Transcript

[00:00:00] Today’s episode is brought to you by DaxCopilot from Microsoft. DaxCopilot is an AI assistant that helps automate clinical documentation and workflow to let you be more efficient and reduce all the administrative burden that comes with patient care. To learn more about how DaxCopilot can help improve healthcare experiences for both you and your patients, visit aka.

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Hello, everybody. Welcome to knock, knock. I with me, your host, Dr. Glaucomflecken, a subsidiary of knock, knock. Hi. Hope you had a wonderful day. I’m coming to you in the evening out here on the West coast. And it just so happens to [00:01:00] be election day, election night, I should say. Uh, and I, not only is that going on, but I am also on call and election, the, I always start like trying to watch the election coverage.

Uh, and I, I am endlessly impressed by the TV commenters who can just Talk for hours, six, seven, eight hours well into the night, just constant, there’s constant chatter. Uh, it, it stresses me out just to hear that constantly, but it’s, it’s impressive that they’re able to do that. It’s just, it’s very. It’s very internal medicine of them, like that’s, I feel like that’s a skill that would cross over well into internal medicine rounds.

They could very much be a, like a CNN or a BBC or a Fox News anchor, could probably do well as a hospital doctor. Um, but I, [00:02:00] I, I had to leave because I’m on call. Like I thought maybe, uh, you know, being on call would be a, a reasonable distraction from election night. Um, but then I remembered that it’s private practice ophthalmology call, um, which will only keep you distracted for so long.

In fact, I haven’t really gotten any business, which is not a bad thing normally, uh, but, you know, it wouldn’t be like terrible, um, to have something else to do while all of that’s going on. But this is my last, last night of call. So if I’m a little scatterbrained, it’s, it’s fine. I make fun of ophthalmology call and it is like my call is nothing like what it used to be.

I’ve talked about call every time I have a call week, I always go over with you guys. So, I have a few, a few things to tell you about my call, call week. But, uh, um, you know, it’s just, it, it’s just a lot of extra stuff, like a lot of [00:03:00] phone calls, a lot of when I’m in clinic during the week, I get all the, On call things that happen during the day.

So add ons in the clinic. So my clinics are always busting. Um, uh, I’m also doing surgery and just, just a lot of extra things. Uh, you know, getting phone calls from urgent cares and emergency departments, the four different hospitals we cover. So it ends up being maybe not so much like. Over in the middle of the night type stuff, but the days are very, very busy.

And so I’m just, I get a little tired and now I’m at the very end of the call week. I might be a little scatterbrained here, uh, during this episode. Just bear with me. Alright, just, but, but don’t have any sympathy for me as, again, a private practice ophthalmologist because I, I can’t hold a candle to, you know, my surgery, general surgery colleagues who like operate in the middle of the night routinely whenever they’re on call.

Like that sounds like it sucks, like real bad, um. Thank you for doing [00:04:00] that, by the way, those of you who take general surgery call. Um, no eyeballs in the middle of the night. Eyeball, it’s great. Eyeball emergencies don’t happen in the middle of the night, or so I’m told. Anyway, or maybe so you’re told. Um, the So my call, let’s see, oh, first before we get into my call week and how it’s been, which by the way on a scale from 1 being the easiest call week I’ve ever had as in my current position to 10 being I have to go to the ICU, I would give this call Week of five.

It’s like, it’s been kind of, there’ve been some rough patches for me, uh, but overall fine, like it’s whatever it, I’m glad it’s almost over, uh, but first, just a recap from last, the, the last week’s episode that was posted where I talked about, uh, some of the, uh, the worst glasses, uh, spectacles worn by fictional characters in [00:05:00] media.

It was a fun little segment of the episode last week, uh, but you guys, uh, kind of cooked me in the comments. I, I got a bit roasted, uh, on a number of things. One, and I don’t even remember talking about this, I mentioned something about, I was trying to remember, oh, I remember, I was talking about Scrooge McDuck and the glasses he wears, like on the end of his nose.

