 Hey, good morning. Thank you all for being here. We're gonna get started. We appreciate you guys being here a little early at 730 so we can have kind of a robust discussion with our distinguished guests this morning. We're so pleased to have Dr. Courtney Kraus join us from Wilmer I at Johns Hopkins. She is an associate professor of pediatric ophthalmology there. She also runs their intersegment division within pediatrics and so she has very broad expertise in the field of pediatric ophthalmology. We are excited to learn about this through her case presentation today for our pediatric ophthalmology subspecialty day and just like with many of the other presentations within this kind of genre of Grand Rounds, we're going to have a discussion about each case. Ideally following the case but certainly if you have some burning comments that you'd like to raise during the presentation, please feel free to kind of raise your hand. We do want it to be interactive and enjoyable. So without further ado, I will let Dr. Kraus take it over. All right, thank you so much Dr. Owen. Thank you everyone. Very very much for waking up early and spending your Wednesday morning with me. So I am going to go through hopefully three cases. I think I chose them to really give you a sense of the breadth of pediatric ophthalmology. I think that's one of the things that makes it such an exciting subspecialty is that we really are kind of comprehensive eye doctors in every sense of the word. I have no financial disclosures. Here's some of our objectives and let's kick it off. So my first case is going to be an amblyopia discussion. And before I delve in, I do just want to give a little plug for kind of what brought me to ophthalmology. I think I really appreciated when I was a medical student how it was one of those fields where we could be clinicians and surgeons really grounded in evidence-based medicine. So much of our decision making was really founded on clinical trials. And you could really see that come through in all of our attendings that we were shadowing, particularly, I think, in the areas of retina, uveitis, cornea, glaucoma. And I think sometimes in the Peds Clinic, it's just so fast moving. You see your attending, see a kid, wear some glasses, patch for a couple of hours. And sometimes you do miss a little bit of how much evidence-based research has gone on to really give us an idea of what to do when a kid presents with amblyopia. So I was actually the second opinion for this six-year-old male. He has a history of myelinated neurofibers in his right eye and the associated mixed mechanism, amblyopia. He has a visual acuity of 2070 when I met him and he's doing great in his left eye, 2020. You can see he's got some stereo. He has excellent alignment. He's ortho, distance and near. And just to give everyone a little sense of what the back of those eyes are looking like. This is his fondest photos of his right and his left eye. I do think it's important to kind of notice that we do have a little bit of sparing of the fovea. So the macula doesn't seem to be extensively involved by the myelinated neurofibre. And that's important for visual prognosis. Here we can see the OCT and you can see a little bit of that hyperreflectivity that we see with the myelinated neurofibers. So some additional history. What's he wearing? He is myopic, shouldn't surprise anyone in that right eye. And he's wearing a hyperopic prescription in the left eye. On cyclopletic refraction, we see that he's pretty much appropriately corrected in his prescription, in his right eye. And he is underdosed in his left eye, which is exactly what I would have done. Cut the plus for someone who is orthophoric without any crossing. So brief overview, I keep mentioning this myopia is very expected. The clinical triad that we see with myelinated neurofibers, anisomaiopia and severe often treatment resistant. Ambliopia does sometimes get this moniker of Stratsma syndrome. It's pretty rare. We see it in less than one percent of individuals and half of their eyes. And some of the risk factors that we expect to give the kids poor visual acuity are the higher degrees of myopia approaching minus 10, minus 12, minus 13. Obviously, if there's any involvement of the macula and then the presence of strabismus, this little paper is actually the first description of the clinical triad of myelinated neurofibers, myopia and ambliopia, which was actually in 1917. So going back to our patient, he's been in glasses with excellent compliance since he was two years old. So that's awesome. What do we know from our ambliopia treatment studies? Well, we do know that seventy five percent of kids who have mixed mechanism, ambliopia, which is this kid, are going to see improvement in over two lines of vision. And that was this kid. He went from twenty four hundred to twenty one twenty five with glasses alone. Now, a couple of caveats. This is going back in chart review. He was two years old at some of these initial visual acuity tests. And I'm sure most of my Peds colleagues can say, well, you get a two year old and then you do nothing and you bring them back and their vision is probably going to improve. That's that test retest phenomenon and also the aging effect of just getting a toddler comfortable with the visual acuity testing environment. So some of that visual acuity improvement is definitely real, probably less so compared to, you know, kind of what we're seeing. So another question that we are starting to answer right now with P. Diggs ambliopia treatment study twenty two is should this child have been started in glasses and patching simultaneously as opposed to what we did, which was initiate patching after he kind of stalled with his glasses treatment. So this kiddo he patched off and on. He didn't have the best compliance and we know from ETS five that this does, if done well, offer improvement in visual acuity and kids with moderate to severe ambliopia and our kid improved a little bit. Again, sort of in keeping with his sort of more poor compliance. Kind of taking a step back. ETS twenty two is really asking the question, would a child improve faster and have to do less total patching time if they start the glasses and the patching simultaneously compared to what I think is more the sort of go to treatment, which is start glasses, wait for them to stall and improvement, then start patching. Personally, I like the sort of staggered approach because I tend to see that when the child improves in their visual acuity, patching mess met with a little less resistance, probably because they're seeing a little bit better out of their ambliopic eye. So I think you get a little bit of buy in. But the fun thing about ETS twenty two is we're actually doing parent and child surveys, so we're going to get to learn a little bit about