 Yeah, how's everybody's weekend? Great. I was just seeing, you know, Brevin application. But on the right of the rotation, you do that on the top. What is it? On the right of the rotation, are you seeing? A little bit of what we're going on. So I'm going to come and see. Yeah, I think they're, well, they got permission, but they're one of the changes in fact. The person I write, the meme is in here. Yeah, it's a great killer job. It's still that poster and answered questions like, it was my job. People watch way up with this, like, stunned look. Take the pictures, that's kind of an autograph. Big time. The, once you enter this lecture, there's part of the lecture from last time that I gave you guys the free time to do everything again. So I was charged with East Trogias and Ex Trogias. And I really wanted to focus on the basics. I feel like I didn't really understand this as I was a fellow. That's why I haven't sat through this lecture multiple times as a resident. So it's going to be, again, very interactive. Please kind of guess and feel free to get it wrong. I just think it's more, but it's just too painful at the time. First case, what do you guys say? Pseudo-psyptopia. Why would you say pseudo? Because the light reflects is symmetrically centered. So, yeah, that's a nice one. So you look at the clear light reflection right there and there, it is dead seven. This is a pretty tough one, though. But for all dead sources, that looks crossed. And so you see why we have so many referrals for kids that ended being pseudo-ET. Because it's not easy to tell. And I'll tell you, this kid has all the features that we look for and try to differentiate. The first thing we can call as prominent epicanthophones. You can just tell that, right, this kid really covers over the inside of a conjured typhoid. So, when you can't see that medial conjure typhoid, it looks crossed. And one of the reasons that this kid kind of pours over the inside of the eye is because of that flat nasal bridge right there. So you look at an adult from like a side profile and the nose gets in a little bit, not that much, but a kid that the nose gets way in and comes out. So often to show the parents, because they're dead like that, I don't want to give the parents a complex of their kids, because they don't want to find that they were older, but they have something wrong with their kids. I'll tell them, the flat part of their nose is going to grow and pull that skin up and in and they'll look normal. I'll grab the skin right here and pull it in and they'll look normal. And if the kid will let me. And the parents will be like, oh, phew. So, like we said, you cover up the medial conjure typhoid. And then kids, you know, the other kind of group of kids, in addition to all these things is when kids' eyes are just close together and look across. This is true of adults, too, with it. If you have a short interpupillary distance, don't be fooled by that. And measure it if you think, you know, if you see like in the 50s or, you know, for an adult or low 50s or a high force for a kid, then you'll kind of realize it. You'll have to make it look across. And then the most important thing is the corneal eye reflex to do an ultimate recovery. I had a mentor who told me every time I diagnosed pseudo-ET, I hadn't followed up in a year. And I think that's a great, there's just a great principle there when you think this is nothing, just to always be sure. Because the, or even six months, and I had this just a few months ago, the son of a neuropediatric neurosurgery fellow, the other one, I thought it was pseudo-ET, but I wasn't quite sure. And so I had to say, come back in three months. And I gave my email address and said, send me pictures if you feel like this is wrong. And you feel like it's different. But right now it doesn't look across. And then two months later, or three months later, my son of a game was crossed. The chat at the time was just, didn't have really good fixation. I couldn't do a good ultimate recovery testing. And I missed the first time. So it happened. And so not missing it is not an ideal that you could try to do all the time. I think you have to just put checks in there and try to do these things. But then when it happens, you're still going to catch it later. So pseudo-ET or real-ET? Real. Yeah. So this is, I feel like whenever we're talking about ETs and XTs, people just throw up the type of, a type of ET or type of XT and then give you a big bullet point of all the things that it is. And I want to kind of approach this for, this kid comes to your clinic, and you're thinking about the process. So we're going to kind of, this looks more clinical than just categorized by diagnosis. So 18-month-old comes in. The model tells you that they've been rising and crossing for about three months intermittently. What's on your differential and what are the most important questions that you want to try to figure out? In click. Go ahead. Yeah. Yeah. Most worrisome, least likely. And I want to, because I feel like also as a resident, I didn't have any sense of what's most likely versus least likely. And so we'll try to compare that too. So you're always