[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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knock. Hi,

everybody. Welcome to knock, knock. I with me, your host, Dr. Glaucomflecken. Thank you for joining me this fine evening or whatever time it is, wherever you are. This is your one stop shop. All things eyeballs. If you’ve been going about your day [00:01:00] doing whatever it is you’re doing and then after you got home from work, you’re like, man, I could really just close out my day, start my evening, drift off to sleep with little eyeballs, little eyeball knowledge, maybe not little eyeballs, normal sized eyeballs, but the knowledge is also just a little.

I’m not going to overwhelm you. But you’re in the right place. Here we go. Um, I’ve got a few things. Uh, I’ve got another, um, you guys have been really enjoying the Kind of mystery patients. I’ve got another patient to tell you about today. Not really a mystery, but an interesting new diagnosis that I made.

Uh, and, uh, and so we’ll, we’ll talk about that a little bit later, but here in the open, uh, I want to just talk for a minute about Denver. We had a show in Denver and, uh, we, at the, uh, at the Denver improv, uh, which, uh, was, was awesome. Man, the, uh, the, the costumes, people came out. [00:02:00] You know, if I could redo this whole tour over again, we’re now at the very end.

We have one date left in Chicago next month, but if I could like go back and do it all again, I would, I would do. Bigger venues because like I so many people wanted tickets, but they couldn’t like there were only like 370 or something for this venue and and we should have done more You know We a couple of the places we went to had like six or seven hundred seat Venues and even those were selling out.

And so I Apologized to all the people that tried to get tickets on this on this first go around But couldn’t because they sold out too quickly We’re, we’re doing more shows. All right. It’s, uh, the, the, this, this, uh, wife and death tour. It’s been so much fun to put on, to come and see audiences, uh, to see the, the costumes you guys come in with.

Lots of unicorn headbands. Uh, we got, uh, uh, some, some radiology glasses, uh, lots of scrub, [00:03:00] uh, scrub hats, just, uh, you know, surgery. Um, attire, I should say. Uh, so it’s been really fun to see that. Bicycle helmets, of course. There was a new one in Denver. Somebody showed up dressed as an eyedrop bottle. They had like a beanie hat.

It was really tall. Uh, that was the color of, uh, it was a dark blue cap and then a white shirt that was basically like the label of Kosopt, Dorzolamide Temelol. It’s a glaucoma drop. She looked exactly like, like a human sized COSOP bottle. It was incredible. A plus for creativity. Uh, I took a picture with, I got a post, I forgot to post the picture.

So, uh, I’m going to put that out there, uh, as you’ll see that if you follow me on Instagram. Maybe Twitter, Blue Sky, I’m really enjoying Blue Sky lately, it’s nice, it feels like early Twitter, uh, and so, uh, anyway, [00:04:00] I love that costume, I love everybody that comes in costume, I know, I know how good an audience is going to be, it’s just, it’s based on how many costumes I see out there, and that’s what’s so fun about the small venues, the comedy clubs, because they’re right there, all the, it’s like there’s engagement in the audience, you can feel the energy, It’s, it’s awesome.

So, uh, appreciate everybody for coming out. But one more thing I got to say about Denver, it is absurdly dry. I it’s like every, I don’t know why it still surprises me. I go to Denver, like, I don’t know, every other year. I think last time I was there was when I gave the, um, the commencement address to the med school a couple of years back, it always just, just blows me away.

How freaking dry that place is like I just the moisture just sucked out of my body and I just you can’t drink and I don’t know how people live there. How do you live in in Denver and by the way, like I know it’s like everybody goes crazy or the [00:05:00] Denver, the mountains or let’s just be honest here. People who live in Denver, like if Denver didn’t have mountains, it would be Iowa.

Okay. Like, let’s just, let’s be real here. Yeah. The mountains are beautiful, but Denver is just Iowa with mountains that that’s what it is. And so, uh, you know, don’t get too proud of yourselves for having beautiful mountains to look at. All right. I get it. It’s great. Like better than cornfields probably.

Sure. But, uh, I’m just saying like other than the mountains, not a whole lot to look at in Denver. That’s very flat, not a lot of vegetation and it’s dry as hell. Yeah. So, anyway, had a great time though, I really enjoyed it, I went to Meow Wolf. This is like this art art, the like hundreds of artists all came together to make this, this huge interactive, uh, I don’t even know how you describe it.

