 So just to make sure before I get started, is there anyone else that wants to bump me back a little further? So I rotated here back in August and did a couple of weeks with Dr. Bernstein. And when I was working with him, we had this really interesting patient come in. So basically what I'm gonna do is just pretty briefly present her case and show some of the imaging and then talk about a really quick differential and then basically just open it up, see if anyone else has other thoughts or ideas or comments. So this was a 30-year-old that came in with the chief complaint of no vision in the left eye. So since childhood, she never remembers having good vision in the eye. She does remember that as a child, she could see somewhat, but she can't really describe how well it was and that over her lifetime, it had been slowly getting worse with no problems in the right eye. She didn't have any associated pain in the eye, no other visual symptoms as far as flashes or anything like that. And the reason that she was referred, she hadn't had any recent new problems, but her primary care physician wanted to just make sure that everything was okay in the right eye, she was still seeing well and the right eye was being taken care of. So as far as an ocular history, she remembers being diagnosed with amblyopia as a child. She had had some patching done on her right eye, but it never really helped vision in the left. Like I said, it continued to just slowly deteriorate over years. Then back in 2002, she had seen Dr. Harry and so she knew she'd been diagnosed with some kind of mass and a retinal detachment in the left eye and going back through her records, at that time she was seeing hand movements. She had a pretty significant visual field defect but she did have some vision out of that eye. She hasn't had any other previous treatments. The medical history is only significant for Graves' disease which is pretty well controlled with Mathemazole. So on exam, her right eye is seeing at 2015 and her left eye had no light perception. Pressure was equal at 21 in both eyes and the right eye had a reactive pupil, the left eye had a different pupil area defect, leukocorea. Slip exam was otherwise completely normal on both sides. So looking at her fundoscopic exam, so this, you can see this is the findings of the left eye. You can see it's this really large mass that you can't even keep in focus when you're looking at the rest of the fundus but it's, here's one that's focused back a little bit more on the mass. But you can see it's this really extensive calcified mass that's underlying an exudative retinal detachment and you can see the superior boundary of this. You can see the area of retinal detachment and some pigmentary changes there and inferior boundary along with some kind of just artifact on the photo. And then also interestingly on our exam and this will kind of play into our differential but she had this capillary hemangioma on the left side of her face, pretty close to her ear and obviously this isn't a picture of our patient but it looked somewhat similar to this. We weren't examining the belly button or anything like that. So something to keep in mind. Yeah, so our next step was to refer the patient back to Dr. Harry where she had an ultrasound done and Dr. Harry brought the results of the ultrasound and it's gonna spend just a couple of minutes talking about that. This shows the lesion back in 2002 when I first saw her and it's kind of fade over time to this is what I just called it and it's also good at the B scan. This is the lesion here. Here's the thickness, here's the sclera and it was rather vascular at that time, vascularity. This is the most recent exam just a couple months ago in September and here's the B scan of the lesion. Basal dimensions are pretty close to the same. Calcification starting to show up as brightness here as calcium, see some shadowing but it is bigger, it's a non-vascular which isn't. So again the B scan consistent with the vascularized mass with surface calcification and importantly there's not a significant change in size maybe some slow growth over that time. So thinking about a differential for vascularized mass and kind of thinking back to that hemangioma that we saw close to the ear kind of the top of the differential is a retinal capillary hemangioma. So capillary hemangiomas these are relatively common benign vascular proliferations that most commonly occur in females and these are usually seen in infancy so there'll be two phases where shortly after birth at about eight to 18 months of age you'll see a period of rapid proliferation and then that's followed by basically a long period of over many years of slow regression and involution. So half of these will be completely gone by age five, 75% by age seven. In rare cases they'll never completely regress and then there's another form of these called congenital hemangiomas and the main thing that sets these apart is rather than coming on shortly after birth these are present at birth and there's two forms of these they're either rapidly involuting or non-involuting. So the rapidly involuting are completely gone by age two and of course the non-involuting hemangiomas they grow in proportion to the patient throughout life and they never regress. So I think it's a good possibility that our patient either had one of these infantile hemangiomas that never fully regressed or one of these congenital hemangiomas that was the non-involuting type and kind of grew in proportion to her throughout her life. I think that's consistent with slowly worsening vision over her life and slowly drawing intraocular mass. And that's a piece of history that I'll still need to get from her as far as if she, of course she's not gonna remember but if anyone remembers, if she had this at birth the hemangioma on her face. So less likely possibility is Coat's disease or Coat's lesion. So this is a disease of retinal telangic pages that lead to exudative retinal detachment. And it's much more common in young males which makes this less likely. There is a range of severity here but in the most severe forms you can get these large masses with exudative retinal detachments and it can lead to total retinal detachments and blindness in the eye. And then a third and even less likely possibility just based on the rarity of these is what's called a retinoma or retinocytoma. These are a benign retinal tumor that are somewhat related to retinoblastoma in that if you remember the RB1 gene and the two hit hypothesis of getting retinoblastoma these have the same two hits in that RB1 gene but what they're lacking is further downstream mutations that are required in order to fully express retinoblastoma. These are originally thought to be regressed retinoblastomas but they're not thought to be a separate entity and two to 10% of carriers of the RB1 gene are found to have these. And there have been a few case reports of these transforming into retinoblastoma so it's thought that these could possibly be pre-malignant. And I also did read that there is some reports of actual spontaneously regressed retinoblastomas as well so kind of my thoughts on this case is regardless of specifically what type of lesion this is we know that it's not rapidly increasing in size and we know that there's no more visual potential in the left eye and it's not bothering the patient. So I think the goal of management will be to carefully monitor this lesion and to make sure that care in the right eye is optimized that she has at least annual exams to make sure everything's okay in the right eye and otherwise watchful. Basically just close monitoring of this intracromass in the left eye. So any other thoughts, comments? Dr. Bernstein or Dr. Harry or I think that's something to think about. Again, I think words that's not really bothering her and okay for the right eye. I don't see necessarily a purpose in it besides just for curiosity sake but I think it could be like she did before. I'm not actually sure exactly what the testing for that is. Glasses? Just so they didn't even have to have a strip just kind of like carbonated lenses. Yeah, you see enough open globes that they'd be ashamed to be walking down the street and somebody hits a rock with their mower and boom, that's what happens. About time we let you give your talk. That was a good one. That was a good one. That was a good one. I'm telling you, my wife.