 All right everyone, we're gonna get started just a minute early Today's grand rounds. We have three presenters The first presenter is Sean Collin. He's a PGY 4 If I was to give a spirit and animal to Sean Collin It would be the Pangolin, which is found in Africa in Asia. It's a highly intelligent sometimes self-isolating creature that likes to explore and ask a lot of questions Sean Collin's presentation is entitled providing eye care for Utah's uninsured and underinsured Thank you Tyler. I'm curious what questions the Pangolin asks Is this food? Also, is that the one with the armor on it? Does it have a little bit of armor? That's very nice. I like that. I like that So yeah, so I'm going to be talking about providing eye care for Utah's underinsured and uninsured patients, specifically at the Marin Eye Center I did a lot of talking with people for this presentation I talked with attendings, I talked with fellows Talked with front desk staff, with PFA's, with people on the fifth floor And it's an incredibly complicated topic And there's a lot of murkiness in it This presentation is my attempt to synthesize everything I've learned and there will undoubtedly be inaccuracies in some areas of incompleteness But I hope that provides will come away with a better idea of ideally what track a patient should be taking if they're self-pay And how they can sort of minimize the impact on their own clinic flow And provide these patients with the best care Really briefly, I'm going to talk about the Utah telephthalmology program Which is saying that we started a few years ago It started small with People's Health Clinic in Park City It has pretty rapidly grown to include Moab Free Clinic The Association for Utah Community Health, which is an umbrella organization comprising all the federally qualified health centers in the state So we're working with community health centers, Inc. at seven centers in the Salt Lake area Family health care with two centers in Southwest Utah Mountain Lands Family Health Center with four centers in Provo One in Eastern Utah and Enterprise Valley Medical Clinic In Southwest Utah for a total of 15 clinics We've been working with one clinic in sort of a pilot project for the past year And as you can see, the orange line there is their diabetic retinopathy screening rate So they've gone from under 30% to almost 70% over the past year It's a fairly large clinic But it is ultimately only one of the 15 that we're going to be working with in the next couple of months So we're getting a lot more patients identified that need eye care And many of them don't have insurance As we expand this, this is not terribly pertinent But we're going to be working with INUC Which is one of the two FDA approved AI algorithms in the US We're using this AI in the background program Because they're fully autonomous program IART is not approved for the camera that the clinics have chosen to work with One thing that is exciting just learned about this yesterday Is that their AMD and glaucoma algorithms just got approved for fully autonomous use in Europe They're not approved in the US But they will be implemented with the AI in the background So our clinics will be some of the first in the US to have access to that technology All of our clinics are using this camera They've all independently come to the conclusion that this is the best one And I can talk more about any of the sort of specifics of this program with people if they're interested But the end result is that we're seeing a lot of pathology This population, you know, we're screening lots of uninsured patients And the rate of pathology, the incidence of pathology is just very high Lots of diabetic retinopathy Lots of glaucoma Other issues And so we need providers in the state who are going to provide care for these patients As a bit of reassurance to the to the people at the Moran We are not relying on the Moran to provide all of this care And in fact, we're actively trying to offload a lot of this burden To the community So we've set up this outreach has set up this website the Utah teleophthalmology program Which should be going live in the near future It will be a resource for clinics to find providers who optometrists and ophthalmologists Who have specifically signed up to provide eye care for uninsured patients at an affordable Cost we gave this presentation at the Utah Ophthalmology Society We had an incredible response from the people there So many people there signed up on the spot to provide care specifically for uninsured patients Or to be a resource for that For providers at the Moran, there's no real need to Sign up just being at the Moran You will be seeing some of these patients But if you would prefer not to see any uninsured patients You can reach out to Erica and she can help to facilitate that Erica Ruiz that is she's right here. She's going to be talking in a second from from outreach Regardless though, even as we try to offload patients into the into the community There will still be self-pay patients coming to Moran Of course there always have been but a lot of providers have noticed that there are More at least some of which is due to this program And when patients come here, they have a few options. They can pay their bill up front They can use a payment plan sign up for a payment plan They can apply for financial assistance And if all that fails, they can be set up without reach and we'll talk about all these a little bit more Ideally when a patient comes to the Moran, they end their self-pay They'll go through sort of this process here So they'll check in at the front desk. The front desk staff will Check, recheck, confirm that the Patient is indeed self-pay uninsured If they are before they're even roomed, they should meet with a PFA and they should be given an estimate of the cost of their visit And they should be given a financial assistance application They can't complete that until they actually have the bill from the visit But they can be sort of educated about that process After