And how, you know, dysfunctional, like, just not helpful or practical that those glasses are. Uh, how it reminded me of, like, glasses that a, one of the characters on Golden Girls would maybe wear those glasses. Uh, it’s like grandmother glasses. But I couldn’t remember during the episode, I couldn’t remember the name for the show Golden Girls and you guys let me have it.

How dare you not remember the Golden Girls said at one putt four one [00:06:00] five two. I apologize. I have no excuse. It’s a classic. Be Arthur. And the rest, um, uh, it’s, uh, you know, Golden Girls, people are, people are shocked. I couldn’t remember the name of Golden Girls. I think I threw out Designing Women, which is like even worse.

But I remember that somehow, cause I remembered it used to come on like during the summer, like right after Price is Right or something, if for some reason Designing Women would always come on. Um, couldn’t name a single thing about that show. Uh, anyway, also there was one comment that made me laugh. Um, these are, by the way, on my YouTube channel, uh, for the podcast at Glaucomfleckens.

All these episodes are posted there. Go. I love reading your comments there. Uh, let’s see. Who was it? It’s, uh, at NicolaPlays1134 said, I have no idea if this is canon, but my guess is Clark Kent’s glasses stop him from accidentally frying things with his heat [00:07:00] vision. Kind of breaks your cover when you do things like that.

Uh, made me laugh. Uh, you’re right. Absolutely. That, it’s, it’s reasonable. I mean, I don’t know, like those are some strong, we’re talking like serious polycarbonate lenses to be able to block, uh, the eye vision, the heat vision, heat rays, but you would think you would still see the eyes glow red if that was the case.

So I don’t know. Maybe there’s just a tiny little bit of like a trace amount of kryptonite in the lenses. That’d be kind of cool, right? That makes sense. Like just, just enough to where he still has like x ray vision, but won’t fry people with the, uh, with the eyes, the eye lasers, I don’t know. So, thank you for those comments and the feedback, I really appreciate that.

Alright, uh, let’s see, other comments, and then, uh, a couple people had some suggestions for topics. Two, two of you wanted me to talk about floaters. Everybody’s always [00:08:00] so interested in floaters, that’s because everybody has them and they’re all annoyed by it. You guys hate floaters. Alright, so I had, uh, just as I do every call week, I always have, uh, things come up about flashes and floaters.

So, we’re gonna get to that. Um, in a bit. In fact, let’s take a break. We’ll come back and jump into my call week.

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It’s not just a form you fill out on the website. Yeah, that’s a personal connection they make and they’ve helped more than 6,000 physicians get disability insurance. Hmm. I wonder if they can help you maybe to find out more and get a free one-to-one consultation. Go to www.pearsonrabbits.com/knock knock.

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Okay, here we go, call. My last call of the year, I don’t have another call week until March. It’s very exciting, very exciting to have a five month break of call, four month, whatever it is. Uh, and I was thinking about it, like, as I, like, what, what has my mental status been like through, throughout the week?

And [00:10:00] I got, I got woken up like more often than I usually do, uh, what, during sleep. I think the latest I got a page was like 1 a. m. And I go to sleep, I try to go to sleep by around 10, so it definitely woke me up. And I, as I get older, it’s just, it’s harder for me to fall back asleep. I used to be able to do that so easily.

I don’t know what it is, uh, I just can’t, like, I’m always, every time I get woken up by a page, it’s like, 45 minutes, I’m, I’m awake until I finally fall back asleep. I don’t like it. I’ve always prided myself on my ability to sleep anywhere at any time very quickly. Maybe it’s, maybe it’s a sign that I’m too well rested, that it takes too long for me to fall back asleep.

I need to be more tired that I’ll just fall asleep on a stairwell. I don’t know. But anyway, so I was thinking about like, what’s the best week, like night of call. So I take call from a Wednesday to Wednesday and what’s the, what’s the, like the best day. And what’s the worst day? Well, the best day I [00:11:00] think is the best night is the night before it’s over.

So tonight, I’m excited, like call’s almost done. It’ll be great when I wake up in the morning. The worst one is the, the first night. It’s the first, because it’s like the anticipation. It’s like, Oh, I’m starting a whole week of this. In my mind, the call week is always going to go much worse than, than, uh, than it’s actually going to go.

