Transcript

Will: [00:00:00] Today’s episode about eyeballs is brought to you by the Nuance Dragon Ambient Experience, or DAX for short. This is AI powered technology that helps physicians be more efficient and reduce clinical documentation burden that causes people to feel a bit overwhelmed and burnt out. To learn more about how DAX Copilot can help reduce burnout and restore the joy of practicing medicine, stick around after the episode or visit Nuance.

com. That’s N U A N C E dot com slash discover D A X. Knock, knock,

hi.

Hello everybody. Welcome to Knock, Knock, I, with me, your host, Dr. Glaucum Flecken, your one stop shop for all things eyeballs. This is where you want to go. You don’t buy eyeballs from me, but you do learn about them. [00:01:00] And it’s, uh, it’s, I, I really enjoy, I’ve grown to, to appreciate the time I get to spend in the evenings, uh, recording these episodes about all these different topics.

Some of them about ophthalmology that, uh, that I haven’t really thought about in a while, like retinopathy or prematurity. So, or, or eye worms. Common topics like glaucoma or various trauma related things. We kind of go all over the place. And so I encourage you if you’re, if you’re wondering, when is he going to cover this topic?

When is he going to cover colorblindness or whatever it is you might be interested with your vision. Go back and look at some of the prior episodes. We post them every Thursday and see what I’ve done already. And, and, and so I’ve done a lot. We’re going to keep going with it. We’re probably like, I don’t know.

25 episodes into this. And so every week, every week we got a different eyeball topic. This week, it’s thyroid. [00:02:00] We’re talking about thyroid eye disease. I’ve gotten a number of requests about this. Uh, before we get to our topic though, uh, I want to talk about a few things. I have been informed, and this is not the first time I’ve heard this, that I talk slow.

I am a slow talker. I don’t deny this. I don’t deny this, I did grow up in Texas. If you grew up, I know I don’t sound like it, uh, somehow, my mom has a tremendous Texas drawl. Uh, my dad does not. I don’t know, I don’t know how I escaped it. Well, I haven’t lived in Texas since. 2008. So you do kind of lose those things.

Um, there are home videos of me as a kid with a, a Texas draw. Uh, but I’ve lost it now. So people are surprised. You don’t sound like you’re from Texas. Um, but I do, there are certain characteristics that I, I, I I’ve, I’ve kept. [00:03:00] And one of those things is that I talk slow. This is a real thing for people who grew up in the South.

I don’t know, just everybody just talks a little slower. And, uh, I really felt this when I moved from, after college, Kristen and I moved from Texas. To Dartmouth, to, to New England, which is the opposite end of the spectrum in terms of the speed at which one talks. And I, I noticed it. I, as soon as we got there, I was interacting with all these attending physicians and people and my classmates who are from the North or other parts of the country, and I was like, wow, they, they really do talk fast here.

And I, I, it’s, it sounded like I was just, my mouth was full of like syrup. Like I couldn’t get words out fast enough for these people. It was a noticeable difference. And so it doesn’t surprise me to hear that. [00:04:00] Um, uh, it was a good friend of mine, uh, who, who informed me once again, you know, you talk kind of slow and Kristen, you know, on our knock, knock high episodes, she talks kind of fast.

So it does make for tricky. I wish you could do like. Selective speed adjustments based on who’s talking. That’s an area that is an innovation with listening to podcasts are so popular. Now, I feel like we should have that, right? You should be able to say, okay, when, when, when Dr. Glockenflecken is talking, I want it as, 2x speed.

And when Lady Glockenflecken’s talking, just normal, because she talks at a reasonable space, at a reasonable pace that a normal person would enjoy listening to. And so I just, I guess I’ll just say, thank goodness you can speed me up. I hope you’re doing that. I hope you’re breezing through these eyeball episodes at whatever you like to do, one and a quarter, one and a half.

One and three [00:05:00] quarters. I don’t know. I don’t know what it takes. Uh, but, uh, I will not apologize for the speed at which I talk. It is just who I am. And I, it cannot change. I, I, I can’t do it. I, there’s no, I can’t speed myself up at this point in my life. I’m, I’m almost 40. I look, come on. I am what I am.

