 You got your papers out, all ready to go. Number two, I think I got some feedback yesterday that my quiz was a little too hard, so it's a little easier maybe, but no promises. So this is your quiz question number one. It has to deal with the anatomy of the iris on the pupil. And it is important to know what you're looking at and what is normal. So the question here is, and it's even multiple choice, so it's a little easier, I think, is what is the normal location of the center of the pupil compared to the center of the eye? Is it inferonazole? Is it supronazole? Is it inferotemporal, or is it suprotemporal? Does anybody know? Yeah? Well, I mean, did you answer it on your paper already? You got it? Does anybody know? It is inferonazole, and it's unfortunately no rhyme or reason. It's just kind of where mostly anatomically things end up. So just important to know when you're looking at a normal iris and normal pupil, you're going to have some displacement from the center of the iris of the center of the pupil. Question number two. So I want you to list three signs of Horner syndrome other than meiosis, ptosis, and anhydrosis. And I think I could think of maybe eight. So you get three. It's not too bad, right? So I'll give you 15 seconds. Seconds left. There we go. You ready? Can somebody scream some out for me? Sorry? Perfect. That's a good one. Anything else? Like how am I sign this involvement? No. No, it's not a sign. What is happening? How about flu and ophthalmos? That's a really great one. Or an elevation. What is happening? You're having a seizure because it's too stressed. All right, so this is a list, right? So again, ptosis, anhydrosis, your classic medical school teaching. You're not in medical school anymore. You're ophthalmologist. So you should have a bigger list of things that are associated with Horner syndrome in terms of the signs. So dilation lag is your classic, classic thing we talk about with Horner syndrome. So really important to think about that. Reverse ptosis, of course, is associated with the sympathetic innervation of the inferior eyelid retractors, which is equivalent to the mular muscle in the upper lid. So it's a reverse ptosis. And as Dr. Warner had mentioned, it gives you an appearance of pseudoanophthalmos. When you do your exophthalmometry, of course, it is not the case. And that's why it's called pseudoanophthalmos. But the appearance of the ptosis and reverse ptosis gives you that sunken eye look. The conjunctival hyperemia is really important as well. And that's just related to the removal of the sympathetic tone of the vessels. And so a lot of the time, what patients end up being treated for when it's not picked up correctly is for some kind of corneal or dry eye or infection or allergic reaction in the eye, because that eye just looks red. So unless you pick up the subtle ptosis and subtle anisocorrhea, they can't end up being treated for anterior segment problems, which are not anterior segment problems. So again, really important to keep in mind when you're looking at somebody with unilateral red eye and maybe some other neurological symptoms. Iris heterochromia is also an important sign. It is traditionally thought of as a congenital hornar syndrome sign. And it develops in children, because if sympathetic innervation is disrupted at the time where the melanocytes produce pigment and deposit pigment in the iris, you basically get anisocorrhea. So if you have a unilateral hornar syndrome, you get anisocorrhea. And the iris that is lighter is the one that is the abnormal iris. And classically, the timing for that is thought to be probably up to two years of age. So there's been some studies done on the development of the color of the iris in children. And up to two years is when you can actually have development. So even if you have a theoretically, even if you have a acquired hornar syndrome after one year of life, then you still could end up with iris heterochromia. Again, abnormal iris is the lighter one. The sympathetic innervation is required for melanocytes to produce pigment. You can get transient increase in accommodation, because of course, you just get a parasympathetic drive. As your sympathetic drive is impaired, again, temporarily transiently, you can get reduced intraculopressure for the same reason. Has anybody heard of Harlequin sign or what that is, or Harlequin syndrome? Very good. Yeah, so that, again, is one of the findings. And which side would it be the hornar syndrome on? So Christian, which side would the hornar syndrome be on in Harlequin? Sorry? The normal side. Correct. So again, think that that's actually the opposite side. But the sign is called for the facial flushing. And then we don't quite understand why, but there's some kind of sympathetic input towards your hair being curly, if you're naturally curly. And if you remove sympathetic input, you actually get a straight, half the hair straight, or some part of the hair is straight, and the other side is curly. So I really don't know the explanation. I don't know if Dr. Warner, you have heard of why that's the case. But I don't think we've figured that out yet. They scared me so much it made my hair curly. This is true. All right, so there is a case. So we have a 63-year-old patient. And she came into clinic just last month with a two and a half week history of Anisechoria. And the Anisechoria was greater in the dark. So I am going to get one of the maybe PGI chews to describe to me what you see. So this is a photograph of our patient in a room light. And she's looking far away. She's looking at distance. Well, you know, we traditionally beat up our patients in your ophthalmology clinic. So. Holy Mary. All right, Chris? Upritalia is a nebosis. And there's also people that are smaller than the right injection in the right eye. Oh, in the right eye, you mean? Oh, OK. Anything else that you think is on the photo? The nebosis in that left eye. Good. So what's the MRD? I just estimate. Yeah, and then what do you think of the right? The right eye, maybe four and then. I agree that. So that gives you two signs of Horner syndrome. So we've got ptosis and reverse ptosis. Reverse ptosis, good. That's pretty good, right? So apparent on ophthalmos, I think, is a really nice thing that's exemplified here. Just looks like that eye sunken because of that appearance of the ptosis and reverse ptosis. So, but you know, I already told you, right, that