whether that's actually even evidence based. Maybe the kids like having a shorter kind of overall treatment time. So stay tuned for the results of that. Now, this kid, often on patching, not really complying all that great. So stop patching, moved on to atropine therapy. Initially it was weekends only and then they titrated up to four to five times a week. And the OG of ambliopia treatment studies, ATS one, did confirm that patching and atropine are pretty equivalent when it comes to treating ambliopia for the less than seven year olds. And our kid really did better with this. You could see that his compliance was better. He bought in. He went from twenty one twenty five to twenty seventy. And now we're back to where I'm at this patient. He's twenty seventy in his right eye is twenty twenty in his left eye. The parents really want him to be twenty twenty. What more can be done? They're asking me. So going back to a cycloplegic refraction, I thought, OK, well, let's give him a planolens on the side of the left eye for those days that he's doing his atropine penalization. If you think about it, he's got a little bit of increased hyper-opic help when he's wearing his glasses prescription. And if we take that away from him, he'll experience even a little bit more blur effect. Does the evidence support this? Well, ATS eight actually looked at atropine and compared it to atropine plus a planolens, their results were actually less than impressive. But if you actually stratified out to the high hyper-opes, they did see a more robust response. So I think that's where this kid actually stands to have the most benefit. He's not just a plus one cycloplegic. She's a, you know, plus four and a half almost. And and that's what he did. He improved another line. But parents are impatient. They're back in two to three months and they really want more done. So what else is there? There's di-coptic treatment. And that's what I really want to go into today. So what is di-coptic treatment? So di-coptic treatment at its core is a binocular activity that the child is going to be doing, wearing, participating in, that in some way reduces or rebalances contrast to the fellow non-hamblicopic eye, this child's left eye. And then there's also sort of a superimposed masking, which many times is bilateral. So they get a little bit of a masking effect on the ambliopic eye as well. So wide variety of content options out there. There's movies and TV shows. There's games. There can be experiential alternate realities. So there's active and passive forms. So for this child, we selected Luminopia. So Luminopia partially just because it was the first FDA approved digital therapeutic, it's been available for use in the United States since late 2022. You can prescribe it through Epic. You can send it to a pharmacy and then they handle all of the insurance, the billing, everything, and they just send it out to the child and their family with what I've heard is a fairly low copay. So it's a movie based digital technology. And you can see here this child's wearing a pretty cool virtual reality headset. It's been FDA approved for the treatment of ambliopia in kids four to seven with the caveat that it's forest or business and anisomotropic ambliopia. So technically we could kind of consider this kid an off label use, although he does have kind of that anisomotropic component. So what is the kid doing? Well, he gets to look at this relatively large array of web based video content. One of the criticisms that I've really heard about Luminopia is that the digital content does skew younger. It's a lot of Disney Junior PBS kids. So great for your four year olds, your five year olds. Sometimes your six to seven year olds might want a little more sophisticated content. But you can see here, they're kind of putting the headset on and then they get to go through just like you would use your VR headset and select some of these cool devices to watch. And then this gives you a little bit of an idea of what the child is actually seeing. So the fellow non ambliopic guy has a reduction here. You can see the 15 percent in contrast. And then there's these cycling masks. They have six different dichoptic masks. And what it's doing is it's stimulating the child to have to use binocular visual summation to get the whole picture of what they're viewing. So you can see he's got masked out areas on the ambliopic eye. So it's a pretty cool technology. What does the study say? Well, Luminopia did their own clinical trial and they randomized kids to either continued glasses versus glasses with treatment with Luminopia one hour a day, six days a week. They had a primary endpoint at 12 weeks and they looked at the frequency and severity of adverse events. Just to note, this was very similar to the dichoptic therapy that Peter chose to study in ATS 22. That was a game based technology. So a little bit different in the format, but it was a one to one randomization of glasses versus glasses plus treatment. So the results are pretty encouraging, but I would expect that. You're looking at comparison to glasses. You saw almost a double improvement when you use the digital technology compared to just continuing glasses alone. I think the real selling point for Luminopia is the adherence. So here you can see, I mean, they had 88 percent adherence with Luminopia over the 12 weeks. When we looked at the PDG studies in ATS 18, which was the falling blocks, there was something like 13 percent completion rates. And then when they tried to make the game a little more interesting and use the dig rush format, it rose slightly to like 30 to 45 percent. So Luminopia really does win out in its attraction to the children that are participating. And then, of course, it is positive that there were no serious events reported. So going back to our patient. So he improved from 2060 to 2040 at the end of the first three months of Luminopia therapy and actually did get a little bit better in stereo acuity. It is worth noting the confounder that I couldn't quite bring myself to stop the atropine, because to me, I just couldn't see how one hour of Luminopia play was equivalent to sort of all of the amblyopia treatment we were piling on him. But I had him come back on Monday a little early because I really wanted to know what he would be doing. And he was 20 30 minus two, which was just mind blowing. And, you know, he's seven now. He definitely admits that he's kind of aging, I think, a little bit out of some of the technology of some of the digital library that he's got. And so he's using the Luminopia closer to like four to five times a week. And now they're doing the atropine Plano closer to like three times a week. So I think what we're going to try and do is be pretty happy with where he's at and just start to kind of pull back some of our amblyopia