And then, uh, After, as I, when I wake up in the morning and usually don’t get called, it’s, it’s, uh, I’m like, Oh yeah, I forgot. It’s private practice ophthalmology. Like it’s not bad. Stop complaining. Get out of your own head. Tell your brain to shut it down with the anxiety. You’re going to be fine. Don’t complain.

That’s like the night after I wake up or the morning after I wake up after my first night of call. Um, so. I got a lot of patient phone calls, uh, which are fine. You know, we have a call for our patients, and so a lot of post op questions, and you know, people having symptoms, and [00:12:00] um, I would say with cataract surgery, some of the more common ones are new floaters, uh, and so it’s really common to have a sudden appreciation of floaters.

shortly after cataract surgery. And part of that is because you do have, sometimes you have some debris floating in the eye after cataract surgery. Um, you can have like little bits of cortex, like tiny little pieces of cortex, which is like a part of the old cataract. The eye will clear that stuff out.

Also just inflammatory cells, um, and some of the viscoelastic, which is this Gel like material we use during cataract surgery to hold the spaces open, to create space in the eye, allowing us to work. We use it for lots of different things, but sometimes we leave some of that stuff in the eye and people [00:13:00] sometimes can see it.

But also, just, when you have floaters after cataract surgery, more often than not, it’s just the same floaters that you had, it’s just your vision is better now. You don’t have a cataract in the way that’s just washing out all the detail in your vision. Now you have a nice clear lens and boom! You can see floaters better.

It’s kind of a minor little downside to cataract surgery is if you have floaters, there’s a good chance those floaters will be a bit more prominent after we make your vision better. Now, the brain has this remarkable ability for most of us to adapt to that. It’s called neuroadaptation. It learns, Oh, these floaters, they’re not actually like something I need to see and adjust.

Kind of shuts them out, ignores them, and you just don’t notice them as much. They’re not floating around as much. Maybe you’ll notice them when you look at the [00:14:00] sky or a bright wall, white wall. You’ll say, Oh, there’s my floater. You can find them. But, uh, but over time, you just don’t notice them as much. And so that’s, that’s what I always reassure patients who have floaters after cataract surgery who call in to the on call doctor at midnight.

I’ve got new floaters. What do I do? It’s okay. All right. If you have flashes of light, that’s different. So, flashes, and we’ve talked about this, flashes of light often can indicate a retinal tear or retinal detachment, which is a risk of any intraocular surgery. You have surgery on the eye, You know, the retina is a delicate structure.

It’s entirely possible you could have a retinal tear, just as a result of the trauma from the surgery. It’s very unlikely that that happens. Flashes of light, like big like lightning strikes in your vision, that’s, that gets us a bit concerned about that possibility. So post op questions, really common on my call week.

Um, sometimes people [00:15:00] have subconjunctival hemorrhages. which is just like bruises, like you get a bruise on your skin when you get a bruise on the eye just as really concerning to people because it’s just this bright red spot on the eye, so we get that sometimes. Um, and then, and then we get, you know, flashes and floaters, we get, you know, eye pain, dry eye type symptoms, sometimes contact lens related ulcers, but I had a couple interesting ones, couple interesting patients.

So one, which is a, is a, A mythical thing that you, you, you, you always learn about, you hear about it and, and, but you, you never actually get consulted for it. And that is a patient that they think has Wilson’s disease. They consulted me to come look for something called a Kaiser Fleischer ring. So let’s dive into this a little bit.

This was the first time I’d ever gotten a consult for this. I’ve heard about consults like this. I’ve always been told that these are basically [00:16:00] bogus consults, and I’ll tell you why. First of all, this is an inpatient. A patient was admitted with psychiatric disturbances, you know, wild, wild mood swings that were very unusual for this patient.

The family corroborated that, recognized that this is not normal. It’s not normally like this. And so, and they couldn’t figure out what was going on or having trouble figuring out. So they did a fairly large workup and, and lo and behold. There were a couple of things that jumped out. There were abnormal, um, like cortisol levels, ACTH, like pituitary hormonal changes.