the anisecary was greater in the dark. So you kind of have your differential narrowed down a little bit. But it also helps you, again, just that subtle ptosis, reverse ptosis, apparent on ophthalmos. And you have the anisecaria. And you put it together. One thing she does not have, she doesn't have iris heterochromia. So you probably, it's not congenital. And she's got the achemosis around there. So something must have happened to her. So, yeah. Is her eyelash a little left side? More curly. Well, almost some cops have been told that she stayed. No, I think it's just the other right there. It's just the darker background. You don't see them as well. And so then this is a picture of the same patient. And this is her looking at near. So you're basically looking to constriction to near. And she had that. And then here is a photograph of exposure, light exposure to the right. And you're looking for a kind of consensual response. And if that, and that is indeed present. And then we did this. So the light has turned off. This is five seconds. This is 15 seconds. What do you see there? Five seconds. 15 seconds. Very good. So this is a sign of Horner's syndrome called dilation lag. And again, a really nice thing to look for, because it really, you can even avoid, in this patient it's kind of classic. You've got your ptosis, you have your reverse ptosis, you have your anus acoria, you have your dilation lag. So you're getting the idea that this is Horner's syndrome. And in majority cases, actually, it's pretty convincing. So even drop testing is not necessary. And we actually didn't do drop testing in this patient, because I think all the signs were pointing to Horner's syndrome. And this patient actually had a surgical resection of her thyroid. And she developed a really large hematoma on her neck. And supposedly, that was compressing her sympathetic pathway. I will have to caution you. I do remember seeing one case in residency where a patient had had a tumor resection in her neck. And she developed Horner's syndrome afterwards. And it's easy to assume, well, this is just post-surgical changes, nothing to worry about. And this was about probably six weeks after she had had her resection. But there were some other things going on. So we decided to reimage her. And she actually had recurrence of that tumor in the short period of time in the same area, compressing her sympathetic chain. So just be aware of looking for other things and not just discounting things to post-surgical changes, because multiple things could be going on in the same patient. So we actually offered this patient repeat imaging. But she chose not to do that. And we're just going to observe her and just make sure that she does well. And when was the surgical time? Yeah, it was about four weeks ago. Yeah, like three or four weeks ago. Didn't it make this injury up? Yeah. Well, I think this is probably maybe post-surgical or something like that. I don't know where they went into it. But the ecumosis had no relevance to it. Well, it had relevance because it was post-surgical. But it wasn't a traumatic event or anything like that. OK, so the next case is a three-month-old baby. And the parents bring him in because about one and a half weeks ago, they noticed anisocorrhea. And so maybe we'll get Nico to comment on what you see here. And I always, it's sometimes important to mention pertinent negatives in this case. So what are pertinent negatives in this case? The upper eyelids use symmetry for its notosis. Very good. What other signs of horner did we talk about that he does not have? Look at his face. So it doesn't have any symmetry in the flushing, right? So that's important to note. And stepping back, even before you think about something like horner syndrome, he does have anisocorrhea. So what's another important pertinent negative that is nicely exemplified with the corneal reflexes in this photograph? Yeah, so they're central, and there's no apparent deviation. So presume that this child did have right-horner syndrome, right, have a little bit of meiosis on the right. Would we expect iris heterochromia in this child? Three months. No, so as I mentioned, right, so it, well, it usually takes about six months for it to become apparent, but up to two years sometimes. I guess it depends on the natural pigmentation, right? So I'm a child. OK, then this is the room in the light. This is the dark room photograph. Nico? So? Yeah, we actually didn't think that it was that different. It was less than a millimeter, about a millimeter or so, or less. And it was relatively symmetric, and we're comfortable because there was no ptosis, no other concerning findings. So we are going to be watching this little guy, and we thought he had physiologic anisechorrhea. So we have question three from your quiz. And again, it's a multiple choice. Yeah, sorry, yeah, the parents had looked at the photos, and he's had it since birth, so. Or at least like, at least the first month for sure. All right, what's the answer to this one? It is C, and the concern with apoclonidine and bromonidine is what? Yeah, CNS oppression. So we really do not like to use any of the derivatives in children, and it depends on kind of the source you look at, some sources say even up to eight years of age. Majority of sources say maybe two years of age, and after that, it becomes relatively safe. But it just has to do with CNS penetration of both drugs in children as compared to adults. So do not give bromonidine or apoclonidine to children. Cocaine is actually safe in children for testing. So what age? So like I said, so most sources say about two years, but some say up to eight. So I would just avoid it in children if you have access to cocaine in general. I did want to mention a little bit more about physiologic anisechorrhea. You did mention a few points about it, but up to 20% of population actually do have physiologic anisechorrhea and walking around with unequal pupils. Usually it's less than half a millimeter difference, but classically we talk about less than one millimeter. And the amount can vary depending on time of day, and it can actually flip eyes as well. So you can see that traditionally anisechorrhea is the same in light or dark, but it can be more obvious in the dark like in our baby as you can see just because dark conditions just makes things I guess a little bit more obvious. So the confusion often comes in, especially