Alright, so, uh, I apologize to all of you who are like, You should, actually, you shouldn’t be mad at me because you can speed it up. That’s, that’s the beauty of technology now, right? You can put me at whatever speed you want. Anyway, I’m just gonna keep talking slow. Anyway. All right. I hope you’ve had a good day.

Uh, I, I, I’ve, I enjoy, um, you know, this is, is honestly a way to help me decompress a little bit from, from long days as an ophthalmologist. And yes, we do have long days occasionally. Um, I did today do my, uh, physical training, so I am a bit tired. I’m a bit sore. [00:06:00] My, um, my trainer was on my ass today. He.

Really did a number on me. Uh, it was, uh, I was, I was squatting the hell out of everything in that gym today. And, uh, I am not like super strong, like this is why I have to have a trainer because I do not have the self discipline to, on my own, go to the gym to exercise, to lift weights. Uh, and you can tell because ophthalmologists are physically the weakest specialty in medicine.

And it, and I look it, I look, I’m very lanky, I’m tall, I’m, I’m skinny, uh, I put on a little weight. As I’ve gotten through my 30s, but still, I just, so I’m trying to, trying to fix that. I’m trying to like get into a habit, but I needed somebody at my local gym. I needed to basically pay someone to just make me so tired and, and, and it just put me through the ringer [00:07:00] and I, I need to, I need to have like skin in the game, uh, to, to force me to do this.

So, and he really, uh, I, I am going to be hurting tomorrow. So anyway, that’s, that’s, that’s the, the state I’m in right now. I’m, I’m very tired. I can’t, like, I thought about recording a skit tonight, but holding the phone up in front of me to record myself felt like too much for my muscles. So instead I was like, I’ll just sit at the microphone.

I don’t have to move too much. And we’ll just talk about eyeballs. All right. Uh, the other thing I want to discuss before we get to our topic is the parasite episode. So I went through, uh, the comments. I love, let’s, let me just talk for just a second about like internet comments. Um, they can be overwhelming.

You know, I, I actively post on. All different plat all the [00:08:00] platforms. YouTube, TikTok, Instagram, Facebook. Twitter. I would say that the, the comments, I don’t, I cannot get to all the comments. I don’t. In fact, some, some platforms I never read the comments. I just don’t have time. I can’t do it all. So I’ll rarely read comments on Instagram and Facebook.

Um, I would say I probably read the most comments. On YouTube and then TikTok as well. And part of that’s because they’re so funny. You guys are hilarious. Like you, you routinely make me crack up on the comments on my skits in particular. Uh, the fact that you know all the lore and the background and the characters and what they did in a video like a year ago, like you can pull that stuff out.

That is so fun for me. I love seeing that. Um, but it’s particularly helpful, those comments, uh, for, uh, for planning these knock, knock I [00:09:00] episodes. And so I, I, so I really love going through those, uh, YouTube comments because all these episodes are on YouTube, the video. If you want to watch me, um, Uh, you can, you can see how skinny I am.

And, uh, let’s see. So some really good ones on the eye worms. I was, I was really looking forward to seeing what these comments were. Uh, I’ll just read like a couple, like some people were just like, were super pumped. Like, yes, I clicked immediately. I was so excited to see an episode on eye worms. And if you haven’t listened to it, please go and listen to it.

I go over some of the most horrifying eye worms. Loa Loa. Uh, we got, um, uh, various nematodes and roundworms and things crawling in the retina, in the brain, and along the optic nerve, all these places, all these things. So, um, the one comment here, at NickyWhite476, I saw the video title [00:10:00] and said, Oh, Jesus, why do you do this to me, Dr.

G? Uh, and then I realized that someone had suggested it. Why? My eyes are itchy now and I haven’t even watched it yet. I physically repelled from the screen when you talked about Loa Loa. Six to eight inches long, these worms. I’m never going anywhere. You can get that. I want to vomit. I am so disgusted and disturbed by that.