Um, and so they did a, a, a scan looking for like a pituitary adenoma, but also they sent a ceruloplasm and copper levels. And sure enough, those were abnormal. And so they had this, this situation, the primary, and when I say they, I mean, the primary team [00:17:00] and this, this, uh, the situation where. Just not quite sure what direction to go.

Like, what could be causing this? Like, is there a pituitary adenoma? Which, it turns out, there was something in pituitary. That’s the thing. But, there’s also this second thing. That’s Wilson’s disease. Which one is, like, more unusual? I don’t know. They’re both pretty unusual. And so, basically, they’re wanting, uh, the, the neurosurgeons before.

Before, um, you know, deciding to proceed with an invasive thing like a surgery to remove a pituitary adenoma to try to, like, fix this problem, um, they wanted an ophthalmologist to weigh in to see whether there was this thing called a Kaiser Fleischer ring, which would push them more toward a diagnosis of Wilson’s disease, because it’s not going to be both.

Like, the odds of two zebra diagnoses both happening at the same time, [00:18:00] one in a billion. Like, that doesn’t happen. It’s always, it’s one thing. It’s never two things. You always want to, it’s very rarely, I won’t say never because there’s no never in medicine. It’s the human body. Weird stuff happens, but, uh, um, you’re always taught to like, try to find one unifying diagnosis to explain a patient’s condition, and oftentimes you can, um, but in this case, like, it’s not going to be both of these two things, so it’s going to be one or the other that’s causing this problem, and so we had this, this weird situation where there’s these Kind of, not wildly abnormal, but a little bit abnormal in terms of this, these, this copper level ceruloplasmin.

I’m not going to go into details about like Wilson’s, that part of Wilson’s disease, because I don’t treat that. But my role is to see if there’s this change around the eye. And so with Wilson’s disease, one of the things you can get is called a Kaiser Fleischer ring, which [00:19:00] is this golden brownish, Ring right at the at the edge of the white part of the eye around the iris So kind of at the the the outside of the iris and it’s not like actually on the iris it’s actually on the the the in the cornea sclera conjunctiva, it’s a deposit of copper basically that just encircles the the edge of the cornea the edge of the iris kind of right there and um And the thing is, when you, when a patient has a kaiserfleischering, they will 99, 999 times out of 10, 000, they will have a vast array of, of symptoms related to Wilson’s disease to the point where it’s not subtle.

It’s like, [00:20:00] Oh, this is clearly Wilson’s disease. You got signs of liver, uh, uh, liver involvement. That’s a, that’s a classic thing that, uh, Wilson’s disease affects the liver. Uh, sometimes patients are jaundiced from, from liver failure from, from this disease. Uh, you get. It’s, you know, edema of the extremities, like speech, swallowing difficulties, uh, uncontrolled movements of the extremities, uh, spasticity.

Like there’s all kinds of stuff that can occur with Wilson’s disease. And it’s once by the point. Of which you would have a Kaiser Fleischer ring on the eye. It’s like, way, the horse is out of the barn. So that’s why in the ophthalmology world, we’re like, well, you’re never going to get consulted for this because it’s, it’s gonna, you know, it’s going to be obvious.

It’s going to be absolutely obvious that beyond the point where they even really [00:21:00] need an ophthalmologist to weigh in because we’re not going to treat anything. Like it’s just a sign of this disease, but that is way outside my area of expertise. Like I’m not managing patients with the Wilson’s disease.

I don’t even know how to treat Wilson’s disease, but I know what that looks like, a Kaiser Fleischer ring. So. This is like this weird situation. And so I, but I talked to the doctor on call and they’re like, you know, it’s just be really helpful. I could tell it’s so funny. Cause whenever someone gets on the phone with me often, not so much with emergency medicine, but with other doctors, like, like this time it was a hospitalist, like the first thing they say to me is I’m, I’m so sorry to bother you on call and, and I’m just like, dude, like I, I’m watching Netflix.

I’m sitting here watching like reruns of The Simpsons with my kids, like, I’ve got time to talk about this thing with you, all right, it’s okay, I [00:22:00] can find time to make it over to the hospital sometime in the next few days to go and check and see if this patient has kaiserfleischer rings. Do I really need to do this?

