 All right, so we're doing pupils today. So first let's talk about the approach to anisechoria. And this is pretty basic. There's a really good focus article that just gives you this nice algorithm that you can use. And I refer to it every once in a while. The first thing I like to do if I see someone or I'm getting consulted for someone who has unequal pupils is I want to measure their pupil sizes in bright light and dark light. And that's the first part of my algorithm, tells me if this is more of a sympathetic problem versus more of a parasympathetic problem. So if the difference is more pronounced in the dark, then I'm wondering about there's a sympathetic problem, specifically a Horner syndrome. And I can go down this list over here. So is there a symptoms? Maybe they have some anhydrosis if it's a third order Horner's. You can confirm with a number of testing of note this is kind of old. We don't actually have any hydroxyamphetamine anywhere. So you can't really do that anymore. But you can also look for dilation lag when you see the patient and that's something you'll see in Horner syndrome. And you can find, I won't go into it because some of these videos are a little long, but on the novel website, Dr. DeGree has a whole bunch of really good videos and movies and pictures of things like dilation lag. So you can kind of see what it's supposed to look like. We use cocaine to confirm a Horner syndrome. You can also use apriclonidine advantages and disadvantages. So the cocaine is better for a more acute case, but it's harder to get up from pharmacy. We have a bottle of apriclonidine in clinic. The problem with apriclonidine is if it's acute, you do need to have some denervation super sensitivity occurring for it to work. And so you might not pick it up acutely. The other thing is a CNS depressant. So we try not to use it in pediatric patients. And then the hydroxyamphetamine is really helpful for determining if it's pre versus post ganglionic. So if it's a third order Horner's, it shouldn't have an effect on that pupil. But if it's prior to that second or first order, it should. But again, we don't really have any hydroxyamphetamine anymore. The other thing that might be going on is it could be a physiologic anisechorrhea. And that's something to always keep in your differential. And then one other thing that you might see is a little old AD syndrome. And we'll talk about that a little bit more. And then also just getting a look under the slant to see if there's some other reason for that pupil to be a little smaller. So then what if it's more pronounced in light? Well, then I'm leaning towards parasympathetic dysfunction and I might be thinking more about a third nerve palsy. But I also really want to look at the overall iris structure too, because I have to have 80s people on there as well. So I look for the segmental paralysis of the iris sphincter. Look at their extraocular movements, look for ptosis, things like that to lean you more towards a third nerve palsy. So the concern with an isolated anisechorrhea that's more pronounced in bright light is that it could be an early third from a compressive lesion. The parasympathetic fibers are on the outside of the nerve. And so as it's starting to be compressed, it's gonna start hitting those before it starts affecting extraocular movements. And then with these patients, you can use pylocarpine. You can use a very dilute pylocarpine to confirm 80s people. And you can use a heavier dose like 1% to see if it's more of a third nerve palsy versus traumatic medriasis. Okay, so let's get right into the cases. So this first case, this is my neurology resident. So we got called to see a 72-year-old man. He was in a rollover accident, really bad one. Trauma has seen him. They checked him out. They said, okay, he's stable. He's got like a CTE of the neck and some X-rays. We're just gonna go review these, but otherwise he's stable. One thing we noticed is that he has a right-blown pupil. Can you come down and take a look at him? He's also, he's weak on the left, but we think he has some fractures on that side. And so we go down and your brief op, though, exam is that he's 2020 and pupils will take a look at that, but there's no APD. Extraocular movements, visual fields are all full, and the fundus looks fine, but he is weak on the left and on the left upper and lower extremities, but he also has an up-going toe on the left. So this is what he looks like. And what you're thinking, this is one of the first things you look at as an opthal resident are his feet, right? So this is why they're talking about, yeah, we think he fractured his hip just because hip fractures will frequently cause this external rotation of the leg, but he's got an up-going toe. So that should point you more towards a central nervous system issue. What do you guys notice over here? Exactly. So this should point you towards some kind of autonomic issue on one side, specifically on the left side, it should be a sublateral. And then what do you guys think of his right-blown pupil? Blown pupil. You're all looking at me like, wait, are you triggered? So yeah, so this is not uncommon. I've gotten this consult a couple of times where the concern is, look at this really big pupil on the right, but it's no, look at this really small pupil on the left with the ptosis. So what do you guys think in here? First order horners, I