I don't have any financial disclosures give you an outline. First, this will be a back to basics kind of talk. Will start talking about the retro bulb, our anatomy, uh, and then go through a typical visit and look at some important points history. And what are red flags to to shift out of mode to look for a different kind of optic neuropathy. I missed it. Elements of the examination talk about about visual field defects. Review the classic things. Uh huh. My general radiographic imaging and laboratory evaluation protocols when I don't think that, um, it's just called coma. And there's some other potential for optic neuropathy and talk about it. The case of the end. Going back to basics. Of course, we have right left segregation throughout the visual system that that segregation changes at the chi as, um, all the nasal fibers cross over to the other side. You know, the ones, of course, representing the temporal field. And then from there on, everything is represented on the opposite side of the brain, depending on which field it came from. Part of differentiating these, uh, effects comes down to the fact that the optic nerve at the beginning reflects the rental nerve fiber layer of the retina, and then it has to segregate to change and let the fibers cross over the other side at the chasm. Basically, we know the classic progression of nail step, argument, altitude and defects that we see with glaucoma resulting from superior, inferior problems. The optic nerve these fibers have moved over covered the temporal peripherally nerve by the time we're getting for the Kiowas. Also, the central fibers have moved into the center part of the nerve. The central field fibers part of the Earth. Really, throughout these encounters, unlike a lot of, um, economic visits when it's really a recognition problem, history starts to become important, and it's mainly that something stands out in the history is very different. Um, my basic classification optics were up. They start age, whether the patients younger, elderly, of course, most our elderly career types of the young, uh, as a consequence, many young patients a little more worrisome. What are the patients comorbidities. Do they have any known? Uh huh. Cancers that have known vascular pathetic risk factors, of course, is a unilateral bilateral. Anytime that there's a symmetry, it's more worrisome, painful or painless? Uh, computer progressive. Anything that has a high acuity to the presentation is more worrisome. Presentation, really to focus on the bad ones here. Uh, young patients. It's always concerning anything that's highly asymmetric and or even unilateral. I worry a lot more than it stands out as something different. Pain is basically a red sign red flag type sign in any acute presentations. Concerns examination this case largely as, uh, confirmatory and starting to get a hint about where to look for further information from the real things. Acuity is important. Any object or empathy that starts to involve acuity? Um, it's very bad prognosis. It's not perfect. But seeing whether the person also has color vision loss, either subjectively or it's a hard place or many other things can be outdrew. I think you're up with These have a high propensity to take color vision, mhm, well written and other problems relatively later in the progression people exam is important. Um, really, for practical ophthalmology clinic, I think encouraging technicians at any time that someone seems vision is much worse than what I really complain about a problem in when I have your technicians protocol, be stopped and then check with you and see whether you think there's any reason to go checking people's yourself. Um, contract, your pressure forced if it's high, already leading to a typical company, normal or low, either typical or normal or one of these other problems. And then visual fields mentioned before looking for anything that doesn't fit the typical superior, inferior damage the optic nerve. And that the fund is looking specifically to see what others progressive company that's vertical before horizontal versus some other pattern processing the optic disc. Also expect the basic, really high power lens, the slit lamp. I think it's the best way to get a very clear, detailed view. Looking at the optic disc itself, it's really important to correlate whatever field findings are there, uh, the abnormalities that a person has in their field or in their central vision that if the person has easily dominant loss, that we really look for superior, inferior damage to the nerve, looking for temporal damage to the nerve, correlating with central laws good and then the unique pattern. When someone has temporal visual field loss of looking for band or bowtie atrophy or band or bowtie cup. Yeah, we were very much of this horizontal cupping or horizontal atrophy of the nerve. It's a strong sign that there's some other process underway. Also corresponding to look for central defects in the vision or temporal field. Real defense? Uh huh. Insular studies can be, of course, very helpful for two main main ones. Being the most helpful fund is photography. Just a document where things are if you think something is normal, being able to look back and really make a good comparison beyond just what we don't our examinations also ct uh, the retinal nerve fiber layer common protocol CT, also very useful for other optical properties. And getting back to these questions about which segments of the optic nerves are affected, whether there's a symmetry whether they correlate individual fields, there's an old diagram of the classic problems going back to the visual system as we get near the chi as, um, with Tennessee temporal rather than nasal based visual field defects that progress, uh, the guy hasn't really starting to affect both sides. Beyond the chasm, uh, effects become hm on Imus Variations through C D E. F G H. I on the rest of the skin that really just tell you maybe where it is on the pathway, the central nervous system. The main thing is anonymous, and effects are beyond the chi as, um and certainly have some neurological components, the ones that the guy has A more important, it can be a little tricky. Has more visual field defects. Bring out a little more detail. We always think about the classic when, uh, my temporal him anoxia. Of course, often this can start in a more subtle way and pituitary being most common compression from a low, uh, instant use defects that are denser, superior early from may be hard to judge on pattern deviation, depending on how much the problem is progressed. But there are other kinds of skin Thomas to at least, um, it was a more difficult situation. The junctions. What I hear the right eye has typical kind of liberal loss, but the left I just looks, um, bad. Generally depressed there, Uh, and then there's the tricky When the junction als how much a queer it's possible to get one. I that's quite badly affected, while the other eye doesn't even have the temporal field effect. Yet