 We're going to hear from Griffin Jardine. He's going to talk to us about another interesting topic. And hopefully, we'll learn something about sudden onset strabismus, basically, when you're worried. Morning, everybody. I thought this was always a challenge as a resident. I think you see a lot of acute onset diplopia and strabismus. And when is it non-neurological? Other ways to differentiate. I've made a little reference to Hamlet's soliloquy here. And I think it's one of the most famous soliloquies in all literature. I think it's fitting because he's in this existential debate about life and death. And life has this sense of powerlessness. Maybe he calls it the slings and throes of outrageous fortune of the things that we're kind of subject to. But death has this big unknown black box. And I think that's similar to imaging, right? We're unsettled with the unknown of not imaging. And yet I do think when you send patients down that path, I don't think it's benign. I think all the testing we do has associated morbidity. And sometimes it's just emotional morbidity that we're leading up to the MRI. The family's in a real panic about this being a brain tumor. And if it is a brain tumor, we need to catch it. But I think it's a challenging balance in medicine that we all do with probably frequently. So I think maybe it's a more controversial, interesting topic in things like mammograms and cancer screening where these lead to biopsies and incidentalomas. So maybe it's your business that's maybe not as controversial. But let me start with it. Just go through a couple of cases on this topic. So first case, it's a first year medical student, actually here at the U, with sudden onset depletion with all these patients' permission, I share other cases. So never has had double vision prior to this. And they're really a healthy otherwise. Are there any questions? What are the questions that come to mind for you as to whether or not to differentiate this from being something that's really concerning or neurologic versus something that's maybe less concerning? Any thoughts? But great question. No trauma. Anything else? Family history, so no family history or strabismus. That's a great one. And I think we're seeing so frequently the genetic piece to a lot of the strabismus that we see in clinic. Binocular, binocular. What does that mean, doctor? Just kidding. Yeah, great question. Binocular. His medical student just had his anatomy lecture. And actually he was very interested in giving me some of these detailed questions. So good question. It's only he only has it in a particular, when he looks at particular direction, which starts. Disturption. To the right. Why don't we jump into the video here? So this is telemedicine out of the best. He actually said this to me before going to the ER since he's kind of an acquaintance. So that's where he's doubles. The whole story is he's actually neighbors with my brother-in-law. And this came up in a conversation. My brother-in-law said, I think this is what Griffin does. So yeah, so why don't you text him? So that's the video. So now, does that answer your question? Image or not image? Who wants to get an MRI on this guy? How about a fat scan first? Kathleen, what a great thought. So let me get to that real quick. So here we go. You see clearly what's this called? What diagnosis or clinical description would you give this? Especially in right gaze. I know you all just eat, drink, and sleep through business, right? It's like the great topic of ophthalmology. So left, if you think overaction, which would look like what diagnosis? We're going to left. Fourth nerve palsy, yeah. So I asked him, well, how long have you been tilting your head? And his response was, I tilt my head. And Kathleen's recommendation, I say, can I just see your? Because he said, this came on on Sunday. I've never had it before then. And it came on Sunday. And I can now have double vision all the time. And I said, can I see your name badge that was taken six months ago as a student? Here's our question. Handled boy. He looks like he's really in this great existential debate there. So I get his name badge from six months ago. And what would you see? It's not a new head tilt. Yeah, Bob, the next thing. So he's got what we call facial asymmetry or mid-face hypoplasia. So in patients with congenital fourth nerve palsies, their face morphs and absorbs a little bit of the tilt. I'll give you some more dramatic examples here. But look at that one. So if you draw a line between their lateral canthi and the edges of their lips, you can see those two lines are not parallel in these patients of congenital fourth nerve palsy. Another one, here's the most dramatic one I've seen in literature back from 1967. That's from a congenital fourth nerve palsy, all that facial dysmorphism. So of course, I'm twisting the story here. I didn't get to see him first. But if I saw this patient, I would have not gotten an MRI. I think we've got plenty of data to suggest that this was an acute decompensation of a congenital problem. But the ED got him first. And they ruled out a brain tumor. And of course, everyone's a drug addict until proven otherwise in the ED. And he turned out to not be a drug addict. So fat-scanned photo album topography is what kind of differentiated this as a congenital congenital problem. So case two, another medical student. You should sense a pattern here. We're probably doing something wrong in medical school to cause all this to your business to come out. So acute onset esotropia