treatment. But either way, with a funnest photo like this, I think it was a pretty exciting outcome just to give a little bit of time to the other digital therapeutic that's out there. It's curcite. So curcite is made by Nova site. It was approved about six months after Luminopia. And its novelty is that it incorporates eye tracking into the digital therapeutic, which is pretty cool because what they end up doing, this is the non amblyopic eye wearing the red blue, the red glasses and the red blue and they selectively blur only what the fovea is actually looking at in the digital media and that size of the foveal blur and the depth of the density of the blur is determined by the child's amblyopia. So it's pretty cool. And then the non amblyopic eye just used the blue filter. The curcite actually did a randomized non inferiority trial that was more similar to ATS 18 where they compared curcite to patching. And this was actually pretty good to see that it was non inferior. And I think that's again what we're expecting. We're not looking for something probably to surpass or supplant or get rid of the utility of patching or just looking for something that maybe is another offering for our patients. I think it's also worth noting many times you'll hear your reps for the digital therapeutics really tout that this binocular treatment is going to improve stereo acuity, which makes intuitive sense. But actually the studies aren't really showing that as much. And again, maybe we just need more data and more studies. But at least right now, we're not seeing a huge stereo acuity gain over patching treatment. But we again are seeing really good compliance. So just kind of wrapping up this case and then I'll pause. PDIC studied the binocular gameplay. They looked at falling blocks. They looked at dig rush. These are really, really boring games and the compliance was terrible. So I really feel like if this gets into the kind of for-profit digital media space, there's a potential for these games to be really explosive. But right now the evidence really wasn't behind them. Luminopia is awesome. I think it's portable. Kids really like it, but it is limited by its library. The Cure site, it's got this really, really cool eye tracking technology and really unlimited content. I didn't mention this, but the child can actually pick from Hulu, Amazon Prime, Netflix, they can pull up anything on these little tablets. There's parental controls that you can install. But what I've heard is that the Cure site tablet and the eye tracking really need to be on a very stable, non-moving surface. So it's not like you could pack your kid in your station wagon and he could do this on the go, whereas again, a plug for patching, you can put a patch on a child and you can take them anywhere. You know, so you really are tying your kid down when they're doing some of these digital therapeutics to the Wi-Fi or your hot spot or just the confines of what they need them. And then, of course, we have to view any use of digital technology in sort of light of what the AAP recommends for digital media use. So I'll just pause there. Any of any of you Pete's guys using any of the digital therapeutics? No, I think we should start a group. We have the rep out and we have the opportunity to try it out for the school. The things that I thought were interesting, I asked about, sorry, I know that I asked about for business and for the Lumenopia because I was thinking, you know, if you had a large angle for business, you wouldn't be lined up to use the technology. Thank you. And so how do you think about the Lumenopia versus the Cure site? Could Cure site maybe be used more effectively in a Shurbismic who was currently Shurbismic? Yeah. My understanding from the reps with Lumenopia is it's actually contraindicated if the angle of deviation is over 10 to 12. I've definitely like pushed it and I've prescribed for a kid who was like 15 and intermittent. I the the rep for Cure site also said that they they abide by that same Shurbismic rule. I again, don't know if you could push it and what it would do to the eye tracking software because there's no eye tracking on the amblyopic eye. And most likely your amblyopic eye is going to be your out eye or your in eye. So I think that's worth considering. The other thing is there are PD requirements. I'm sure they told you about. So you have to have a PD of at least 52 in order to use the Lumenopia. And I think a similar one for the Cure site. I think it's actually 54. So, you know, I think if you have a child that otherwise is doing no amblyopia treatment and they have a larger angle, Shurbismic, I have a partner of mine who did start like a large angle XT with dense amblyopia on some Lumenopia treatment. And he said there was no benefit. And I would have to imagine it's just that they're just remaining out. They're remaining suppressed and they're just not get taking advantage of the technology. They're just like I'm watching a blurry half view of some digital content. Yeah, I know I learned so much from this case. It's a great case and I want to not take too much time to get to the other cases. But question number one, were the parents of this child engineers? One was a doctor. Yeah, OK, yeah, they sound a little intense. Yeah, but that's an incredible outcome. I mean, I've got a lot of patients with a couple of patients with malnitid neurofibrillary. It's such difficult amblyopia to treat. I'm kind of blown away. I know. I was actually a little. Congratulations. That's really exciting. I saw on the the the refraction that you gave them that you cut the plus off the hyper api guy, but you didn't cut the plus off the my api guy. What's your thoughts on that? Oh, yeah, that's a good question because it came to me kind of like that. And so I have a hard time when they're already like my personal practice is when they're already over about minus two myopic in one side and then very hyper apic on the other. I tend not to cut as much or drop with more myopia on the myopic eye. I think it's just been my personal practice. I also think keeping in line with these parents, if I tried to give him more minus on that right eye, they would have been very, very upset with me. Yeah, I think it does. I mean, you always worry about anisoconia and not having to be minimized anisoconthropia, but I thought that was interesting too. And last question, how often are you doing the ambliopia drops more than twice a week? I that was interesting to me too. I'm not doing that very often. So, I mean, not frequently, but if I have a moderate to severe ambliope, I still start at the twice a week. Just, you know, even though the studies told us moderate, severe, you start at daily atropine, which I've never done daily. So I usually always start at twice a week. And then if they fail to respond