It’s a, it’s a, it’s a, it’s not really a museum because you can touch everything and you can, but, uh, um, it’s, uh, it, it, The only way to, [00:06:00] you just have to go, like go to the website, look at it. It’s, it’s sensory overload is what it is. My kids loved it. We loved it too. But by the end, my head was just spinning and just, just, I felt like my eyeballs were, were, were getting sucked out of my head, uh, just with all of the, all of the, uh, the, the flat, the lights and the, the colors and the noises and fascinating.

Never, never experienced anything like it. Meow Wolf. Go check it out. Uh, okay. Before we take our first break though, breaking news. This is what you come to Knock Knock Eye for is breaking news, right? President elect Trump has named his director of the Center for Medicare and Medicaid Services. CMS. And I thought this was a joke at first, but it turns out it’s true.

It is Dr. Oz. Now everybody’s going to know this by the [00:07:00] time you hear this episode. This will probably come out in a couple weeks, but, uh, I, I have no words. I, you know, I, I. I, I’m not, this won’t be the first time I’ve made fun of Dr. Oz. I mean, we all do it. It’s, it’s, he’s low hanging fruit. It’s, it’s very easy to make fun of Dr.

Oz just because of, of, you know, he’s kind of like the OG grifter in healthcare. You know, it’s just, it’s just, uh, he started with, uh, Oprah and was, you know, hawking all of these, um, these like lose weight fast diet type stuff. Like just look at Google image search, Dr. Oz magazine. And look at all the magazine covers, it’s, it’s like, follow my plan to lose 10 pounds fast and like nothing, losing 10 pounds fat, like nothing healthy will make you lose 10 pounds fast.

Like 10 pounds over like. A few weeks. Okay. Now we’re talking, but 10 pounds fast, like 48 hours. Come on. And he’s, and then he’s gotten [00:08:00] into trouble doing different things. He’s been sued a number of times, um, uh, for misrepresenting the effectiveness of fat bursting supplements on his show. It’s the supplement stuff.

Uh, there was like a, a, a green, what was that? A green coffee extract, extract green coffee extract as a miracle. Weight loss drug supplement. I don’t, whatever he calls it. He got in a legal trouble with trouble with that. So it’s, it’s, it’s kind of a punching bag as, as particularly in the healthcare community, but I think even outside of healthcare at all, everybody kind of like realize he’s kind of a.

Kind of a gimmick, kind of a, you know, and it’s, the thing is like, he’s a board certified surgeon. He’s like, I think he’s a cardiothoracic surgeon. Uh, and, um, uh, and it just kind of through his, his, his presence through, you know, Oprah and the, and later on the Dr. Oz show where he brings up all these things.

He, he once had, uh, um, an episode about conversion therapy where he had, you know, [00:09:00] Proponents of conversion therapy, um, uh, on to, to discuss the, the potential benefits, which there are none. It’s, it’s, it’s soundly denounced by everyone, especially everyone in medicine, everyone in healthcare for sure. Uh, so he’s gotten in trouble with that.

It’s just all these things are just added up over the years to make him not the most trustworthy source when it comes to conversion. So, that brings us to today, him being announced as the director for the Center for Medicare and Medicaid Services, which is like the largest and most influential entity in healthcare in the U.

S. It’s what determines everything downstream from how medical practices function, how hospitals are paid, how physicians are paid, uh, what services patients [00:10:00] can get covered by their both public and private health insurance. It affects, CMS affects everything and man, it really doesn’t feel good to have someone who is so susceptible to these.

It’s grifting the supplements, the, the things that have no basis in medicine and evidence, no evidence base for, for so many things that he’s, he’s tried to sell people over the years. It doesn’t feel good that he’s going to be running like the most important healthcare entity in the U. S. So. Well, maybe he’ll prove me wrong, Dr.

Oz, I don’t know, um, but you know, and I, like I want a physician, I would, I love the idea of a physician, uh, uh, uh, heading up that center. CMS. I, I, I love it. I love, I think it, it’s, it definitely should be that, that we need more. [00:11:00] Physicians in leadership positions in healthcare, but how about someone who’s like practiced in the past 20 years?

