 cornea path and you've got homo you've got homo path so which makes sense I mean that's fine so you won't get it all at once you get it spread out so we're going back to Paris this is the opera house this is where Phantom of the Opera took place that's the roof where he would kind of hang out with the gargoyles up there and this is the um this is where the monument to the Bastille is you know the Bastille day celebrates the start of the French Revolution and of course you know in Paris there's a strike every day I mean so there was like a strike here I can't remember what they were protesting but if you just go there every day there's a strike and somebody's protesting something so it's a big protest there where the you know where the monument was but you know interspersed with all that of course you've got this is a shopping mall so a little bit nicer than fashion place mall if you look and so you look up at the ceiling and they've got this gorgeous stained glass ceiling and all these levels here so you know a bit upscale a little bit as I said a little bit nicer than fashion place mall and this is what it looks like of course you've got your obligatory Chanel ad in the center but you can sit down in there and you can get some you know tea or wine for like you know 30 euros minutes great and here's the ceiling so it's got this beautiful stained glass ceiling so this is right down from where the you know where the obelisk is where all the protests are all right so we're going to talk about the optic nerve and so when you're looking at an optic nerve here you guys all look at optic nerves every day it should have a sharp border it should be flat it should have a good color to it some people say pink some say yellow and any event not white and you look at the blood vessels coming out you know the veins and the arterials you should not have hemorrhages around here should not have elevations so that's what a normal nerve should look like all right so we're seeing a nerve in a sagittal section Chris what stain is this it's a trichrome stain and so how can we tell it's a trichrome three colors very good I can't put anything by you guys on a Tuesday morning so what are they staying what are the two main things that they stain that let you kind of discern things all right so what you want to remember the two things that they may they stay it stands connective tissue blue and it stains what we call mesenchymal tissue red and so if you look at an optic nerve you know you look back here the sclera is blue the optic nerve you know the sheath is blue but the actual axons and fibers coming down here are red and so when you look at the optic nerve and the axons come from the ganglion cells they come through the lamina crebrosa and then they form columns of axons right here I'm like what happens to the axons as they're coming out through the lamina crebrosa posterior what happens to them they get milanated they get milanated exactly so you know the optic nerve had itself about 500 microns but by the time you go to the nerve it nerve behind with all the myelin and the sheaths around it it's about a 1.5 so 1500 microns so it's three times as big and so you see this nice pattern here now we're looking at the nerve and cross section here Marshall what tell me what all these layers are as we're looking at the nerve here in the cross section um you have the optic nerve sheet on the outside that surrounds the entire nerve the peel and the arachnoid with the csf in between and the arachnoid graduations all right so the way I like to look at this my analogy I use is the fiber optic cable so each axon becomes milanated so that's the little fiber optic itself each little fiber wrapped with plastic around it then they form bundles of these axons with little pia around them so that's the fiber optic bundles and then the entire thing is wrapped in a pipe that's buried in the ground and that's the optic nerve sheath so the nerve sheath is continuous with the dura and then you've got your arachnoid subarachnoid space where csf flows your arachnoid graduations are here and then the pia the little piocepti surround the individual bundles of those axons as they're coming down and then of course what is this right here Brad central retinal artery central retinal vein exactly so remember they come through that central artery together that's why you get arteriosclerosis causing central vein occlusions all right what are we looking at right here close up here are you on it and it's the trichromstein with the so here's the sheath here's the arachnoid granulation subarachnoid space look at the little piocepti so this little piocepti send little fibers around the columns of axons and there's the columns of axons running down this is a cross section this is longitudinal now um alley in between these axons running along here the cells are kind of in the periphery along where the piocepti are what kind of cells live in the optic nerve here okay ligard endocytes astrocytes exactly so in these in these little cell columns live astrocytes so the good endocytes and then there are little microglial cells almost kind of like the Mueller cells of the csf and so little microglial cells live in there too and then of course here's the piocepti and here's the myelinated axon bundle all right so you're a you're a student or yeah never mind students don't get pipped but fellows do all right what are we looking at right here again all right so here's the central retinal artery here's the vein now as you go further away from the optic nerve head they get further apart just remember that central retinal artery comes off the ophthalmic artery it goes through the optic nerve you know a waist back sometimes eight ten millimeters back and then penetrates through and goes to the center and so as you get further and further back they get further and further apart all right what are we looking at right here Sean well that kind of