interested in policy. It turns out that kids, they're very rare. Especially isolated from anything else. You know, the kids that you're inviting, you know, they're brain tumor and that's what science, you know. What else would be on the differential? We use that, but you have to check abduction every time, nonetheless. Refractive air, yeah. Anything else on your differential? Sensory ET. Sensory ET, totally. Great. Perfect. And with refractive, the other one is accommodated ET. Maybe as we're kind of, there's an old one right there. What's the one, if a kid comes in your clinic and they've been crossing intermittently or constant and around the stage, what's the one thing that you care most about and finding in that first use of the air? Prescription. Is this kid hemorrhagic? So that's the first, so whenever you see a kid who's crossing, the first question is, is this kid hemorrhagic? The most common type of crossing is a common ABT. So your very first question, so every kid comes from crossing, and you look at it and you say, well, I'll measure this, but what I really care about is this kid farsighted or not. Even if they're ambiopic, that's the same question, because if they're farsighted, you just can put them in glasses. So that kid, though, straight right out of the glasses. So let me talk about accommodated ET real quick. And again, this is most common of all the ET's. And this gets, question on the board is much more commonly than these, like, misdiagnosed blockade ET. All these weird entities you read about and you can, like, put them in the light. So I'm going to really make sure this is kind of drilled up. So accommodated ET, the range is four months to seven years of age, meaning anyone who comes in crossing, you can sort of put it in glasses. What do you think would be a, is there a cutoff you guys know of how much hyperopia you'd be willing to put, to try out glasses on versus when you say, there's no way this is accommodated. That's, like, less than two, maybe? Two's a good number. Most people say three, and that's kind of like what's in the books, the textbook, because it's more than three. I think that if they're crossing, depending on how it looks, I often try out glasses too. You'd hate to do surgery on something you couldn't fix with glasses. And then if you fix with, if you do surgery, and then they end up being farsighted, you have to put them in glasses, but go XT in glasses. Because you get relaxed, they're focusing. See, I mean, so you, yes. I think two is two. That's the number probably that was. I think it's the most wise. There's an intermittent, especially when it first starts, so when parents describe this intermittent crossing, recombinant and comminity, if there's a family history of it, it's one of the most common strident entities that run through families. And this would, to your point, reason this is a six nerve policy, you'll see these in the ER, not uncommonly. Kid comes in, gets really sick, or has a bad cold, or just something, happens, and then I start crossing. And everybody, there's no way you'll stop the CT scan on that child. They'll just do it. Which is probably not a bad thing, but if I was in the ER, a kid who was just having bad colds, had sudden crossing, and I checked his surgery to plus four, I would push back against getting imaging, because he's healthy otherwise. This is the kind of entity that just came out of this hole on the straight eyes that just broke. So the if anyone could give me a line for why uncorrected acrobia can cause crossing, how would you try to explain this to a family? Or to a group? So when we are accommodating, our pupils constrict, and our eyes sort of turn in, and so if you're having to accommodate, just to see what we see at a normal distance, that's going to happen. The pupils are going to constrict, the eyes are going to turn in, and they attempt to focus like we do when we read a post. Yeah, great job, Chris. The near try is kind of what you're referring to, right? Yeah. It's a recombination of pupil constriction and convergence. In the brain, they're just married to each other. You can't divorce them. Yeah. This is a term that they throw around, insufficient fuginal, I feel like astrophysmologists love these really complex terms, and they kind of just make it hard to grasp the feeling. So don't be thrown off by this stuff. You just can't keep your eyes straight from focus. So again, that same case presentation, when you put the glasses in, you don't know if it's accommodated in ET until you've given them time in the glasses. So again, I tell you guys, one or two things will happen. It's not going to get better. It will partially get better, or this will just get rid of the cross ball altogether. And you don't really know yet until you have come back in three months or two months with everyone. So occasionally they'll be straight at distance, but then they'll continue to cross at near. And those are the kids who you consider having this high accommodative convergence to a combination ratio. And I don't actually think that means that you probably will, because this is a lot of it. But I feel like this is way over complicated, and again, if