Like that would be great. Let’s have someone who’s actually practiced seeing patients, dealt with billing, dealt with reimbursement, dealt with the insurance coverage for patients under CMS. Who know what it’s all about. Like the guy hasn’t been practicing since he jumped on Oprah’s show years and years ago.

Like it’s, it’s been a while and that bothers me. That I want physicians there. In government, like making these important decisions that affect all of us, but someone that’s a little bit more trustworthy would be great. All right, let’s take a break.

Kristen. What? We got to talk about disability insurance. Why’s that? Because I don’t have it. I know. I wish I did. I wish you did too. I should have gotten it before I had testicular cancer, and testicular cancer again, [00:12:00] and a cardiac arrest. Yes, we thought we had time, but it turned out we did not. Well, let me tell you about Pearson Rabbits.

Tell me. This is a company founded by a physician, Dr. Stephanie Pearson, an OB GYN, who had an injury, was unable to work, and is now an advocate for physicians and wants to help others avoid similar mistakes. Hmm. Pearson Rabbits has decades of experience, takes its time to get to know you, your medical history and what you need.

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.

Again, that’s. Pearson Rabbits, P E A R S O N R A V I T Z dot com slash knock knock to get more information and protect your greatest investment, you.[00:13:00] 

Okay, we got the serious, like, soapboxy stuff out of the way, so If you’re still listening, thank you for sticking around. I, I don’t like to wade into politics because I want, I want to stick to, to talk about eyeballs. That’s really what I want to do. I like, I really like eyeballs, but this is like when it, when it starts to like actually Potentially affect like the things that I like to talk about in my content, which is healthcare and the healthcare system and how it affects patients.

Like the Dr. Ross thing is kind of important. So anyway, we’ll, we’ll see how it goes. Um, all right, so let’s, let’s get to eyeballs now. Okay. So, uh, looking at the feedback on our YouTube channel at Glaucomfleckens, by the way, go check it out. A lot of great comments. Thank you guys. So the, the, the post that, uh, the episode that recently came out, I talked about my ophthalmology call week.

I talked about, uh, going into, to the, uh, into the hospital to see a [00:14:00] patient who they thought might have Wilson’s disease. Well, guess what? Wasn’t Wilson’s disease. Um, it was something else. Uh, I, I’m not going to go into too many details cause it’s kind of a rare thing. Uh, but, but anyway, I talked about Kaiser Fleischer rings and, and everything.

And, um, and you guys loved like hearing the thought process of, of how I approach somewhat unknown types of cases and, and, and how I come to my differential diagnosis. Well, I’m glad, I’m glad you guys enjoyed that, uh, because I’ve got another patient for you. Alright, this just came up really within the past few weeks.

I’ve been trying to figure this out and I got some lab tests that, that, that helped tremendously. Alright, so this is a patient, relatively young, I would say like 60, 65. I had done her cataract surgery a few months back and everything went great. That was really the only thing that was going on with this patient was that she had cataracts.

So I did a cataract surgery, she was happy, vision was great, doing well, [00:15:00] uh, and then about two and a half months after the cataract surgery Um, I, I got a triage from our, one of our techs that said, uh, your patient who you’re having surgery, who you had sur, who you did surgery on is Having double vision.

And at first my initial thought was what could have gone wrong during surgery to give the double vision? But then I learned that this, the symptoms just started a couple of weeks ago. Now about three months after the cataract surgeries were done. So that kind of rules out any like perioperative complication that could occur.

But because I was thinking about it, you know, the things that can give you double vision right after cataract surgery. There’s a couple of things. Uh, one would be, which is much less of an issue really, is if someone has had, has a really dense, really bad cataract, can’t see anything, it’s like light perception vision out of that eye.

Usually what they’ll, what’ll happen is that, [00:16:00] that eye can sometimes start to drift out. Basically the, the, the, the brain just, just ignores that eye. It’s not seeing well, so it’s not going to worry about it. And you get what’s called like an occlusion exotropia. The, the, the eye’s not seeing anything, so the eye’s just going to start drifting out.

So usually it’s an out type of thing. It’s exotropia. The eye becomes exotropic. Sometimes you don’t have that, but still, after you take that, Dense, severe cataract out, you put a nice clear lens in, the patient all of a sudden can see 20 20 again. Well, That’s great, but the brain still has to like turn it on, still has to, to, to figure out how to use the two eyes together again.