a nerve dig nerve hyperplasia so is that a bilateral or unilateral condition okay and and what does it cause in terms of vision pretty much nothing it doesn't do anything interestingly this can run in families and so i'm always curious it's not common that you see these but every once in a while i'll see this in a younger person and you know if the mom or dad happens to be with them i'll say do you mind if i look at your eyes too and sure enough a lot of times it'll be there too so you see that small optic nerve this is the nerve right here and then it almost looks like this little crescent of sclera showing through it because it's really small and hypoplastic and so people have argued do hypoplastic nerves make you more at risk for aion or anything like that it's not so much the size of the nerve head itself is maybe the size of the cup in the nerve so if you whether that really causes anything so optic nerve hyperplasia not really a big pathologic condition what do we see in right here Rachel so what do we call that coloboma what does coloboma come from yeah from the greek of course coloboma so your mission tell me what coloboma means so somebody who's got a computer here look it up what does coloboma mean now look it up what does coloboma mean from the greek see who gets it first defect very good all right so i know are we recorded there was an attending who chose to call students this you're my little coloboma you can guess what was i might be working for i won't say anything because i don't want your grade to be affected so all right so coloboma so interestingly colobomas in the eye let's go back to chris where do they occur usually when you see colobomas so they can occur in the iris or they can occur in the optic nerve typically inferiorly and why do they occur there um yes their development and it's where you have incomplete closure of the apoptosis exactly so remember all the way back that first lecture we did on the embryology of the eye you know the optic vesicle comes out from the neuroctoderm and then it invaginates and as it invaginates the vessels come up and what will happen is it starts to eventually form a circle and it fuses at the equator and then goes anteriorly and posteriorly so when you get improper fusion of that you get the coloboma so the colobomas are usually posterior at the optic nerve or anteriorly at the iris and they're usually inferior maybe slightly nasally but so you can see this is coloboma the optic nerve had inferiorly here what is this this looks like what's the name given to a large optic nerve coloboma morning glory morning glory and so why do we call it a morning glory because morning glory is a plant that's got like a trumpet horn and so if you think about it when you go back this is in focus anteriorly but it's not in focus deeper because it literally goes away from you so it's like you're looking down that flower and it's really just a large coloboma i mean kind of a coloboma vende you know if you're using the starbucks analogy so you know you have to do that in starbucks because if you say small medium and large if you say we're gonna have four bucks for a small cup of coffee that's ludicrous so they call small large it's 1984 speak and large medium becomes grande and large becomes vende and so if you make it sound lat you can charge even more for it so so this is a grand this is a vende you know optic nerve coloboma so morning glory all right what are we looking at right here marshal um so we see the optic nerve there's what appears to be pallor temporally and then there's a central pit exactly so you have an optic nerve pit here temporally so what are we and this is what it looks like pathologically i apologize i had to copy this out of a book i've just not we don't usually integrate eyes for this and so you can see here's the optic nerve over here nasally it's pretty well developed and normal but temporarily here you see this pit right here there's no good optic nerve fibers it dips in here and you see that there's csf here and there's loose connective tissue what's the biggest problem with optic nerve pits exactly so this fluid and i'm sorry i don't have a picture of that so it can actually course out and it's not to the csf and so it can actually course out underneath the retina temporally here and then you can get edema under the under the macular those are tough to treat because what do you do you can't laser that because you know the laser is going to kill the fibers there you can't really go in and put stitches in i mean these are tough to treat so you really don't know it's hard to get rid of that fluid that's underneath that when you've got an optic nerve pit all right brad what do we see in here looks like a lot of my eliminated nerve fiber layer all right is that a problem uh generally not um it should start at the laminate fibrosis so i imagine you can get like an enlarged blind spot but i don't think it really generally has issues exactly so you don't you don't really get those axons that disrupted but because you've got all that myelin sitting kind of above some of the fibers going through you do get an enlarged blind spot but you don't get arcuate defects or segmental defects you get just an enlarged blind spot i always tell people when i see this because this is curiosity i always say you've got some extra insulation in the nerve fibers where it shouldn't be there and the reason i tell them that is i say you know what if you maybe you know in a car accident and have your head banged and somebody looks inside your eye in the er you know they're going to start putting bolts in your head to relieve the pressure so you know i'm telling you've got some extra insulation in there makes your optic nerve look funny so if anybody's ever looking at your eye and suddenly gets really excited let them know that you know you just have a condition you were born with so i i tell them that it's extra insulation that