they've got all that, they have the information they need to move forward with the appointment with the provider if they'd like Which most patients will And then they receive their bill and after that it's sort of incumbent on them to figure out how they're going to pay it Absolutely and we'll go into each one of these Quite a bit more There is one sort of consideration here You know, according to the No Surprises Act, which was effected in January of 2022 They should be getting a good faith estimate Before they even come to the Moran That good faith estimate should provide the expected cost of their visit There are tons of logistical difficulties in actually doing this. I'm not sure the extent to which it happens But this is the actual sort of Text from the No Surprises Act Regardless whether they get it before they come or as soon as they arrive, they get this estimate This is what it looks like. This is an actual scanned de-identified copy This is basically the charges that a patient would get for fun as photos in an OCT Comes out to about $300, which in the grand scheme of things is not that much And you can see that there are facility charges and then provider charges here on this bill They do get a 30% Contribution to care from the University of Utah on the base charge So, you know, once they have met with the PFA's, talked about those things, gotten the financial assistance application Then explained that they will get a bill They proceed to their appointment And I just wanted to give some examples. A lot of people already know these numbers, but some may not Of what patients might see in their bill So, Intervitorial Injection will be one of the most common things that these patients need There are several options. Avastin, Iliya, Vabizamo, Lucentus Avastin is of course generally affordable, so it's an okay option in that regard The other drugs we often have samples of, which can be a good option for a patient who needs treatment on their first visit But then in particular, Iliya and Vabizamo have very good free drug programs that patients can enroll in My understanding is that they're actually quite a bit easier than the financial assistance program, especially the Genentech program for Vabizamo right now But even if they get these drugs covered, the $2,000, $3,000 for the cost of the drug is covered, they're still paying roughly $700 just for the cost of the procedure The facility fee is $579.20, they get that 30% contribution to care, so it's $405.44 But the interesting thing here is that for an insured patient, the insurance company will get the same bill, $579.20, but then only, hey, $346 So patients paying out of pocket are actually paying about $60 more than the insurance companies, just in this example here A few more procedure costs here. The main point is just that these numbers are very large, even for something like a YACAP Salotomy, patients can be a couple thousand dollars out of pocket The website at the bottom has examples of some of the procedures that patients might have and the costs of those procedures, but it's not very comprehensive The only ophthalmologic procedure that I could find was for the YACAP Salotomy, but that website's available to everyone, you can be accessed by the public The financial assistance program here, patients should be getting a copy of this when they come in before their visit when they meet with the PFA's It's a fairly involved application process, they need to complete the application, explain their financial status, provide bank statements, income, tax returns, pay stubs And then they need to complete this whole application here, where they're asked to provide their household size, income, assets, medical debts, other debts And it's really important to know that these patients can get help with this by calling the number on the first page of the application My understanding is that if they call that number, someone will walk them through this application step by step And it can be very intimidating, so it's really important that patients know that they do have that support system as they're going through the process And after they do, they potentially get a really awesome coverage, up to 100% of the cost of their care covered It may only be approved for six months, that's what the technical literature says on the website, the policy I'm not sure how much that's enforced or if it's easier to reapply, but that is the policy Now I'd actually meant to turn this over to Cindy Hart, who's one of our lead PFA's at Mid Valley, a few slides ago, but I think now would be a good time Just if Cindy's with us on the call just to talk about what PFA's can and should be doing with patients who are self-pay when they come to Moran for the first time Cindy here, you should be able to unmute yourself She's not, okay, well that's fine So, but basically what I was hoping and what I understand she would say is that the PFA's here can meet with patients again before the visit Before the patient's roomed, give them that estimate of what the procedure or visit is going to cost Talk to them about the financial assistance application and, you know, give them sort of the reassurance that they'll need when they get their bill The benefit of having them meet with them before their visit is that it doesn't take up an exam room for the provider, minimally disrupts clinic flow, and hopefully that'll make things smoother for our provider who are seeing the patients Yes. Yeah, so they'll be identified as self-pay when they come in, when the appointment is made, you're right, they call, they ask what insurance do you have, I don't have any so on and so forth, they're identified So when they come, the front desk staff will talk with them, double check in their chart that they are in fact self-pay and do everything they can to make sure that they are not insured in some way that the patient might not be aware of. That's kind of the process they go through the vetting process. This part I really don't want to touch on too much at all. The question