or they're slow to respond, then I will go up to usually four to five times. And I think for him, it was his he was really getting close to being seven. There was a lot of intense pressure to kind of see what could happen. So it was like all hands on deck. Mm-hmm. Yeah, I think that's kind of one of our other that we've talked about it already. Oh, yeah, so given this patient with engineer parents, this kid has nine diopters of anisomatopoeia. At what point would you put them in contact lens to minimize that anisoconia and encourage binocularity? So what I didn't mention in this case, because I feel like it just opens up a whole new can of worms is I'm also doing dilute atropine in his right eye. Oh, I know. So we've talked about and that again, you know, he came to me with that. And I was like, I see no reason not to continue. I can't exactly say that you are you're the exact demographic that we know this doesn't really apply to. But they've already asked me about my side contacts for that side. And so I think we're going to see one therapy through to the end. And then try and kind of mix things up. But I usually start contacts in responsible, kind of motivated children as early as like eight, nine. I wouldn't have a problem with that. Very one last thing I learned a lot from this case as well. And I just prescribed lumenopia for the first time for a patient. And I'm kind of curious to see how it'll go. Have you seen much difference in like cost based on their diagnosis? Like getting the prescription approved for lumenopia if they don't exactly fit the FDA guidelines versus not. I mean, I think I always include anisomatropic amblyopia or like just straight amblyopia and those are the two that I've built it under. Yeah, because I actually use it a lot more for like kids who've had cataract surgery or kids who have glaucoma and there is some degree of like depravation overlay and but I'm always using the code of just like straight amblyopia. And they've all had it covered. We were having this discussion yesterday, whether it's either, you know, Maryland aid is a little more forgiving, but so far everyone has been really good. What I've also found is the reps are pretty good about helping and offering assistance programs. So if you were finding that there was a family that was just getting a co-pay that was outside their means, I've been really encouraged at their willingness to kind of work with them. I think they really have a strong desire to just get people out. And if it all doesn't work at all, one of the upcoming PDAG studies is going to actually be lumenopia. So then everything will be covered under that umbrella arm plus patching. Yeah. Awesome. OK, thank you guys for the great questions. All right. So I'm going to move on to this anterior segment case and post year. So this is a little six week old male that came to me with a history of by bilateral coenal atresia in maxillary hypoplasia. And he was sent to me because they found people are abnormalities. It is worth noting he had a negative evaluation for charge syndrome. So when I saw him, he fixed and followed well with both of his eyes. Eye care pressures were great. He clearly had micro cornea. And then he had these sort of bilateral inferior, infranasal colobomas. This is the left eye up here. You can see you can kind of appreciate the micro cornea. And then he had large bilateral inferior fundus colobomas. And I apologize. These are another one of my patients, not his. I couldn't get him to sit still to get great photos. But you could see they were very extensively involving the post year poll. So moving on about one to two months later, he's about three months old. Mom calls. She's very worried he's rubbing his right eye constantly. Now I ask her on the phone, is the eye red? Is it tearing? Is it swollen? She's very worried about glaucoma. I'm hearing the feedback. I'm not so worried about glaucoma. She says the eye looks exactly the same. It doesn't look red. He's not tearing looks the same size. He's otherwise totally acting normally. We happen to have an appointment scheduled for the very next week. So I didn't rush her in and bring her in any sooner. So here's my adorable patient. And let me see where my mouse is. So here we go. You can see the rubbing behavior that he's doing. So this is this is what she describes as kind of the rubbing behavior. So I'm going to play that just one more time. And I will tell you, I did not think he was rubbing. I told I think he's doing something else. And I think this one really kind of shows what I'm getting at that he's doing. And kind of what's a little bit more unique about his right eye, maybe compared to the left and why he's only kind of what I would argue is pulling on that right eye. So I kind of freeze the picture right there. And let's go to the next one. Isn't it a clever little baby at like two and a half, three months? I was blown away. So yeah, you picked up exactly on what he's doing. So when you kind of zoom in, what you can appreciate is he's got like plenty of clearance of the lower lid to view his pupil and then over here, that's his pupil. So like when he is not tugging down on his lid, he's totally occluded, which I thought was so amazing. And so I obviously wanted to know, you know, am I just really impressed with this genius baby and kind of making myself believe this? But then we dilated him in the office on that side. I put a drop of fennel effort in and he stopped pulling. So I was like, OK, well, this seems pretty promising. So I sent the parents home with a prescription for dilating drops. And I said, just watch and see if we're actually correct. And they did it. They would dilate him first thing in the morning. They would dilate him after he woke up from his morning nap, his afternoon nap. And mom would say, you know what, if we're out and we didn't have the drop and you can start to see the pupil come down, he is right back to pulling on that lower lid. So I mean, I just thought this was the coolest thing. But I also thought what more can we do for him? Because obviously, you know, the dilation, it's working so we can continue that indefinitely. And I don't think there's anything wrong with that. I actually ran it by my oculoplastics colleagues because I was like, should we pull the lower lid down a little bit for him? I mean, that seems pretty low risk. And maybe he could just kind of get him a little bit more clearance of the pupil. And then we talked about actually doing pupil expansion. So after many months of dilation, he kind of hit his one year age. I was really waiting for him to be one year of age, kind of work through with some of his other medical issues. There was also this was right in that time where there kept being those recalls of dilating drops. So that was really frustrating for mom. So we