I went over the math right now, you probably would forget it anyway by OCAPS. So I just want you to just get the principle, and that is in your brain, so these two are kind of, again, they're married, and we're focusing on crossing, and it just turns out that the brain has an inbound to the two. So the amount of focusing that the brain does, it just drives too much convergence of it. And the whole goal of these kids is to get their eyes straight, so that they can get that sensory motor fusion that we talked about last time. So let's go through a bunch of cases here. First case, and maybe we'll just bounce around the room, we're going to go for one time together, so we'll do a handful of cases. So starting with lead. Plus four, ETS 30, and you guys know, what does the epoxy mean? The near, yeah. So crossing the 30th distance near the 30th as well, plus four, and these are all 18 months old, new patient exam, what are you going to do, lead? So you already know the description of plus four, so what's your manager playing? You haven't done anything yet, you haven't done glasses, you haven't done is this a kid you put in glasses or not? It looks like it's a competition, so I don't know if I would put in glasses just yet, just because you know, this is I mean it may be it may be related to some other issue, I don't know. So this is and this is why I think this is why I'm glad to have these numbers up here. Don't be thrown off by the fact that it's crossing the distance near. This still very well could be accommodated. But again, you're touching on I don't know what this is, so are you watching out of glasses or angle of glasses? Well how would you know if it's accommodated? Well you test them you see if they're actually greater or isotopia than they actually do in the near person's distance. So turns out in theory that makes sense that's not how it actually transits to clinical practice. So the way to know if this is accommodated is you put them in glasses. We're almost regardless of the difference between these two. Confusing, but I'm trying to simplify this because I feel like the theory of County BT is you're right. You can see maybe you see some more crossing it near than the distance would suggest, you know, at County BT and in this case and you have been appeased to sort of you're demonstrating some good kind of sound thinking of understanding especially if they're crossing it all and they're more than plus two glasses even if they have limited abduction, I still work with glasses. Because you need to see what happens. Different foals, allergic refraction. That was too nasally. So if you put them in glasses, can they come back for ortho near distance? Really kind. So let's do another case after we go ahead. So what do you do with this one? So this is kind of what we're talking about. Crossing more in near and distance are you going to do something different this time? No. Why not? Because I just want to say what they do with the plus four first. Cool. So you put in a plus four same thing happens. So again, don't get caught up in greater distance in the air. If the key comes in crossing, sometimes I feel like I don't even need to measure this. I'm going to bring back my glasses and then I'll see what it is. Exactly. And then remind me of a name I'm sorry, I'm still learning. I'm Lindsay. Lindsay, okay. So what would you do in this third case? I would start with the cyclopletic refraction initially and then have a back. So you come back and then these are the measurements now. So this gets a little more tricky, Lindsay, but if they're ET, so in their glasses, they're now 20 in distance and 35 near. What are you going to do now? Your options are so redialate and check the description one more time put them in bifocals or use your business certificate. I might I might redialate recycle please, make sure I got the full, they're not like a plus five and then I would try bifocals. So for boards and O-caps do exactly right. Whenever you see this, the first answer is redialate because O-caps and boards want you to to be surgically conservative and just conservative to general. Every answer that's like if you can get away with watching observations, you should write the answer. It turns out though let's say they come back and they're still less, no change. Would you do bifocals or sort of three? How old are they? They're two. I would send them for a surgical U-val. Yeah, so surgery would be appropriate here. Because there are two, they're in this sensory sensitive developmental stage or developmental age or vision. You want to get this kid straight as soon as possible so they can recapture that sensory fusion and get vexed ariopsis and other things that they you bend them from high and straight eyes. You don't want to sit around them. If they're not straight, you've got the full protrusion on them. And then to contrast that with this one. How much surgery do you do on that kid for case three? So kids who have a comedy TV always air towards doing more surgery. Yeah, you do probably 35. They'll eat it up. Some people go for the higher number and then they add another recession to the recession. So we'll jump to this