often comes up sort of what do you have to bill for what don't you have to bill for do you have to order imaging. So definitively that it is illegal to provide a service for free, if the patient, if the provider knows or should know that it will induce some sort of payment from a government health plan. That's for sure. In terms of whether or not it's, you know, illegal to provide a service for free. If the patient is uninsured. That's something that I haven't been able to get a very clear answer on, although it is clear that it, it may be in violation of University of Utah compliance rules. The other thing that's definitely clear is that you can minimize the testing that you order order only what's necessary and just be aware of the patients coming in who are self pay and and you know don't don't get tests that aren't absolutely necessary for outreach. This is obviously an incredible resource for all the patients. We get tons of operations site a patients getting cataract and trigium surgery. We are mid valley retina clinics on Saturdays, where patients incur no bills no charges when they go, but it is a limited resource. So it's very important that patients go through the proper channels that they apply for the financial assistance programs the drug programs before they go to outreach before they refer to outreach, Erica Ruiz from outreach really runs. Effectively all of this and so I was just going to have her speak up right now and just talk about sort of the most important things that providers should know about when to refer a patient outreach and how. Bring you a microphone. Hi, so, typically with our retina clinic we are able to do injections imaging and lasers, and we want to save those spots for patients that have gone through all this process and completely cannot qualify for any type of assistance. So, as soon as you get a retina patient and it's self paid don't send it straight to our reach haven't go through a pee fee and go through all that process. First, that will actually help them in the long run because they do qualify for financial assistance are able to get assistance throughout the whole hospital not just for outreach for sorry retina. And then for our operation site day. We refer patients that need cataract surgery that have gone through the whole process, the vetting process, and we'll get them into our continuity clinic to see one of our chief residents. Once they see the chief residents and they determined that they need surgery we'll get them in with our surgeons who have agreed to waive their fees. And they'll get them into their regular or scheduled during the week Monday through Friday. We still have to pay for the facility fee outreach desk, but at least the doctors are waiving their fee for to do that so that's pretty amazing. And we also have our once a year cat operation site day event that's held on a Saturday, and we typically do about 18 surgeries on that day. The capacity for the year for surgeries is up to 174 surgeries that's 18 surgeries a month that our doctors are doing during the regular working hours or over our days. And then our Saturday event is 18 patients. So we've been able to do a lot of surgery cases since we started doing the adding patients who are regular or. So it's pretty amazing what the surgeons are doing the chief residents in our PFA sir working to get those patients taken care of. Thank you so much. And just to be clear, I think sort of the main points, then are just to before referring a patient outreach to make sure they've gone through the whole process new PFA apply for the financial assistance. And then they can just contact you directly with that patient's information once they have that correct. Perfect. All right. And you touched on this there but continuity clinics are a good place to send these patients, especially for cataract evaluations. I bundled and call and consult here because it's the same sort of billing considerations apply. There are various restrictions or qualifications that each of the insurers need in order to be able to bill. But again for uninsured patients were really able to minimize their charges. And just for residents to know when a patient comes into your continuity clinic and they're uninsured. If they've come through an established channel like people's health clinic, Fort Street clinic, Malayhe clinic, they should be well vetted there if they're uninsured that means they're uninsurable. And those patients will generally be covered by outreach if needed. Other uninsured patients though we're not coming through one of those channels needs to still meet with a PFA before their appointment with you. So that's important to know. In summary here, before the visit patients may or may not get a good faith estimate of what their visit costs will be if they don't get it beforehand they should get that first thing before they are roomed. When they meet with the PFA they should also be provided with a financial assistance application informed that they will receive a bill and that they can't complete that application until they receive a bill. And then we'll proceed with their visits where the sort of incumbent on the provider to minimize charges as possible. They have to apply for the financial assistance program in the drug program. Remember that they can call that number on the front of the financial assistance application to be walked through the whole process, and then refer to outreach only if they're denied the other assistance. As far as the provider role here, a lot of this still comes down to individual initiative and motivation here at the Moran. So, every member of the team is vital in providing this care from the front desk staff to the PFA's to the technicians. If they can understand the process and know the resources that are available to the patient in order to reassure them, give them the information they need that goes a long ways. And so just building that culture within your clinics is a super important step. You can minimize charges by ordering only