So it’s not unusual for a patient to have temporary double vision right after cataract surgery as the brain gets accustomed to seeing with two eyes again. That’s pretty common. So it might be just a couple of weeks, sometimes a month, but it’s pretty quick. The eyes, the brain will figure it [00:17:00] out. Um, and, uh, and, and, and you’ll, you’ll see single again.

So that’s, that’s a less, less troublesome reason why someone can have double vision after cataract surgery. A more troubling thing would be if, in preparation for the cataract surgery, a retrobulbar block was done. So, a retrobulbar block, there’s different ways to provide anesthetic to the eye for surgery.

So, the first is you can do topical anesthesia. That’s what I do. That’s what most ophthalmologists do still, do at this point, is you just give a bunch of numbing eye drops, bupivacaine, proparacaine, tetracaine, some combination of all three Get the eye nice and numbed up and then you do your surgery.

Patient doesn’t feel anything. Great. Now the downside to that is the patient can still move their eyes. So that’s why you got to talk to the patient. Sometimes during the surgery, they look at the light, look up, look down. It can be kind of frustrating for the surgeon because some patients just. [00:18:00] They’re not that great at keeping their eye still.

Sometimes they have a little movement. Sometimes they have nystagmus. Sometimes they just don’t follow commands. Sometimes they can’t even really see the light because the cataract is so dense. And so they’re kind of just searching. They’re just moving around, moving their eye around. Most patients do just fine and they’re able to get through it with maybe with a little coaching from the surgeon.

We’re really good at that. I’m good about managing little tiny eye movements. Sometimes there’s big eye movements that do cause problems. That’s not very often though. But if someone just can’t do topical because they, they can’t keep still. They can’t keep their eyes still. Um, usually it’s, there are some surgeons have been practicing for a long time and have just gotten used to doing retro bulbar blocks.

So what that entails is taking a giant scary needle. It’s like, I don’t know, four or five inches and you You insert the needle on kind of the, [00:19:00] below the eye, kind of outer third, through the eyelid, underneath the globe, underneath the eyeball, into the orbit, and you inject a combination of anesthetic, deadens the eye basically.

So it makes it to wear temporarily, the patient won’t see anything, but they also can’t move their eye, because it, it renders the eye muscles. Um, uh, uh, it’s, it’s got some paralytic to it, so it’ll make it to where you can’t move your eye. You can’t see. It’ll give a little proptosis to the eye, bring the eye up forward.

So it’s a great way, uh, to, to do surgeries, uh, for like, um, a trainee if you’re an attending and you have a trainee that you’re coaching through the surgery. A block is a great way to do it because it controls all the, the unpredic unpredictable factors of the surgery. It keeps the patient from moving their eye, or if it’s a patient that you’re not sure they can stay still or the a topical anesthetic [00:20:00] just isn’t working for that patient or, or a variety of other reasons.

If you just want more control, maybe it’s a tough case and you wanna make sure you’re, you’re accounting for everything that could go wrong, including the patient moving suddenly than a retrobulbar block. Can help. Uh, I don’t really do, I haven’t done a block in years, um, but, uh, it’s still done pretty routinely, uh, around the country.

But what can happen is if you don’t get the needle in just the right place, sometimes you can actually send that needle through the inferior rectus muscle. You want to try to avoid that. You don’t want to hit a muscle with this because you could tear the muscle. You could cause strabismus. And so that’s another reason why someone might have double vision after cataract surgery.

That was the whole point telling you about retrobulbar blocks. And also because they’re a little bit scary. And so I wanted to present a little bit of a, a little bit of, uh, of, uh, of excitement to the podcast here. Okay. [00:21:00] So, um, Why was I even talking about this? Oh, double vision after cataract surgery. Yes.

So my patients, it’s like what? Getting on a tangent here. But it’s not really a tangent. So the patient, these are the things I’m thinking of. Obviously, I know almost immediately. Okay, this is not related to the cataract surgery. So what else could it be? Well, it could just be some unrelated thing, right?

It’s been three months. Other things can happen to the eye. So I’m like, all right, let’s get the patient in. So, I think it was the next day the patient came in and I, you know, took a look at everything. The lenses looked great. Everything looked fine. The patient was noticing. Here’s what she was noticing.