heard, very good, because he's got some CNS involvement that should put you towards the first order. So someone comes in, I love how they always, like, you're the only person in the ED, so they give you this EKG, and you just always act like you're like, oh yes, ah, excellent, yes, and all you're doing is you're just reading this up here. And you read that he's got sinus bradycardia. Nothing else going on, so you say, sounds good, thank you very much, and you hand it back to them. All right, and then you just decided to poke through his imaging because you were told so far everything looks negative but they're reviewing it with radiology. What do you guys think? Yeah, I was gonna put some arrows on this so you guys could see it a little more easily. But this was an interesting case for me for a number of reasons. And I'll just kind of show this, so he had this bad fracture at about C7. He has this, this is a sagittal MRI T2 weighted image of the C spine and he has this hyperintensity down here. And then this is an axial view and it's not super easy to see but you can kind of make out this hyperintensity in one half of the spinal cord. Anyone know the double name eponym for this syndrome? Brownsacard. Okay, and as you guys, as someone pointed out earlier, it's a first order Horner syndrome, right? Because your sympathetics run from the hypothalamus, all the way down to like upper thoracic and that's where you get your first synapse. So this is the first order. So first order Horner's, you should see some CNS involvement. And it comes out there, goes to the stalate ganglion, goes around the subclavian artery over the apex of the lung. So you could have a pseudo aneurysm and an IV drug user. You could have a Pancos tumor, right? And then it goes up here to the superior cervical ganglion. Synapses now your third order. This third order, it's important, goes up the carotid artery. And if it hits it at the common carotid artery and there's a dissection causing the Horner's, then you can have anhydrosis. So we won't go through this in detail, but it's good to have a differential for your Horner's syndrome. We don't care about Horner's syndrome because the Horner's syndrome itself is hurting the patient, but because it indicates that there's something more sinister going on. So in the case of a first order, you're thinking about a stroke as one of your major concerns. Although in this guy's case, he had a Brown's card and it was traumatic. With a second order, you might think about a Pancos tumor, although they're incredibly rare. If you see kind of a slow smoldering Horner's syndrome and it's like less than three years duration, and that's one thing that hasn't been done, you might want to get some chest imaging. And then third order, a major concern is a carotid dissection, which you do want to deal with urgently. So sometimes a right-blown pupil is a left Horner's syndrome. Check your pupils in light and dark. And with this guy, I remember we had this whole team of neurologists. We had two medical students. We had the Stroke Fellow and we had the junior resident and then we had myself. And while everyone was like carefully mapping out this guy's sensation to a Brown's card, I was looking around for the light switch in the trauma bay. Have you guys ever looked for the light switch there? So you really want to look at anisechoria and bright light and dark light, right? And sometimes it's a little hard to find that trauma bay, but you got to do it. The other thing we did with this guy to mention his genes were hanging over a chair next to his bed. So with his permission, we took out his wallet, looked at his driver's license, just looked to see, is this something he had before his trauma? Because if so, then we're not gonna, that's not gonna play a role in our localization. And then the other thing is just look over the image in yourself. You could be like, well, I don't know how to read spinal images, but you guys all read that one just fine. So you remember the other people that are going through there are rushed, they're seeing a ton of other patients. I know you guys are too, but if you can just open up the imaging real quick, just make sure it is what it is. You'll be surprised at how often, especially overnight, a really busy RADS resident will miss something pretty obvious because they're just not looking for it. Okay, the casual blown pupils, one of my favorites. All right, so I get called about this 34 year old guy. He's referred for a right blown pupil. So it happened, this is like Wednesday and this happened middle of the day on Saturday. He notices that he has some blurry vision when he's trying to read his bills, middle of Saturday, right? And he goes and looks in the mirror and he says his pupil is super dilated. So I show him some pictures, Google image pictures and he says it was like that. It was just blown open. And it was just that right pupil. So he walked into the emergency department and he got an MRA head and neck, MRI brain, everything was normal. And they referred him to neurooptho non-urgently but he was just terrified. Someone had told him, oh, this could mean you have an aneurysm and MRAs aren't really great for detecting aneurysms. It might have been missed. And so he's just really terrified. He's calling Anne Chisholm at the front desk and he's just begging for an appointment. So we just bring him in and