shouldn't be there and it just looks funny when you look in there all right what are we seeing right here hang on it always little yellow what do we call those optic nerve jucin and where does jucin come from almost actually it's from the german i think it means just like bumper deposit or something well you guys have your computers here what does jucin mean it's from german the word jucin but with the oh wow thing on the u and it says that the translation is glad interesting i thought it was like bump or something mine says weathered or rock crystals note or bump or something okay so in any event it does come from the german so see germans somewhere sneak in there and by the way that the germans didn't take it from the greeks just the Romans you know so so this you know jucin you don't want to get confused because i mean there can be jucin in the macula there can be jucin in the optic nerve even though they're little bumps or deposits they're completely different things and so you can see on this one the reason why you want to be cognizant of jucin is if these jucin are buried deeper it will sometimes give the appearance of pepladema exactly so you want to be very careful so you see this disc at first glance couldn't look a damn at us but you see these little bumps on here ali what's a test you can do right there in the clinic to tell you whether there's buried jucin or not if you're worried about that ultrasound and how do you do that ultrasound all right you do a b-scan but what you want to do is is what are these jucin made of calcium and so calcium really reflects that ultrasound light so you can put that b-scan on there you find the optic nerve shadow and you see these bright white spots on there and then you just turn the gain down and the whole eye almost disappears but those little bright spots stay there and so you can tell optic nerve jucin now these are just varying appearances this is pretty blatant this one a little less so and so you can see a little bit more buried jucin there and of course this is now I mean this is an autopsy eye but there's there's definitely lots of jucin there and so you can see that buried jucin and pepladema the difference is really tough to tell so that's where your ultrasound is really helpful where you know you're going to be really excited about this patient or you're not going to be excited at all so you can do that right in the clinic with the b-scan and when you look at these another test you can do you can actually do a CT scan because you see that the jucin just light up here on the CT scan also so the calcium makes them light up right away at the optic nerve head and this is pathology now this is a growth specimen and you see that they are anterior to the laminar crebrosa so the deposits are kind of on the inside surface of the here's the laminar crebrosa here's a calcified drew drew boys drew singular I don't know I don't know my German grammar singular or you says drew is singular yeah so it's probably singular here you see here's the laminar crebrosa here's the optic nerve head there's that calcium right there there's a calcified optic nerve head and now those can disrupt the little fibers coming in there so you can get some some nerve fiber layer defects that are arcuate when these drusen come in the problem is again you can't really treat these a whole lot I don't know what you can do about it here's another one right here and more down here so these calcified all right what are we looking at back what are we looking at here now so you see that that margin is fuzzy here you don't have a distinct margin of course if you're looking at with a 90 you would see that that was coming out towards you that would be elevated so what would your concern here be okay edema so that's good that you said that because you got to be really careful they'll they'll got you you on boards so papal edema what is the definition of papal edema exactly so that's really important to remember that so not all swollen nerves are caused by papal edema you can have unilateral swollen nerves and so they'll often show you these on like oral boards as a gotcha and if you say papal edema they go tell me more and so remember papal edema is bilateral so you can't tell them on a single picture and it's by definition due to increased cerebral spinal fluid pressure so when you say this when you see it just a single one you say that is optic that's a swollen optic nerve and then if they say what could cause this well if it's bilateral and has increased CSA pressure it could be papal edema and you get extra browning points you know on your on your oral board so be really careful how you define that and here you can see hopefully even a student would not miss this so as you look in there's that markedly edema this elevated nerve look there's flame hemorrhages on it here there's congestion of the vessels coming through here so this is you know grade four grade five depending on what scale you use to grade optic nerve edema this is the ultimate grade of edema and we look at it right here here's the lamina crebroso and you look here's a swollen elevated optic nerve had the vessels are dilated but look there's even hemorrhages here on the head so that's that's papal edema here you can actually see the fibers of the lamina crebrosa bowing forward it's a definite forward bowing this is a little bit more subtle did i did i ask you something at john on this okay john what could this be all right so you could get you know blurred margin if you have acute ischemia so that could do it what else could give you a blurred margin if it's really acute exactly so even like an optic neuritis type process and so you know your differential of uh you know kind of swollen irregular nerve here i mean you know you want to look at it broad categories again you don't want to just jump right in and say something so again if you're on all board you say well it could be ischemic early