again. So you put them in glasses. Go ahead. So what do you do if they're ortho-at-distance and ET of 20? I put them in the blindfold. So why would the blindfold be the right answer here you're right. And the wrong answer here. Because there's crossing greater distance. Because I mean they were trolping at a distance since they needed help with that. So it looks like it's still accommodated when they're accommodating there going across. Perfect. So and bifocals are so commonly misunderstood. If the kid's not ortho-at-distance and they're not fusing at distance like you could do a ortho-at-distance you want to make sure this kid has sensory fusion ability because the two of us are working together at distance but they're not near. That's the challenge that's going to benefit from bifocals. If you put up the word ortho-at-distance and they're suppressing one night even though their eyes look straight and they're just not fusing with plus 3s over they have no stereo who cares if this kid's crossing near but it's not going to be cosmetic. So you don't need to put every kid your bifocal who crosses more near than they do at distance and you don't need to put every kid who's ortho-at-distance in ETX-20 just the ones who you feel like have potential for sensory fusion. At this age you can't do a lot of sensory tests so you're going to do it with most kids but bifocals are typically over prescribed for kids and you would never want to do it in this case because they're not fusing in the distance so it's not going to do anything but they have to be fusing in the distance and have fusion potential in the air that you can get in your bifocal so great and perfect product so they don't have fusion potential in what example would that be let's say they have congenital ETX in it so they're crossing from birth these kids, their eyes don't work together they don't have binocular fusion almost period so you can do stir-business surgery or straighten that kid out let's say he did surgery and they got to be ortho-at-distance but you can tell with all these tests that whenever they're looking in the distance they're just switching between the two eyes they're not fusing both eyes together they have mono-fixation and then you measure them up near and they're still crossing they might have put it in the microphone but he's looking up here so I think kind of voluntarily it just looks like you're looking at your hand and you can't tell right my hands like double but you just can't tell so there is a big part of the stir-business surgery that's cosmetic to have these kids function normally in their social life so like a two-year-old though with a bifocal are they going to really use like, can you get it on there huh? the answer is yes if you selected the kid appropriately so why does the kid walk around with a tilted head and when they have a fourth-year of palsy why do they just suppress one eye? because they're really fusing because they want to fuse there is a powerful drive to fuse if you can so why does the kid use plus five who you know for alternative purposes can't see clearly unless he kicks in all about accommodation and crosses his eyes why would he intermittent across because when his eyes are straight you know that he's not focusing right? it's because the brain cares so much about both eyes being straight and trying to fuse so much so that it would actually not even accommodate the full amount to get a clear picture just to keep guys straight so you'll see kids you'll know when you selected appropriately a kid with bifocals if they're particularly near they sneak their chin up to the bifocal just instantly and they'll do that on their own and the kids are smart enough you don't even have to like train and tell parents that's what they need to do they'll just do it and not that many kids actually need bifocals because most of them you put them in the bifocals they come in and they chin down to look at the near-carb over the bifocal then there's probably in particular cases it's very helpful but you know it also is over to you so 5 month old baby it's certainly real crossing looking at this how would you describe this that this is all you saw what do you learn about this picture what do you learn from this picture they're fixating with their left eye at this moment it's a large angle so it's perfect large angle maybe some inlubriate in the right eye how would you find out if they had inlubriate in the right eye this is a 5 month old baby I'd cover their left eye and see if they'd cry I'm trying to look as you do right yet so yeah so cover their left eye and then the other way not just to see if they'd cry but if you cover their left eye you cover their left eye and then you hope that this eye is going to go woop and look straight at you right and then as I come off I watch how long they hold with that eye that's the whole maintained thing on the CSM so if they maintained that eye I'm like oh this is an alternate fixated right what type of if you had to guess what entity of ET this is congenital probably congenital at this age congenital is really large angle from a really young age there's equipment glasses these kids eye straight glasses so you still approach it because if you remember what was the earliest age that we see a congenital ET do you remember that range? 