ended up deciding to do and what's very similar to like an optical iridectomy, I'm going to apologize. I don't have videos of this case. We upgraded our microscope in our children's hospital, which previously was about as high quality as ones I use on my mission trips. So that was a pro, but it has no video capability. So all of my cool cases I can't show you, but I can kind of tell you what we did. I use a technique that's very similar to what I do when I'm kind of targeting an optical iridectomy for Peters. And the reason I like this is because I'm going to kind of show you. This is my clip art version of what I was doing. So one thing that I will say about this kid that was really fascinating when I got him under the microscope is you could see the coloboma extended to the zonule. And so he definitely had a little bit of ectopia lentis because of the zonule drop out in that area. And for that reason, it makes it doubly important that we not hit the lens, nick the lens, cause a cataract or need to remove the lens. Because obviously then you're looking at not really being able to put a lens implant in and really being a little bit different. So when I do optical iridectomies for Peters, one of the things that I like to do is I like to use just retinal scissors. I always like to plan my incision so they're not like directly over the area that you're trying to clear, because we always close these with Tenno vicaral. We're closing them with some degree of suture and that tends to scar. So especially in like a Peters kid, if you end up, you know, this is the clear zone and you enter right here, he's going to end up getting like a little scar right over what you just kind of created your pupil for. So it's something worth when you're kind of doing your your incisional planning. You want to put it somewhere where it's not directly over your pupil. And then I kind of like to make just like a nice vertical incision, because of down the road, his face shape changes or in a Peters kid, the corneal opacity lightens a little bit, then you can actually just go in and it's a quick, easy stitch to actually close the pupil. And so then we do this fun maneuver. So that's exactly what I did in the hour. I feel like you were there and that's kind of what he would look like. But actually, this is what he really looks like. And so again, not the best there, but it's like, right. It's about this size. This is him when he was still on atropine. I kept him on atropine for a couple of weeks after. But he's done beautifully. He's a little unsteady because of the retinal colobomas and just the nystagmus that you see, but he's maintaining well with both eyes. He's not pulling on his lower lid. I mean, it's just a really fun case. Mom is just thrilled. So I think most of you guys kind of know the the history and the the etiology of colobomas. I think it's fun because what were the surgical indications for colobomas? There's usually not many, sometimes cosmetic reasons. And also, of course, if you get an accompanying cataract or retinal detachment, just to kind of give you an idea, this Olmstead County review seem to show that only about a quarter of presenting colobomas are present in the anterior and posterior segments, so they're not the largest percentage of the kids that we see like this. And then similarly on Monday, when I was thinking about fun cases, I saw one of these three patients. And what I thought was so cool is it just shows you the breadth and variety of visual acuity outcomes that you can see with fundus colobomas. So I thought I would end with that with this like multiple choice question, who you think is patient one, who you think is patient two and who you think is patient three, but I think it's just amazing because the one I saw on Monday was twenty twenty five in the eye that has the coloboma to rule it to bring it down to A or B as an option. And guess this, I'll tell you fine. So let's see. So my twenty twenty five one was my middle one, which kind of makes sense. I think it's probably the smallest of the colobomas. It definitely doesn't involve her fovea, although her nerve is a little small on the on the right eye. And she still is twenty twenty. This is a little girl extensive. She's got a little fovea hypoplasia. And I think that's the twenty fifty. And then this is a little kiddo with bilateral colobomas. But surprisingly, twenty twenty five and this left eye and the views a little poor because he has a little tiny cataract on that side. So with that, I can pause if there's any fun. I know it's it's mostly just kind of a cool case of really like the smartest three month old that I that I'd ever met. Motor skills for that little right kiddo. I know I think that's why I was like that can't be what he's doing. But it was very reproducible. And I think that's where the dilation kind of trial was so reassuring to both me and mom before we went ahead and did the surgery. Yeah, great case. Again, the pediatrics you learned to never underestimate a child. My one question for you is have you ever used of a tractor to just take a bite out of the sphincter? I've done that a couple of times. What are your thoughts on that? I do. I definitely do. I think I did that on another recent case and especially when I feel like I'm not going to I just need like a little bit of expansion. The the vetrector, sometimes I do worry in like a microphthalmic eye. It's hard to get the angle right with what me wanting to kind of avoid the limbo based scar. So sometimes the the angle of the vetrector just isn't good enough. And the the retinal scissors are a little bit firmer. But I do use the the vetrector not infrequently. Yeah, sometimes these eyes have really shallow into your chamber. And so yeah, I do have pulled the iris out of my wound and then cut it. I don't know if you've ever done that for Peters or like Peters where sometimes you don't even have much of a pupil. So you're creating a totally new optical ear to me and just pull the iris through the paracetesis. I've not done it like that. No, but I think that that definitely works well. And I think it creates probably more of like a polychloria situation. The only thing I would I would say is if if it does end up the Peters clears a little bit, then they might be a little light sensitive. Well, great case again. Courtney, just this is Craig. Quick question about what you use for dilating the patient. Yeah. So we use tropicomide. It's really hard to get over the counter or prescription. Fennel efferent, I was just having a lot of difficulty with that. So I want something that would do as little cycloplasia as possible. And so that's where I went with tropicomide, but it comes with the caveat that you end up having to put it in multiple times a day. So that's kind of the pro in the con. For some of also another question