what's necessary and then also you can delay treatment if that's appropriate non central DME or moderate glaucoma. You can see that patient build on the absolute minimum possible and then see them back in a month or two after they've had time to complete the financial assistance application after they've had the two or three weeks for that to get processed. And then give them the treatment they need, you know, with the security that it will be covered by that program. It's just extremely important to encourage them to complete that application to call the number to get the help they need. And then just in general to understand the patient experience be able to reassure them in the various aspects of the appointment and of their health care that they are understandably concerned about in the future. You know, this is an imperfect system, and none of these solutions are fantastic. Some ideas that are in the works are having a full time optometrist at the South mean clinic which is actually a school of medicine clinic none of University of Utah clinic and so has some flexibility in its ability to bill and charge patients. And optometrist would function to triage patients without giving them much billing and get them set up with the financial assistance program. And another idea that would really be beneficial is having a full time social worker here at the Moran with the specific role of interacting with these uninsured self pay patients and helping them with the financial assistance application helping them with surgical scheduling but also just providing education, providing help with transportation with medications. And actually Dan clay commented here that the University of Utah pharmacy services has a program that can also help patients afford their outpatient prescriptions it's called the medication support service and he has info in the pharmacy if anyone wants that. These are just a few special considerations I'll leave people to read these on their own, we've only got a couple minutes left. So I'll turn it over to any comments questions. Thanks so much for looking into all these, you know, pathway in the channel. I think a lot of times it's been unclear in the past, not necessarily because not necessarily because I think mostly just because people have not done a deep dive as you and I know a lot of these processes have been in place a lot with our PFS are to be really one clarification is with those outreach patients that come to chief clinic, continuity clinic from, you know, fourth street clinic we've always been told not like to bill a 99 basically no charges. Are we supposed to be billing for the visit and then outreach reverses those charges. That's a technical question just closing encounters wise. I feel like hasn't really been made clear to us before. Yeah, so let me get let me get a real accurate answer. 99 is actually something that was a bit historical. We'll get a better, better answer back and then just a couple of comments. Let's see another question. Thank you. This is like working within this for years. It's been still less clear that it was just now with you doing that this is something that will live on and that is faculty asked questions are going to be referred to this on on meringue or for many years. So thank you. This was a heavy left couple things that that I think are important, you know, surgeons we waive our fees for this operation site. And sometimes you might feel like well what what's the institution doing on their end. You know anytime you allow a free for both surgery to go into a special spot. And that's why across the country programs do not do this in the regular or block is because of the opportunity costs and the loss of revenue. So I think it's just an institutional commitment that is worth noting and then I do want to give a shout out to Tyler at fridge who is going to be looking at, you know, if we knew how much things were at the time that they were being ordered in a modified behavior in a way that could really affect costs and utilization. So I don't want to say anything. I'm really excited for that. Oh, there you are. Okay. If someone is denied the assistance. Are they then what are they told them are they told to then go through outreach or talk to the provider and I can see that maybe they might just go away if they don't have a Absolutely that that is a tricky situation. They're denied financial assistance that would be the time to send them to outreach what they're told. I would imagine they're just told that they've been denied financial assistance and though to that end, you know, I think it would be important to tell the patient at their visit what to do if they're denied financial assistance certainly they can contact the provider and then the provider can reach out to Erica to establish them in whatever outreach channel they need to be in. No, thank you for your talk, Sean. This question might not just be for you but for anyone in the room. Sometimes I'm looking at medications that we send out, and not just for under certain populations just in general and I think we really fascinating or Maybe if we had kind of an estimate on what it would cost a patient so, you know, the various derivatives of a certain medication or artificial tears for instance, should I recommend one brand or another. This cost, how significant of a factor is that a play and I don't know if anyone has a list or kind of a database that they use when they send things out I think that'd be really great to share. I found myself referring to good Rx electric look at the different prices. Otherwise, it's a little bit variable with different choices, but in terms of kind of a overall estimate. Thanks for that time. And if you do have any feedback on the process. You know, Dr Kyle would explain that if you have you hear that in your PPAs are uncertain about how many things they can be referred to any part with time experience navigating these situations for sort of continuing education on the process, and then I personally would be very