in double vision. I'm guessing the same set of questions. So here we are, image or not image. Are there any things that you want to look for? I heard Benedict Cumberbatch played a fabulous hamlet. That's what they say. So what are some of the things you can look for in exams? Anything that you could use on exam to help differentiate this from a neurologic emergency versus a non-emergent issue? Great question. It is competent. Full ABduction in both eyes as well. Anything else on exam you're going to look for? Expound or why you would look for that? These great neurologists in the room. Yeah. Anything else? Psychopathic refraction? Yeah. Late in hyper-over. One of our big questions is with all these esotropias, there are an accommodative component here. So let me go through these exams and things that we saw. So I don't have pictures of this patient, but these were some of the features we saw here. What's going on here? Let's shout out what the finding is. So looking in either side gaze, what do you notice? So yeah, there's bilateral, inferior oblique overaction. Is this a bilateral fourth nerve palsy? Probably not, because this is esotropic patient, but they've got this inferior oblique overaction. As we're doing the testing, cover up one eye and uncover and we see the eye has just floated up quite a bit after being occluded. What's that called? DVD. For time sake, I'll jump ahead with latent nystagmus, right, the euclid one eye. And then you have a nystagmus that comes out and it's the fast phase beats away from the euclidur. So these are all features of a congenital strabismus complex. So patients who have inferior oblique overaction, DVD, latent nystagmus, and no stereopsis, they almost definitely had to have this from birth to get all those features. Why did this woman acutely decompensate? That's a question for the wellness committee at medical school, but we see the patients can maybe have some degree of motor fusion. But when they lack, when your eyes are crossed in the first year of life, the ability to be binocular and have sensory fusion is significantly disrupted. And that causes patients to have all these phenomena. There's a question that usually kind of ninches, or kind of, what was it, not, clutches. Clutches, thank you, clutches this, which is anyone, anyone, this is a good sort of thinking question, but any thoughts? How could you ask this question, ask a patient about their binocularity and their before this, because again, this came on on Wednesday, it's Friday. What's that? Sports. Sports, being able to, like, depth perception questions, yeah? Any others, any others? 3D movies. 3D movies, those are such a rip-off. They're just 2D. Yeah, that's a great one. They always say, they always say, it's like the emperor who has no clothes. It's like, I guess I should be thinking this is normal, because everybody else seemed to enjoy it, but the movie sure doesn't look 3D to me. The movie is 3D. Yeah, yeah. I've had patients not tell me that they didn't pass the 3D component of their driver's license test. Oh, interesting. The one that I find is a really high yield is binoculars and microscopes. They always have to close one eye because they can't get the two images to fuse together. And she says, I've never been able to use binoculars my whole life. So again, I wouldn't have gotten an MRI on this patient because I think there's enough to suggest it. Then I had the luxury of the MRI, the ED already got a MRI and it was normal. So I think that is that question. So let's do a third case. Shout out, what are your concerns, thoughts on this patient, whether you image or not image? Ritual bulbar on the shutter? Yeah, so they didn't get a block for surgery, but that's a great question because sometimes we put the block into a muscle inadvertently and can cast your business. It was good. I mean, it was 20, 40, 20, 50 and she's now 20, 20 in each eye. Ooh, yeah. Look at that brow. What do you know about that right brow? I mean, she's really engaging that right brow. So this is pretty significant ptosis in addition to, you can see by the corneal reflex and ET. So what's your feeling on this one? Bayesian, what are you seeing so far? Who would image by raise of hands? Who would get an MRI? And this has been very gradual. And who would not image and just say that we- Do a sleep test, rest test. A rest test? So rest test is negative or she doesn't have increased. No signs of my seeing it, but a great question. So let's just show her motility exam here. This is a great example of classic floating saccades. Watch the right eye here. It moves much more slowly as the left eye darts over the right eye floats. So what's the diagnosis here? Right six. Yeah, right six, nerve palsy. Ptosis is on the left side now. Yeah, the ptosis wasn't as obvious here as it was in the picture. So on clinic, I'll kind of repeat the exam. It was pretty consistent right ptosis. So that's her MRI. So she had a baseball size meningioma. They got the MRI on a Friday and called her back in and did surgery on Saturday. With that degree of kind of herniation and midline shift. It was amazing that she was so well. Her personality had changed over the course of a year and she just thought it was aging. And anyway, she was, they got this successfully resected and she did great. It was slow growing, but it would be taking a lot of space. You can see it invading the cavernous sinus. And I think on her, one of the take-homes is she had multiple cranial neuropathies. And I think that's a definite reason to