4 months so if you had one kid who looks like congenital ET for all intents and purposes but they're plus 5 you still could have been glassed I had a little girl who was plus 6 or plus 650 and I put in glasses but mom said she had been crossing since she was like 2 months old and her eyes didn't do anything so I cycled her eyes so that she would have to have the glasses to see well right because she wasn't sure if she would wear the glasses the full cycle would do the fracture so even atroponized she gradually took out the glasses still had the exact same like 60 diameters of ET so you still go through that process clinically it's not always like obviously congenital ET or obviously congenital ET for anything we can go so congenital ET you see it there's a number of terms again to get to run around ocular instability in its infancy that kind of is derived from the pathogenesis they feel like there's a you know what causes this but the fusion center of the brain that helps the two eyes lock together and the reason people feel like this is because even when you fix these kids even at a young age they often have subnormal fusion stereopsinist and all those tests the worst for that test seem like they're suppressing a lot so can they not fuse and therefore they cross or is it motor development, do they come out cross and therefore they can't fuse because it was early crossing and just that critical window we don't know do these kids tend to have amblyopia? yes yes what is one of the things or the tricks that they use that often prevents amblyopia in these kids because I would say these kids do have amblyopia do you see it in a fair amount but probably less than a common ABT do you see something where they switch do you remember the term it's called so these kids so if they're this way and you're on this side they look at you with that eye and then if something happens over here they just switch to look at you with that eye so they've got these eyes that are just like surveying the opposite worlds at all times of course and they just switch you don't even know what you're looking at often so do you guys know what we often see in conjunction with congenital ET there's other findings that come out and he guesses late and nice diagnosis late and nice diagnosis, perfect so when you're working a kid up and they're plus 5 crosses that's a little bit now they're 2 you come up with one eye and also you see that eye jiggle and all of a sudden you're thinking this isn't a common ABT so that's where that stuff kind of comes in handy too anything else DBG DBG we often see if you're a legal reaction to do you see that in a common ABT there's also a bit more common in this the so of course if you look at the outline I'm going to explain to you this because I don't think this is part of that so I'll leave you to talk to you about it so what happens is you cover one eye and the eye that's getting covered up if you had a see-through glass that eye that's covered up it starts floating up and it it breaks it breaks it breaks it breaks is the one that the yolk muscle always works so one superior eye just fires the other superior eye just fires so one eye it does its own thing that's the only time you see that that long time I did it the so two of these kids is surgery and these kids get an average of three surgeries over the first 10 years because it's just a very unstable alignment it keeps coming back it comes out kind of more commonly they get older they try to improve fusion so here's kind of, I feel like if you read that chapter of BCSC all these I don't know, I just want to use distracting type ETs because they're just all so much less common the ET, I've never seen this see how it says syndrome it's just like an extreme form of congenital ET so they have no stems and they look out they read about this as being tight sensory ET one eye doesn't see well so does anyone know when you see sensory ET versus sensory XT in the adult world the sensory eye what's more common, the ET or the XT the XT so the difference is we have no idea why when an eye doesn't see well and they're younger than five it tends to turn in when they're older than five it tends to turn out so in the adult world you always see sensory XT but in the early kind of P-flang you see all the senses of ET divergence and sufficiency so what are the measurements? do you see an ET greater near or distance what would an ET be greater do you think or divergence and sufficiency? distance so if you see it and the kid has elevated ICP or brain tumor what are you worried about? binaural or secondary palsy so you don't want to mix up divergence and sufficiency for binaural 6 that you can get from elevated ICP because they can't have depth so most secondary palsy's are greater distance than they are here nystagmus blockage syndrome turns out the neural point is whether they are in the reverse show anyway don't get too caught in those things we're going to jump into exotropias now does anyone sense a theme going on here? balance balance yes that's