Not really, because It’s not a subtle finding, typically, like you can look at the patient’s eye with your naked eye and see if there’s a brown ring around the cornea. Um, certainly with like any kind of magnifying glass, just, just pull it up to the eye and look at it. But I get it, like they want, they want an expert to weigh in.

I’m there, I’m the on call doctor for that hospital. So anyway, I did it. It took, uh, it was a 10 second consult. I just walked in, looked at it. I took a, uh, one of my fisheye lenses and I just held it up to the eye. Looked at, uh, no, it was a little bit of Arcus, which is a sign of cholesterol deposit in that same orient, same distribution.

Not this, not the right color. Definitely not a, not a Kaiser Fleischer ring. So from my [00:23:00] perspective, as an ophthalmologist, I do not see anything that would suggest Wilson’s disease. That was it. That was, I called the hospitalist, told them what I found, and I don’t know what happened with the patient. So, um, uh, I’m kind of, I sign off at that point.

I’m, I’m off the, I’m off board. You know, I just get like on board. Let’s get, let’s get cardiology on board. Let’s get ophthalmology on board. I am not on, I am on the dock. I am watching, I’m waving at the boat as it sails into the bay. It’s never for me to see it again, and that’s okay. I’m much happier on dry land.

That was an interesting one. I had never received a consult for Wilson’s disease before, so that was a first. Fun, but it was an okay first because it didn’t take much time, so. But I could tell that patient was in very good hands, they were very, just all the doctors were communicating very well. You love it when that [00:24:00] happens, when they’re all on the same page, they’re talking to each other.

They’re the easy communication. You’ll love that. Okay. Let’s take one more break and I have another much more difficult patient to tell you about.

All right. So, call was pretty much like going along swimmingly, you know, I had, I think I did, I, I counted it up a couple of nights ago, but probably I would say probably 10. Calls from the four different emergency departments that we cover to triage eyeball stuff. And fortunately, none of them involved me actually.

There were no pants patients. That’s good. So I didn’t have to put on my pants and come in to see the patient right away. Um, uh, they were all triageable. So I was able to, you know, either [00:25:00] get that patient, get those patients in the next day in the morning, like one of them was almost definitely a flat, a, a, a retinal tear, a retinal detachment, uh, but the call came in at 2 a.

m. We’re not going to do emergency. Retina surgery, 3 or 4 a. m., that’s very specialized. It really does help to have your people there who know how to do that type of surgery, know how to assist, set up the equipment, all that stuff. And so that was a, get your right in to see the retina doctor, uh, the retina surgeon.

And so other than that, that was the closest thing to a PANS patient I saw all week, but. I had still had some diagnostic challenges and so one patient came in with new onset vertical diplopia. So, I’ve talked about this before, when you have a, on new onset diplopia, [00:26:00] Before you talk to your ophthalmologist that’s on call, if you’re the emergency physician, primary care, whatever, urgent care, I’m going to ask you, is it monocular diplopia or is it binocular diplopia?

That means when that patient covers an eye, the double vision goes away completely. If they cover the other eye, it goes away completely. If the patient ever says, I have double vision in my left eye, That’s probably going to be monocular diplopia. That means if they cover their right eye But the double vision is still there.

Well, that’s not a misalignment to your, their eyes. That’s not strabismus. That’s dry eye. That’s rarely something like a lens dislocation, just much more rare than, than many people in emergency medicine would lead you to believe. Mostly dry eye, 99 times out of a hundred dry eye. Uh, but [00:27:00] binocular double vision is what we get concerned about.

So that means you cover an eye. Double vision goes away. They need both eyes open in order to appreciate the double vision because each eye is seeing the image in a different place because the eyes are misaligned by inocular diplopia. So, I had a patient, ended up seeing him in clinic, on call patient, and um, had new onset vertical diplopia and it was legit.

It was, Way far different images. So the first thing I try to do with, with this type of thing, first of all, this is like dropping a bomb in clinic because we got, we have like 40 patients in clinic on average, and you bring in a new onset diplopia. Sometimes, that, it just, the clinic comes to a screeching halt.

