 So I guess I'm introducing myself. I'm Lloyd Williams, I'm one of the second year residents, and I'm gonna try to go through this relatively quickly so that there's time for discussion. This patient was not presented, seems there was some confusion. We were unable to even get an adequate exam in the pediatric clinic, so it wasn't felt like it would be possible to bring him in and for any of you to get an adequate exam with so many people. He was previously presented by one of the medical students, but since then, more information has been acquired, and also a lot of people were away at the academy, so Dr. Greese is hoping that people can offer some suggestions. This is a four-year-old male who presents with, who presented very light sensitive and his left eye had a red eye, a lot of eye rubbing, squinting, perhaps some clumsiness and some changes in performance. He'd had an eye exam greater than a year ago, where the findings that I'm gonna show you were not seen. He has a past medical history of hydrocephalus and a past ocular history of congenital iris and retinal coloboma with microaphthalmia in the left eye, otherwise an unremarkable history. We were unable to get a good visual acuity. He doesn't cooperate with the exam. He has some evidence of a cleft lip hyperteleurism and a small eye on the left, so we scheduled an EUA. On the EUA, his pressures were normal, and a vascularized mass was found in the anterior chamber with a hyphema. There was no view of the iris or lens and no view of the posterior chamber. And at that time, our differential diagnosis included retinoblastoma, persistent fetobasculature, medjiloepithelioma, uvidus, toxocara. From two weeks later, a repeat EUA was done. The hyphema and anterior chamber mass were still present and there was still no view of the fundus in the left eye. The exam of the right eye was basically normal. And the patient was referred to the shield's at will's eye. Laboratory tests were also done. Toxocara was negative. ESR was one. Chem 8 and CBC were roughly normal except for a low hematocrit. HSV IgG was negative. I'm not sure what the significance of a positive IgM in this particular patient is. So they were evaluated at will's eye by Jerry and Carol Shields who did not think that the patient had retinoblastoma or medjiloepithelioma and that their thought was that this was most likely a lateral persistent fetobasculature and they suggested serial ultrasounds and enucleation if the eye became painful. During one of the EUAs, we also did an ERG which was flat. So it's our thought is that this eye has very little visual potential. Sorry about the typo here. If it is medjiloepithelioma, the Shields thought that it would be possible to follow it without risk of extraocular extension. And so their differential diagnosis, although they thought medjiloepithelioma epithelioma was less likely, their differential diagnosis included persistent fetobasculature and medjiloepithelioma. They thought that this eye was likely headed for glaucoma, had a poor visual prognosis, that a fine needle or open corneal biopsy might be possible. And they thought if this were done in enucleation it would also be a reasonable follow within roughly a week of biopsy. We did another EUA now five weeks after presentation, after the patient returned from Wales and found it still a normal IOP with a new sheet of yellow-white tissue across the pupil. The mass was still there. The hyphema or mass maybe enlarging is difficult to tell and I'll show you some pictures in just a little bit. Whether or not this is increased size of the mass or a consolidation of the hyphema, still no view of the iris or lens or posterior pole. I'll show you also ultrasound at MRI, but a brief summary of them is that there's no unequivocal calcium. The eye is in fact small with a flat AC and a hypervascular AC. Posteriorly there may be a persistent hyloid artery. So here's a, I'll just go through four pictures which are pretty similar of the anterior chamber. This is from November 10th. This is November 8th. I'll go through them in this order. So this is October 25th. You can see this mass. This is, these vessels are deep to the cornea in the anterior chamber, not on the cornea. This is, I'm sorry, I don't have the right order here. This is the first picture, 10, 8. This is the second picture, 10, 25. So that's the difference there. And this is the third picture, 11, 10. That's correct. It's anterior to the iris, posterior to the cornea. In particular, it's difficult to see whether or not this one is in fact growing or if you're just seeing more of it because the hyphema is changing. This one appears to be growing as well, although that could also be consolidation of the hyphema just showing you more of the mass that was already present. And so then this is the most recent whereas you can see that this is, in fact, more prominent than it was in this image. So the ultrasound, these are from Dr. Harry. This arrow represents the lens and this represents a peripheral vitreous membrane and a tuft visible on the optic disc. Flat AC, elongated ciliary processes. A vitreous membrane with fibrous material on the optic disc. And thickened cornea in the area, perhaps a fibrovascular membrane. This is a CT scan, which doesn't show any clear calcium here in the left eye, which is smaller. This is a T1 non-contrast image where you see thickening here or a membrane. Here's a T1 fat set. You see the mass here. And here's a T1 fat set post-contrast. Does anybody wanna see any of those images again? That's been done and that was pretty flat.