regarding some of your other patients where you've done the sphincterotomy, have you seen that actually regress over time where you have to go back and do it again? Or have you felt like one single good sphincterotomy has been sufficient to create that visual access? Usually I am pretty I create a pretty nice opening. So I think that for that reason, I haven't seen it regress as much. But I think I err on the side of really making sure because I do feel like it's easier for me to go back and close it if I need to. Right. I don't know if it would be really my experience with colobomas is they tend to not stretch very easily. For example, if you're trying to recreate a centralized pupil, even an adult, the tension lines are so aggressive that it doesn't look as cosmetically good. Later, it tends to stretch back out. But one thing that has been helpful for some of our adults where we're just trying to re center that pupil a little bit or shape it is intraocular cottery, so you can use 25 gauge fine tip. It's what retina uses to use for intraocular cottery. And you can use it as an iridoplasty tool. Oh, so you just do kind of slow burns and reshape the pupil where you want it. It can sometimes be helpful. It may sometimes regress if you're not aggressive enough, but at least you're not removing tissue, in other words. Yeah, I like that idea. I think it's always challenging to operate in these really tiny eyes, because I think it just limits what you're able to get in there safely. But but I think that's that's a really nice thing. Thank you. That was a really interesting case. I just had one quick last follow up question. It does piggyback on the cottery. I was wondering, my experience has been that sometimes you get bleeding that could be sufficient enough to increase scarring. And so if that happens, do you use cottery or do you worry that cottery that close to the lens is going to just significantly? I mean, if you put OVD between your iris and your lens to get space to put in your scissor, that OVD will act as a conduit. I think if you put cottery, that's always been my thought that if you then try and cauterize your iris, the OVD will kind of act as a conduit and make it more likely to create a cataract. But I actually haven't tried that because I thought it was too high risk. How do you think about that? How do you control bleeding and what steroid dose do you use to try and make sure this doesn't scar to the lens capsule or back, you know, scar the pupil back down? Yeah, I think your point's really valid, especially if you're going for like that edge. But if you're you're cauterizing kind of on top of the iris, I think you have like enough posterior iris stroma that you're going to block that from being conducted through the viscoelastic. I am very, very liberal with my viscoelastic when I'm, you know, kind of cutting just to kind of tamponade bleeding and I'll maybe leave it there for five minutes or so as just sort of a way of kind of before I'll wash it out. And then if I get some bleeding again, I'll hyper inflate and then just kind of wait for a bit. And I tend to think that that helps a lot. For steroids, I do tend to do about Q6 and the first week at least, I like them on atropine because I want to kind of make sure that I'm keeping the people as widely dilated as I can. But you will find sometimes that you can get like a little adhesion to the lens capsule and I think that at least by keeping the people open, it's going to hopefully get that posterior synechiae more posterior or peripheral. Inflammation is really hard to control in kids and I don't rely on the parents to put in drops personally. So I think that vitreous stain is so incredibly useful for almost all my anterior segment cases for kids. I just put vitreous stain in and I asked the pharmacist to make it very concentrated, not your typical dilution. And so that really quiets things down immediately. If you're really worried about a fiber response, TPA is fantastic as well. Just add that in at the end of the case. And then a little subconj catalog can help get them through that. And so you're not really whatever the parents are putting on is just gravy. Yeah. Do you have you ever done the steroid injections, the long acting like ducks? What's it? Dexacue. Thank you. Yeah, we used it for quite a while. I used it for about a year in my adult patients. And we found some problematic issues. One was staining of the IOL. You can get this residue on the IOL that I had to go back and actually polish about a dozen patients where you would just get this vehicle residue on the on the optic of the lens. The other one was it actually caused iris atrophy. I was just going to ask you. So Rachel Simpson, I had published a few case series of patients where that droplet of the Dexacue contracted over time as it dissolved and ripped off the pigment of the iris. And so we stopped using it. And so now for long acting steroids, we either use subconge catalogue or we're using dextenza, which is a punctile insert. Yeah, I don't know if that could be useful for children, but we've mainly have used it for our adult patients. I think Ed was starting to use that. Ed Wilson, where Leah and I were fellows, he started to use some of those in his pediatric cataract surgery patients. And I think that is actually kind of the goal. You know, we do intracameral moxie or oflox because we're really trying to give them as droplets of a post-operative course, because I fully agree with you that you really can't count on on your parents to get all the drops in, especially when you need to control inflammation. All right, well, I know some of you guys have to get going to places. So let me finish up with my last case with some funds for business. So this is a 72 year old female. She was sent to me by another community pediatric ophthalmologist. She had had some dyplopia that began after she had had a cosmetic procedure unknown, performed internationally, and then she surprisingly went back and had a second cosmetic procedure also performed. And while the dyplopia resolved after the first one, it did not go away after the second one. So now she's about a year and a half out from her procedures. And she's still noting this persistent right up gaze dyplopia. So otherwise pretty benign history. She's had cataracts out. She had some Lasik when before her cataract surgery, she was always a mild. I hope we're not dealing with someone who's a really, really high my hope. She's got good vision on my external exam. I couldn't find any obvious scarring to kind of clue me in, but I kind of have an idea of what I think they did. And we did a CT scan just to make sure that there was no hardware or something we needed to be aware of and there was no obvious hardware. So this is her. So what is scaring the community ophthalmologist is