on it could be inflammatory and then in that inflammatory you'd say okay demyelinating diseases things like that and so it's got a fairly broad differential depending on what the vision is and depending on you know what the history is and other factors that you look at and so why would i be showing you this structure rachel what the heck is this why would i show you this at this point exactly so when you see a disc like this one of the things that you don't want to miss is you know you could say all right could this be ischemic and so of course you can have your run of the mill we call it aioan anterior ischemic optic neuropathy you know classic history is what and when does he when does this tend to happen when do they notice this most often exactly so remember your blood pressure tends to get pretty low really early in the morning and so again it's a vascular path more male than female because you know males tend to smoke and eat more you know cheeseburgers and all and so although women are catching up now women smoke just as much as men now so they're slowly catching up but so it's a vascular path and oftentimes it'll be unilateral of her first thing in the morning but you do not want to miss what rachel said which is giant cell arthritis and so you do temporal artery biopsy chris is this positive this is a negative yeah so something we see all the time in the lab this is a nice you know pretty good looking artery there's the luma and there's the intima little bit of intima thickening what layer is this right here turn along last to glam and so how do we describe that how do i what do i use to say what it looks like oh you guys have been out of path that's right so this looks like the mississippi river you know when they show you those satellite pictures when there's all the floods in the midwest curls back and forth i guess the other thing you can look at is like you know the old because this occurs in old man you know old man's pajamas you know with the little elastic on there so internal elastic lamina what layer is this the muscular muscular media and then here adventitia all right what do we see in here mike pj sign okay see much of an internal elastic lamina and then the muscular and you look at that where that lumen is narrow and look how thick that intima is where the heck is the internal elastic lamina should be right there it's gone where's the muscular media should be right there it's gone all right what are we showing here so what's another word people use on this condition exactly so we call it temporal arthritis giant cell arthritis and so you can get a non-arteritic aiom but what you do not want to miss is an arteritic aiom and so if you are at all suspicious and you see a patient in there in the clinic and you do the lab tests that's sure enough the set rates high and the um what else what's another test we do besides the set rate crp exactly exactly so crp is high set rates high so you're very suspicious what do you do immediately start steroids start steroids right away okay marshal you start the steroids right away then you want to schedule them for biopsy to make sure you've got the diagnosis how soon do you need to do that biopsy some to 10 days exactly so that's really important because sometimes people now this is the the the thing that really bothers us here at a referral center outside doc will see these guys they'll say well i think it's temporal arthritis let's give them 40 a prednisone is that a good treatment uh no it's too low of a dose so it's too low of a dose but now i think you don't have a diagnosis so what happens when the patient gets crazy from the prednisone or they get accepted necrosis or bleeding ulcers the diabetes is out of control you say well do they really need to be on this you don't know so seven to 10 days later that biopsy becomes negative and then we play a game we say is this healed arthritis was there arthritis there so you gotta have a diagnosis very very critical and so but you can do it within seven to ten days as long as you do it the the biopsy will still be positive but don't wait because they could lose their other eye in the interim and so do the biopsy and of course this you know you gotta have the diagnosis if they do run into troubles with steroids you need to know do they really need them or not and this is is an entity that i just said what the heck is this do you see any inflammatory cells or giant cells on there yeah it doesn't look healthy either yeah so where's the internal lactic lamina it's not there it's not there muscular media a little bit here boy look at that right here completely gone there so what do we call this entity we just said it short term memory gz well beyond that this is healed arthritis so this is after a patient's been on steroids for a long time and then you do the biopsy so sometimes it's blatant like this you look at that you say okay that's that's healed arthritis this patient definitely had arthritis but sometimes it's more subtle than that you see a little disruption of the internal lactic lamina get some areas of muscular media thinning but you can get that even in severe arterial sclerosis so you want to make that diagnosis at first but this is one that we can also make a diagnosis this is called healed arthritis what do we see in here i am okay maybe a little payable look maybe even a little bit fuzzy there so you've got one of these this could be an old gca but what if this patient were 20 okay so you know this is the saying that is the classic saying okay if you hear hoof beats you look for horses you don't look for zebras okay so what would be the horses here demyelinating should be your concern would be possibly demyelinating disease here you know histories you know different they're younger now that you know they may have have some you know some visual loss here some pain on movement why is it really important to make a diagnosis of you know if you've got