 Good morning everybody happy to have another great Grand Rounds. I know this is a very exciting one. I've had circled in my calendar for a while. I'm Brandon Kennedy and one of the PGY-3s I will be moderating today. Up first we have Dr. Liang coming to us from New York, presenting a case presentation and a review of optic nerve sheathmen and genoma. Please welcome Dr. Liang. Hey guys, thanks for inviting me to these Grand Rounds to speak. So spent a month on the neurophthalmology clinic last month, which was really great to see all the pathologies that we see also in the hospital with our patients. So this is one of our patients that our neurosurgery team here saw first and then we, Dr. Warner have followed up in clinic. So I'll just get started. So we have a 45 year old female who came to us through the ED presented with seizures. It's about like more than six months of headaches, blurry vision and really not any significant history. That's a concern. You got a scan on a mission. So you can see this is Axioscan of T1 with contrast. You can see here as we're going through that she has multiple meningiomas notably in the olfactory groove and also in the left spinoid wing. That's extending into the, into Meckles cave and possibly the carotid sinus. And then you can see here in the crown a little better. We didn't get any optic any or MRI orbits at this time, but you can see that kind of a lot of cause of possibly her blurry vision is stemming from these from this obvious compression. She doesn't have any notable family history and she her symptoms were relatively benign until she presented to us. So she was admitted to actually the Huntsman in August. We had ophthalmology come in, evaluate her. She did have bilateral optic disedema. That was notable. And then we pursued a section of the two largest meningiomas that we had seen or like the meningiose at that time, but in the left spinoid wing that was likely causing compression in that region and then also in the olfactory groove. At that time, during the procedure she didn't know we did an anti tear left side of crime and deck to me to respect this left spinoid wing mass and we had not seen grossly any evidence of extension into the optic optic nerve canal at this time. And she had came out of the surgery really nicely came fully intact which we did note that she did have continued to have this new six palsy likely secondary to to the procedure. And that we started to we followed and referred out patient to Dr Warner, and she did nicely as she left to rehab. So, when she we, when she was re evaluated and rehab she was found again to have this six palsy minus four and the bilateral disedema was improving. And then this is just kind of what axial images of seeing the before T1 contrasts before and after. And so we got majority of the mass out with probably some minimal edema this time. So, she followed up in clinic with us in October and their ophthalmology. Basically from assessment she does have she did have a slight point three APB. Otherwise she was pretty much intact no pressure to her eyes, and her visual fields were full. She did have this evidence of is a is a hyper isotropia. That was worse on left gaze and confirmed on Maddox right testing objective subjectively, but improving on from fire to from when she was with us and in the war. In terms of her edema she still had some indistinct margins but improving from from post pre op. She's again her visual fields were pretty good she did have on her Humphreys, a slightly enlarged blind spot on the left side, but nothing that was too much abstracting. Too much of her visual fields that she could really appreciate so as much improved again. Now looking at the scans before and in the pre operative MRIs unfortunately with no evidence of, or with not getting MRI orbits, you know we we couldn't understand or assess whether or not there was true extension into her orbital canal at that time. So we did pursue to get MRI orbits of contrast to further assess whether there was extent secondary extension of the meningioma from the lesbian wing into the canal. So before we kind of go through the her pre op imaging just wanted to kind of go over the optic nerve she's meaning meningiomas which is a very rare, relatively rare diagnosis and pathology. Usually the classic triad that you'll see is visual loss optic atrophy and evidence of retinal carotid collateral so typically this triad even though it's kind of known. And the diagnostics for this type of meningioma is not always presented in this fashion, you may have only one or two of these three. These symptoms to kind of give you perspective it's about only one to 2% of all meningiomas that we see. And what's more rare is for you to see a primary optic nerve she's Leo meningioma. Typically, if it's primary to rising from the capsules of the rachnoid that surrounds the optic nerve itself and then accounts for about 10% of all orbital meningiomas so even smaller fraction of what the optic nerve she's meningioma is already account for in in the diagnosis. More commonly we do see it originating intracranially. Again, when it when we have these olfactory groove or left spinae wing meningiomas that easily can extend into the cavernous sinus and into also the carotid canal, the optic canal. From a review paper you can see just for examples on what you would see on MRI so on the, on the right side here you can see the primary optic nerve she in meningioma