 See if there's time left to do the other They're both relatively short so this was a patient that Last year when I was on Neuroophthalmology rotation came into triage clinic complaining of double vision and some headache and maybe a little facial numbness on the left side and Was referred down to us and we took a look at him and Came to find out that three months before he came to us He had had an episode of double vision and he went to a you know a local eye doctor and got a new Refraction and actually his depulpia kind of went away and so he kind of let it go for a while and About a month before he came to us the double vision came back and then the numbness began a week before he Came back came to us and then his left eyelid started to droop down And that's once the headache started he decided it was time to come in his past about history and and other histories were essentially negatives healthy guy other than a refractive error no ocular history and He denied any swallowing difficulties or breathing difficulties no fatigability with Either systemically or with is a double vision and had no history of a head trauma or eye trauma On exam it was 2020 no APD and the pupils were equal I did have a minus two deficit and up gaze the left eyes his color was full He maybe had some mild red desaturation left eye Conflict visual visual filter full he did have a ptosis and a left hypotropia measured at 35 diopters and a subjective numbness to his left lower face kind of in a v2 v3 kind of distribution Again on also an exam he did not have a Kogan lid twitch and no fatigability and When you tested obicularis oculari Strength it was equal and normal And this is a picture he took of himself and he let me he sent to me for use with this So this is attempted up gaze As you can see in the right eyes he's looking up and you can note the ptosis on the left and the Hypertropia the deficit and up gaze I should say so from the history an exam we came up with a differential diagnosis Which included you know a third nerve palsy either pupil sparing which you know he had equal pupils at this time or possibly a An evolving third nerve that would eventually involve the pupil And I thought it'd be useful just to go over kind of the the different causes of these if you can kind of Split them up Often times the annual an aneurysm will give you a pupil involving third nerve because the the parasympathetic fibers run Parallel and right next to the posterior communicating artery as the third nerve travels parallel to that Vessel a compressing mass of some sort would Potentially more often give you a pupil involving third nerve a trauma uncle herniation Ptoteri apoplexy there's other you know parts of the history though. It's Suggest that and a zoster infection Pupil sparing third nerves are often due to ischemic Microvascular disease this cavernous sinus syndrome Arteritis such as giant cell arthritis and aberrant regeneration can give you a third with a pupil sparing Other items in our differential included myasthenia You know as we were testing for it with the cogumlet twitch in the obicularis weakness thyroid eye disease chronic progressive external ophthalmoplesia and Possibly orbital pseudo tumor although they didn't have any of the associated symptoms that would suggest these diagnoses So I thought it would be useful also to discuss when you image do get obtain an MRI Head and neck for these patients orbits. I guess any pupil involving ophthalmoplesia They deserve an imaging if it's a pupil spit, you know if the pupils normal as it was in our case You you would decide to image if they're younger than 50 unless you have you know a really clear Ideology for ischemic, you know, micro vascular problems long-standing diabetes type 1 diabetics or Uncontrolled hypertension for years and you may decide even if they're under 50 to hold off on imaging An incomplete third, you know Which in our case, you know with this patient would fit in it could be an evolving third that eventually will you know Give you an anisecoria Any other cranial nerve involvement would deserve imaging Children less than 10 or symptoms if they've been long-standing with no improvement you can certainly Just fine imaging So in our patient we obtained an MRI which was normal and also a CTA head and neck to evaluate evaluate this Perfusion and it was also normal a lab lab tests That you could order would include a CBC blood pressure fasting blood sugar HB a1c sedrate CRP and platelets and Tensilon test And other things that aren't on here acetylcholine receptor, you know tests To rule out myasthenia. So in our patient He did have an elevated white count and You know, this was this was all These first let's see one these first four Bullets were obtained on the day of evaluation because we sent the patient over the emergency room to get imaging and at the same time Recommended these tests. He was admitted because of his elevated white count and he obtained an LP because of the headache and the facial numbness and these other they were worried about a central nervous system infection the LP was normal and then Subsequently as as his hospitalization progressed they did obtain acetylcholine receptor binding antibodies Which was high blocking antibodies were low, which is kind of characteristic for Most myasthenic patients that the binding antibodies will be high but the blocking antibodies are less commonly found We did not get musk antibodies So his treatment actually he resolves spontaneously and You know, they sent him home with this diagnosis of myasthenia He does occasionally get diplopic by the end of the day and I think he's had subsequent follow-ups even since then This was about a year ago. Stosis went away. His pain resolved spontaneously CT chest was normal and we did get him to the neuromuscular folks for management of his symptoms and treatment and so this was a afterwards as Tosis had resolved his depopulated resolved and just overall looked better than that first thing so Just a quick review on myasthenia Oftentimes there is fatigability. It's one of the hallmarks Although when he presented he didn't have that so it goes to show you that there's a lot of variability with with with this finding women are affected more often in men it tends to be a Disease that affects the middle-aged individuals Often 85 to 90 percent of patients will have ocular disease and it often will show up before the systemic symptoms So ophthalmologists and optometrists are often the individuals to first find this 15% will resolve spontaneously Without treatment There's an associated with association with thymic hyperplasia and thymolmus, so you always need to get a CT of the chest and and the impotence to To remove a thymolma or an enlarged thymus is is low It's also associated with other autoimmune disease graze room to it the most sensitive test to the to Diagnose myasthenia is the single fiber EMG It approaches I think 95 percent sensitivity There's the tensilon test edrophonium or prostigamine which has a longer half-life Which can be performed in the office, you know under controlled Conditions need to have atropine, you know around in case they have a significant adverse reactions the acetylcholine receptor antibody tests are very useful as they were in our patient with with the Different types that have different levels of sensitivity The other things you can perform in the office is the rest test where you have them Just lay their head down close their eyes for 30 minutes and give them a chance really and and then Once and then have them sit up open their eyes and notice if there's a difference in the ptosis It's or the ophthalmoplesia the ice test is another way you place a you know cool washcloth with the ice bag You know on top of it and give them a good five minutes of of this cold therapy And then again measure their ptosis before and after to see if there's an improvement. I Think that's it with that any questions or comments from faculty Yeah