happy to have feedback about patients who are coming from this screening program. If you're encountering any issues with them or, you know, their insurance status or whatever when they're coming into your clinic could be really helpful to hear. Thanks. And just to address two comments that were posted online. Dr Fluchenstein basically said thank you for all the information that you provided Sean. And then I believe Dan Clegg had mentioned University of Utah pharmacy services has a program to help qualified patients for outpatient prescriptions this is called medication support service, and there's information in the pharmacy or at the pharmacy, if you are all interested. So our next presenter Abigail Jebara she's also a chief ophthalmology resident. If I was to choose actually I asked her what her spirit and animal would be and she chose the mere cat, because she's small. However, little did she know the mere cat is one of the strongest animals. In fact, it is impermeable to snake venom and does not drink water. It gets all of its water and nutrients from what it eats. Abigail Jebara will be presenting a team effort management of granulomatosis with polyangitis. Thanks Tyler. The no water thing sounds like me on a VA or days. Let's see. All right, good morning everyone. I'll be presenting a case of a patient that I saw with granulomatosis with polyangitis. We have a 68 year old Hispanic male who presented to triage clinic initially, who had a history of two months of significant bilateral ocular pain, photophobia, significant redness and blurry vision that was intermittent. His testing was overall normal vision of 2030 2020 uncorrected normal intraocular pressures, normal pupillary exam, normal visual field testing, full motility and color plate testing was full bilaterally. He turned to his slit lamp exam, a lot of red here you see. So of note he had no proptosis. He did have bilateral injection with some scleral show as well as his injection did not blanch completely with fennel effrin. He had no proptosis as well as keratitis. He had a peripheral corneal haziness without staining and trace pigmented cells post dilation in the anterior tumor on the left side. Mild cataract, no vitritus, no retinal findings. So the question was where to go next with this patient who looked like this on slit lamp exam. As you can see hopefully on the screen, I know it can be difficult to see up there. There's a slit lamp photo of the left eye super nasally there's a bluish tint there which is kind of the uveal show of scleral thinning, as well as those deeply injected vessels, and along the limb is there you can see some of those immune deposits or inflammatory reaction there. There we go. Also important was his review of systems over the preceding year he also had a dry cough sinusitis and an unintentional weight loss of 15 pounds. In summary, this is a patient with bilateral scleritis and keratitis with scleral thinning in the setting of one year of dry cough sinusitis and unintentional weight loss. The diagnosis is broad and really depends upon the patient's symptoms, whether or not the patient is presenting more with pulmonary symptoms or sinusitis. In this case I looked more kind of the ocular findings. You look at other vascularities, you look at other auto immune diseases things that can cause orbital inflammation scleritis. You can't forget infection causes, as well as malignancies that can present like this. Next we moved on to the lab workup getting different lab testing for the C-Inca titer was elevated and I have the reference value there as you can see it was quite elevated and that reflexes to the ELISA test for anti-PR3, which is also elevated. Of note his CMP and urinalysis were normal and then things that were tested that were not that were normal or negative were the listed here things here which can also present with similar findings particularly other great masqueraders such as syphilis and tuberculosis. We also got a CRP and ESR which were elevated in the setting of systemic inflammation. There was a question in the beginning given some of his ocular symptoms and some headaches that we were thinking about GCA. However, given the whole clinical picture, there was in the end a low clinical suspicion for this. The next steps of things that we ordered were because of this deep ocular pain that he reported and a question of whether or not there were orbital findings although he had no proptosis we did obtain an MRI orbits with and without contrast, as well as a CT chest given his elevated C-Inca and anti-PR3 and referrals to rheumatology and the pulmonary departments were made. He was started on prednisolone eye drops four times daily in both eyes as well as naproxen orally twice a day. This is his MRI orbit with and without contrast. Here there was no orbital inflammation but you did see at the insertion point of the optic nerve bilaterally and in this cut the left eye is better shown than the right, but there were enhancement on T1 post correlating with stir bright signal intensity, which was consistent with scleritis of both eyes. Moving on to a CT scan chest, this was kind of the thing that stood out most to me in his history and reviewing his case was he did have this Hylar lymph adenopathy more prominent on the right side. You can see here marked here 12.6 millimeters and 13.8 millimeters here as well as these scattered bilateral pulmonary nodules and this is just the report for that. So the Hylar adenopathy wasn't very specific and it's not for this disease. So the question of a neoplastic process kind of guided our next step which we would have done anyway given this diagnosis would be a biopsy. So CT guided a finial aspiration biopsy was performed with the right lower lobe. And it showed characteristic necrotizing granule granular inflammation with multinucleated giant cells and confirmed our suspected diagnosis of GPA. This is just a representative image of the pathology that you can get with this disease, the necrotizing granulomus inflammation