and this evidence of hyper hyper intensity on T one contrast, basically just showing this encapsulation of Iraq cells growing this primary primary meningioma versus when you're looking at a patient with a known meningioma and you're trying to assess for extension into optic canal you can know I would, you can typically trace it from the, the, the cavernous sinus and then into the canal itself things you can see it invading. To, to kind of also show how difficult it is to actually diagnose this pathology when there's not any other obvious signs like having in this case having seizures and headaches. The group at Emory did do a long term retrospective study on assessing the, the delayed diagnosis of optic nerve she meningiomas and, you know, they've had with 39 patients that were confirmed, having this pathology, it took 70% had about delayed diagnosis that could be as long as five years. Most commonly the, this type of error was due to, you know, failure to assess or pick this up during clinical exam. And then second most common error was assessing the imaging itself. And a lot of these patients that they had diagnosed majority that were misdiagnosed were thought to have optic neuritis so this is about, you know, treating what you supposedly think of optic neuritis for about a few years before basic hammering down that diagnosis. So I think, you know, with the rarity of this disease it's still very difficult to diagnose. But I think what's important to note is that, you know, with any concern of pathology especially with symptoms that are not consistent with optic neuritis it's important to one always get the MRI imaging and initial presentation and to make sure that you know it's read by multiple radiologists and confirmed if it's not fully consistent. I think what's also difficult about this again is this diagnosis is very elusive in the sense that patients typically have slow compression of the nerve itself. You have gradual decline in your visual acuity at times based on what at times with the diagnosis you don't typically have to treat immediately, especially if they're not having known symptoms. But the for the basically the main diagnosis treatment for this would then be stereotypical radiotherapy SRS versus surgery itself. And there was a lot of studies out there that really confirm the use of fractionated. Stereotactic radiotherapy to treat optic nerve chief meningiomas in this study, one of the larger studies to date done in Germany here. They had a patient sample from the 90s to 2005 with 109 patients, 113 eyes with about about 30% of them being primary primary meningiomas versus secondary and we're all given fractionated stereotypical radiotherapy at a dose of about 54 gray. You can see here that there was relatively good tumor control about 100% in within the first three years and also 98% in the in the following five years. They typically had patients typically had 30% of them showing visual deficits with it improving from 33% to about 20% in in that one I affected. And then, typically, if there was contralateral visual deficits, there was an improvement from 10% to 6.7%, which was not necessarily significant but important to note. So, I think what's important to know is that, you know, when you have this diagnosis of an optic nerve chief meningioma. The idea of treatment is very standardized in the sense of a important referral to radiation oncology to assess, but still requires a multidisciplinary discussion. And again, I think, you know, for our case for our patient who had a secondary possible secondary optic nerve chief and meningioma, there are times that, you know, surgery can play a good role in it. And that's when that depends on basically the presentation of the meningioma itself and the, the degree of an invasion they, they have into that canal. So when, when there's evidence that that there could be a safe dissection for an arachnoid plane. It's easy to then essentially peel off that mass itself versus when you have a primary meningioma, there's very poor surgical planes and difficulty to basically parse out the tumor itself versus the nerve, which causes a higher risk for permanent damage in the optic nerve itself. In this, in the secondary meningiomas, we've, there's also better, a better understanding of when surgery is appropriate is when you can basically stratify your cases into where the meningioma is compressing the nerve itself, whether it being intraorbital, conicular, or in the, in the cystic, cisternal portion of the optic nerve. So typically when it's not as fully invaded into the optic into the orbit itself, there's a better visualization and surgery and improved come decompression, especially in this. This review that stratified these cases showing that they, they did compression in the cisternal portion of the optic nerves for 50% of it. Excuse me, they had compression in the system portion of the optic nerve showing 50% of the patients having improved acuity, and then compression within the optic canal itself when it's present only 31% of their patients had improved. And this is when compression of the intraorbital stuff, there's only 11% improved. And this is accumulation of studies in a systematic, systematic review that basically compiled all these patients across multiple studies to assess this. And so for our patient here, you can see, this is her MRI, fortunately for her as this is the post op about in November. And we don't see, we did