that she looks really good in primary, she looks really good in down gaze. And whenever I'm operating on strabismus adults, I like to tell them my goal is like primary and down gaze. I like don't want to mess that up. So she's coming here already looking at what I would probably say is a good post-op outcome. She also has great stereo. She's doing a little bit of suppression, but she is not happy. And you can see she had a pretty large left hypo in head tilt. It got cut off. So I wrote that there. And then we don't have the measurements for her up in right gaze. But this is her in primary. You can see she looks great. And then this is her when she looks up into the right. So I don't know who would operate on her. Before. What more information would you like? Not really well. We we didn't do four sections in the clinic we did in the operating room. The superior of Blake's a little bit tight. But I'll give you some more information just to help. The assumption that I had is that she had internal lower lid bluff. That's kind of what I'm thinking. Yeah, not as far as I know. She had no external scars and I would have thought that she would be someone who I'd be able to pick up a little bit of a scar. And so I'm assuming she had something done to her lowers. She also looks pretty good for a 72 year old in terms of her lids. So that are in terms of like lower lid bags. So that was my presumption. So I'll show you her fundus. So there was market in torsion of her left eye. And so this actually made me more compelled to start thinking about surgery. Because even if she looks pretty good in primary, there's a good chance she's having to kind of fuse this much kind of in torsion and that's going to be a little bit difficult for her. And she's probably fatiguing and kind of getting symptomatic sooner in that right gaze and I would assume. So we do a lot of Lancaster red greens at Wilmer. So, of course, we got a Lancaster red green. It's pretty much impossible to talk to Dave without a Lancaster red green. So you always have to get one for those of you who aren't as familiar with this. Typically, this is the scanned in one to the chart, but typically what you end up seeing is there are red lines and then green lines designating the right eye and the left eye. And then this is the patient's right. This is patient's left. This is what the left eye fixating. So you can see the left eye is going to be on these target dots. And so what this does, just to introduce the Lancaster red green, if you're not as familiar with it, is it really helps? I think particularly in cases of paralytic and restrictive strabismus, give you a sense of the subjective level of dysfunction these patients are having. So this is what the patient is doing. They're wearing red green glasses. You've got a dim room. Your goal is to maximize dissociation. So this is something that's going to uncover the maximal amount of deviation. And then just by convention, we always put, you know, the right lens, the right eye with the red lens. So this I think is a photo from the 1980s. But these same little dots are still in the rooms in all of our exam lanes. And so you can see here this exactly mimics that sheet of paper that I showed you. And so what we end up having is the examiner start by holding the red torch and they align it at the center point. And then the patient has the green torch and they overlap them. And the degree of torsion or crossing or uncrossed deplopia or up or down gives you a sense of what that subjective experience of deplopia the patient is having. And then you repeat the whole thing with the left eye fixating. And you do that just by switching torches. So then the examiner has the green the green torch and the patient has the red torch. So this kind of just shows you a little bit what we would kind of map out if the patient had a little bit of a left gaze hyper as well as a little bit of an esotropia. And then you move down, you can kind of see that switch. A little bit of an assumption of, you know, you see the cross versus the uncrossed deplopia and then kind of going back to our patient. So what I think it nicely illustrates for you is just the in torsion that you see particularly in this up and right gaze, as well as that there is this vertical that's not insignificant across all of the right gazes. So we did decide to offer her surgical treatment. But what I thought would be best one, we wanted to verify. We usually like to dilate on the table. So we're looking at fund distortion at the start of the case. And some people will use resolution of the fund distortion as a marker for kind of doing your chicken stitch in your superior oblique recessions. But we actually like to do the superior oblique on an adjustable so we can actually wake the patient up and have some of their feedback. We did feel like there was some moderate tightness of the superior oblique. So we went ahead and recessed it. And so for those of you who haven't seen or kind of are not quite sure what's involved in the the adjustable for the superior oblique, it's actually not as challenging as you would imagine. I think you start by just kind of doing your standard initial securing knot in your proximal portion, locking bites at both ends. Then you bring it up a good six to seven millimeters and you pass through the center of the muscle. And then you're just going to tie this as your pole. And then one thing that I think is super important is putting this traction suture proximal to where you're going to be cutting the superior oblique tendon, because what you'll find is when you're trying to do your adjustment, the patient, you're going to ask them to kind of look down. Sorry, but that ends up putting the superior oblique on stretch. And so you can lose sight of what you're trying to adjust. So by having that traction suture, you can also pull and actually visualize your pole and your noose a little bit better. So then this is kind of what you're looking at. And then same thing that I usually do, I just do like a two to two around and a square knot and so that I can kind of move it up and down, measure out. We measured out three millimeters. We repeat four stuctions and look at our fundus torsion to kind of make sure that we've got something that that we really like. And then we send her out into the recovery room. So she woke up. She I think the big thing I was worried about for her was not so much getting all of the vertical that was going to be present in that up and right. It was just not overcorrecting her and down gaze or primary. And we were able to accomplish that by just kind of assessing in an additional millimeter. This is kind of what she looked like. It actually really resolved a lot of that limitation in elevation. So got her stereo up to nine out of nine. So she was really happy, which in