Obviously, that’s not the patient’s fault, like, they got a problem, they’re coming in to see me. It’s partly just because we have to, there’s [00:28:00] so many patients we need to see, and our schedules are so full right now. But whenever, um, whenever people complain about waiting, Too long at the doctor. Sometimes it’s because something, a patient like this comes in who requires a little bit more attention than we, than we were planning on for that appointment slot and we do our best ideally.

And we, we, I do try to like communicate with. With the patients that are waiting on me, like it’s going to be another, you know, it’s going to be a little bit longer, you know, to try to just let them know, I think that does help, does help to give a heads up, I think people do appreciate that, rather than just like sitting in an exam room, waiting for 30, 45 minutes.

So anyway, um, when a patient comes in with double vision, the first thing I’m trying to do is find a pattern to it. And by pattern I mean, try to figure out which muscles Which extraocular muscles are not working? So the eye is going to [00:29:00] move in a particular direction with motility, with cross cover testing, and that helps you determine, okay, is it a sixth nerve palsy causing weakness of the lateral rectus?

Is it a third nerve palsy where you have the eye that’s down and out? Because you don’t have function of A variety of muscles, your superior rectus, your medial rectus, your inferior oblique, all innervated by the, um, the, uh, Third cranial nerve. Is it a fourth nerve palsy? Fourth nerve palsy where you would have the eye, affected eye, kind of moving up.

You don’t have superior oblique function, so the eye is going to be up and then you turn the head certain directions and the dilapidopia gets worse. So anyway, I’m doing all of this testing, having the patient look in all these different directions, try to figure out what the pattern is. [00:30:00] I wasn’t real successful.

Um, it’s a, it was a big, this patient, large vertical diplopia. It kind of patterned out to a fourth nerve palsy. That was what I was thinking that it’s most likely, but it wasn’t exactly what you expect to see with a fourth nerve palsy. It was like, it was like 60 percent there. And so I had this, Ideally, it’s just, it’s like slam dunk, oh, clearly, look, the eye, it’s, there’s an esotropia, the sixth nerve’s not working, the eye’s not moving out, that patient has a sixth nerve palsy.

I didn’t have that easy slam dunk, boom, I know what the nerve palsy is. So I’m thinking, for this patient, I’m thinking it’s a fourth nerve palsy, and uh, And so you’re, so now I’m thinking, okay, well, what could cause a fourth nerve palsy? And, um, uh, the most common things are like trauma can do it. All right, because the fourth nerve, the trochlear nerve has a very [00:31:00] long course in the, around the brain and in the cranium, so, so it’s very easy to, for it to be damaged by head trauma and that’s really common.

We see that after bad car accidents, bad concussions, patients can have a fourth nerve palsy. No history of that with this patient. So then I’m thinking, okay, well, could it be an ischemic? Fourth nerve palsy. So we see ischemic nerve palsies quite often, especially in people with have, who have a vascular history, diabetes, high blood pressure, history of stroke, you know, coronary artery disease.

They’ve had heart attacks before, you know, they have vascular problems. All right, well that can affect the blood vessels that feed these Cranial nerves. And so you can get, with diabetes, it’s most common is a 6 nerve palsy, but you can also get a 4th nerve palsy and it’s what we call an ischemic 4th nerve palsy.

It’s not a stroke, it’s just a little bit of [00:32:00] lack of blood flow to that nerve that temporarily causes it to malfunction, but most of the time, ischemic nerve palsies, uh, can come back and get better. Sometimes it takes months, but it can get better. So I’m thinking, okay, could this be an ischemic nerve palsy?

Well, it was po it’s possible. It’s still possible. I don’t know the answer yet. I’m still in the process of working this patient up. Um, but, uh, there’s no history of any that, any typical, Vascular problem. With one exception, this patient has a history of giant cell arteritis. Six years prior, this patient had giant cell arteritis.

Now it was biopsy negative giant cell arteritis, so the way you diagnose giant cell arteritis, classic symptoms, scalp tenderness, temporal headache, sometimes jaw claudication, fatigue, but also you have lab values that are abnormal. This patient had all of that. But had a biopsy, because you [00:33:00] always get a biopsy of the temporal artery to try to make the diagnosis histologically, but that was negative.