not see any evidence of extension into the optic nerve itself. And it looks like the her recurrence has been pretty minimal at least three months from surgery. And this is the corona just to visualize the orbit. So this is a, the corona slice of the MRI orbits itself. So, at this time she's getting stereotactic radiotherapy for her other meningiomas. And we're going to continue to follow up outpatient in clinic. So that's all I have, but is there any questions you guys have. So I didn't see a specific comment on the reason why I think there's more design notes. I think with compression you can have, there could be a confusion of what patients are describing as headaches versus I pain itself. In that paper, it is not clear how much they delved into the thinking behind the prior misdiagnoses, rather than this is the presenting like the referral diagnosis. And, you know, I think that when somebody's making a referral, you know, and they're sort of shouting out to their person, what's the diagnosis. I think you're right us. Yeah, you know, it can be a little random. I was just curious about that systematic review. So I think, so this paper was neurosurgery based paper so I think it was more, they didn't have the specific data of the community itself of how much there's improvement I think it was unclear when in the review itself the threshold of what they did based on a proven acuity. There's a lot also she's from a patient before. Irony of this microphone height is not lost on me for this ergonomics talk. I apologize. How do you flip this again. All right, so I'm going to be talking about musculoskeletal injuries and musculoskeletal injury prevention, especially for ophthalmologists. So like Tyler, my journey with this started also as a third year medical student and ergonomics and surgery is something that I first heard about as a medical student on my general surgery rotation in a grand rounds presentation, which was very lucky, but also an atypical experience because when a group of general surgeons were surveyed listed grand rounds is the least likely place to obtain ergonomic knowledge. I do not want that to be the case for the Moran. So I want to just start with a brief representative case. This is Dr. C. She's a 33 year old ophthalmologist she's one year into attending practice. She's caring she's affable. She's not one to inconvenience a patient or colleague. The patient is sitting too low or sitting too high she goes low looks up and vice versa if the patient is too low she goes high cranes her neck over to see that bar peripheral retina. When she comes home after a long day she slumps into the couch her neck aches her back aches but this is all a mark of an honest day's work. Five years into a career she notices her right hand starting to get numb at the end of a long day of cases. She has suffered for 10 years and she has persistent cervical and lumbar pain. She started cutting back her or cases due to her pain burden, and is starting to worry about her longevity and the career that she loves and worked so hard to obtain. Eventually she goes for a scan to your surprise she has multi level degenerative changes in her cervical spine and also canals stenosis. Two years of trying to push through things she just can't anymore and undergoes a cervical fusion and starts planning for an early retirement. Although this case is fictional those cervical images are all from real prominent practicing ophthalmologist in America. And I worry that this story is coming to represent the arc of the modern ophthalmologist beginning even at the earliest stages of training. And that same fear is beginning to take root, I think in our community, broadly, and perhaps editorial titles like this one are not overly sensational. I think we've known anecdotally for a long time that being a practicing physician places strain on the body, but the first real documentation about musculoskeletal injury rates and ophthalmologist came about in the early 2000s. Since then we've discovered the rate of work related musculoskeletal injury amongst ophthalmologists is about 50 to 75% of all ophthalmologists, and across all those studies approximately 15% of ophthalmologists plan to retire early due to musculoskeletal pain, and roughly 50% of ophthalmologists report decreased productivity due to musculoskeletal pain. And this is because time spent in the OR, not age, height or duration in practice or time spent in clinic during the day is the best predictor of developing musculoskeletal pain. And I care providers develop musculoskeletal pain at a higher rates than our family medicine colleagues and other non procedural colleagues. We have three patterns we experience. Most commonly the cervical spine as we hyper extend and flex our next sometimes with heavy headwear on this produces muscular fatigue. There's dis compression degeneration leading to things like cervical apathy, articular surface degeneration and canal stenosis. We hold our lenses and instruments in awkward positions for prolonged periods causing micro ischemic injuries of the shoulder that lead to micro and eventually macro tears of the rotator cuff. We rest our elbows hard on hard tables compressing the ulnar nerve causing it sheath to inflame thicken and fibrose our wrist cock as we hold lenses and surgical instruments that we squeeze too hard. And we slump in our chairs, both when we are with patients when we are documenting or sitting in grand rounds. In