She’s having vertical double vision. She noticed that her eyes had been kind of red, a little bit more red than they have before. A little bit of irritation. And she feels like her eyes are like bulging out of her head. So, these are all interesting symptoms like by themselves. So I do my exam and I start with, uh, [00:22:00] checking motility.

Alright, so I’m looking at where the eyes are moving and they’re moving back and forth pretty well. They’re moving up. There’s full motility. But when I do cross cover testing, so I cover one eye and then move to the other eye, there’s a shift. And there’s very clearly a large, a rather large, hypertropia on the right eye.

So, the eye, that eye is kind of Displaced up compared to the other eye. And so it’s kind of, you know, going up and down like that. So it’s called she has vertical diplopia. So what could be causing that? Well, the first thing it’s probably the most common thing and the thing that I was thinking of immediately was like, okay could this be a Fourth nerve palsy, I think I’ve talked about in a previous episode, there’s different ways that the fourth nerve, the trochlear nerve, can be damaged, there’s uh, trauma, uh, no trauma, this, this, this patient, uh, could be a vascular disease like diabetes, high blood pressure, can cause temporary damage to that nerve and cause a vertical diplopia like this patient was [00:23:00] presenting with, but the patient didn’t have any vascular risk factors, totally healthy, very, very healthy patient.

And then I did some more testing with prisms and looking for a pattern that was consistent with a fourth nerve palsy. And I didn’t see it. I’m not going to bore you with what that pattern is. But the point is, it just, it doesn’t, there was no pattern to this double, to the misalignment to her eyes. There was no, I could not follow a pattern that would lead me to a specific cranial nerve, a specific muscle.

It was all over the place. She had double vision in almost every position of gaze and it changed depending on where she was looking. And I could not figure out. When you can’t figure out a pattern to double vision, it doesn’t look like a 6 nerve palsy, that would be more of a horizontal diplopia, alright, where one eye doesn’t move out.

4th nerve palsy, we talked about that. Vertical, but it’s very consistent [00:24:00] with, you know, whether or not they tilt their head and whether that makes it better or tilting it the other way makes it worse. There’s a very specific pattern to a 4th nerve palsy. That wasn’t it. Could it be a third nerve palsy?

Definitely didn’t look like a third nerve palsy. You can get a vertical diplopia with a third nerve palsy. There was no motility deficit to suggest that. There was no ptosis, droopy eyelid. There was no anisocoria. There wasn’t a dilated pupil. Did not at all look like a third nerve palsy. So when there’s no Pattern to the double vision.

There’s two things that should jump right to the top of your head and it did for me. One was Myasthenia Gravis. Myasthenia Gravis. Is a disease that affects the, the, the nerve terminals. Uh, you don’t get, uh, acetylcholine activating the muscles. And, and I, you know, I, I, I didn’t like look up the mechanism of action.

I think I might’ve gotten that wrong, but I do know [00:25:00] that it causes, it causes posis and it can cause what we call an incompetent diplopia diplopia that doesn’t follow any specific pattern. The other thing. The third thing that you think about is thyroid eye disease. Thyroid eye disease is also one of the more common causes of double vision out there, but it also can give a pattern that’s unpredictable, that doesn’t follow what the textbook says for cranial nerve palsies.

So at this point I’ve kind of ruled out a cranial nerve palsies and I’m thinking, okay, myasthenia versus thyroid, could it be one of those two things? And there’s also other like strange things, obviously like stroke is always on the differential, a brain tumor pressing on a nerve, that’s got, that’s, that’s, that’s something that you got to think about, that could be pressing either on, either an orbital tumor, pressing on an eye muscle, or um, or pressing on a, probably not a cranial nerve, because you’d have cranial nerve palsy.

So it’d be more like [00:26:00] a retro Retrobulbar orbital type tumor that could be causing problems there. Less likely. So I’m thinking myasthenia or a thyroid. And then I do the rest of my exam. So now I’ve gotten my, I’ve done my, my, my motility measurements. Now I’m, I’m looking at everything else. Pupils are good.