Doesn’t mean the patient did not have giant cell arteritis. If all the other signs and symptoms are pointing to giant cell, it’s probably giant cell. She was treated for it, and everything recovered just fine. So, okay, well what do I do with that? Well, she’s not having, with seeing me, not having any, Classic symptoms that she had before with the prior episode of giant cell arthritis, but she has a nerve palsy and that’s something you can get with giant cell arthritis.

So that’s on the differential. So I also, you know, so I’m making my list of things I’m going to order and, um, I’m putting ESR CRP platelets. Giant cell arteritis labs on there. I’m going to check that, obviously, with her history. I got to do that. The fact that you can get a nerve palsy with giant cell arteritis.

Um, and [00:34:00] then, because this is not like a classic, if it was a classic fourth nerve, like, obviously, a fourth nerve palsy based on the eye movements and all my testing, um, And there was a vascular history, I wouldn’t do any neuroimaging. You don’t need to. It’s clearly, okay, 4th nerve palsy, vascular history, it’s ischemia.

Or 4th nerve palsy, had a car accident two weeks ago, that’s it. No need for imaging, but it’s not, it’s a little bit up in the air. You know, no, there’s no classic presentation here. And so I got to rule out like a stroke or a, um, or a tumor, you know, pressing on that nerve that could be causing this. And so I also ordered an MRI.

So that’s all in the works, and we’re gonna get that done, uh, fairly quickly. So it, it’s, and, and, and I’m, I don’t know. I, I’m, I’m telling you guys this because I, I, I think it’s interesting to hear a specialist like thought [00:35:00] process of how we approach these complex problems. And, you know, I, I don’t, I don’t, I don’t know yet what the answer is.

I’m hoping to get to the bottom of it. And the other thing I’m thinking of is, um, another reason why an adult may have. A misalignment strabismus, um, that doesn’t follow a particular pattern, which is, there’s two things. One is myasthenia gravis. This did not seem like myasthenia, there’s no, there’s no fatigability, I checked all that.

But thyroid is another one. She had been having some redness to her eyes, some conjunctival injection. No proptosis, no flare of the eyelids, no eyelid retraction, I think that’s less likely, but I went ahead and ordered TSH and thyroid stimulating immunoglobulin test. So anyway, on the differential, it’s wide.

Thyroid, we got a [00:36:00] brain tumor, we have stroke, we have ischemic fourth nerve palsy, um, and uh, giant solar arthritis. So we’ll see. I’ll update you guys next week when I know more. That’s what’s going on. And, um, and that’s my call week. That’s it. Does that sound fun? If you listen to that whole presentation and thought to yourself, this, Sounds great.

I want to do that thing that he just described. I want to do all that. I want to be involved. Please do an ophthalmology residency, go do a neuro ophthalmology fellowship, and you can do that stuff all day. We need neuro ophthalmologists people, please, you can work right next to me, we could just, we could be buddies, I would love to have a neuro ophthalmologist on my hip, we’re connected, we’re the same pair of [00:37:00] pants, we can both fit, extra extra large, right next to it, that’s, I don’t know, what am I talking, see I told you, I’m getting, it’s a little bit much, I, that’s, I went too far with it, alright, anyway, uh, it’s a different kind of pants patient.

Thank you all for listening. I’m your host, Will Flannery, also known as Dr. Glaucomflecken. Thanks to my executive producers, Aron Korney, Rob Goldman, and Shahnti Brooke, editor in engineers, Jason Portizo, and music is by Omer Ben Zvi. Uh, always keep in mind, you can send me any comments, questions, uh, if you have any thoughts of, uh, on what the things I talked about today.

I’d love to hear them. Uh, go to the YouTube channel at Glaucomfleckens. You can also listen to this anywhere you get your podcasts, but at Glaucomfleckens, leave a comment. I read them. I read them here, following a week. Uh, so let me know. I’d love to hear from you guys. Knock Knock High is a human content production.

We’ll see you next time. [00:38:00] Goodbye.