see him real quick. We're four days out. The pupil is getting a bit smaller but it's still slightly larger on the left. His exam is otherwise normal except for that pupil. So not super easy to see with his dark iris. So I put this in here just to help you out because in real life you'd lean in there really close and you'd get a closer look at it. So RLF, anyone know what that stands for? See it on that imaging all the time when we do pupil photos. Room light far. All right, so important when you're measuring pupils to make sure they're looking in the distance so that you don't get some accommodative change to the pupils. And then D15 is in dim lighting for 15 seconds. So we've got our bright and our dark. It's the first part of our algorithm. What do you guys think? Diagnosis or what do you think compared between the two? Which one is more chronicist? Which one's abnormal and right pupil to the left? So the right one's abnormal and the difference between the two is it more pronounced in dim lighting or bright lighting? Bright lighting, right? So are you leaning towards problems with his sympathetic or his parasympathetic? Parasympathetic. Okay, so the thought here is maybe a third nerve palsy, right? But an isolated pupil, right? No ptosis. I told you his extraocular movements were all fine and this is what we got. So I start talking to this guy about what about some eye drops? I mean, look at this pupil that he had before. You don't get that without putting something in the eye, right? So I'm asking him about eye drops. He's like, no, no, no, they asked me about that. I didn't put anything in my eye, nothing. So I'm like, oh crap. I thought that'd be easy. Well, what else? What were you doing Saturday when this happened? He's like, I was just out in the yard pulling some weeds. Oh, what weeds? These really annoying ones. They're pretty looking but they're all over my yard. And I do a Google image search. I show him this exact picture and he's like, that's the one. That weed's all over my yard. It's everywhere. He's like, oh, okay. So this is a hot day in August and you're kind of wiping your brow like this. Maybe wiping the sweat off after you pull some weeds there. And he's like, yeah, yeah. In fact, I think I did that. Okay, well, case solved. So Jimson weed is this weed that you can find around here in Utah. And sometimes they describe it as getting in the eyes of farmers too. If it gets caught under their tractor and they're kind of working under it or any kind of vehicle they take out in the field. And it has atropine in it. And so it can cause this kind of toxic or pharmacologic medriasis. We won't go into this, but just a nice list for you to kind of look through when you're wondering about possible pharmacologic medriasis. So history, history, history. It's so important. This guy did not need an MRI brain. He did not need an MRA head and neck. He just needed someone to kind of think about what could possibly have gotten in his eye and how. No, a patient's med-less too. Go through that med-less very carefully. And there's some things they won't think to tell you about. And so I'll talk about that in a second. But another important point here is blown pupils from herniation. They don't walk into the ED, right? So if this person's sitting there having a conversation with you, they're not herniating. So you can, you know, everyone else is gonna be just going crazy and sometimes you'll get a call from the ED and they're saying, no, drop your open globe, come here and see this patient right away. This person's dying, they're herniating. But everyone can just calm down, take a rest, sit down, take a little time to talk to the patient. Another thing though is there's some stuff that can become really important like asking them about travel. And so I had a case where someone had this pharmacologic medriasis and I wasn't really sure what was going on. Nothing on their med-less really made sense. They did talk about, they had some recent travel to Mexico. Is that a big deal? And I thought, ah, probably not. But as they said that, they did this with their head. And I saw this little patch behind their ear. And I was like, would I travel to Mexico? Is that a scapulamine patch? Yeah, yeah. I didn't tell you about that because it's not one of my regular meds. I just take it when I travel. It's like, oh, okay, great. And so the anise acoria was on the same side that they had the little patch there. And then the other thing is you can sometimes get this consult from ICUs. And so it's important to take a look at their mask and take a look at what medications are being blown in through the mask. And sometimes that isn't documented is easily either. But something to look for. Yes. Is that from like some circulation? Or is it? And Dr. Werner brought this up one time when she was in med school. This guy took this student up in the front, this really fidgety student and put this material on his hands. And then at the end of the lecture, he said, so how often were you guys touching your face and your eyes today? He was like an infectious disease professor. And they're like, well, hardly at all. And then he turned on a black light and this guy had like his fingerprints all over his eyes and his mouth and everything like that. So someone might tell you, oh yeah, I put it here, but I didn't touch my eyes. It's like, bull crap. We all touch our