if no reason is either too much toward the front of the Casa very lateral. I think the Cardizem and, of course, monuments in Ethiopia classic for everything beyond the chasm. Get some clue about these really rare lesions that affect the optic track. There's a Contra lateral, relatively fair people. Everything because those defects, because more of the temporal visual field nasal fibers across you actually get a contra lateral visual field defect on the field with a temporal field. I, with the temporal field loss, should have a R a p d if it's in the truck. My general protocol for radiographic and laboratory evaluation starts with the MRI. CT certainly sometimes can play a role if you're really suspicious, an orbital mass or an orbital based process. But in general uh, MRI superior, it's probably superior for the orbits as well, but it works as a more time consuming, more difficult for patients. But really, I think too many parts here, Maria the orbits, looking along the course, the optic nerves. These studies also be very good use of the high as, um no. Using contrast is helpful to account any subtle infiltrating or inflammatory diseases along the optic nerves. I have a protocol that I send all my patients with really ask explicitly for actual images and colonial images. Mhm. One can miss something that the other can pick up and fat suppression really important in the orbit, where there's such a bright signal from the orbital fat to look for his subtle problems to the brain. Almost always also have a company. Studies really, because looking for any other kind of process elsewhere in the brain is ahead for what's happened in the nerves. Laboratory studies. My routine is to look targeted at reversible ideologies. B 12 and four late often advise women to this, um, and then infectious things that can all over the body produces all kinds of problems. Syphilis and tuberculosis is not great for sarcoidosis, but at least something that raise or lower suspicion. Additional tests. S, R N, C R p. If the patient is elderly, the patient has the pain. The patient had cirrhosis few guys ahead of the vision loss really important to either raise or lower suspicion. For giants arthritis, Simon often checked, especially if the person has history of gastric problems. Adriatic surgery, heavy alcohol use and then sometimes genetics looking for labour Hereditary after the dominant optic catcher Last, uh, third or so of the presentation about a case came to me and follow up a few weeks ago, after problems at the beginning of the year actually came into our one of our comprehensive ophthalmologist complaining of eye pain. It was a 52 year old man that a reported history of amblyopia, which always raises some suspicion. Also interview, um, cardiovascular disease, presented with my pain and eight years of decreased vision in the left eye, reportedly and complained about this problem eight years prior. Gone on an icy division, no abnormality in the eye and basically was, um, halted at any further evaluation until until this year went through the basic presentation, the vision clearly decreased on the right. Interesting problem here on the outside. Uh, there wasn't documented confrontational visual field testing and burden, but but one work checking, really. Technician can just make sure that they're really doing it. Split with him. Mm, Basically just remarkable for a little bit of both me and gland dysfunction and some cataract that really weren't in line with the degree of visual impairment. Linda. The funnest examination. No, The main thing that stood out here, of course, is that this person is company company. That's worse than the left eye. And there's already some question of whether there's power in the left eye, maybe some changes in the vessels as well. Um, important thing not all companies is glaucoma is coming. It's a curious thing. Sometimes the nerve just turns pale, but other times the nerve becomes corrupted. Local coma clearly favors cupping some of the different opting Robert these can really each of either of these patterns the assessment, the note. Then we ordered the copy symmetry, maybe possible powered, um, question whether the person had some vascular event in the past, explain the subtle findings in the vasculature and then came to a discussion of risk. A vision loss with glaucoma classified as a glaucoma suspect during this visit. Certainly important address. But what about these other problems and a critical decision? And the visit that really help bring this person back on track and proper care is that the ophthalmologist recognized that there was a problem in this level of incongruity with a typical Dhlakama suspect examination and had the patient come back for the testing, uh, to visit. Good question about the timing in a patient who has had symptoms for years and years, I think follow up of within a few weeks is a reasonable choice. So I brought him back sometime in the next month or so to check those colored plates. Given us that central vision, uh, not to dilate the patient and to check the people's, uh, imagery just to look at whether these copies are accurate or not, and then feel the no c t the album of the year. Two weeks later, the patient came back. The things that stood out on this repeat examination. The color vision is clearly down on the left. I still preserved in the right eye, and this time the physician checked and we found an RPG on the left side. There's a Humphrey visual field. I talked to you about some non classic matters, but here is a closet one, uh, my temporal human opiate. And we do see indeed that the left hand is a little more affected and really has come over and started doing things. The central vision. So somewhere between right and Berlin that really would start to classify. This is one of these functions. Could your NFL you can see even though just the great scale picture here, you can see the profile and is very copped it. So come that it's hard to tell truly whether it's for vertical or horizontal and also very thin here on the bottom. The numbers bringing up clearly are very low as well in the mid sixties for both eyes. So what to do? I was contacted. I think about this patient at this point, the question of such a long case along progression of symptoms, whether it would pursue emergency room or not, decided to go forward, the patient had imaging. Um, even if you don't really look at radiographs frequently, this one stands out. There's this huge mass originating in the cellar, extending superior early and really making it impossible to find. The guy has some of the optic nerves. At this point. Researcher was consulted, patient underwent transplant, transcendental perception and really stabilization of vision. Really. The points looking for things that stand out give us a great opportunity to save. These were patients who have something different in our typical optical properties. I hope we're giving you a few clues on critical signs and make them stand out. Thank you.