turn made me very happy. And so that's my last happy to hear if anyone has questions. Do you guys use the Lancaster green at all here? No, do you have the dots on the wall? OK, that's the biggest barrier to it, actually that. It does take a little bit of time. So it's a fun thing for a fellow to do. Very fun. OK, OK, then it is, you know, you could also do. Do you do has screens or double Maddox rods? What do you usually do for torsion? Yeah, I like double Maddox rods a lot. I think that there might go to, especially for like fourth nerve palsy is things like that, but it's in the sort of borderline. What am I looking at with this hyper? Why are they not fusing two diopters when I give them the prism? And then you do the Lancaster red green and you just see these really surprising torsional patterns. I think that's where it can be super useful. So definitely a test just for adults or business. I probably did because she saw me because I only have the tests. We only have the Lancaster in Baltimore, so she saw me in Bethesda. I'm pretty sure she had some torsion on that, too. So they're very concordant. My assumption was that she got some sort of damage to the inferior oblique and it ended up scarring because I felt like the superior oblique was tight. But I think what happened, it had been a year and a half. And so she just kind of sat there with this like scarred and or peretic inferior oblique and then the superior tightened. It's my my working assumption. So just just one other question, Courtney. It looks like a acquired Brown syndrome and Judith and I were just E.T. and not more of like the the XT and up gaze. But otherwise, yeah, it looks a lot like an acquired Brown. Yeah, we're just curious. What do you think is the cause? The cause. I think it's probably some sort of damage to the inferior oblique. That's my assumption versus they went way too far back in the orbit. But my thought would have been if that would have been the case, I don't think I would have gotten as much impact from doing the superior oblique because I would have been very anterior to wherever the scarring would have been in the superior orbit. So I think the fact that I was able to get some degree of movement back means that there had been some contracture or scarring at the location of the inferior and then the superior tightened with some time. Yeah, if you don't have the previous surgery dictations of our international surgery, cosmetic, international cosmetic, too, I bet she had superior orbital surgery and develop Brown syndrome from that. That'd be my guess. Thank you. That was super interesting. Forgive my forgive this question, but it looked like so for your recession, you did the suture spacer, right? It's like a suture spacer exactly. And then the suture spacer has a new adjust. Yeah, OK, got it. So super easy to just kind of incorporate in your practice is super easy. So so David Granite, the reason why I have done those primarily David Granite, though, has been a big proponent of an actual recession where you put it eight millimeters back, you you recess the temporal aspect, you know, at that insertion to the nasal pole, eight millimeters back on the border of the superior rectus and you could do it adjustable or not adjustable. But I wondered, have you do you have any experience with that? You know, do you, you know, there's so much debate in the literature. Should you do the silicone spacers? Should you do the suture spacers? Should you just do a regular recession? And and it's such a hard problem to fix that some of the literature is difficult to interpret because it's just a difficult condition. But you all are pretty unique, you know, because there is like we were still, you know, juries out on the exact cause. But in terms of what I want to put more foreign bodies in that, I probably not. So I don't think I'd want to put a silicone spacer in there. Yeah. I think the appeal of actually doing a true recession is you're not really leaving anything behind. Yes. And that's really nice. So minimal scarring, if you worry that that is part of the problem, the problem. Yeah. Yeah. Do you close the capsule around your suture? I try to. So I put a little temporary like plain gut and I leave it just long and untied. And so then after we do the adjustment, then we close it. OK, because that minimizes great. This was just such an amazing outcome. It really worked well. And so I've done a couple of adjustable superior leaks always as, you know, very, very varied. And I've had at least two or three massive fails. So I should probably, you know, in the spirit of showing, you know, negative outcomes. And then I've had like slam dunks. It's very one or the other. And I think really trying to get to the nuance of of why that is, you know, because this was a relatively small risk, you know, yeah, baser length for what is done. And so also usually you're looking at more of a primary deviation and she really had nothing. And so that was where I think a regular just, you know, size, size would probably have overcorrected her. Yeah. Super interesting. So overall, with Strabismus surgery, my over the years I've been doing this, if there are many different surgical procedures, either they all fail because it's a total third nerve or many of them work in cases like Brown Center. So what I've done is I've tried to develop procedures in my practice that have a couple nice features. One, I feel comfortable doing them just my skill skill level. Two, trying to minimize complications. And then three, procedures that are reversible. I don't like irreversible procedures very much. I like to be able to take people back to the operating room. And but for this specific thing, I would I abandon the idea of silicone spacers because they can erode through conge. Yeah. And don't use a lot of permanent suture. Right. It's suture granulomus. I did. No, I didn't. Yeah. So I feel like you have to. Yeah, it's otherwise it's going to dissolve and then they're going to be separated. Yeah, exactly. We that's the other, you know, I have moved. I agree with what you pointed out. But I do like putting like my inferior rectus recessions on permanent enjoy, which I do think creates this possibility of suture, erosion and exposure. But the inferior rectus, I think, is really prone to slipping. Yeah. So it's it's he's very right. There's always a choice and a balance. OK, does anybody else have a question for Dr. Krause? No, my my future ophthalmology. Oh. And I wasn't able to check the online make in. I think I can see it. Can you is are there any questions in the chat? OK. Great. Well, if nobody has any other questions, I'd like to thank Dr. Krause for coming and sharing these interesting cases as part of our pediatric ophthalmology grand rounds and let you all get to your next your next thing. Thanks, everyone.