eyes. All right, transient anise acoria. So this is a clinic case we have, 36 year old lady. And she's referred for this transient anise acoria. She has two episodes in which her left eye becomes dilated for about 24 hours before resolving. She's just had two of these. One of them was like years ago. She doesn't remember the exact circumstances. Maybe someone gave her scopolamine patch for some nausea, but this most recent event, she's watching everything like a hawk. She didn't have anything like that. Nothing in the eye. She swears there's nothing in the eye. No headache, no double vision. Nothing else going along with this. She has a history of migraine, but she was not having one when this happened. So again, totally normal exam except for the pupils. And these are some photos she gave me. They're not terrific, but you can see some things here. This is at the onset. She just takes a picture of herself real quick. And then this is 10 hours later. And you can see from this bag back here that she's sitting in an emergency department somewhere getting evaluated. So what do you guys think? Which one's the abnormal pupil for to tell? Yeah, and part of this is the history. She just tells you my left one was just kind of blown open and not very reactive. When this happened to her in the past, it was also the left eye. So any thoughts on this one? Transient anisecoria in a 30-some-year-old woman, otherwise healthy, normal exam otherwise. By the time she comes in and sees you, it's gone. Her pupils are totally normal. You look at it under the slit lamp. There's no sectoral palsy, permaform movements, anything. Totally exposed. Sorry? One of the differentials like benign and episodic drys. Okay, good. So that's the differential. Perfect. So they also call it springing pupil. And it's more common in women than in men. The median age is about 31. They usually last about 12 hours. They're give or take. And then sometimes they'll have a visual blur when it happens, headache, orbital pain. Sometimes they don't have anything associated with it. But the important thing is that it goes away. And you can't find anything in a very careful thorough history of any kind of pharmacologic dilation. So remember, again, to check the person's meds, toxic exposures. Another thing that can cause transient anisecoria is cluster headaches. So asking about that. And then there's this thing called tadpole pupils, another picture from novel that's kind of neat. It's the sectoral pupillary dilation that can last for a few minutes at a time. So people will get it for a few minutes, goes away, comes back a few minutes, goes away, comes back a few minutes, goes away. Maybe it goes on for like a week, couple times in a week, then it goes away and they never have it again. It's thought to be a benign condition. But there are other things. There's something called midbrain corictopia where people can have just like an off-center pupil because of midbrain pathology. So a couple of things to keep in mind there with transient anisecoria. But most of them not really sinister, not pointing towards like a sinister diagnosis. So you can usually kind of take it down a notch and relax with these patients. There's another kind of interesting one and this was a case of kind of a reverse horners that Dr. Katz was telling me about called porfor dupeti. I just thought this was kind of interesting. So you can't really see much difference in her pupils right here, but you can see her eyelids kind of retracting on this side. And it's caused by the opposite of a horners. So a horners, you're stopping that sympathetic innervation to that side. In this syndrome, you're stimulating that sympathetic nerve by irritating it or something. So it's described by this guy porfor dupeti, this physician back in like Napoleonic France. And he was mainly seen it in soldiers who had slash wounds from like a saber to their neck. And so initially they would have this porfor dupeti, this reverse horners. And then as the irritation went away and everything kind of took its course, it became more of a horners syndrome on that side. But people can have this kind of reverse horners transiently as well. Okay, now how about a transient horners and a little peanut? So, seven year old girl and she has apparently a horners syndrome that comes and goes. She's here for RSV infection. Oh yeah, sorry. So in this case, she doesn't really have a, if you can see it, I don't know that you can, a lot of Anasacoria, but the cases I was reading about, they still have a larger people on the affected side. And so it's just like a reverse of horners. The people's gonna get a little bit bigger. The eyelid's gonna retract a little bit. And then later after the damage has taken its effect, if it's from traumatic damage, then you're gonna get a smaller people and a little bit of ptosis on that side. Is that because there's almost something that you've brought there, right? So what I was asking is because of the sphincter muscles having a greater reverse response than the dilator muscles, would you necessarily see that as a trigger? Or would you just mainly be looking for the dilator traction? So your constrictors, right, are gonna be a little overwhelmed by the dilators, which are, I see what you mean, yeah. That's a good question. And I don't have a good answer for that, but from what I've read, it sounds like you can have either