Eye pressure is good. Um, vision is normal. Uh, but then looking at the eyes. It does kind of appear to me like one eye is a little bit more proctotic. It’s pushed out a little bit more relative to the other eye. So I get out what’s called a Hertel exophthalmometer, which is a device that can help you measure the distance One eye is, compared to the other, out, away from the body, away from the face.

And yeah, there was a small amount of proptosis. One to two millimeters within the range of normal for just a person with no problems whatsoever. So, equivocal, right? That doesn’t really point me in one direction or [00:27:00] the other. And then I look at the eyelids. Could there be eyelid retraction? With thyroid eye disease, you get what’s called lateral flare of the eyelids.

Alright, because as that eye gets pushed forward from the thyroid eye disease, it causes you to have retraction of the upper eyelid. And it’s kind of like someone staring at you, like staring wild. Wide staring eyes. Alright, that’s kind of a thyroid look. And she did have a little bit of that. So, and then the redness.

That’s the other thing. So, the redness to the eyes. Uh, they didn’t look that red to me, but I can see, I can understand kind of what she was talking about. And with thyroid eye disease, you get Injection, you get redness kind of right over the muscle insertion on the eye because it’s an inflammatory disorder, thyroid eye disease.

So that’s where I’m like moving, I’m inching toward thyroid eye disease. All right, let’s take one more break, I’ll come back. And tell [00:28:00] you what I did.

All right. So I did some, for this patient, I did some, uh, some fatigability drills, just, uh, exam techniques, which are very fancy. I have her look up for like three minutes and see if she starts to get droopy. See if the eyelids start to get droopy. That’s, uh, like a fatigue test. There was no fatigability, so nothing that would suggest a myasthenia.

Also. No swallowing difficulties, no breathing difficulties, no unusual weakness of the shoulder girdle or hip girdle muscles, no swallowing problems, just nothing to suggest a myasthenia type picture. So that’s coming further down on my differential. So now I’m like, starting to really hone in on thyroid eye disease.

So, I’m thinking this might be the cause. So, the things that I decided to [00:29:00] order was, first of all, anytime you have double vision and someone’s over 60, you always have to think about giant cell arteritis. Talked about that a couple episodes ago, uh, and so I went ahead and sent some, uh, uh, inflammatory markers, ESR, CRP, platelet count, looking to see, make sure that wasn’t What was going on here?

Those all came back normal, by the way. And I also sent her with a instructions to have a thyroid test done. So a TSH, a T4 and, um, thyroid stimulating immunoglobulin. Thyroid. I sound so smart when I say thyroid stimulating immunoglobulin makes me sound like an internist. I love it. So anyway, I went send her to go get those done.

And before I send her away, though, for that visit, there’s two things with thyroid eye disease you gotta make sure, if you think that’s the diagnosis, number one is you gotta make sure that there’s no Optic [00:30:00] nerve dysfunction because what happens with thyroid eye disease is typically it’s like 90 percent of the time It’s a patient with Graves.

They have hyperthyroid and what will happen is the eye Muscles that surround the eye they get thick and fat They’re just big old muscles and what they can do is they can start to squeeze the optic nerve Because they get so big and that can cause vision loss and blindness That’s the first thing you’ve got to make sure is not going on is any kind of optic nerve compression from thyroid eye disease.

This patient was fine. No issues. 2015 vision. Doing great. The other thing is dry eye, so because those muscles around the eye with thyroid are getting so thick and fat it starts to push the eyeball forward. That proptosis that she was talking about, my eyes feel like they’re bulging out of my head. Well, it can bulge so much that it causes exposure of the cornea because the eyelids are starting to have trouble closing over the eye.

That [00:31:00] definitely wasn’t happening in her case because she didn’t have that much proptosis. There’s no dry eye whatsoever. So I ruled out. All the big bad things. So I sent her to the lab, get the GCA, the giant cell arteritis labs, the thyroid labs, and then I also ordered an MRI, uh, just because I wasn’t totally sure, uh, that this couldn’t be some kind of a tumor or something.

Maybe I, my measurements weren’t that good. Could it be, uh, like a, some kind of third nerve, I guess it’s possible. I just, I didn’t feel comfortable with the whole picture to, to, to. To absolutely say that there’s no intracranial process going on. So I went ahead and ordered the MRI. Um, would a neuro ophthalmologist have ordered an MRI?