very yin and yang tall and short happen to be opposite opposite so yes but it seems like the most obvious questions have like the most delayed response but it can't be that simple so a lot of people think that exotropia is just equal and opposite to esotropia but there's some balance turns out they're not at all similar so this is what did me in for a long time I was like oh I don't really have this I see it all incorrectly about this it's just totally different so we're going to talk about intermittent exotropia here for a second so in intermittent exotropia I have the kind of occasionally wanders out there's two questions there's a couple questions that really matter what are those questions any guesses? like what percent of the time that they're crossing exactly what question what are you trying to determine with that question whether or not you're going to do what? surgery surgery is how often it's happening any other questions come to mind this kind of catches the same thing how often does the eye go out how long does it stay out for almost every parent can kind of catch that and a lot of them say it goes out all the time they say how long does it stay out for and they say like 3 seconds is that a case you do surgery on it just snaps out and snaps back like every hour that just sounds like pretty good control so these two questions I feel like really capture what we're looking for to actually gauge control so intermittent ST this is a so a new principle you don't see in a common PT kids with PT don't control their crossing but kids with ST the way I explain this to parents is the eyes are out when they're relaxed but the brain wants them straight so it's a tug of war and what we're trying to figure out is who's winning that tug of war and how can we help your brain win out to keep the eye straight and we have to go and change the anatomy because otherwise the relaxed anatomy is just pulling those eyes down so let's say a kid has 15 diaphas of intermittent ST and the other kid has 50 good diaphas of intermittent ST are you more likely to do surgery on one or those or what does that matter in your in your surgical decision making it doesn't matter as long as they're good control perfect actually it determines how much surgery you do not whether or not to be surgery yeah perfect would you think that this breaks down a distance or near more often the intermittent ST so what are you going to see this when the kid is reading or looking at the car window looking at the car window yeah yeah so almost a little counter intuitive right because the eyes are out and they're doing something up close that's a whole bunch of convergence but for some reason we see this way more distance so let's see this video work this video I feel like captures intermittent ST we watched it just a couple of times there so watch your eyes straight what just happened there which eye went out first the one that I was covering and then what happened when I uncovered it didn't snap soon the left eye snapped back but then one of the right eye did it went out so what do you know about this child's fixing eye it's a left eye just put it in front of her face though for 3 seconds when she was looking at the distance was enough to break down her fusion so when I uncovered that didn't snap back so her control is actually poor that makes sense this is what poor control looks like she's straight so once I had her fusion the brain doesn't have two pictures to lock together so one picture disappears so that eye just goes towards resting but then when I uncovered she said well you know what I actually prefer my left eye so she switches to her left eye and her right eye stays down so a lot of times when I had to look at it in your tire without doing anything so I had to just switch to look at this to see what happened because the control at near is always stronger than that at distance and then watch what I did so I'm going to do the same thing I'm going to act near, I'm going to uncover her eye and watch what happens what happened, do you see that? the eye was out but is she straight or is she out now so I uncovered it and I uncovered it and really quickly it went right back to being straight to looking at the target so what's your control at near poor or good? good, yeah because the minute I uncovered it before she even blinked that I came back it's right now so what happened there? she started to go out and then she scratched her head and she focused on her finger and it came back in really interesting she kind of just clicked her eyebrow and then she fixed her control so same time around would you quantify that as fair poor, fair or good control? fair it didn't, it was fair people often use a blink as the determination of separating good and poor so if the eye stays out and they blink it comes in then you say it's either fair or good if they blink and stays out then it's usually poor so it's pretty easy to case this is a busy slide so let's just cut this down this is the four phases of determinants the way this often starts what's the x without anything else? what does that stand for? x of 4a which means what? will you see this? no so you often, these