or. So in this case, for this lady, I don't really see a lot of Anasacoria, but in the other cases they described in this paper and another one, they did have Anasacoria with the affected side being a little bit more open. So since that sympathetic system is being irritated, it's gonna overwhelm the constrictors a little bit on that same side and it's going to overwhelm that eyelid and kind of pull it open a little bit as well. Okay, so transient horner's in a little peanut. So now the seven-year-old girl, she's got a horner syndrome that comes and goes. She's admitted for an RSV infection, totally unrelated, but mom and dad have numerous photos of her with and without this and they're not really worried about this. She seems to have had this like all her life, but the team is really terrified about this and says would you please come and just take a look at this patient, see if this is really a horner syndrome, see if there's something we need to do. So again, exam is totally normal and let's take a look at this. So this kid, you can't really see the pupils too well, but there is no Anasacoria and this kid right here is already dilated. But what would you, how would you describe this? If you see this patient and then you give me a call on the phone, what would you say? And she knows that this is how it changes. Like transient, he lateral tosses. What's she? The ptosis goes away when they move their jaw and she'll know this, right? She's like, yeah, my mom and dad have noticed while I'm chewing food, it just kind of like comes and goes. And so she knows if she opens her jaw or she moves, she uses her lateral teragoids and moves her jaw to the side that it kind of resolves that ptosis. Doesn't just resolve it, but actually causes a little bit of retraction on that affected side. Arcus gun, right? So this is the synkinesis between the levator and a person's teragoids or other jaw muscles, muscles of mastication. And so it's something that this kid was probably born with. It's probably benign. You can kind of stop there. So this Marcus gun jaw wink. So remember, not all ptosis is horners. Look at those pupils very carefully. So it brings up a good topic though, which is horners and kids. So a congenital horners is usually gonna be benign. Does anyone wanna hazard a guess at what's going on with this kid? So he has a heterochromia that they describe with congenital horners. And so you can see he has this really light colored iris right here, but he has some meiosis and some ptosis on this side. Anyone notice anything about his hair? Straight on this side and curly on this side. So this congenital horners, it's usually benign. The kid was born with it. They had some damage at birth. Maybe it had to do with how they're delivered, forceps or something like that. And so because they don't have that, the same sympathetic innervation on one side, the thought is that melanin requires that sympathetic nerve pathway to kind of make its way to the appropriate tissue. And so they just stay, when kids are born they have these blue eyes, they just stay blue-eyed on that side. The other thing is it has something to do with how the hair curls and so they'll sometimes have curly hair on the unaffected side and straight hair on the other. But if you see a congenital horners, and in fact there's a literature about a 47 year old man that was diagnosed with congenital horners, wasn't noticed until he was 47. He has this heterochromia. He goes in and they image him and they do all this stuff and then they just start looking through these old photos and he had always had this, just no one seemed to notice. But then what if you see a horners in a kid that's an acquired horners in a kid in their first five years of life? In that case you should be thinking about like a neuroblastoma and some neck and chest imaging might be required. Another thing to remember with horners is that a lot of your cases are gonna be idiopathic anywhere from 30 to 70%. And if you've rotated through clinic, you guys know that we don't always have a good answer for why someone has a horners. Sometimes we have a theory, sometimes we don't have anything, but we just know it's not one of these sinister diagnoses. One thing that I remember seeing too, rotating through primary, this was a horners syndrome, post-surgical horners syndrome and everyone kind of terrified of what happened here and we didn't touch this kid's head or neck. Like their head and neck was not positioned in any kind of awkward way and that's not where we're doing surgery. We're doing like a robotic surgery right down here. I know it's the same side as the horners but like we didn't touch that. I know the sympathetics don't go down here. Like what could be going on? And then the next question asked was, how was the patient positioned? I told you, their neck was fine. How was their arm positioned? Because this kid was like in this position for eight hours and so you stretch the lower brachial plexus where your sympathetic nerves run through and they probably had a stretch injury of their sympathetics on that side. And the horners actually improved dramatically afterwards in that kid just after a couple months which kind of corroborated the whole stretch injury. Then the other thing here is that cocaine is the agent of choice in pediatric patients and the reason you don't wanna use the apriclonidine is it's also a CNS