fibrosis is multinucleated giant cells that you can see here, and a lot of inflammatory cells collecting essentially in these areas of granulomas. So, as I mentioned, we refer this patient to rheumatology it was determined that his disease is pulmonary and ocular involving with renal sparing. He also reported polyneuropathy, which can be seen in this disease. So that was an important question that is kind of a great area for this patient but something that is still possible. Given the severity of his lung and ocular involvement, there was a concern for a high risk of relapse which does happen in GPA anyways and something to be very aware of in these patients. He was diagnosed with rheumatology quite closely and is on prednisone. At the time he was started on a one milligram per kilogram dosing with a taper down over time and retoxymab infusions every six months. So GPA is a multi system autoimmune disease and as I mentioned, it's a classically necrotizing Grammy granulomatous vasculitis that involves small to medium arteries and veins and that's important as it kind of differentiates it from different types of disease. It classically involves the upper and lower respiratory tract causing granulomas. Classically, if you go back to your step setting, you can see a saddle nose deformity when the septum cartilage collapses with this disease, and you can also have focal segmental This disease is typically seen in middle aged patients. It has a predisposition more for Caucasian individuals but can really happen in anyone and the ocular orbital involvement tends to be 15% at time of presentation, up to 50% in the course of the disease. Orbital inflammation is the most common as it's thought to be a contiguous inflammation from the sinuses and spread to the orbital tissue. Secondarily, other more common presentations are like in our patient, episcleritis, scleritis, keratitis, less frequently but still possible are uveitis, optic neuropathy, retinal pathology and contiguous with orbital inflammation is an NLDO. So inka, as we all kind of think back to what we learned in medical school, antibodies directed against the cytoplasmic azirophilic granules of neutrophils and monocytes. This is specific for vascularities so inka is such as GPA, microscopic polyangiitis, eosinophilic granulomatitis with polyangiitis which is formerly known as Turkstraus syndrome. Inka is present in 95, it's pretty specific for GPA as well as PR3 Inka to evaluate these things PR3 Inka is typically tested by ELISA. So the treatment really depends upon disease severity, kind of a stepwise therapy up you start with steroids and then you move on to methotrexate sycophosphamide or rotuximab. The really severe diseases you'll treat with IVIG or plasma exchange typically as a combination of steroids and an immunomodulatory therapy. So if your treatment was available before immunomodulatory treatment was used, there was almost a 90% mortality in the first five years, so it was significantly, significantly dangerous to these patients. Rotuximab of interest which was used in our case is typically more tolerated than methotrexate or sycophosphamide. It's effective at treating ocular manifestations and pretty effective at preventing relapses which I mentioned does happen quite a lot with this disease. That's an interesting point because I thought that if it wasn't involving the kidneys, then the patient would have a better outcome in general but that's not necessarily true. It's kind of a misnomer to categorize it that way. Serenal involvement parallels disease severity, but the lack of renal disease does not imply decreased morbidity. That's something really important to note as they can have upper respiratory. They can have CNS involvement as well. So that's really important to keep in mind that that doesn't mean that you kind of let your guard down at all with these patients. As such, monitor and kidney function is essential because in a prior big study done with 158 patients, it's present in 18% of patients at presentation, but over the course of two years up to 77 to 85% of patients do develop renal involvement. So that's really important to watch them closely. In the patient's clinical course, the treatment has been upheld well in him with topical and systemic steroids, as well as retuximab infusions. He's had no progression of inflammatory ocular disease over the course of the last two years that we've been watching here in clinic, as well as no renal involvement that's popped up. One note he did develop tracheal stenosis, which is found with GPA and is being managed by ENT. He has an upcoming cataract surgery of the right and left eye with Dr. Laura Shell with a perioperative course planned of topical pred catorlac and oral pred. This was a team efforts, kind of alluding to my title here. There really is something for everyone when it comes to GPA is kind of a masquerader just like a lot of these inflammatory or infectious diseases that we see. It's important to know that involvement of other specialties is important in this patient. There was neurology, rheumatology, pulmonology, ENT, and so many other specialties that were involved in the care of this patient. So, in terms of the Moran side of things, Dr. Laura Shell with UVitis is kind of quarterbacking his care. So, for the PGY2 for me two years ago, lessons learned from this is it's kind of hard on call when you're looking at these patients and trying to figure out what's going on but take a breath, step back, go through your review of systems because that can really elucidate as it did in this patient, the underlying cause of their pathology. Examine the patient at the slit lamp in different directions of gaze. And in this patient, if you didn't lift the lid and look superior that you might have missed that scleral thinning so that's really important as it's not readily available in primary gaze at the slit lamp. Beware of masquerading or unclear clinical pictures that's where the whole clinical picture kind of comes into play. So that differential