 So lucky for everyone, I've got some more strabismus, but it's mixed in with a little bit more. So this is a 12-year-old male that I've been following for the past couple of years. He came in a couple of years ago just for his yearly eye exam. Mom was concerned that his right eye was drifting out even more than it had in the past. She was noticing this with and without his glasses. He wasn't so concerned though. His past ocular history was significant for excellent ocular albinism. And this was diagnosed by history. His brother had a similar diagnosis of nystagmus and poor vision, as well as his uncle. And if you looked at Mom's eye, just even using the direct ophthalmoscope, you could see that she had a few iris transillumination defects. His skin coloring was otherwise normal, and his only finding was this nystagmus and a little bit limited vision. He had a history of strabismus surgery in the past. He had had some esotropia as a young, young child, and had undergone surgery at two and a half years of age. And given the surgery, it sounds like it was a pretty big deviation. He had a three-muscle surgery, so they loosened both of those medorectis muscles and then also tightened his right lateral rectus muscle. His past medical history was a little bit interesting. He, when he was five years old, one evening was at home and playing around and grabbed the nightstand and said his vision had completely blacked out and that he couldn't walk. His vision came back after a minute or two. But I thought that was interesting because I always get these kids who come in with vision loss and they usually don't end up having much. But they took him to the ER, did an MRI, and noticed that he'd had a small pontine stroke, which they thought was related to recent infection with chickenpox. At the time, they did an MRI, found a large, sizable, extraactile arachnoid cyst, just as an incidental finding that five years later they redid an MRI and they could barely tell where that stroke had been and that cyst had gone largely reduced in size. So just kind of incidental history. On exam, he had limited vision. He had a left eye preference. His vision was 2060 in that eye and 2060 with both eyes. He did not have any stereo vision. His color vision was normal. He had a fairly significant horizontal pendulina stagmus. It was quite noticeable. He had some iris transillumination defects. He had the foveal hypoplasia you generally see and he had quite a bit of with the rule of stigmatism, which is something we sometimes see in these kids with albinism. On exam, using a cover test, he had an exotropy of 20 prison diopters that was fairly comatent. Testing in these kids can be a little bit tough because they've got pretty significant in a stagmus. So sometimes it's hard to know what the end point is. But he was pretty comatent. He also had a little bit of a left hypertropia and it looked a little bit more in that right gaze. He was pretty similar at distance and at near. He had just a small left face turn and a little bit of a head tilt to get his eyes in that null position. When I was testing him, when I put up a 25 prison diopter lens and put it base out, he said he got diplopic, which I thought was interesting and we'll talk about that a little bit later. Also interesting was that when I looked at him by Krimsky, I measured quite a bit more than I measured with the cover test, meaning when I just put a prism up and shined a light to center that reflex in the center of the pupil, I measured more with the Krimsky than I did with the cover test. So here are some pictures. Yes. Oh. Oh, sorry. It should be base in. No. It should be. No, it should be base out. It's base out. Sorry. It is base out. So I did this cover test. Sorry. I'm confusing myself now. When I did the cover test of 20 and I neutralized him and I thought he was a 20 prism diopter, esotropia. Exotropia. Sorry. It should be. You're right. It should be base in. I keep confusing myself. Yes. Correct. Correct. No, with it neutralized, he's not diplopic. With it one more, he was diplopic. When I put up a 20, he said, I'm confused that. When I put up a 25, he couldn't. The reason that's interesting is because he's at an albino and we're going to talk just about his binocularity. But yes, this is wrong. It should be base in. Sorry. And now I'm looking at his pictures here. He has a fairly large exotropia. Sorry. This is driving you crazy, right? Clip it on me. I'm driving Judith crazy in more ways than one. Okay. Just looking at this kid, he looks a lot more than the next T20 to me. Just based on that reflex. Reflex here in the center of this pupil. And it's not in the center here. And when I put up a 20 base in, it still looks XT. So I have to put up about a 40 to get that to neutralize. And when tech checking a little bit more about obliques again today, when I have him look this way, this eye seems to shoot way up here. And so he's got some left inferior oblique overaction. He also seems to have a V pattern. His XT is smaller here than it is up here. And that also goes with his numbers where he has a little bit of that left hyper that was worse in this gaze here. This little dot here is just from his previous surgery. Sometimes we see that after we do a meteorectis recession. He also seems to have a little bit of right inferior oblique overaction as well. And this eye seems to pull up a little bit more when he looks this way. It's a little bit harder to see in this picture here. And you can maybe see some underaction of this superior oblique. So I decided to do a strabismus surgery to try to fix that XT. And then also to try to fix some of that incompetence. I mean, arguably I could have gone after both of those obliques, but honestly he wasn't noticing that so much. And so I just decided to just go after that left inferior oblique and try to bring that down this way and try to help that V-pattern a little bit. I also decided to just operate for just that 20 because when I tried to treat him with a 25, he got the pulpic. However, he's still going to look XT because he's got this positive angle cap, meaning that his numbers are different based on Kribsky versus Alternate Prism Cover Test. So I did this lateral rectus recession. I did an inferior oblique recession as well and just put the, you know, put the inferior oblique four millimeters back