Thank you for watching and listening to that. I was also feeling a little grossed out going through all those different worms. Um, I worms, why are you like this? This is the most horrifying video title ever. Of course I immediately clicked on it. Someone was very disappointed that I didn’t have any eyeworms to actually show you because I did in hindsight Like why do I what I shouldn’t really tell you like I don’t have eyeworms [00:11:00] to show you today Why would I be a very strange thing to hold on to I feel like it’s like something like an infectious disease specialist would do

I can’t get the vision out of my head of Jonathan waving tiny flags from the sidelines, cheering on Dr. Glockenflecken while he plays missile command on a patient’s eyeball. That was in response to, uh, basically to treat one of these worms. You shoot it with a laser. So I do enjoy that, that, that, that, uh, visual.

So anyway, thank you all for the comments on the iWorm episode. Go and check it out. It was a lot of fun to do. I’ve really enjoyed seeing the response there. Um, yeah. So, and then going back to just, you know, my thoughts about, about internet comments, because, you know, I get this question a lot, like, do you read comments?

Is it, is it good for you? Like, does that, How do you feel from com because, you know, the common trope and thinking is that internet comments are, are [00:12:00] useless and they’re just going to make you mad and angry. And it depends on the content you’re making, right? Like when I make semi controversial videos, which honestly I don’t do a lot of, the most controversial things I do is when I, you know, make fun of UnitedHealthcare and stuff and, and most people can get on board with that.

But what I do, here’s what I do when I post content. I will read the comments, usually on, on TikTok, that’s always the first place I post my videos. I’ll post it to TikTok and then it all pretty much immediately goes to YouTube. Or, most of the time I’m recording these skits late at night. And so I’ll post it at like midnight or 11 or somewhere on TikTok and then I’ll schedule it to post to YouTube at like 6am.

And uh, so when I post to TikTok, I’ll read the comments for like, Maybe 20 minutes, if that, maybe even less. And then I just put it away for [00:13:00] like at least two hours. I just go and do something, do something different. Uh, and I just forget about it. And it, that’s, I, that was like a, a change I made that has really helped me.

It’s me because you just get so sucked into the response, the dopamine hits of everybody liking your video and everything. And it’s, and then, and then you start to perseverate on the like one or two people that say something mean about you. Like, uh, the, like, have you been getting sleep, Dr. Glockenflecken, you, uh, you look horrible.

I, I, I got a comment like that recently. You look tired. You got bags under your eyes. Yeah, I do. I do. Do you know that I’ve had a cardiac arrest and cancer twice? I deserve to have bags. I have earned the bags under my, the wrinkles around my eyes. I have earned every spot on my face. I, it’s, it’s just the way life is sometimes.

And so anyway, those are the types of comments that you [00:14:00] just like, why? You know, it’s, it’s not worth your, your time and energy to like, think about those things. And so I started just, you know, Like limiting myself and the amount of time I spend looking at comments. Um, so anyway, that’s, that’s my thoughts on comments.

I love, I try to get to as many as I can, but I can’t hit the comments on all the platforms. I do see a lot of the ones on Tik TOK on YouTube. So if you, if you want me to read your comments and your reaction, I’m most likely to do that on those platforms. And I appreciate all the humor, all the feedback.

It really is a big part of, of what I do. All right. Should we get to our topic? I think that’s enough. That’s enough exposition here. So let’s take a short break. We’ll come back and we’ll talk about thyroid eye disease.

All right, here we go. Thyroid related. Ophthalmopathy. Ophthalmopathy. That’s a lot of consonants in that [00:15:00] word. We love our consonants in ophthalmology. We like to throw little H’s in there. We got a random L from time to time. It doesn’t make any sense, but it is what it is. Alright, so, um, let’s talk about this.

And the reason I chose this topic is because it’s actually, it’s fairly common, um, thyroid disorders. I don’t know how common those are just in general, but a lot of people have them. And thyroid eye disease is an interesting disease because it can cause severe problems for people, both functional and In terms of, of your ability to see, but also cosmetic and we have been looking for a way to treat thyroid eye disease effectively.

We have things and we’ll talk about the different treatment modalities, but, um, there’s, there’s one that, that has come up recently within the past couple of years, which, uh, has changed the game for thyroid eye [00:16:00] disease. And so we’ll get to that in a second. So let’s just talk in general. A few bullet points about this disease.

So it’s an autoimmune disease exists on a spectrum of ocular manifestation. There’s lots of different ways it can affect the eyes. All right. It’s the most common cause, thyroid eye disease, the most common cause of proptosis in adults. So proptosis is when you have one or both eyes that just is sticking forward.