diagnosis and really thinking through things is super important in these patients. And finally collaboration is key. The management of patients with GPA is not possible without our rheumatology colleagues. Here are my sources. Thank you so much for your time. I really appreciate it. Thank you Abigail for that wonderful presentation. Our next presenter. We actually double check to make sure we don't have any comments. The next presenter is David Batros, a PG Y one with neurosurgery. I did a quick Google search of him and found that he is from Egypt and moved to Indiana when he was about nine. And so my spirit animal for him is the steep eagle, which is the national bird of Egypt, and travels through massive distances, both individually and as a pack. His presentation is on the neuro ophthalmic manifestations of acute hydrocephalus. And you need to unmute him. You should be able to unmute yourself. Perfect. Thank you so much. We'll get your presentation. All right. Is it okay if I share my screen. Go for it. Okay. So first off, thank you so much for that introduction. I did not expect that and actually didn't know that about the, the Egypt spirit animal. So thank you very much. So I'll be presenting on the neuro ophthalmic manifestations of obstructive hydrocephalus. You know, knowing that there are sort of a lot of different entities within hydrocephalus but trying to focus and kind of make it a relatively streamlined presentation. So just a very quick kind of history of the ventricular system. He kind of started as early as Aristotle, and he was kind of the first to describe these cavities that were located in each hemisphere, as he saw in many kind of the animals. In the cadaveric dissections that they tended to have these holes in their brain that they've contained some fluid again these were limited by fixation ability and things like that so it was it was sort of difficult to elucidate further. In the humans at least in the 1300s they were able to sort of get to this, this in the picture here this like tri-chemeral system or three-cavity system that they saw, thought that this facilitated the regulation of the flow of the Numa, Sikicon or the Spiritus animalis and or the psyche and allowing kind of the transition of memory, all of which were ultimately changed over time. So they got to Leonardo da Vinci and they had wax models they would fill these the ventricles with wax and we're able to preserve them and so they had these semi-accurate representations of what the ventricles look like in vivo so to speak. And then that slowly developed into our understanding today of what these ventricles look like which sort of the general outflow starts in the lateral or the lateral ventricles moves into the interventricular framing or the framing of Monroe into the third ventricle through the cerebral aqueduct into the fourth ventricle, ultimately ending up through sort of the framing of Magendi and Lushka and into the arachnid granulations is at least the traditional thought there's more kind of emerging evidence that there are lymphatic vessels that are involved in the the resorption of CSF as well. And so there's many points that you can kind of disrupt the ventricular system and cause obstructive hydrocephalus so we'll start at the most kind of proximal point which would be the framing of Monroe. There's a case of a colloid cyst and generally these are typically thought to be fairly benign but if they get to one of the least the risk factors if they get to above seven millimeters they can kind of cause obstructive symptoms and about a third of patients may actually present between 35% will present with acute hydrocephalus and rapid deterioration as a result so generally these are left alone until they get to become this size and so we see here this one was obstructing the frame and after surgery kind of allowed for adequate decompression more distally at the cerebral aqueduct kind of we're more familiar with this in the pediatric population with congenital aqueductal stenosis, but this certainly can happen in adults this is a 47 year old that had a venous anomaly anomaly that was kind of kind of see here where this arrow is that was overlying the aqueduct, not allowing adequate drainage and sort of a slow development of his hydrocephalus, but ultimately kind of required some sort of intervention in his case it was it was a shunt, because they couldn't treat this the venous anomaly adequately. And then kind of moving all the way to the fourth ventricle again going back to the pediatric population where these are usually can see their epipendemomas which this specific kind of cases or medulla blastoma anything that is as a space occupying lesion and the fourth ventricle can kind of have proximal hydrocephalus so everything above that so third ventricle lateral ventricles are typically attached as well. And so there's many kind of intersections between the optic pathway and at least in the ventricular system so going from the optic nerve into the chiasm, the chiasm kind of a butts or gets starts to get close to the third ventricle definitely the optic tracts. And so the larger naked geniculate nucleus, and then further optic radiations are typically less affected by hydrocephalus but but certainly can as well in in in fairly severe hydrocephalus. So that's kind of a kind of a bunch of proposed mechanisms of why hydrocephalus causes kind of the manifestations that will go over in a second but the the underlying issue is increased intracranial pressure, and so that can kind of have two effects that can have direct optic nerve sheath, sheath distention and choroidal folds which can cause the defects you see in the visual on the visual fields, as well as axoplasmic stasis or the inability for axoplasmic transport due to the the increased pressure not having the kind of adequate fluid pressure or too much. As this progresses over time, you can kind of get optic disc swelling external compression, if it lasts any even longer time kind of hypoxia and gliosis and eventually