depressant. Okay, case number five, it wasn't there before. So 37 year old woman who comes to clinic, she has this right blown pupil that was noticed by her sister yesterday. I don't know, sorry, it was noticed by her sister today. She knows it was not there yesterday. She takes a lot of time doing her makeup. She did not see any change in the pupils. Our sister's a nurse, tells her you should go into the hospital right away. So she actually came to the emergency department to be seen. And then someone wheeled over a slit lamp to get a better look at her. So the pupil, so it's three millimeters and left five millimeters on the right and the right pupil is unresponsive to light with this decreased accommodation. And then you just whip out your reflex hammer and you're just checking their reflexes for fun because I know you guys have a lot of time on consults to do that kind of thing. And you see they don't have any deep tendon reflexes. Any thoughts going on here? She's walking into the emergency department. So it's probably not a herniation, 80s people. Any other thoughts? Yeah, okay, totally. I can sometimes trip you up, right? Is when you see two things and you're like, I gotta make these two fit. And it's like, well, what if this one has nothing to do with that one? So it could be that, right? Cause she could be like a really bad diabetic and she just doesn't have any that you can find, right? So you get her under the slit lamp. You blow the dust off the slit lamp in the emergency department and you sit her down and you put her chin up there and you're looking at and you see this. And conveniently your slit lamp has these little arrows that point towards this. What's going on, right? Sectoral palsy. And again, a good couple of videos that you guys can see on novel that Dr. DeGree has up there. Any thoughts then? Pharmacologic or 80s? More than 80s, right? So they tend to have this unreactive. So again, some teaching points. Unreactive people and a conscious patient. Get them under the slit lamp and see if you can find that sectoral palsy, right? Because you're thinking either pharmacologic or 80s people, those two should be high on your list. And you can check after one week with a dilute pylocarpine. And I thought I'd just put this in here. If you guys ever want to try it out, this is kind of the recipe for getting yourself some dilute pylocarpine ready. And this is the criteria for it. If you have like a 0.1% dilute pylocarpine, the affected people should constrict at least a more than a half millimeter than the unaffected people after you put it in. But it's also important to note that you can actually see super sensitivity to dilute pylocarpine in third nerve palsy. It's much rarer, but it's still something to keep in mind. And then people can have bilateral 80s pupils and that's gonna be more common in someone who has widespread autonomic dysfunction like somebody who also has a diabetic or alcoholic neuropathy. And then there's this midbrain correctopia as well where that I talked about earlier where people can have this kind of oval looking pupil because of rostral midbrain damage or an extrinsic compression vision. So the midbrain's being compressed. You're thinking, okay, this must be like herniation, but it looks like there's some sectoral palsy to that or maybe they're just oddly shaped. It could be this kind of midbrain correctopia. And then some important things to remember with tonic pupils. So day one, your big pupil is not gonna be reactive in light or in dark. And I'm sorry, it's not gonna be reactive in light or with accommodation, with near. And you will still see the sectoral palsy acutely. One week after that, then it becomes super sensitive to dilute pylocarpine. Eight weeks after that, they start to get their light near dissociation. And the people will start to redilate after constriction really slowly. Hence it gets that term tonic. And then several years later, they can get this little old 80s pupil. So this is from an article of a guy who had a right 80s pupil. And then this is 10 years later, you can see he's looking a little grayer here. And now this pupil, if anything, looks a little smaller than the other. And notice the eyelid here compared to there. What might this guy be mistaken for? A horners, right? So something to keep in mind with a horners is it could be a little old 80s. And I think just last week, we had a patient with a little old 80s in clinic. Okay. Was that a real case? This one here? No. Like a horned 80s. Oh, I mean this one. I don't think so. So there's something clearly wrong with it but it's nice. The others were. Okay. So let's go on to the questions. And we're going to have 10. We're going to write down your answers. Where are you lacking in need? Yeah, here. It's because Tara's a lot better. That's a good sound. All right, next one. Please write down your answers because you're going to keep track of your scores and determine whether it has the highest score on the quizzes at the end of the lecture series. It's a pie from Dr. D. Green. Oh. I don't know. I don't know what you're talking about. I'm using the words. There's software for the mission of falling pharmacologic agents as the safest to use in children. You see a patient with a left-warners who's exams are otherwise normal but this happened yesterday after a legal accident. Small little fender bender on the highway