 So Terry we're going to talk about between me and Julia and I guess someone Eileen. Yeah she did her part sort of. So originally she did do a video on the problem of being like previously worked in the box to lead in the bank and she hadn't responded over the weekend. It's totally fine. Even then to that one she was fine. So the BCSC definition of what functional vision loss is it's non-organic or non-physiologic vision loss complains of visual symptoms that no physiologic or organic basis. There are four major categories. They include an aphor and visual pathway where the visual acuity or the visual field is affected. The oculomotility and alignment pupils and accommodation or the eyelid position and function as well. Some of the associated psych disorders that the BCSC wants you to know about include malingering which is the willful feigning or exaggeration of symptoms for secondary gain. It's often monetary. Munchausen syndrome was feigned or induced physical damage for secondary psychological pain such as getting attention from a physician. And hysteria where you just have this subconscious expression of non-organic signs and symptoms. And often these patients exhibit behaviors where they're unconcerned about their symptoms. So that's usually like the distinguishing feature for hysteria. So what's the significance of functional vision loss? Well you have to watch out when you suspect functional vision loss because you don't want to become the person who's working against the physician. You really want to try to help them out and try to figure out why they're acting this way or why they're having these symptoms. So it's important for the physician not to work against the patient but actually try to work with the patient. And don't stop at the diagnosis. Treat it as if it's a real diagnosis and that they need the proper treatment as well. So the diagnostic approach. So establish good rapport with the patient from the starting exam. Don't start with like are you really sure that you can see you're not at both eyes? It'll just be normal. Perform H&P assuming that the patient does not have functional vision loss. Treat it as if it's something real and take a full H&P. Treat it seriously. And then pay attention to whether the history does not make sense with the level of vision loss. That's when you should start suspecting whether or not functional vision loss is actually real. And during the history also you also want to see, you want to keep a close ear to whether or not there's potential secondary gains. So if the patient starts focusing on impending litigation or disability determination rather than on the diagnosis and the treatment. That's a little suspect. And you should always try to implement the everything counts principle where each piece of information from the moment that they make the appointment all the way to the end of the appointment is really important. It helps to direct like what you exactly want to do during the examination. And in the tertiary neuroophomology office setting it says in the BCSC that patients who wore sunglasses were more likely to have non-organic vision loss. But I don't think that's entirely true because I know that Katz says that there are many patients with a real organic disease or a photophobic that wears sunglasses to the appointment. There was a study out in Atlanta by the other very large neuroophomology group that if you wore sunglasses when you came into the clinic, likely that if you had any non-organic vision loss, it's higher than if you had patients who did not. And then there's sunglasses on. And the three ones are obviously very different from the dark sunglasses, but you have to kind of, with the dry eyes symptoms that we have in Utah, you have to be aware of the fact that sunglasses is not always a sign of appointment and vision loss. So some of the general behavior and ocular capabilities says things that you want to pay attention to. Can the patient ambulate into the room, into the chair? If they say that they can't see at all, you're out of either eye, but they're able to do that, you know, that's a visual task. Can they find and shape the physician silently, outstretched hand on arrival? So you don't say anything, but you just reach your hand out. If they reach out their hand as well, you know, they can see at least that. And then is there a problem with the non-visual tasks, such as signing it at the front desk? Focus on whether the exam does not make sense with the level of vision loss. And you always want to use misdirection, and we'll go over some of these techniques. So you're pretending like you're testing vision in one eye, but you're actually testing the vision in the bad eye, you know. And then diagnostic confirmation usually is that the patient does something that should not be possible based on the stated symptoms. So for the next part of my talk, I'm going to go over some of the tests that you should implement when somebody complains about monocular vision loss, right? And then Julia, I think, is going to cover the binocular vision loss test. So first thing you should check for, obviously, you know, do a full exam. But the most important parts of the exam include check for the normal pupillary responses. You know, an APD should be present if there's fully organic in the right eye, unless it's post-chiasmal. I mean, not post-chiasmal, but post-past the lateral geniculate nucleus, then you can get vision loss without an APD. But then you also have a monocular prism test with a four-base-out prism test. So what you do is if somebody's complaining about, you know, poor vision in the right eye, say they can't see you out of the right eye, you take a four-base-out prism, put it over that right eye, both eyes should shift towards the apex of the prism, right? And then the bad eye will stay fixed, you know, in that direction, and then the good eye should refix it or converge, okay? If they do do that, you know that they at least have some vision out of that eye that you put the prism over, okay? So that's one way of testing that. You also have the vertical prism dissociation test. You put a four-base-down prism over the good eye. A patient with symmetric vision should be able to see the two objects kind of superimposed on each other. You know, they'll see two objects basically inducing diplopia. However, if there is true vision loss in the bad eye, then they should only be able to see one image. Does that make sense to everybody? And then there's also the fogging test. It's one of the confusion tests. Basically, this is the concept of misdirection. With a four-opter, you put plus-10 diopters in the good eye, and then plano or their current prescription in their bad eye. Then you tell the patient that you're making sure their good eye is still okay. Then you ask, is one or two better as you change the good eye from plus-10 to plus, you know, 9.75? Then you go back to plus-10 while you're leaving the bad eye at the current prescription, and you just keep doing that same, like, oh yeah, you know, is your vision getting better? If their vision does get better and they start reading the 2040 line, then you know that they're reading out of the bad eye. This doesn't work on people that are plus-10 now. Very true. That's right. All right. And then stereo vision testing. Be careful that some patients just pick up on monocular cues. But concept behind here is that binocular vision is really necessary in order to do some sort of stereo vision. So, you know, at least that they're able to see out of the other eye. And then there's the pulveric phenomenon. Can one of the PGY choose to tell me what the pulveric phenomenon is? Go ahead, Lee. So, this is where, because of the generation to say the nerve transmission, you can have a slowing effect, kind of a, it's almost like if you use pendulum, you'll see, that's right. It's due to poor conduction. It's like in the rate of conduction between the two optic nerves. That's why you'll see that the image, actually, something that's swinging back and forth perpendicular to the visual axis will actually look like it's coming back and forth, right? So, with the pulveric phenomenon, you can use this. You place a 0.9 log unit filter over the good eye, tell the patient you're testing the good eye, and then swing the pendulum back and forth perpendicular to the visual axis. And if the patient sees it moving in a circle, then they likely have binocular vision in the setting. And then lastly, all the tests that Julia's going to go over for binocular vision testing, you can also use those for monocular vision testing as well. In terms of management, what do you do? Once the diagnosis is made. So, encouragement and understanding are key. Being empathetic, because a lot of times this is very real to the patient. So, don't just be dismissive. Confrontation should be avoided, obviously. Reassure that the problem is real, and it will resolve over time. Stress that the patient has a good prognosis. And if the complaint is in monocular vision, consider patching the good eye for limited periods of time each day to train the bad eye to see again. If the patient's a child, involve the parents in the discussion, obviously. And then consider how to address the underlying issue. Like, for instance, this cycle really needs to be evaluated. You know, you need to evaluate this patient. Here's our new little guy, Ezra. For those of you who never saw this. All right. Three questions. Name two prison tests you can use to confirm functional monocular vision loss. You guys ready for the next one? Everybody ready? And lastly, Reese, tell me the first one. And then Ashley, what'd you get for this one? So basically what happens if you put the prism over the bad eye, they should both shift. And then the one that the prison's not over should reconverge. Chris, what's this one, Conraddy? You might have actually come in late, so I don't think you covered this one. But, Rick's. You angry? Man. That's it. Yup.