kids you measure it they have a little 4a distance with an ortho in the air and six months later they've got an intermittent that mom sees when the kid is looking at the car window for some reason that's when it always comes out in their car seat, looking at the car window right before bedtime when they're naps or when they're sick all the times where you're getting your anatomy and then you're neuro trying to keep your eyes whether there's anything that's making your brain not fire and also accelerators then your anatomy will have the eyes tired sicker just daydreaming so what happens is you get this intermittent xt and then near you have this smile x of 4a they're often different you'll get a 30 xt 30 of an xt distance and then they go manifest in distance and then intermittent near and then they go manifest at both so this is just the progression if you watch most of these kids what happens what do you think would be the optimal time for them to be in a short period 1, 2, 3 or 4 3 some of them 3, 2 and 3 so you don't you certainly don't operate here you don't have to operate here because they're still fusing it near they're still using their eyes together enough that they often aren't losing stereo options and other things here's where they start kind of falling apart and actually you kind of let in here you just let parents guide you so based on that do you think control worsens or improves with age yeah, yeah, exactly just like that progression some are made stable and a few improve hence why it's good to watch this for a little bit because they do get that exception so we're going to talk about that we're going to talk about that is Anne going to be a common thinner in the xt no, it's not does that worsen with age just because they start having mono fixation so you don't see mono fixation on this so there's a great question mono fixation is when they're still suppressing even though their eyes are pretty close to being straight see it a lot with congenital AT and certain cognitive ATs but they have subnormal stereopsis so they don't fuse very well so they suppress one eye at least centrally and they confuse peripherally and actually these kids have great stereo most of the time their eyes lock together really well they just get tired and for some reason their ability for them to overcome the resting state of the eyes alignment just decreases in age I'm not sure why so they don't suppress at all suppress the eye and it goes out but that's it sometimes they actually will have they won't suppress entirely the peripheral vision of that eye that goes out these guys will have like wicked peripheral vision there was an NFL lineman who went and saw one of my mentors with this huge inmate XT and said oh what was this fix and they fixed it and he came back and he says I can no longer see the receiver running on my left side it's just like really effective you undo it, isn't that crazy for the cults true story so let's go through some cases again I think we are at Chris 2 year old with interval XT of 40 at distance and 20 at near with good control for both what do you do you have to remember the old movie speed sorry can't erase another one has very pale performances and just a little light the good control for both radio Chris sorry I knew I was so zealous no you do not want to touch this so good control you can watch this as long as you want so long as you have good control I'm just teasing Chris out great answer so what you want to do is if they are controlling it there is no rush here are you surprised that it's larger distance than it is in the air based on that progression I told you this is what we expect so I'm going to check the vision I'm going to double check what if this kid was minus 2 would you put him in glasses yeah so how easy do you think it is for your brain to fuse two blurry images versus two clear images at a distance probably harder so if this kid is a myo it's not going to make it has nothing to do with the combination or that way of events it's just going to give them clear pictures to lock together so this kid you're going to monitor maybe put him in glasses does that make sense so it's good control don't touch it I'm going to give you one more time in terms I said I'm going to give you guys thank you so they are like minus 2 over here of course they're doing over minus because if I give them a minus 3 then they have to do a little bit of accommodation and accommodation and convergence are tight so that's the whole theory of the over minus it's not really getting happening so there's a big debate whether we over minus these kids force them to accommodate which will help kind of bring their life together if they're already myopic I have to do over minus them anywhere from like 50 to a diopter a huge long term benefit at the end of the day if they're really over minusing them and holding their control that way that's not a long term solution because they're going to start getting you know, asthenopia and eye strain from focusing as they get older you can't do that forever so I usually do a little bit of over minusing if they're already in myopic and then just watch it okay go ahead it's a little