 So, I just wanted to present a patient that I saw in neuro ophthalmology clinic. It's a syndrome that we don't see very often, and we got a pretty good video of it, so it will be something that hopefully people can take a look at and remember in case they see it in the future. This was a 74-year-old female who was presented with ocelopsia. In July of 2010, she experienced 10 minutes of slurred speech and left-sided weakness, and went to the Intermountain Emergency Room and was found to have right vertebral stenosis. At that time, they attempted to stent that, and during or slightly after the stenting procedure she had a major stroke of the basilar artery and was left with a dense left hemiplegia. She also experienced some intermittent diplopia over the following weeks and had a repeat stenting procedure that improved and eventually resolved her diplopia. However, then beginning in September, so now two months later, she began having ocelopsia where she had difficulty focusing, dizziness, and vertigo difficulty walking in addition to her left hemiplegia, but no nausea or vomiting associated. Past medical history included hypertension and hypercholesterolemia and atrial fibrillation, all risk factors for the stroke that she had. When we saw her, she was on Coumadin, Lorazepam, and Toprol. On physical exam, she was 2060 and 2040 with no improvement on pinholes. She had no APD. Visual fields, color and stereo were roughly normal with a moderate decrease in stereo vision like you would expect. Her extraocular motions, she had a full range, but she had a continuous pendular horizontal nystagmus, which also included some torsional and vertical components at times and square wave jerks, but she had no diplopia, no phoria, no tropia. On exam, she also had a rhythmic twitching of both eyelids, the left side of her face and the left side of her neck, and mild to moderate cataracts in both eyes. Her funnest exam was normal. So this is her eye movements in some video of other salient features of the case. So you note that the eyelids are also twitching bilaterally. This, of course, is the view of her inside or mouth. You can also see the left side of her face is twitching. Residents want to say what that is. You know, sometimes as residents, we don't look below the eye, but looking at her palette and the lower portion of her face really helped clinch the diagnosis. Certainly something that we don't see very often, but something which is pretty obvious when you see it. So ocular palatal myoclonus is rhythmic oscillations of the eyes and palate. It occurs not immediately after the injury, but sometime after, roughly two to 48 months in the papers and case reports that I read. It can occur after a stroke, which would be more common, but it can also occur after trauma. So this lady, hers, was after a stroke and it started roughly two months after the original insult. It's a relatively slow frequency of movement in the range of two to four hertz. It can be either unilateral or bilateral. And the bilateral is more commonly a pendular motion like in this patient. And the unilateral often has more of a rotary component. And on MRI, in most of the case reports, I saw the patients exhibited an inferior olivary enlargement, which also was not evident on the original scans after their stroke or trauma, but occurred roughly two to four years, or two months to four years after the original insult about the same timing as the ocular palatal myocles. It's not clear what causes this. Some papers I read thought that it related to abnormal discharge from the Purkinje cells in the flocculus. And in different papers, I also read that the original lesion may be in the ipsilateral dentate nucleus, ipsilateral superior cerebellar peduncle, or the contralateral central tegmental tract. So treatment actually turns out to be pretty difficult. Most of the papers in case reports I read, they tried various things with various levels of success. Possible treatments I encountered were baclyphine, carbamazepine, clonazepam, gabapentin, diazepam, sodium valproate, and memantine. This patient in particular had been on baclyphine without success and was currently on laurazepam. They had started Neurotin after seeing us and as the dose was ramped up, they experienced increasing dizziness without resolution of their symptoms. So in terms of their last note in the rehab clinic, they still had not found a medical solution to her oculopallidomyoclonus. Some people have tried Botox and or surgery, including resecting muscles and attaching them to the periosteum or large recessions of both inferior and superior rectus, in which one case report reported some success with dampening the vertical oscillations in a patient. But of course there would be risks with large muscle surgeries like that as well. In her, I can't think of what you would Botox because she has rotary, vertical, and horizontal movements. Recession, that's what I meant. In some of the case reports, they found medications for certain patients, like some of the medications listed here that seem to dampen it or nearly remove it. So it varied for every patient. In the case reports I read, some had modest improvement and some had actually significant improvement. Alright, Dave DeMille.