We have a way to measure this. It’s called a hertel exop. Hertel, Exophthalmometer, God, see, I, see, sometimes I don’t, don’t have the words exophthalmometer. Is that what it is? I just call it the Hertel. I’ve never used that second word. I swear to you, I’m a board certified ophthalmologist. Anyway, we use a Hertel.

It’s a little measuring device where you can measure how far forward the eye is in the socket. And so, you see [00:17:00] an eye that’s proptotic, One eye moving forward, sometimes it’s both eyes and this usually happens kind of gradually over time. Uh, the most common reason for that is thyroid eye disease. It’s also the most common cause of acquired double vision.

So, double vision is a common symptom of thyroid eye disease in adults, I should say. Uh, women are more commonly affected than men by about eight to ten times. So, much more common than women. And here’s the interesting thing, a lot of people will Associate thyroid eye disease with Graves disease. So it’s like, Oh, you definitely have, you know, if you have thyroid eye disease, you have Graves disease.

They go hand in hand. Graves disease of course is a, is a form of hyperthyroidism. So high thyroid levels causes you to have thyroid eye disease. That’s not totally true. Yes, patients are most commonly hyperthyroid. 90 percent of patients with [00:18:00] thyroid eye disease are hyperthyroid, have high thyroid, but about 5 10 percent have normal thyroid.

They don’t have any, any blood levels of thyroid hormone that’s outside the range of normal yet they have thyroid. thyroid eye disease. Kind of interesting. I’ve seen a patient like that. And then a very, very small percentage, about 1 percent of patients are actually hypothyroid. So it’s, it’s not as clear cut as, as Graves disease equals thyroid eye disease, but um, it’s close, 90 percent association.

So, so it is most likely to be that. And the, and the chance of having Graves disease and by association thyroid eye disease is about seven times more likely. Just another reason not to smoke, everybody. Don’t do that eyeball tip of the week. which I still don’t have a sponsor for, is don’t smoke. Don’t smoke, please.

Don’t smoke, don’t smoke, [00:19:00] don’t smoke. It causes all kinds of things. It also increases your risk of, uh, macular degeneration, thyroid eye disease, Graves disease, it’ll hasten cataract formation, dry eye, the list goes on and on, you guys, alright? Smoke billowing up into your eyes and, and just, come on. This is not good.

It’s not good for you. That’s your don’t do that eyeball tip of the week. There’s also an association with myasthenia gravis. 5 percent of patients with Graves disease also have associated myasthenia gravis. It’s kind of interesting. Um, and quite often the beginning stages of thyroid, uh, thyroid eye disease is asymptomatic.

So patients may not know they have it at first, but then as the symptoms get a bit worse, uh, you start finding these symptoms. So here are the symptoms. This is what you can see. So, a patient comes in, we talked about the proptosis, alright, that’s about, about 50 to 60 percent of patients will have some degree of proptosis, alright, you can [00:20:00] see that.

Soon as the patient walks in, I can tell, the eyes just have a certain appearance to them that screams out thyroid. Thyroid, thyroid. And so they’re more, more, more prominent, obviously, with the proptosis, but also there’s eyelid retraction. So if you look at your eyelids in the mirror, you’ll notice that the upper eyelid, it typically, it kind of crosses over the iris, the colored part of your eye.

But when you have eyelid retraction in the setting of thyroid eye disease, that eyelid, it kind of, it’s, think about it, that if the, if the eyeball is being pushed forward, And we’ll get to why it’s being pushed forward in a second. Then you can imagine that you’ll be able to see more of the eye, because that upper eyelid gets kind of pushed back.

And so what happens is you start to see the white of the eye above. All [00:21:00] right, so instead, instead of the eyelid, the upper eyelid crossing over the colored part of the eye, the iris, instead, it’s, it’s higher than that. And you’re seeing the sclera, the white part of the eye between the upper eyelid and the iris.

All right, so that’s, that’s eyelid retraction. This, I, I, it’s so fun doing this because like, it forces me to try to really, paint a picture for you, especially for those, I mean, for everybody, but for those who are listening, right? I don’t have, I can’t show you the pictures. You can go and look at it. You can Google it later.

