 Now here's another example, this is a baseline examination. This patient has some induction problems predominantly in the right eye. Now we're giving two milligrams of Tensiline IV. Here you can see the tulsis. This is what we're using as our endpoint. Two milligrams we usually use as a test dose, and we are doing this because we don't want to give the full dose not knowing how the patient's going to respond to Tensiline to begin with. So we're not really expecting any response to Tensiline two milligrams. This is a procedure that if you're going to see patients with induction problems, lid problems, or neurophthalmology, you should get comfortable doing the Tensiline test. It's generally a safe procedure, and what we do is we fill up a syringe with atropine to have it laying at the side in case we need it. It's rare that we would ever need to use atropine, but it's not a bad idea to have available if you need it. Okay, we've just given four milligrams of Tensiline. I think that if you keep staring at this patient, as though you were the examiner and the person performing the test, you would find it very difficult to see whether or not there's any kind of response to Tensiline. What you might want to do after you've looked at this tape is to re-go over it on fast forward, and I think what you'll see is that there is, in fact, a fairly dramatic response to Tensiline. Now, here the lids are coming up. If you remember, at the beginning of this segment, the ptosis was so bad that they were obstructing both visual axes. Now, what we've done, which are not going to be shown in this tape, are we've taken still photographs before the Tensiline test and after, and showing those photographs to any objective observer is fairly convincing that there's been a response. Now, here, look at this. The lids are way above the visual axis, and this constitutes a positive Tensiline reaction. And there you can see that infarduction of that right eye is now better as is superduction. So the technique that we like to use here at the neurophthalmology clinic is a two milligram test dose of Tensiline, flush it with saline, wait for a minute or two, then a four milligram dose of Tensiline expecting to see either a positive or a negative response, and wait for a few minutes, and then another four milligram dose of Tensiline. Alternatively, another way to perform the test is a two milligram test dose and then an eight milligram dose of Tensiline, pushing it slowly over 20 seconds or so and flushing it with saline. Here we go with another four milligram dose. And you can see in the interim period, the first dose is worn off a little bit and you can see those lids are starting to droop again. Now, we've pushed the Tensiline in, we flushed it with saline. And I think you can see those lids are starting to creep up a bit. Now, this is sort of easy. When you've got objective endpoints with myasthenia gravis, particularly Tulsa's or an obviousduction deficit, you have a nice endpoint to use for Tensiline testing. The problem occurs when you don't have as an objective endpoint. For example, the patient complains of Diplopia, but by your exam the deductions are pretty full and you don't see any Tulsa's. That's a problem. The problem is what are you going to use for an endpoint? You don't have something objectively that you can see that will improve. One technique that we've been using is Tensiline tonography which does provide an objective endpoint. What you can see is with strengthening of the muscles with Tensiline, there is a mild but observable co-contraction of those muscles that can be picked up by continuous intraocular pressure monitoring device. We have that back in the glaucoma clinic if any of you are interested in doing it. Also, I would suggest talking to photography because I've left a set of teaching slides on how to perform Tensiline tonography to talk with any of the folks in photography and they can pull those out for you. Fairly simple technique. This has been a pretty long segment, not particularly interesting, but it's to make the point that sometimes you need an objective observer and taking still photographs can be particularly helpful. If this hasn't been too much for you to watch, what I would suggest is go back, put it on fast forward, and you might see a bit more dramatic response.