optic atrophy. But more acutely you can kind of get nerve fiber layer edema or exudates, as well as sub retinal fluid. If it's severe enough and acute enough you can kind of get retinal hemorrhages as well. And so the mechanisms of injury are, as we sort of just described, mostly at least the current thought is reduced axoplasmic transport, due to increased pressure or possible venous congestion. But then there was sort of this this fairly recent paper last year and brain that drew samples of CSF from the lumbar subarachnoid space and the optic nerve subarachnoid space in patients with IIH as they were kind of moving towards optic nerve administration. And they noted this much higher concentration of the of lipokaline type pristine gland and D synthase, which they actually don't really come down on a definitive role for they say possible it is neuro protective in some ways, but as it accumulates over time and may have toxic effects. And so this is really more of kind of an emerging theory, but certainly a possibility in terms of metabolite formation or stagnation. And so the common manifestations of these are papillodema this diagram is from Moran actually and so the, the grading at the frozen scale at least as the grades over one through one through five with subsequent as you get more and more visualization of the optic disc, and or the vessels, overlying the optic disc the sort of denotes worsening papillodema and more and more visual threatening edema vision threatening edema. And sorry going back to papillodema so there was sort of a lot of these studies in monkeys at least where they intentionally cause these obstructions. And in a lot of their, in a lot of the monkeys their papillodema didn't occur until about five or six days in some it only took about two days of hydrocephalus to have this, but sort of papillodema is thought to be, I guess what you would call subacute kind of finding in papillodema and hydrocephalus but certainly could be acute for some folks. Transient visual observations, they're kind of more commonly seen in the non obstructive or the idioma intracranial or idiopathic intracranial hypertension patients can be positional worse worse and with postural change. And the exact mechanism of these TVOs isn't very well elucidated but they're sort of two theories both of which are relatively old. In the myelin distortion kind of at these nodes of wrong via and in the 70s were done on. And they would sort of have traction on peripheral nerves and observe kind of the subsequent damage after the thought that this may have a role in TVOs, as well as transient ischemia of the optic nerve. And the right now nerve fiber damage isn't a kind of another manifestation this is something that you know we've seen over and over again and they're off the clinic and folks with, again typically the patients that I saw where I each patients but this could certainly happen in acute hydrocephalus is swelling under kind of the right nerve nerve fiber layer or under it. And with this typically manifest with his inferior accurate visual field defects first and or widening of the blind spot. But in acute settings and acute obstructive hydrocephalus you can kind of get superimposed ischemic disk changes, secondary to decreased orbital blood flow. And then there is sort of an honorable mention here for dorsal mid brain or paranoid syndrome. A lot of kind of what we see for paranoid is is could be direct compression of the dorsal mid brain. But certainly if there was is a more distal kind of compression that's causing enough hydrocephalus to put pressure on the on the tectum, the dorsal tectum. And you could get the same same syndrome and so that's kind of characterized by an upward gaze palsy due to damage to the rostral interstitial nuclear of the medial longitudinal fasciculus or MLF. You can get convergence retraction in the stagmus which is at least thought to be due to inhibition or decreased inhibition from kind of the super nuclear centers as well as the bilateral eyelid retraction sort of those are the relatively same proposed mechanism, as well as near dissociation. And so that's also thought to be by compression of the posterior commissure, where the nuclei responsible are more dorsal for light than they are for near and so you kind of get light near dissociation and in cases with hydrocephalus you can certainly get concomitant kind of papillodema as well. And this sort of the diagram here of the setting sun eyes or sun setting eyes in a lot of the pediatric patients with the macrocephaly here again denoting hydrocephaly. And the kind of common other manifesting manifestations that are not ophthalmologic would be headaches nausea vomiting and alter mental status. And all of these are related to increase intracranial intracranial pressure. The reason for these is, at least for obstructive hydrocephalus is less sophisticated. It's typically, you know, get rid of the obstruction in some way or relieve or divert the CSF that's causing the increase intracranial pressure. So, for a bunch of the examples that I mentioned the college cyst, it's resection for the venous anomaly, the thought was, you know, attempts at taking care of this endovascular which was unsuccessful. And then for the fourth ventricular tumors again it's resection, but in the folks where you need sort of more immediate treatment. We often can do external ventricular drains to help divert CSF. For people that you can't get rid of the obstruction, you sort of can have long term CSF diversion with implanted shunts so that's ventricular either perineal, plural and the lung cavity or atrial shunts as well as for children is a lot more common we do endoscopic third ventricular to divert CSF. And kind of one of the other ways to address this is with optic nerve sheath fenestration, again aimed at sort of giving the CSF and the stagnant or the increase intracranial pressure sort of an outflow. And so that is all I have for my talk these are my references, and then kind of happy to take any questions.