was the next best thing to do. You want to rule out a thyself. And the reason you want to get that urgently is they could have a thrombus sitting in there and it could mean a certain way wrong if it's not. Usually though, if they don't see an active thrombus, they'll just have a patient. If there is an active thrombus, they'll also have time to admit that instead. You see a 35-year-old woman. She's otherwise healthy, writing knowledge to people. We'll sit for a palsy for informed movements. So yesterday, you get some dilute chiropractic heartbeat. You can still empathize. Write people feels to shrink it down. What's your next step? A. So I would go A. Remember, you've got an acute AIDS pupil. That's what this looks like. And they haven't developed that super-sensitivity to the pilot carbine yet. But you've got sectoral closings that are otherwise healthy. And oftentimes, AIDS pupils are not imaged. And we oftentimes don't use diluted pilot carbines. It's just kind of crumpled. So I would feel comfortable not doing anything for now, but bringing her back in maybe in a week and then testing and just seeing if it's changed. And then you can also talk to her about, here's what you did if you started working out. I'm not sure what you're trying to do. Take a walk. Take a walk. All right. What percentage of people with foreigners will never get an answer as to why they have no answers? 80 to 50%. So it's anywhere from, like, 30% to 70% that, like, we just usually get people with a ball of heart and 50%. You see this 25-year-old woman. She's found down in a bathroom at the emergency department. Shortback her to be discharged. She was seen initially for a headache. Right pupils blown. Just take her intubator right there. No questions asked. They can't extubate her now, but she's a large. She's following commands. And she got an MRI brain. She got an MRI head. Everything's red as normal. And then someone calls you and asks you what the next step is here. She does not have any sectoral poles. Said D, but not that comfortable. OK, so any other phones, OK? I would do A. This is actually a case they had. And they MRI'd her three times. And they vessel-imaged her with an MRA and then a CTA. And I think they did it conventionally in jail as well. They were terrified of having this person. And then someone started talking to the respiratory therapist. He said, well, I can't extubate her because she's just not giving up that effort. And then you go into her history a little bit more and you find a couple things. One, she's in this single person bathroom. And she's found down with her pants down around her ankles and the doors was unlocked by you. But you should lock the door. I know. I've been to another bathroom or another public bathroom. And then a couple other things come out of a lot of social stressors, psychiatric issues. And then you find out that she works at this urology lab. And they deal with large quantities of atropine. And you talk to some of her coworkers. And so her people took like a week and a half to start to come down. She must have been still a lot in there. And atropine can take a while to come down. But eventually it did come down. Like I said, all her vision and everything is negative. What they eventually did is someone did try some 1% hyalocarpine and it failed to constrain to the eye, which made them think this is probably not a third. She's probably not herniating her x-rock movements. Her state normal this entire time. So let's just make sure this is really a third or not. So is MRI and MRI unable to be sensitive enough that if you had it, then it was a new product? Yeah, so you can sometimes miss like a small PCOM aneurysm with NRA. And there's a book called Common Pit Falls in her ophthalmology. But it was written like seven years ago. And they have a case in there where even back then it was extremely rare for someone to miss an aneurysm big enough to cause a third error. So it could be missed. But the resolution of these scans has gotten better and better. And with everything else in there, I would say let's just try the pylokarpene first. Not wrong to do the CTA. But if you try the pylokarpene and it does react, you're like, hey, maybe this isn't third. Then I would get additional energy. But the pylokarpene will be a lot cheaper. And also, it depends on the clinical situation. Like if somebody has a droopy lid and some motility deficits, then I would get an angiogram. I wouldn't mess around with the pylokarpene. But in a case where the motility is full, and there's no choices, this is for you. All that's I've got is a big pylokarpene. The other thing with our people is it was a lot like that. That one I showed you, the Jimson big guy. And to get it that big, these third nerves are big. But they're usually not pharmacologic big. So it was the other thing. But anyway, all that evidence together. Question six, you're seeing a patient with ptosis and acachoria. There's a smaller people in the side of the ptosis. His raging, stabbing pain on the right side, spontaneously for four hours now, is facing up and down. The lights are on and the urges are apart. He also has this tearing and ejection on the side, but there's no ptosis. His eye movements are totally normal. He tried a migraine cocktail to work. CT head was negative. So what are you guys saying? It's a cluster. So you've already looked at, I mean the CT head, we