demyelinating disease exactly so you really want to look for ms and then you know when you treat these it's interesting i'm sure that the neuro ophthalmology people pound this into the studies they've shown about using ivy steroids as opposed to oral steroids high dose and then a rapid taper and that really does bring back their vision quicker so if you use ivy steroids and you pound them and then you narrow and then you you slowly taper it down six months later what's the visual outcome compared if you didn't do steroids no exactly the same so look that up real quick now you will get an acute recovery and they'll recover vision much quicker and they may not get ms or certainly delay ms but when you look at their actual vision six to twelve months later it's about the same and so what happens is is eventually even if you don't treat demyelinating disease it gets better i'll just show you one here okay so this is what it looks like when you have a say a person who's got ms or optic neuritis you'll often get a focal area of demyelination so it doesn't demyelinate the whole nerve but you get a focal area here in the cross section and see that's demyelinated and here's the longitudinal view here's the normal artery here i'm right in here again you get some focal demyelination so it's important that you look for ms if you do treat them with steroids believe it or not you can actually delay the onset of ms and up to even a couple of years it's unclear whether you can prevent it but you certainly delay it and that's important so it's real critical to treat these guys early but interestingly enough they recover vision about the same after six to twelve months whether you do the steroids or not now this just shows you what hallie what are we looking at here look at how wide that subarachnoid space is what does that indicate exactly so this is kind of an end stage it doesn't tell you what happened it's just tells you that something disrupted it being ischemic being a demyelination whatever now that nerve is atrophy you get widening of the subarachnoid space so if you have an insult to the optic nerve how long does it take for that nerve to get pale yeah months and so if you look in there you say oh the nerve looks pretty good that that you know it takes a while for those axons to die off enough that that nerve gets pale and so you can have an insult and the nerve looks pretty good and then it can take weeks to even a few months for that nerve to finally turn pale and atrophy again this is end stage it doesn't tell you what happened what are we looking at right here yeah so look at the red look at the the central light reflex that's in the center that's a little bit superior so it's almost like that eye is down a little bit full that nerve creases there there's not only ptosis but you get the idea that that eye is coming towards you it's coming out more what would your concern be there okay so first of all how's the patient yeah young patient so what would you worry about if you had some sort of mass pushing the eye out and down in a young person all right so the most common tumor of the optic nerve in a young person is an optic nerve glioma what are these we're seeing right here all right so what is what is Stria of the of the retinamine okay and again that's what I was taught I said boy you see Stria man you better worry there's like a tumor in the muscle cone or a tumor of the optic nerve or something and now as people have studied this what do they find the most common causes opposite appropriately yeah so it's kind of a short flat eye and and so interesting we used to get we said oh my god this is a tumor this is terrible and then people have actually studied these and they look and they said most common cause of this is kind of a small myopic eye with a flat posterior surface and so that's most common but again the other things you said a tumor within the muscle cone including the optic nerve could do this too so you worry about that and sometimes this is the end result if you don't treat these what's going on here Rachel yeah so this is as pale as it gets I mean that's a white white pale optic nerve all right we're showing a scan right here what are we seeing right here all right so you see that it's kind of we call it fusiform and if you look carefully at it it's like that mass involves the whole nerve it's not a mass around the nerve it's a mass in the nerve involving the nerve this is what it looks like when you take it off here's the optic nerve look here's the sheath here this thing is actually intrinsic to the optic nerve and so we said the word optic nerve glioma what's another term we use for these lesions astrocytoma so what's great typically these would be low grades over one yeah so you know astrocytomas remember they grade them one through four one being you know most optic nerve gliomas four being a really severe um real blestoma multiforme that forms in the brain and so these are often grade one low grade and the other thing sometimes people call these juvenile pylosidic astrocytomas this is what it looks like kind of this fusiform enlargement of the nerve itself with the sheath over it so this is why they call it you know pylosidic pylosidic means hairline and so they'll have these little spindly shaped low grade astrocytes in here Mike what are these eosinophilic staining inclusions here rosenthal fibers so you get these little eosinophilic cytoplasmic inclusions here and again they're really classic to a low grade glioma optic nerve glioma so rosenthal fibers and there's a close-up of one of these these kind of eosinophilic deposits that are here and these are called rosenthal fibers now right here i'm showing you something here's part of a normal nerve here's the tumor arising here so you can see that it doesn't necessarily take up the whole nerve yet but it's arising there but one thing you worry about with these marshal what am i showing you right