essence, all of these injuries can be boiled down to too much force over too much time with not enough healing and not enough prevention. The average head weighs 10 to 12 pounds, give or take the lightest indirect headset on the market weighs 1.1 pounds. If you remember back to your physics classes, the torque produced about a point by a weight on a lever arm and a gravitational field is multiplicative. So every pound at 60 degrees of anterior head tilt is being magnified by a factor of six at your cervical spine. So your 10 pound head produces a 60 pound force moment at your cervical spine and your 1.1 pound headset is like hanging an additional six pound weight from your C spine. I think we can all appreciate this is a significant amount of force but how does that translate to chronic dysfunction at the level of the connective tissues specifically the ligaments and musculature. The next several slides show figures from a very elegant biomechanics study of the human super spinous ligament that connects the apices of the spinous processes from about C seven to roughly L three or L four. And what we can see is how tension within that ligament builds as it's loaded. So, due to the heterogeneous lengths of collagen and elastin fibers that are in those ligaments, ligaments undergo a recruitment process where as the ligaments stretch fibers are progressively recruited up into the point represented here by x three, where all the fibers are at maximum length and every additional bit of tension begins to build exponentially as forces applied in the ligament stretches. But this that was just showing the ligament during the loading phase at a set velocity and gives the illusion that these are purely elastic tissues in reality they're visco elastic tissues. And the tension in them produce produced in them rises as a function of the loading rate. So here on the left what we see is that when we double the speed of ligament loading the tension in the ligament is roughly 33% higher for the same amount of displacement. And moving quickly and moving slowly are not force equivalent processes for your ligaments. Additionally, when unloaded after an initial stretch ligaments do not have perfect memory. They have hysteresis and they begin to slowly elongate over the course of prolonged or repetitive loading. What this means is this progressive lengthening phenomenon is called creep in the musculoskeletal biomechanic space. So in this top figure you can see that as a constant load is applied to the super spinous ligament over a period of 20 minutes say by your 10 pound head, leaning all the way forward during a cataract case. The length of that super spinous ligament progressively increases, especially a small micro tears in the collagen begin to accumulate. That's not the case with this represented by the arrow here. Even eight hours later the length of that ligament has not returned to its native position. And over those eight hours that ligament cannot perform its proper function of protecting your diss from the damaging effects of hyperflexion. Not only that but the ligament is releasing inflammatory mediators as it stretches and tears that when transiently present are helpful in signaling the ligament to hypertrophy and become more robust, but when present chronically cause a host of deleterious effects and pain. And this bottom figure here shows that if you repeatedly load the ligament over time in multiple increments of loading, say 10 minutes of a time like when you're doing cataract cases all day. The cumulative creep in those ligaments is even larger. We also know that ligaments are appropriate receptive sensory organ they relay their length and degree of stretch to the surrounding musculature to give those muscles information about how tense or relaxed they should be so when you bend forward. All those inter spinous ligaments are sending information to the erector musculature in your neck and back to fire and help support the added weight of this anterior tilt. And we look at overlaid EMG is at the surrounding musculature during ligament loading what we see is that the EMG signal jumps up quickly at time zero when the ligament starts to be loaded and then slowly tapers off as the ligament length starts to creep. But that tapers interrupted by small spasms that correlate temporarily with micro tear formation in the ligament. And at around 20 minutes here when you stop loading the ligament, the EMG enters a phase of hyper excitability where the muscle feels tired and is prone to spasm. After that, near the eight to 10 hour time point there's so called morning after effect where the muscle tone is greatly increased and spastic, which is, which is why one may start to experience painful back spasms at the end of a long 24 hour call that persist all the way into the early morning or beyond is only after a period of prolonged rest, unfortunately, far longer than our inter work daytime that the muscle tone returns to its functional baseline. So none of that's good, and none of that is encouraging which is why I want to shift gears a little bit and talk about prevention. So the National Institute of Occupational Health and Safety defines four drivers of work related musculoskeletal injury and really number three is the one that I view as the most modifiable. When I think of behavioral factors in our world, I think about ergonomics primarily the way we move and position when we're working and ergonomics