often joke about it. It's totally useless, but you have ruled out some big lead for now, at least. So you could get imaging, but why don't you try treating this first? And the thing with oral triptans, succutaneous triptan will actually help cluster, but oral triptans don't. And then setting this person for an honor and referral before you've tried something to get that pain away, kind of sucks. How long does it take for someone in the 80s to become sensitive to the dietary program? Three possible ideologies for transient cancer for you? Lester? Michael. Pharmacologic, explosion. Pharmacologic. Right here is the lead. So you're gonna have that tadpole people, springing people, right behind the driest. How does that work? People react to cocaine on the third order, rock, silver, rock and roll clown. So, you can see how cocaine works if it's the reuptake of more of an efferent. And so, oral syndrome from any cause that I, that effected on it should not dilate much. It might dilate a little bit, but it shouldn't dilate much. The difference between the two should become anything bigger. And then, what about to hydroxyamphetamine that's the third order? Indemnobility. So, this is how hydroxyamphetamine works. It takes the norepinephrine that's available here, and it pushes it out into the synapse. So, if my third order, you're wrong, it's intact and I shouldn't have some norepinephrine here that's ready to come out into the synapse and do it's business and dilate that eye. However, if that third order is damaged, then I won't have this norepinephrine sitting here and hydroxyamphetamine therefore wouldn't have anything disagreed out to any of the synapse. And so, I shouldn't get any reaction to that. Any questions? So, just a couple of quick points and that is in my general ophthalmology plan, so not my neuro clinic, but my contacts of ophthalmology plan, most common cause of episodic anisocorrhias benign, episodic interlateral hydroxyamphetamine is huge and it's even the story that's the other side is very accurate. When they come here to connect, their pupils aren't normal and that's part of the differential diagnosis you examine them. There's no light near dissociation. There's no motility deficit. There's no ptosis. There's no sphincter palsies. Their pupils are equal. But they often come to selfie showing what they look like here and just found their pupils to be really, really big. And again, they usually last hours and it does not even be associated with a head. These people usually have a migraine in history but they don't necessarily have a headache at the time that they have an anisocorrhia. And they're usually asymptomatic until somebody says, what's wrong with your ophthalmology? And then, the split map is really your friend when you're evaluating somebody with anisocorrhia and you want to look for sphincter palsies. Because if you see sphincter palsies on a pupil that's having them on for a case where you're pretty much deaf and don't have to mess around with your ophthalmology or anything like that, you'll have to get out of the diagnosis. You can also look for trans-illumination deficits. You can look for a posterior synigia. You can look for other signs that the iris had been damaged at some point by a trauma. So the split map exam is really a helpful part of your anisocorrhia evaluation. And if you're ever in a jam, like if you're trying to figure out if somebody has, so the big dangerous things in this lecture are horrors and their fault, right? Those are the things you worry about on call. And those are the times when it's like two in the morning and you don't have any help. Okay, so acute hormone syndrome. You're not going to have cocaine on your drops. You're not going to have hydroxyamphetamine. You're not going to have apricotamine. So you just, the only thing you can really do is look at old photos, and make sure you know that if you can, that they're available and that yourself is new. And if it's new, you just have to scan them in terms of the stern, right? From the whole sympathetic pathway, head, neck, and chest. You know, third nerve palsy, you know, like DR said, if you have a unilateral, big pupil, an isolated big pupil, no motility deficits, autosis, in an awake, responsive, walking, talking patient, you pretty much cross third nerve palsy off your list. If you're really worried, you know, private part being is, you can usually get a hold of some private part being, right? That will help differentiate it from like pharmacologic, or benign, episodic, and dry assist, or some other, some other, more benign cause. If you have a patient with a motility deficit or a little bit of tosis, like that's third nerve palsy, and so prove it otherwise. And then like third nerve palsy is like an hour long lecture, like take care of that. But in an emergency situation, like you are concerned about an aneurysm, but like the more common things are gonna be like diabetes. And so trying to differentiate a diabetic from an aneurysmal third, that's kind of a subject to Dr. Drew's lecture, later on in lecture series. But private part being really helpful in that situation, because if the pupil doesn't react to a 1% private part being, you know you're dealing with something like pharmacologic. The third nerve palsy will restrict to a private part being, so that helps, that's a quick way to help yourself out. Have a nice week.