Maybe not, but I am not a neuro ophthalmologist. And so I did what I thought was best for the patient in trying to [00:32:00] narrow in on the diagnosis. Trying to address the big serious things. So, um, so far, the labs have come back. So, MRI is scheduled for a couple weeks, which we may not end up doing. But the lab tests showed really high thyroid stimulating immunoglobulin, as well as, uh, High thyroid hormone and low TSH.

Pretty much classic Graves disease. So I’m thinking that we caught this patient at the very, very earliest stage of thyroid eye disease before it really starts to ramp up. There’s this active phase with thyroid eye disease that can last for a couple of years and it can be brutal. It can be terrible. It can cause vision loss.

So we’re getting her right at the beginning, which is very exciting. Um, exciting because we can fix it, right? We, we have treatments for it. So [00:33:00] there’s obviously thyroid or, um, um, uh, steroid treatment. That’s what’s, what people have done for like, like high dose steroids to help control the inflammation.

But now there’s also infusion of this medication called te. Um, it’s Tza. Tetum, I think is what it is. I, I forgot the, the little long name, the name. I’m supposed to, the generic name. That’s what I’m supposed to call things. Tza is the brand name. But anyway, uh, the, the data around and the, the, the before and after pictures a patient with, with patients with thyroid eye disease who have tep eza is, is.

Stunning. And so, uh, the problem is, obviously, like every amazing medication that comes out that treats relatively uncommon diseases, crazy expensive, right? So, um, there’s a whole authorization process that has to occur, and by the way, this is not an area that I am particularly well versed in as [00:34:00] far as like all the latest research and everything.

Fortunately, in my practice, I have a wonderful partner who is an oculoplastics trained ophthalmologist. And so, um, I’m setting this patient up to see him on Friday and, uh, he’s going to take a look and see if actually we’re holding off on imaging until he sees her to see, yeah, this is like a hundred percent.

Graves disease, that’s what’s going on, no need for an MRI. Or maybe he might want to change it to a CT scan to look at the muscle caliber because I think that’s probably a better option for imaging if you’re looking at thyroid eye disease. If you’re looking at other things inside the brain, CT is not as good as MRI.

But I’m going to wait until she sees my partner before we decide on, on, um, where to go with imaging. Sometimes even within ophthalmology, things are multidisciplinary. People, sometimes people are shocked. How many [00:35:00] different types of ophthalmologists are there? There’s like 10, 10, 10 of us, 10, 10, 10 versions of us, I should say.

There’s plastics, there’s cornea, there’s retina, there’s anterior segment cataract, there’s refractive, there’s oculoplastics, there’s pediatrics, there’s neuro ophthalmology, there’s ophthalmic genetics, there’s ophthalmic pathology, there’s uveitis. I think I got all of them. There’s a lot. It’s kind of ridiculous because the eye is only two and a half centimeters long.

If that. Actually, that’s a pretty long I, more like 22. Anyway. So I’ll give an update, but it’s really, it’s like 90, 98 percent sure that that’s what’s going on with this patient. And we’re going to get her all fixed up and it’s going to be great. She’s going to do well. We’re early in that process and hopefully we can stop it, slow it down and keep the more serious treatment.

Adverse events that happen with Graves disease from [00:36:00] occurring. So, uh, that’s our episode. Thank you all. Uh, I, I hope you enjoyed this somewhat tiny little mystery case, just an interesting, uh, case that came up. And, uh, I’m happy to, to give you more as they come into my life. Uh, if you have any interesting eyeball things you want to discuss, any patients or not, if you are a patient, you want to tell me about your eye thing, I’d be more than happy to hear it, um, or any other, um, uh, healthcare or eyeball related.

I try to keep it as close to eyeball adjacent as I can whenever we talk about things, including how dry Denver is because my eyes were having trouble. I was, I was, I was dumping those artificial tears on my face, I’ll tell you that. So, uh, but that’s it. That’s all for Knock Knock I for today. Uh, thanks to my producers, Aron Korney, Rob Goldman, and Shahnti Brooke, editor engineers, Jason Portizo, our music is by Omer Ben Zvi.

I appreciate [00:37:00] you all. Thank you for joining me. Knock, knock, hi, and knock, knock, hi is a human content production. We’ll see you next time.

Goodbye.