are very powerful. A good way to prevent excessive loading on your ligaments is to not excessively load your ligaments by putting yourself in unnatural positions. The Academy agrees and in 2017 they formed a task force on ergonomics that developed a course for ophthalmologists that I will link to you all it's available on the Academy website and it's something you can actually take for CME credit. This detailed presentation that they give has way more information in it than I can cover today so I highly suggest that you review it on your own time but I'll cover some of the more salient ergonomics points starting with the use of the computer. This is all of us at some point or another throughout the day back slouched the splayed out. Try to be mindful to have your computer screens at eye level sit on the full seat sit up straight the flat on the floor with the hips at 90 degrees. And the slow lamp to can be a biomechanically dangerous device as we alluded to before, being able to get closer to the oculars is a primary importance to employ all the basic principles of good ergonomics. To validate the patients with their chair can clear under the footrest. And if available, trying to shorten your slow lamp table to allow yourself to get closer to the oculars or purchasing your own extenders or eyepiece angle adapters. You can also get longer head straps so that the patient can be closer to you. Also try to use a soft pad under the elbow when using lenses and try to avoid the use of a hard lens case. Put down your carpal tunnel with hyper flexion or hyper extension when using your lenses. And don't and you don't need to crush those lenses with your fingers with ophthalmoscopy bring the patient to you as much as you can before bringing yourself to them. And in the operating room set the IP slightly below the eye height so you're not hyper extending flexing. Your chescopacular angle is about 20 degrees, your wrist should be rested as to not rely on the shoulders for stability and your arms should be at 90 degrees. And foot pedal height should be leveled possibly with towels as to not cause asymmetric leg height and hip stress. Now ergonomics are fantastic and important part of the injury mitigation strategy but they're not the whole story and I really want to focus on active prevention as well. This is a kinematic motion analysis study that uses different mannequin positions for retinoscopy and refraction and the results are kind of sobering because by changing mannequin position for optical ergonomics during retinoscopy and refraction you can see that statistically. They were able to reduce the time and a non neutral neck position, but it's maybe a 10% overall reduction at best. I think that this change would be more profound for more static tasks like slow amp exams but regardless ergonomics are not the whole story and they only get us part of the way there. Ideal positioning at all times is an unrealistic goal. You all come in all shapes and sizes, and we're going to have to make some positioning concessions in order to work and operate together. The reason we need active modalities as well they're going to allow for musculoskeletal strengthening and ligamentous hypertrophy that are going to buffer us through some of those inevitable moments of strain. So to this end I'll be sending out a guide to everyone with a whole series of resources and exercises that I have compiled through my journey trying to overcome some of my own biomechanics issues and things I learned during the recovery from a lumbar spine fracture that I had in college amongst many other injuries. I don't have time to go through the exercise individually here but my intention with the guide is to have a central resource where people can compile ideas to come up with a focus routine that works for them that they do for maybe 10 minutes a day or even 10 minutes three times a week or once a week. This is intended to be a no pain no gain guide, in fact it's quite the opposite and if you have a pre existing musculoskeletal problem, you should seek out professional guidance from a physical therapist writer starting a regiment. In the last several minutes here I'll just touch on some of the most high yield resources that will be in this guide. So I think that the AO ergonomics best practice course that was mentioned above is a great starting point. This is a variety of introductory strengthening and mobility exercises for the upper extremities C spine and the low back and I think that even if you've just did these things and nothing else you would see a great benefit from that. This is another good one. This is an in office yoga sequence that's made by doctors Palma and Gottlieb is available through the Academy and I will also link it in the guide. This is an ophthalmology tailored and they give you some useful ideas for things that you can do in the privacy of an exam room or in your office. And I think this is one of the most high yield resources that I have used. So Peter at T as a Hopkins NIH trained trauma surgeon and surgical oncologist who is now moved into kind of the longevity and prevention space and he has a whole seven part series. He has a whole host of cervical thoracic and upper extremity exercises that are designed to combat much of the anterior head tilt and chest tightening that we are plagued by as clinicians and surgeons. And then one of the physical therapists that I worked with as an undergraduate had gone