image. You can see here is where she would probably have the, where her cranial nerves were getting compressed. So her surgery, there's a lot of things you can do for a six nerve palsy. One that's kind of a newer thought is, because we wrestle between resecting and resecting the horizontal muscles versus transposing the superior and inferior rectus over to the lateral rectus, so that it can help pull the eye or supply abduction power. And then there's another kind of combination of the two where you transpose just the superior rectus over. So we'll put the superior rectus right next to the lateral rectus and then sew the two of them together about eight to 10 millimeters back so that that superior rectus is pulling or providing abduction power. But in most cases, the medial rectus has been contracted because it's the eye's been esotropic for so long. So that also needed to be recessed. And this is her after surgery. What's interesting is you see that she still has limited abduction as well as limited abduction a little bit. So unfortunately, we can't give these patients full range of motion, but we can give them hopefully what we call a range of binocular vision where at least they can look a little bit to the left and to the right and still have single vision. And she did well from that. Okay, one other case, a seven-year-old with Noonan syndrome. So I see her just as a part of screening, we see a lot of syndrome kids that have a high incidence of ophthalmic pathology and associated with the syndrome. And as I'm following her, she's developing this kind of small angle. It's actually meant to be intermittent there at first and then increased to 35 degrees over the course of about six months. So this is not an acute onset. Is there anything that you could think of that would make you wanna either get an MRI or not get an MRI here? No papillodema. Yeah, that's, you know, part of my basic exam is always checking for abduction, papillodema, and then just looking for other cranial neuropathy problems, ptosis, anisecoria, you know, any facial palsy or numbness and tingling. She has none of that. So I thought I was okay to not image and get into a meteororectal recession. She's a little under corrected and I'm not panicking because it's strabizma surgery. I wish it was more precise, but it doesn't always get exactly what we expect. So she's using it well. And then nine months later comes back with this. So now she's crossing more than she was even the first time around. And so now I think, well, we ought to get an MRI because that's a very unusual evolution. Still has full abduction. Do you have a full abduction? Still has full abduction, yeah. But you have a stroke. Got an MRI. This is tough. I wouldn't have seen this because I'm, but if you look right here, anyone wanna name that diagnosis? Yeah, Bob got it. So it's a Chiari malformation and it was considered by neurosurgery to be about type one and a half. So there is some kind of lower brainstem compression. And these haven't shown in the literature to be associated with a concomitant esotropia. So it's, I mean, this is, I share this case because I probably should have gotten the MRI the first time around. And it's not always obvious. You don't always get clear clues as to whether it's an image or not. So you'll get decompression surgery which has also been shown to correct at least partially their esotropia. This is a great study I think I'm trying to help navigate some of these complex decisions. So this was a number of cases that they grouped into different ideologies as far as sudden onset esotropia and what it ended up being. So Bob mentioned this, you know, if it's accommodated, meaning you find that they're really moderately or highly hyper-opic, that's a large percentage of the patients that we see that have this. You know, a decompensated esotropia, again, that's been in that category of it's an acute onset of an old problem or of a chronic issue. So we still see a handful of idiopathic causes. This is of course number four is the one that we worry about missing a brain tumor in these kids and 6% incidence rate maybe that, you know, one of the debates we have in medicine is what's, you know, we talked about the number needed to treat and maybe there's with imaging the number needed to detect. Do I get an MRI on everybody because there's a 6% incidence rate of catching a brain tumor? That's, I don't think anyone would fault you for that. The, but in these cases, so you took from four down to this bottom point here, these patients all had either papillodema, a really large angle esotropia or they were older than six, which in Pete's, yeah, seven year old starts getting pretty old. So the, my patient that had the Newton syndrome was seven. So they would also, based on those criteria, probably should have immature just based on her older age. But yeah, I think these are not easy cases, but there's a lot of clues and cues you can use to at least try to give you some positive predicted value before you go into getting MRIs as to which who's likely to have pathology and who's less likely. The, some of the principles I use are again looking for those congenital clues I went over. Number two, a neurophthalmologist taught me this, it was two strikes in your out, which is if you see, you know, concomitant strabismus, that's one strike, but by itself that often is an isolated phenomena. And for every one case I saw of that Newton syndrome case where there was a brain tumor, I feel like I've seen 30 cases where sudden onset