bit older child and they're having fair control because it's still good control within years I don't know, I might still watch trying glasses you're spot on with the kind of the head bob yet our hands are tied here aren't they? how many BT's if that kid's crossing and they're either not focusing or they're crossing they're going to develop family opening this good watch that we have to put them in glasses not the kids here I ask the parents what do you want to do I tell them we don't have to do surgery right now this is probably likely to get worse with time it's a little bit of a question if we fix it now or later but some cases do improve go ahead I mean this is kind of the age where maybe kids start making fun of seven happens to become a member but five year olds are still sweet so you're right, you're exactly right fix it now to prevent that from happening so they don't get labeled by the peers when they get to the kind of the mean age then let's say I said hey if five year olds doesn't notice skin color differences appearance differences they tend to not pay attention to these things nearly as much as a second grader they kind of start picking this up so yeah so I have one person telling me I don't want to have to deal with this as they get into that stage of childhood it's just ruthless so let's fix this now if they do have to do it you have to do it so can you do a full workout if they're my outfit then I'm certainly not going to do surgery I'm going to put them in glasses how much would you operate for what do you think yeah about 40 nobody would be doing this so I'm not going to ask that over the uh alright what do you think so this kid's got a perpetual distance if you're going to operate how much are you going to operate for that's a big difference right 40 and 0 less than 40 so this is where this is where the chapter gets this is where NMXT gets lost on everybody is because people like I forget the term I don't even pay attention to any boy it's like to nature's proximal fusion and is this like true divergence excess because it gets so messy here and I don't know that it's clinically relevant what you're going to do here is you're going to prolong their occlusion because these kids do have a strong drive to fuse it near so what you do is you put a patch you cover their eye for an extended period of time and then re-measure it near without ever uncurring both of them so the patch can't come off before you check them in near and then you find out where they're if you can increase their new distance and oftentimes you can build their near measurement up to like 20 or 30 but it just takes time because their drive to pull the eyes together in near is so strong and so after prolonged inclusion the book will say like 45 minutes into the 60 minutes I actually will sit in clinic and talk to them while I cover up one eye and within a minute you can pull out a line and it's usually not the time effective to queue for another 15 to 45 minutes but the OCAS answer is 30 to 60 minutes you occlude them and then you see what happens and then now what are you going to do they're all toward near more controlled distance you can do surgery for it is this the case that you need to do surgery for it now or can you wait so wait because it seems like they're fusing near exactly your hands are tied here so what you may actually see is it's almost kind of like it's less stressful to manage so it's tenacious possible fusion it's this concept that they really have that strong drive to fusing near please so what are you going to do here um you can try covering so do you fuse it no change, still ortho in the air I mean you could still pluck them off and see if it's really bothering you so this is the case yes, promise again you can run that issue of how surgery we are going to do if we do surgery this is where you get like is this a high AC to A ratio um or is this kid just in stage 2 progressing into the next T if they're over here I would tend to just watch it especially at 4 because this isn't socially significant yet is this divergence true divergence excess is like the term that you see in the UCSC it's not that common that you see this and so you need to be familiar with these terms but there's still less common if you get distracted by it I feel like the PCC is very distracting with these concepts that are just not that common or relevant the other thing is you better have a talk about those stages this would be a kid who's just progressing and the two would come back to it so back to the other side so Lee what do you do with this one just hang out very good control there's good control so the drive to do surgeries isn't as high but I guess they are at an age where there's a social concern possibly so so who makes the decision in this case probably that would be the parent exactly right um that again a whole bunch of other entities again these are kind of distracting in these chapters because I feel like you as a resident like I did 100% even next to you all that well and then I smelt all the other entities not that complex um the things that you do see perfect alright that's it thank you everybody for coming any questions