angle surgery fails, sometimes they can have a trabeculectomy with mydomyacin C, later can put in tube shunts, can do some ciliary body to distract the procedure so they just don't make as much aqueous fluid. Other treatment concerns with these kids, amblyopia, we wanna make sure we treat their refractive. This kid obviously has buphthalmos so they're gonna have a pretty big prescription difference between those two eyes, strabismus. Sometimes they'll just take out the eye with the disfiguring buphthalmos is too much and they have really poor vision prognosis. What do you think the most common glaucoma I see in my practice is, I don't like managing glaucoma, but I have a fair amount of them. Aphagic? Yeah, most of the ones are the ones I cause, so aphagic. So aphagic glaucoma is really common and the numbers of incidents kind of go up the longer you follow these kids. So this is a study that looked at 30 years of kids in a big glaucoma practice in Boston and found that 60% developed glaucoma, pretty dang high, 33 months up to 29 years. So many years later, they can still develop it. Risk factors for glaucoma are age and especially if they were operating less than a month, it's much more likely to cause glaucoma, kids with complications, are more likely to have it, this postoperative psychopathic use, but we like that because otherwise they are more likely to develop membranes and things. So you're kind of balancing things here. This may just be because we put all kids on that and all little kids on that anyway. So maybe a little bit hard to tease that out. Early surgeries, yeah. This is another study looking at 80 patients in the risk of glaucoma at five years and one eye in patients who underwent surgery was 50%. So risk of a fake glaucoma is really high. And so I take out a fair amount of cataracts for kids and just follow them over time. And getting IOP measurements is not always possible on some of these kids. So there's other things you have to watch as well. And one of the big ones is refractive error. Just if that's changing rapidly, even in a little bit older kids, sometimes they're refractive error, even though you think about the buphthalmos only in the little, little kids, I do think their refractive error can change when they're having, and I'll show you a case of that in a minute here. You also can look at their hormonal diameter and clarity. Their AC, I have one kid that their AC really kind of just collapsed. They started growing more peripheral, you know, sneakier. And then you can also kind of look at their cup to disc ratio. So IOP measurements, the big one, but sometimes that's not always possible in kids. Sometimes you don't wanna put them under anesthesia just to measure that pressure. So you can look at other things as well. So this is kind of an interesting case. I had a kid who came to see me. Their big complaint was just that little bit of ptosis in the right eye, which is kind of a little bit hard to see. But she came in to see me when she was 10 months old. And it looks like she has a bigger pupil on that eye, but we'll take a little closer look at the minute. She had, you know, pretty normal refraction just a mild ptosis. She didn't seem to have any ambiliopia at the time in a normal dilated exam. If you looked a little bit closer, you could see that she had this, you know, congenital electropion uvea. It didn't seem to be causing a problem. I thought it was kind of interesting that it was also in the eye with the ptosis, but just kind of watched her. Two years later, she came back to me and we checked her pressure and it was 37 in that right eye. What else would you wanna be looking at to kind of confirm that that really is a real pressure? Corneal thickness. Yeah, that's a good one. What else on exam would you see that would tell you that maybe this kid had glaucoma? The nerve. Yeah, the nerve. So she had started to cup that eye. She now had like a 0.6 in that eye. And she came back a few months later. I sent her to Craig. She had been on drops for a few months, failed the drops. He ended up doing a trabeculectomy. And then she came back after that to see me and now had, and I dilated her at this point. I didn't dilate her the time before because her pressure was high and I knew which I was sending her to Craig anyway. And she now has this anisomatropia. So she's a little bit older. She was like three years old now at this point. And, you know, so she had had some anisomatropia developed from that higher pressure. I mean, it's also confounded a little bit by the fact that she had had surgery as well. But so she came in with this prescription. What kind of a prescription would you give in this kiddo? What glasses would you write in this kiddo with that prescription? What things do you think about when you're writing a prescription? If you're going to give the full power and then also bifocals, isn't that kind of, yeah, because she had cataract surgery. She didn't, they just did a, they just did, no, they did not do cataract surgery. They just did glaucoma surgery. So she doesn't need any of that. But yeah, you want to know if you want to give the full prescription. When are you more likely to give the full prescription? If they have any kind of deviation. Correct. And if they're younger, so the younger kids will tolerate more plus, older kids won't. So she may not, I would cut, I'd cut probably one off and give her, but then you have to cut it off both. So if you're cutting one off, just to make the glasses a little bit more acceptable, I'd probably just give her a 50 in the left eye and then a minus 350 in the right. Some people don't like doing so much minus and she's only two years old. So she will probably accept it, but you always want to think about giving the full plus in any kid without any kind of deviation because they're used to accommodating that and they may not like it. So this was kind of something I didn't know about with this kiddo, but with this congenital atropian UVI, they often can get this glaucoma that's really difficult to treat. It can be associated with these other syndromes as well. And it's also associated with ipsolateral ptosis because they're Mueller muscles from the neural crest too. So they've got some kind of abnormality there. Usually seen in teenagers, but anyone with ectro, and then I saw another kid with this after I'd seen this one who came in with a pressure in the 30s too. So some of these atropian UVIs, you just need to follow their pressure and make sure. I mean, you can certainly get this from trauma as well, but these kids, you know, which is different entity, but certainly these kids who have congenital unilateral atropian UVI, you just got to follow them for glaucoma. What would you be worried about in this patient? What do they have on their iris margin? Those are cysts. So iris cysts. Anyone know what you worry about in kids with lots of iris cysts? The bad thing is it can be associated with mutations that also cause thoracic aortic aneurysm. So you always kind of have to worry about that. Iris synchromuscles are smooth muscles like the aorta and so kids with lots of those, you kind of worry about that. Usually when I see kids with cysts, they're just pigment and methyl cysts don't cause vision problems, don't require treatment. Sometimes they go away pretty quickly. I had one kid that, one of you guys called me to the, or I was in clinic and had me look at somebody with a bunch of those right after birth and like a ton, like all around the margin edges. And I saw the kid back in one month and they were completely gone. So they can go away. Sometimes they can have some associated medriasis and a parent accommodation. I haven't seen that too often, but you see lots of kids, the pediatrician will often pick up on it because when they see the red reflex, they'll see some little bubbles on the side there, but usually they don't cause problems. They're just the pigment epithelial. The ones that do cause problems are the ones in the stroma, but those are pretty rare. I've never seen any. Why might you get consulted on a kid with Allogeal? I've gotten a fair amount of these lately. They're diagnosing that. Do you know what, does anyone know what Allogeals is? Bioduct problem where they don't have enough bile ducts and then they go into liver failure. But these kids have posterior embryotoxin. They also have this characteristic period with a pointed chin there. But 15% of people also have just a, you know, one of those posterior embryotoxin. So I have a fair amount of these kids that are all sent to me. I have yet to see a glaucoma, but they like to send them this way these days. And that's about it. The long-term followup require for all these disorders. The big thing is looking for refractive errors, looking for deprivation problems and things we need to treat their embliopia. Diagnosing glaucoma, which sometimes doesn't happen right away, especially as in these A-fakes, years and years later, they can also in a Sturge Weber and things, they can develop glaucoma later. Getting these kids hooked up with vision services at school is really one of the big things I do, especially for like these albino kids. Just making sure they're getting help at school because most of them adapt pretty well, but can have pretty poor vision. Any questions? Thank you. You're welcome. We'll see you later. Thanks for the go.