Uh, but, uh, it’s, this is making me, uh, be very deliberate in how I’m describing these things. All right. So eyelid retraction, proptosis. Um, the other ones are a little bit more subtle. One is called lag ophthalmos. So the eyes are being pushed forward. They’re more prominent. The eyelids have a harder time [00:22:00] covering the eye, the surface of the eye when you blink.

So that’s called kind of a, that’s called an incomplete blink or lack, lag ophthalmos. All right, the eyelid, the eyelids are not coming together all the way when you blink and that leaves, It’s the surface of the eye exposed, which can cause some problems. And there’s a variety of other, uh, uh, symptoms, uh, and signs that can happen.

You can get, um, redness of the eye. You can get, especially over the extraocular muscles. So why is all of this happening? Pathologically is going on to cause these symptoms. The proptosis, the eyelid retraction, the lag ophthalmos. Well, what happens in thyroid eye disease is you get enlargement of the muscles around the eye, what we call the extraocular muscles.

There are six extraocular muscles, right? Four that make a lot of sense, two that are kind of weird. So you got the superior rectus, the inferior rectus, the [00:23:00] lateral rectus, the medial rectus. They are exactly where you think they are. They’re on the top, bottom, left, and right of the eye. Alright, they pull the eye in different directions.

So where are the other two? Well, you have something called an inferior oblique and you have a superior oblique. Alright, these are two different ones. They’re special. They’re special. They, they, they participate in torsion, kind of twisting the eye one way or the other. Don’t worry so much about those.

Alright? I don’t. They make me crazy thinking about these, these oblique muscles. All right, don’t tell a pediatric ophthalmologist I said that, because they love those muscles. So anyway, what you get is enlargement of these muscles, because the process of this disease, you get the muscles become infiltrated with the, with cells, with, with immune cells, because this is an autoimmune disease.

You get lymphocytes, fibroblasts, monocytes, they, [00:24:00] they get into the muscles and they start producing these mucopolysaccharides, these, these, these, these chemicals, um, which, uh, which increase the, the, the, the size of the muscle. They just get enlarged. They get engorged with, with all these polysaccharides that, that increase the water content inside the muscle.

So basically the muscles get fat. They get engorged. They’re just big giant muscles. All right. They’re, they’re swole. These muscles are swole. They are, if you worked them out and you had the ability to do that, then that’s what would happen. They just get big and fat. Now this is a problem. You don’t want those muscles getting big and fat because there is very limited space where those muscles are.

So if we recall the anatomy of the eye in orbit, the eye is sitting there within a bony orbit. Alright, on all sides of the eye [00:25:00] there’s a cone of bone. Alright, think of it as a cave and the eye sits at the mouth of the cave and behind the eye Those bones taper back into a, like a cone. So the eye is like the ice cream cone and the rest of the cone is, is bone.

Well, those muscles. are one of the many things that have to, that fill that space inside the orbit. So if they get big and fat, what’s going to happen? Well, it’s going to start taking up more of that space and eventually start to push the eye forward. And you get that proptosis, you get that eyelid retraction.

And for a while, in mild to moderate cases of thyroid eye disease, this is mostly a cosmetic issue. And that’s You know, people think a cosmetic is not that big of a deal, but this is a big deal because it’s, it’s, it’s, it can be really [00:26:00] difficult for people to, to, to deal with that. Think about how important your eyes are, your face, your facial features.

And so you have one eye that’s proctotic, that’s starting to push forward and then comparing that to the other eye or both eyes and it looks like you’re staring at somebody. And so it, it, it can be very. concerning for, and that’s, which is a perfectly reasonable reaction to this, which is why it’s such a challenging disease to have from the patient standpoint.

So it’s that cosmetic issues that are, are, um, that are, that are troublesome for patients. But then if you get, If you don’t get fat enough muscles, what’ll happen is those muscles will take up so much space in the eye that it’ll start to put pressure on the optic nerve. And this is where you’re starting to get into danger territory.

Because that optic nerve, that cable that runs from your eye to your brain, It’s kind of important. [00:27:00] We need that thing working. You put pressure on it, you squeeze it, it’s not going to function as well. And so that’s one of the main things, that’s one of two big time things that we’re thinking about with thyroid eye disease.