esotropia, they were totally fine. Everything else was actually normal and their normal brain MRI or we didn't get MRI and they continued to be fine. And I think the big issue of medicine right now is this big fear of malpractice lawsuits and missing something. And my personal experience is, is that when we partner with the patient and make it a joint decision, they feel like they played a role in the decision enough that it wasn't any one person's fault. And that Newton syndrome patient, for example, I had talked to her about her, my concerns, whether the image or not to imagine, the mom and I both kind of elected not to get the MRI the first time around. And she wasn't at all upset the second time around when we did get the MRI and found that syndrome, because I think she felt like I was being completely transparent with my thinking with her. And of course, not every patient is that maybe kind and forgiving of the things that we do that or the mistakes that we make, but I do find that that is quite protective. Patients typically don't sue because you miss something they sue because you abandoned them and didn't explain it or did communicate clearly. Any thoughts on this kind of question or comments? Or the, Bob? Well, I think this is great. Using a thoughtful approach to work through things, work with the patient and the family is absolutely what you need to do when you're right on target. This is great. Thanks. I think it's, anyway, in pediatrics, we have the added kind of concern or morbidity associated with imaging that they're put under anesthesia. It's kind of a big deal, it's a big deal to families. And you can see parents on ice always, their pupils dilate every time you talk about getting an MRI on their kid. And from that moment till the time they get an MRI, they're in panic mode about what the MRI is gonna show. And so I think that decision should never be taken lightly and again, it's not always straightforward. Go ahead. I was just gonna say, even an adult, the downside of an MRI is a lot bigger than it used to be with the structure of health insurance now where a lot more people have fight-inductible plans. So you order an MRI and someone might be paying a few thousand dollars just out of their pocket to get the MRI. So I think they at least like to be involved in the decision and know why it's being done. Yeah, totally agree, Brian. By a raise of hands, who here has found an incidentaloma that really caused a lot of patient distress on an MRI that was unrelated to the pathology? Yeah, I think it happens all the time. And I think when you find these things, I don't know if we're really, sometimes it's a serendipitous discovery of a brain tumor that we thankfully caught. Boy, we were lucky that this led, that's the secret of events happened. But a lot of times it just is something that they've got to worry with and they're already maxed out on their stress. Anyway. The other issue that's come up is similar to your unit's patient. The patient who's got comethythetropia has a key artery, but without other neurologic findings that would mandate that the key artery be fixed. I've had the neurosurgeons come back and say, well, straighten the eyes out and I'm not gonna decompress it because I didn't think there was enough reason to do it. So that is an issue and so that if they're being decompressed and it's gonna help, that's great, but it hasn't been a universal thing. Even with the key artery, you find it and you say, well. Yeah. Bob, I'm really curious, your long-term experience with that because I've also, the neurosurgeons that I've talked, I'm also surgery is a way better risk profile. It does. If esotropia is an isolated neurologic finding, what I found is those kids ultimately needed decompression in the end. Is that what you found out? Yeah, it is. Ultimately, they get decompressed because I think at the very least what we do is we cause them to look at the kids more closely. They're looking for other things that they can relate to it. And so I think bringing that to their attention, most of the kids where I've had pushback ultimately have been decompressed. And when they're decompressed with recurrent esotropia after one eye muscle surgery, they straighten out and Jack Walker, who was the initial pediatric neurosurgeon in the Intermountain area, was convinced that decompressing key arteries and untethering cords, both resulted in straighter eyes. And the patients that we jointly followed through spina bifurcate. Interesting. My patient, I think if I would have gotten the MRI the first time around, I would have had that same debate. They said, two miles, deutervous with surgery, it's a low risk. So in the end, it probably would have changed management because we would have gotten to this point anyway where the hysteria came back before we would have done a decompression. But now I think it's pretty clear that they need it. But let me turn the rest of the time over to Rachel. Oh, this last point, you know, it's interesting. We all take it off to say first do no harm. And that can be interpreted out of their way, right? First, don't miss anything because that can be harmful. Or don't over test because that can be harmful. So it's a really interesting dilemma that I think we all struggle with. And I think the more that we collaborate and part of the patients, the better. And we also have to figure out how we're, you know, got to fight the fight against de-conversations to business and medical students. Probably just not too much. Okay, thanks everybody.