here what the heck is that somoma bodies well yeah exactly kind of looks like somoma bodies and so what what does this signify exactly so you want to be really careful sometimes people say well we're not sure this is an optic glioma we're going to do a little superficial biopsy and so whenever you have a big glioma growing into the nerve you can get reactive proliferation of the meninges and so if you do a superficial biopsy people are going to say oh my god that's a meningioma right there and that's not that's actually a reactive proliferation of meninges with an underlying optic nerve glioma so if you do a biopsy you want to be really careful and because the reason why you want to be really careful is what if you do have a meningioma in kid is that bad well so so what i want you to remember that what you want to remember here is if you have an optic nerve tumor that's outside the normal group that you see it in it usually means it's worse and so you see gliomas most commonly in kids you don't usually see them in adults if you see a glioma in an adult that's really rare and that could be really aggressive on the flip side you see gliomas in kids you don't usually see meningiomas in kids so if you see a true meningioma in a kid that's really an aggressive rare tumor and so if you're going to do a superficial biopsy make sure you get some nerve with it not just meninges because you could make a misdiagnosis and that can have real ramifications on the treatment what do we see in here Brad it's an external photograph the right eye we can see is very proptotic with what looks to be like some subconch hemorrhage temporarily really just like a lot of fullness around the orbit with some some edema periorbital edema inferiorly and superiorly right so you want to do you want to do a look what do we see in here so these are it's an optic nerve with optociliary shunt vessels what's that indicative of pressure increased pressure and not only increased pressure but slowly increased pressure so if you surround the nerve with something and slowly squeeze it down and it gets progressively blockage of the blood drain and ischemia you can get these little shunt vessels for now these can form even in a central retinal vein inclusion you can get those too but if you have something that's slowly surely squeezing that nerve in a long period of time you get these optociliary shunts and what kind of tumor does that uh the ninja exactly so here's a scan of a meningioma what is the classic sign that you see here of an optic nerve meningioma tram tram tram track side so you know you go up to snowbird you know you've got the tram you've got the central thing hold it on to the ear curvature and then you've got the two wires next to it and so what this is indicative of is you see the nerve is in the center and the tumor is around the nerve so when you do that um cross section or sagittal section there you can see that it's got sometimes there'll be two one on each side so that's the classic tram track sign that's a sign of something growing around the nerve not intrinsic to the nerve and that's usually what you see in a meningioma now this is a severe meningioma I mean this patient actually had a exenteration here and so you can see this tumor can be huge it's pretty uncommon that it gets that big but it can be pretty huge and what is the characterized the cells that you see here so we say meningioma what kind of cells proliferate in a meningioma actually they're the meningothelial cells those cells that form the arachnoid granulations we call meningothelial cells if you look at them they almost look like squamous cells on the skin or the conch so they've kind of got this central nucleus this rounder pale staining cytoplasm and here you can see them there's almost look like a sheet of squamous cells when you're really looking so these are the meningothelial cells that proliferate what is this thing somoma bodies spell it exactly so there's a double m in there so somoma bodies what are they made of so they've got calcium they've got some collagen in them they're these lamellar concretions that are there so these little round things they're called somoma bodies and these are classic for optic nerve meningiomas so somoma bodies is what you see classically all right we've got something else going on here alley what do we see in here now so it could be coming from the nerve or if you really let me be even next to the nerve so what else lives in that intraconal space that can give you a round slowly growing lesion schwannoma exactly and what are the the classic ways we describe schwannomas all right so what is this one exactly so you see that swirling fascicular it almost looks like you know that you see you know in jacuzzi down in the ocean on zee calypso and you see the little schools of fish swimming together they kind of look like this so you get this kind of schools of fish swimming this is the antony a or fascicular pattern and then you can have kind of a mix soy pattern we've got individual cells and then a lot of this connective tissue it's got some you know some fluid in there and it's got some material connective tissue material in there so this is called the antony b pattern so these are these are what we call schwannomas or what's the official word that we describe them nerily momas another thing that you want to know how to spell nerily momas or schwannomas all right so antony a antony b you don't remember those are the two different patterns that can occur with these all right and again there's the obelisk that everybody gathers around when they do protests again there's protests here every day so next week we do orbit we're going to talk about orbit and then we actually finish first week of march with tumors and then we'll do a review before oh caps or what third week of march so i think we do an oh cap review that second tuesday of march also questions on optic nerves in five minutes