and two millimeters over from that inferior rectus. When I saw him back two months later, he had persistent diplopia with this really small residual and he still looked a little XT by Kribsky. I was unable to relieve any of that diplopia. So even if I put up that six, I couldn't get him to get rid of that diplopia. If I tried to put him back where he was to begin with, I couldn't get rid of that diplopia. He just said it was there all the time. He could never get rid of it. He didn't describe any torsion, but he was pretty bothered by it and this is a, you know, a 12-year-old kid that just said I could never get rid of that other image. But pretty interesting considering that he was in a congenital ET. I mean, he was an ET young and then he had that surgery at two and a half that put him a little bit XT, but he's still diplopic. And he's also an albino, a binocularity. We have Dr. Creel here who's done a lot of work on their VEPs in kids with albinism and we know that the way that their optic radiations go is not normal. They usually have very reduced binocularity and so just kind of interesting. So I didn't know what to make of it and I just said this was two months post-op. I said let's just see you back in a month and see how you're doing. And a month later he was the same and he now I measured a little bit more ET at distance. As I said, it's kind of hard to measure him for these small numbers because he's got that pretty significant nystagmus. I measured him by torsion this time which he had some encyclotorgen. I don't really know what to make of that but still I was unable to relieve him with prism if I tried to put him back where he was again. He said he could never get rid of it and I said well, and dad said no, no, not a chance. He looks so much better. So I just kind of sat on him for a while and I said, you know, those are our options. I don't really know what else to do and kind of and he came back about eight months later, seven months later and it was finally gone and he said and generally felt like his vision was better after the surgery. He felt like things were a little bit clearer and that diplopia had finally gone away. And I just saw him back last week and he said his diplopia is gone. He still has this tiny bit of an ET by measurement and here are his pictures. As you can see, he still looks a little XT just by Krimsky. I'm sorry he's dilated but so it's a little bit tougher to tell but you can see he likes to fix it with this left eye. It's his better-seeing eye. That right eye, you know, is out a little bit. You know, definitely his incompetence in terms of when he's looking to the right that left inferior oblique over-action is better but these pictures make me think that I should have gone after that right oblique. You know, he's still got incompetence this way. He's not bothered by it at all and he still has this little bit of a V-pattern. But overall, a very good cosmetic result. I know and now, you know, now a good result now that we've gotten rid of the diplopia. Yes. He still has the little, yeah and I think that's a null point. Yep, I don't think it has so much to do with him but just some questions I had. I don't know if other people have seen. I've seen a lot of kids with albinism since I've been here. I had more than I had seen in training in Boston or in San Francisco but you know, there's interesting questions surrounding their binocular potential and I just thought it was interesting that he had to begin with. We know that they can have stereo in albinism but usually it's the people who have the really good vision and very small in the stagmus. I thought it was interesting that he had the post-op Diplopia given that he had kind of a history of infantile E.T. Do you have any thoughts on that Bob? Would you have gone after that at the beginning looking at those pictures from the beginning? Do you have anything to add to that Dr. Creel? No. Yes, Dr. Warner. No, I'm measuring an exo. He's just measuring if I neutralize that 20 that he measured. Oh, now, yes. Sorry, now he's an ESO. Correct. Yes. Yes. He will still move out. He will still, when you do the cover, uncovered testing, he still moves out and it's always hard to tell because he moves out and then he moves back a little bit because of that nystagmus, but he is clearly still a little bit E.T. Correct. And that's a positive angle kappa and we see those in albinism. So there's this article that Michael Brodke did and he looked at 21 patients with albinism and here's another kid with albinism who's actually ortho. But it's because of how, they don't know if it's because of how their phobias are formed Yes. Yes. Make it worse, yes. Correct, yeah. Which makes you think that this is some kind of chiasma, but yes, keep going. Yes. That's in ROP, but what Judith is saying is we don't know if that's why it is an albinism. We know they have abnormal phobias but we also know they have abnormal decussation of their fibers and so we don't know which reason this accounts for them in this and as you could tell from Judith pointing out I confused myself too with my prisons. Yeah, and the other thing that I was just going to bring up quickly is what Bob was talking about in terms of these kids do have stereo, some of them. You know, my kid didn't and he didn't have much of a potential, I don't think and I could tell that just by looking at him because his nystagmus was so bad and his vision was not great, but some of these kids but I don't know that and so the point that Dr. Hoffman was making is that we try to get stereo in these kids and sometimes we are surprised with with it. Yeah, that's it. Yes. I wasn't totally aware of that either but when I was reading about it it sounds like I mean I do have kids, some kids with this high but it can go with it and he and his brother both have like four or five diopters with the rule there but I've seen that before. Yes, Bob. The other population that Bob and I have talked about this before, maybe David too but I don't see those huge high with the rules or in like the Native American populations and I don't know why that is either if that's some evolutionary but but then they won't wear those glasses either which is also interesting. But yeah, those are two populations where we often see a lot of with the rule. Well thank you everybody for putting up with us.