when you have an older person with physiologic anisechorrhea and then they have maybe involutional ptosis. And so drop testing is important in physiologic anisechorrhea in case you were wondering why would we test if all these features are present. It's not often clear as can be. Okay, so here's the third one. This is a baby I saw, I think it was maybe a third or fourth year resident and mom sent me this picture. So what sign is this? Yeah, so what sign is the pathology on? So theoretically it should really help you localize where Horner syndrome is. And of course, and you seem to know kind of a little bit more about the anatomy of facial sweating and, no? No, okay. Anybody? Why does that maybe help you localize things? Well, so the way that the pathway for basically vasoconstriction of vasomotor and pseudomotor fibers goes is a little bit different than your pupillary sympathetic pathway. And very similar, it just goes down a little further down the T spine, but when it travels to the superior cervical ganglion it actually splits and fibers that innervate the upper medial forehead actually travel differently than do the fibers that innervate the lower face. So it kind of gives you an idea that, if you have a bit of asymmetry, you know that if the whole face is affected that it's likely either first or second order neuron, but if it's just part of the face like the superior medial forehead then it kind of helps you localize things a little bit. Now I have to say that in kids there's been some publications about the fact that it's not necessarily true and there's thought to be some transynaptic degeneration that happens that we don't actually see an adult. So in adults this may be helpful, but there's been several cases in children where drop testing actually localizes to a different location than the facial asymmetry and the facial flushing. So I will have to caution you against that in children, in adults, it's a little bit more consistent in terms of kind of the asymmetry. Now you did mention that we don't really test for anhydrosis. You can in children, especially if they cry, it's actually like in this case, kind of a nice example of how we can actually see the anhydrosis and the facial flushing that's asymmetric. Some people talk about using like a spoon or even like a prism in clinic and running it over the forehead and seeing the difference of how slick it is depending on the side of the forehead you're testing for. So and I mean, I've, you know, I saw a patient with Harlequin syndrome we actually made him run up and down the stairs just to see kind of where to reproduce those signs. So you can do certain things to bring out anhydrosis and asymmetric flushing. You know, it is a little bit more effort. So maybe that's why we don't talk about it. Yeah, that's true. And so I just want to mention this because I knew we weren't going to talk about too much in the actual didactic portion of the talk is that, you know, like if you think cornering children, like you got to think neuroblastoma, you know, and it's sometimes difficult, especially if a child presents a two years of age to know if it's congenital or quiet, especially if there's no history of birth trauma. So you really, you need to think about that first. And one other point I wanted to make here is the kind of the congenital side of things. Why would congenital agenesis of internal carotid artery cause Horner syndrome? Where does sympathetics go? You need that to kind of guide that. Correct. So if you have developmental agenesis of the internal carotid, you're just not going to have your sympathetics travel to that area. So just again, connection between what your causes are to the anatomical understanding of the pathway are really, really important. Okay, so Lee, do you want to describe this one? Three minutes. Well, you know what? Actually, we're going to go to this. This is one other thing that we did not cover that I wanted to cover today. So I know he's telling you what is going on, but I did want you to, no, I'm not, I'm going to show you this. What is he showing you that there? So the patient is basically looking at near, evoking a near response. So what's happening there? No, well, later, but sorry. So he tries light first, that doesn't work. Then he tries near response and that constricts the pupil. What's that called? Sorry? Light near. Yeah, so light near dissociation. Slowly is moving. Yeah, so light near dissociation. So this is your quiz question four and what I want you to do, this is a little bit of help for you, but I want you to name an anatomic site and then etiology of causes of light near dissociation and I want you to name five of those. A few more seconds. So the first site, of course, is retina. So if you have severe retinal damage, that can give you light near dissociation because of the input effect. Short posterior ciliary nerves get affected in either PRP or peripheral neuropathies of different kinds that can give you light near dissociation. As Nico had nicely explained, adi's pupil site of pathology is ciliary ganglion, so you need to know that. With cranial nerve three, aberrant regeneration can be a cause of light near dissociation, for example, when adduction is coupled with meiosis, et cetera. So that's important to know. Argalobrobrits and pupils localize to the tectum of the midbrain due to the inflammatory effect. And then we've seen a few cases of dorsal midbrain syndrome that are due to either tumors or hydrocephals or other compressive things. And quiz question five is two systemic findings in adi's pupil. This was covered, so we should. And a quick one here. This should just be a quick look. What's this? Can somebody describe the photo quickly? Maybe Lee, sorry, I took away your chance and it's a chance to redeem yourself. And what's this sign called? The toothpick sign or the Q-tip sign? Why is that there? Correct, so he's trying to elevate the eyelid. Eyes down and out, you have anisocorrhea as expected. So as Nico quickly mentioned, you need to image this patient. And this is the last one here. And this is a patient here that has anisocorrhea that was greater in the lip room. And this is him right here. And this is him after installation first of dilute pyloh and then second of 1% pyloh. So what's your diagnosis here? Okay, I'm always running out of time, but these are your quiz questions and those are your points. And I will collect the scores.