 While we have a second, I would like to take the opportunity to introduce three new international fellows who will be with us for a few months. We have first from Bhutan, Dr. Phim Rai, who will be on the retina service doing a retinal fellowship, and he is one of the really well trained surgeons from Bhutan. And then we have two doctors from Ghana. This is Dr. Peter Armat, and he will be on the oculoplastic service doing oculoplastic sandwich fellowship here for three months, then in Nepal and back here. Again, our director from our programs in Ghana, Dr. Seth Martay, will be here, he'll be working with myself and Dr. Clannell. Good morning. My first two weeks here, I had the opportunity to work with Dr. Dries and the pediatric ophthalmology. It was really interesting there, all the things that they taught me in medical school that they told me I would never see in practice. Dr. Dries sees those patients. It was a really interesting two weeks, and we ended up seeing one patient that I'd like to present here. And it's not necessarily a patient that I'm presenting to teach specific facts about this patient, but present him to get some ideas on how we can help this child. So he's a three year old male who's born with bilateral cleft lip and palate. He had an extensive genetic work up that didn't show any genetic anomalies, just that it was an isolated issue. He has hypertelarism, had hydrocephalus, and on an old exam in Arizona where he moved from just recently, he had a keyhole pupil. Microphthalmia, but mom doesn't remember anything else. She says, you know, I had this smaller eye, had a small pupil. We don't know what else was going on. We're trying to get the records from that outside physician. He was away on business this last week. We were unable to get those records. Mom's hopefully working to get those records to us. On our exam, the initial presentation, the chief complaint was constant closing of his left eye, excessive eye rubbing, red eyes. Two months ago is when the mom noticed it started progressing, and he was very light sensitive and there's no reported trauma. On our exam under anesthesia, as this kid was unable to sit still for a full exam, interocular pressures, pretty equal bilateral, nothing really there. Plano in the right eye, left eye we were unable to, and I'll show you some pictures that will describe that for shortened, palbial fissure. Then in the left eye we found a vascularized mass in the anterior chamber with hyphema, no view of the iris or the lens. When I show you this picture, it's important to note that it's hard to tell without the stereo on this, but these vessels that I'm going to show you are actually deep to the cornea there in the anterior chamber. So that's the rectamphoto right there, and that's the mass I'm talking about right there that's actually deep around the limbus. On our view we could see the normal limbo vasculature at 360 degrees around, and this was a separate structure. And then down here about five o'clock there was either a continuation of the mass or a separate piece of the mass. We sent him for ultrasound. We were unable to get the high frequency ultrasound, he was unable to sit still well enough for the high frequency ultrasound. So these were the best we could do right now. We had a tuft on the optic disc. We had a thickened posterior capsule and a peripheral vitreous membrane. Then we sent him for MRI and CT. You can see the thickened area of the retina here and also on the posterior lens capsule right there. Without contrast with fat saturation you get a little bit better view of that in both areas. And then after contrast you can see that the anterior chamber, the lens area lights up a little bit. There's some enhancement there. And then on the CT it's important to note that there are no calcifications. The official read, they didn't really agree with the enhancement. When Dr. Andries and I looked closer at the images we both agree that there is some enhancement there. They didn't really cease anything. And they just noticed the ultramorphology and signal difference of the left ocular lens. So our differential right now is rather broad. There's a few things on here that we're really concerned about. But some of the other things that could be going on are some self-inflicted trauma. Medula epithelioma, retinoblastoma, the diffuse infiltrating type without calcification. A type of infectious ubiotis is something that we haven't been able to rule out yet. Intracellular form body, JXG, leukemia, and persistent fetal vascular, something Dr. Andries and I talked about that might explain the posterior findings, but wouldn't explain the anterior mass. So at this point the next steps that we're taking right now are trying to get the records. I'm doing some lab work out for infectious ubiotis, CBC. And we didn't know they had this mass when we scheduled for the exam under anesthesia. So at that point we couldn't do the ERG. But we'd like to bring the child back to do the ERG. Our main concern are the life-threatening, the cancer issues. And at this point we're looking to see what other tests we might should do at this point. When or if we should consider inuculation and if there's any suggestions from the doctors in the audience. Which slide? Yes. While you're going back I appreciate both eyes and the bell crown. We're a little bit stoned, so I'm really happy to think. But before we jump to the tissue line. No constipation. Not that we found out. We're hoping to get some records, but per mom other than the bilateral cleft palate sit and lip. He doesn't have any other known issues. You can have, I think when you've got this picture where you've got this mass in the back. And again you've got to rule out other things. You've got to find the guy when that posterior lesion would be uncommon to have. A lesion in the hands of your chamber. And that's the granuloma that would save you. You know we don't have that much experience in biopsies. But the one area where finding an aspiration biopsies are unhelpful is if they're fibrous with the vascular. You can get yourself back. You know what you're going to see. There's a lot of tumor in the tumor. Finding a biopsy is very good at doing that. But if you just get some scattered red blood cells and fibrous lesions, you really don't get it. So positive biopsies help to make it happen. You may want to just get a piece of bone. I shouldn't do a lot. You know what you may end up doing? Like do a quick corneal incision opposite. And then come across the anterior chamber and then take a little piece of it. And again that's a negative read. It's a positive read. You've got to know how much that reassures you. Yeah that's kind of what it's going to do. The ERG is flat in that. I'd love to be there. It was under sleep. I didn't even feel the sanity. It was a screen on the crime. If you could hold me down. I just couldn't get a piece like you said in the sand with a silver body. But it's not like this. It's got a lot of donor problems to start with. I think you know. I don't know if that's normal or not. Like this. Not the idol of humans. They're a... I'd call this hypoglycemia. Introchloride. Again, nothing much. Thanks for your input. Thank you Dr. Dries for helping me with this project.