We see a patient with thyroid eye disease, we are assessing that optic nerve every way we can. We are doing a pupil exam. We’re doing color vision testing. We’re doing um, what we call an OCT, which is an imaging study that we do in clinic of the optic nerve. We’re physically looking at the optic nerve.

We’re doing everything we can to make sure that optic nerve is totally fine. Totally healthy and not being squeezed by those big ol fat muscles. Big ol that’s my Texas coming out. Big ol big ol muscles. So that’s optic nerve compression is one thing or optic neuropathy. Compressive, compressive optic neuropathy is one of the biggest problems.

The other thing that we’re concerned about is exposure of the cornea. I already mentioned a little bit of [00:28:00] that, right? The lagophthalmos, the eyelids, because the eye is being pushed forward so far that the eyelids can’t close over the cornea. You need to be able to blink completely because that’s what helps lubricate your cornea.

Alright, in another episode we talked about dry eye. You don’t want the surface of the eye getting dry. It feels like needles poking into your eye, like a hot poker. Alright, and it can cause the cornea itself to start sloughing off and thinning out and severe damage, potentially even open globe perforations of the eye if you don’t have lubrication of the cornea.

So, we see a patient who’s got proptosis. We’re also concerned about lubrication of the cornea, what we call exposure keratopathy. Alright, we don’t want that. And so, we do a lot of talking, uh, in patients with proptosis for any reason, but especially for thyroid eye disease, we are talking about lubrication, [00:29:00] we’re prescribing ointments, frequent eye drops, sometimes we’ll even tape the eye closed.

We’ll have the patient tape the eye closed at night. Sometimes we’ll even suture part of the eyelids together. It’s called a tarsorophy. to prevent too much exposure of the cornea. So this can be a big problem. Uh, you know, we’re talking optic nerve compromise, cornea compromise, two very important parts of the eye.

So what do we do about this? Treatment. So, there is emergency treatment because thyroid eye disease can get so bad if it starts to put pressure on the optic nerve, we have to do something and we have to do it quickly. So, often times what we’ll do, historically what we’ve done is, um, start IV steroids. To try to just decrease any kind of inflammation we can.

You remember all those cells that are causing those, those, uh, those, um, muscles to get large and engorged, you know, the lymphocytes, you know, we’re trying to [00:30:00] quiet that down with some IV steroids and then. What we can do is called a decompression. So I mentioned the orbit, right? Those bony walls. Well, what you can do is actually, this is pretty invasive, but you just bust through those walls with a surgery.

You break the walls of the, of the orbit. You can do one wall, two wall, three wall, sometimes four wall decompressions. And when you, when you butt, when you open up those. When you basically just make an opening in those bony walls of the orbit, it allows the muscles to relax and fill more space and allows the eye to relax back into the orbit.

Obviously, this is a enormous surgery. It’s a very specialized surgery. Not everybody does this type of surgery. Usually it’s an oculoplastic specialist that does this. I certainly don’t do that surgery. Um, but, uh, it’s It’s, it’s a, it’s a vision and [00:31:00] cornea saving measure that you mostly vision, mostly optic nerve saving measure to do that.

And the recovery can be tough. I mean, patients get really swollen from that surgery and uh, but it, it, it, it can help. It can absolutely help. It can save vision is what I can do. And then beyond orbital decompression, you know, there’s, but even with that, often patients are still left with this proptosis, this cosmetic issue.

And then sometimes they also have diplopia. They have double vision. And then you gotta try to treat that, but you have to make sure that the eyes are stable, that they’re not, that the thyroid eye disease is not getting worse or, or progressing. And there’s different stages of thyroid eye disease. There’s this escalation phase, and then a plateau phase, and then a convalescent phase.

So you gotta make sure the patient’s in the right phase before you start mucking around with the eyelid, sorry, with the eye muscles. Doing strabismus surgery and that’s all way more than we need to talk about here. But what I [00:32:00] do want to, the last thing I want to talk about with thyroid eye disease. is this new medication.

It’s called Teprotumumab. Teprotumumab. The brand name is Tepeza, but we’re, we’re, we’re good students of medicine, so we’re gonna use the the generic name. Teprotumumab. I have no financial interest in, uh, in this medication, in any medication, but still not this one. And this is a really a revolutionary treatment.