through Princeton's athletic training program and shared with me this amazing guide which I will link to you all as well. This is a selection of lumbar mobility and strengthening exercises that are stratified into beginner and more advanced categories. And lastly Dr McGill Stuart McGill in Canada he's one of the preeminent spine biomechanics researchers in the world he's published hundreds of papers on spine injury and prevention and over the years has kind of distilled out or identified three exercises that he considers the most safe and high lifting back injury and for stabilizing the L spine, the so called big three, and instructions regarding how to do those and at what interval be provided in the guide as well. And my last bit of advice would be to just get out and move as much as you can, we're blessed to live in a place like this and have a culture that values motion. This is one of our former retina fellows Joe seminar, one of the crew Lars in the central I just want to say special thanks to Amy Lynn for talking over some of this stuff with me and then also my dear friend Tom Holman, who's a physical therapist back in Rhode Island he sent me a bunch of videos of himself and his clinic doing various things to help in construction of this guide. So thank you. Great addition to our training, no versus adding additional things on like Taco Tuesday and kind of the stress so having a wellness thing in addition to not actually having time off for wellness kind of relating to the Tyler study versus our own accountability. I think you're trying to navigate that process through building a scratch. Yeah, I think I think we're going to be here. And the program that I have here is the people who want to have different games or as a whole of these kind of things. I think it's, you know, like the closet. These things I think so are, which I would stress that one, one quote that always is really something he is LeBron fans. And I realize here on health prevention, that's because it's worth it. I'm like, it's really is a huge investment here and you are, you know, losing five years of your career. Yeah, it's just great to talk a lot about the structure of events that happens when you're in these operations. How does that pathological stretching that you're kind of referring to the stretch. Yeah, it kind of has to actually do with a lot of the employer mediators that are released. So, and the duration of time that you should be exposed to that. So, you know, you'll get wiggamentis loading the kind of pro and binary factors that are releasing kind of the first six minutes of that wiggament being loaded or actually pro, pro, pro, high perjury. And after about that six minute time point, which are releasing planetary war to wiggamentis to the generation. So it's really being loaded for too much time. And that's why kind of doing incremental exercise where you're kind of within that loading period where you're releasing the kind of pro and primary mediators. I have a second question for those of us like outside standard deviation of the average height. And is there any like, or resources for even additional things you can use. Yeah, yeah, I'm going to play a lot of that. That's why I'll send all that over the weekend. I know this is interesting to you because obviously you're set up for this afternoon being all the threads that have been pending. One of the things that's going to be really helpful down the road younger guys is that companies are looking at making getting where my to make the heads of displays that that's going to take away a lot of musician. The company in Israel that took the heads of display from the fighter pilots, and is incorporating them into a microscope you are you'll literally burn up the DCR headset and operate for that. So I think there's going to be technology that's going to help you guys. And, you know, when you're in the operating room, you know, it just takes that extra 10 seconds to set everything up ahead of time so that you've got to actually begin with it. I think we don't stress that enough isn't that you want to, you know, when you guys are getting set up to do that we really want to stress the positioning your legs, your feet, your hips, your neck. So we're not doing that please take the extra time we're going to be sure to do that because anything that you do now is going to help you 30 years from now. Ethan did you say there was one online one question. Yeah there's there's two on the chat. There's three on the chat now. I would say also just the dilemma for me has always been taking that extra little bit of time to make sure I'm comfortable at this land for whatever it is. And I have to say I kind of always go for the time I mean I just kind of, I have adapted my body to everything else. It's all over the years. You can just invent yourself kind of to take that extra bit of time, like putting on your mask on the airplane, you know, first if you don't take care of yourself. You know, later on you won't be able to take care of people so still working on it. So when you consider putting this guy on the back for us, absolutely anything about that's where the best ways to put this review and I think about. Awesome. Well, there's no other questions. Thank you. Jordan for the great presentation obviously very important discussion, looking forward to having those resources kind of in our hands and online as well. Thank you everybody for joining really signing off.