Okay. I’ve seen this work. I don’t, I don’t, it’s a, so basically what I’ll just tell you what it is. Um, that would probably be helpful. It’s a monoclonal antibody that was initially developed to treat, to try to treat different types of tumors. Um, but, uh, was later, uh, Uh, thought to, to be used in patients with Graves disease who had, uh, proptosis and the, the, the, the pictures, the before and after for these patients [00:33:00] is remarkable.

All right. It’s an infusion and, um, I, I’m not totally sure how often they get this infusion of weekly or monthly. I’m not sure. But, um, uh, the, the, the, the results are, are fairly remarkable. Um, definitely, you know, statistically, clinically significant. They just, you can see the before and after pictures. Uh, go check it out if you’re interested.

Teprotumumab or Tepeza. Um, T E P E Z Z A. And, and it’s, uh, it can be life changing, this thing. The problem If you could imagine, in the US, is the cost. It is rather expensive and you can imagine how difficult it is to get insurance to cover it. I’ve talked to some of my partners who, I have one partner that does this type of work and treats patients with this.

It’s a lot of phone calls. It’s a lot of prior authorizations and some peer to peer reviews and, you know, all the [00:34:00] things that come with trying to get a very expensive brand new medication, but it, it is, uh, it’s pretty cool. It really, it really does a great job. So, um, talk about, uh, you know, just advances in certain diseases that we just didn’t have great treatments for.

I mean, the treatments worked, IV steroids worked, the decompressions, the thing. But, but nothing that’s as. As effective and you know, that’s not as invasive, right? And so that’s, that’s the benefit of doing this. So anyway, success story in the world of thyroid eye disease. You guys, that’s all I know about thyroid eye disease.

That’s, that’s it. And, you know, I think, uh, oh, we should, I should wrap this up. Uh, we’re at 35 minutes now, if you’re listening to me on two times speed or about 17 minutes in. That’s a little fast. I listen to my podcasts on one and a quarter speed. Um, I listen to a lot of [00:35:00] sports podcasts. It’s my, my, my chance to like turn off my medicine brain because, uh, I, I, for some reason keep doing projects, adding things, uh, for, uh, that are medicine related instead of non medicine related.

You should all have a non medical thing. If you’re in medicine, if you’re in healthcare, like do something like birdwatching. I don’t know, something, get a, have a hobby that’s not medicine related. I, I, I honestly say Ultimate Frisbee is probably my only hobby that’s not medicine related. Um, Anyway, what was I saying?

Hobbies, things. That was it. That’s it. That’s our, that’s our, that’s our episode. I should just wrap this up instead of just drawing this out. Oh, I was talking about the speed at which you’re listening to me talk right now. Anyway, thank you for listening. I’m your host, Will Flannery, also known as Dr.

Glockenflecken. A special thanks to my executive producers, Aron Korney, Rob Goldman, and Shahnti Brooke. Editor in engineers Jason Portees. Our [00:36:00] music is by Omer Ben Zvi. As always, reach out, Leave your comments. I want to see those comments on YouTube, uh, and, um, uh, I want to, uh, just, I want to hear your feedback.

You can email knockknockhigh at human content. com. That’s knockknockhigh at human content. com. Uh, and, um, also check out our website, by the way. We have a tour. Yes, we’re going on tour. My wife and I, Kristen. Our Wife and Death Tour, we’ve gotten rave reviews for it so far. Uh, we’ve done a few shows, sold out shows, uh, and mostly in California.

And, uh, and we’re so excited to take it to other parts of the country. So go to our website, glockenflecken. com slash live and look for, um, the, see if we’re coming anywhere close to you. Now I do still practice ophthalmology, so I cannot go everywhere. I wish I could, we just don’t have that kind of time, uh, um, my partners would not be [00:37:00] happy with me if I just took like a year long sabbatical and did like a 50 city tour, although that sounds so much fun, but we’re trying to hit different parts of the country, so check it out, uh, like 10, 12 cities, something like that, and um, and I hope to see you out there, alright?

That’s it for Knock Knock I for today. Thanks for joining me. Knock Knock Hi, and Knock Knock I is a human content production. Goodbye!