Knock Knock Eye: Stop Putting That in Your Eye, Please
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Hi, everybody. Welcome to Knock Knock Eye with me, your host, Dr. Glockenflecken, your one-stop shop for all things eyeballs and slowly over time, just healthcare in general. Thank you for joining me. So

First of all, I've just got to start this off by giving, addressing some of the feedback that I've received on the most recent episode of Knock Knock Eye that was posted as of this recording, which was the times when I talked, when the episode where I talked about all the times that I have cried.

Actually, it wasn't all the times I've cried. Just the ones that stood out there. Thinking back, I was like, man, my medical career, I've been in practice for almost eight years now. Then you add on, you know, like eight years of training and education before that. So in 16 years, I have cried more than four times.

For sure. But those are the ones that stuck out that really resonated with me. And the feedback, the support, not that I wasn't wanting, I didn't need people to make me feel better because these things happened a long time ago. They still stick with me. But really the point of it was to just, I don't know, I think they're interesting stories, but also just to show people like it's okay.

Like we're doctors are like normal people and have things that make them sad. And it's okay to, to show that. Uh, but the, the, the reaction was really cool just across social media. Cause these episodes, you know, we, we show clips of them all over the place.

And, uh, just people talking about their own experiences and things that have made them cry. Some very, very sad, some extremely funny, uh, in their own way. And it's just, it, it, oh, it just really has, I think helped shine a light on the humanity of, of being a physician.

And in my opinion, as a big thing that me and my wife do, Kristen, lady Glock and Plekken is, is that's what we want to do. That's part of our platform. The reason, like part of the reason we do a lot of this stuff and talk about our own health story and, and everything is, is because we want to show that side of being a physician.

And so, um, uh, so thank you everybody for, for, for your support and, and for, uh, you know, telling your stories, storytelling, we need more of that. So, um, man, it's just like, let's just be okay with crying on the job. Like, it's okay. Like, you know, it's, it's, it's normal. It's totally normal. Uh, and it just, we're all going to be crying all over the place. Sometimes you have to.

Like healthcare, I don't know if you've realized, we've got some problems in our healthcare system these days. And some of them are very sad. And so if you've got to cry, let it out. Let it out. People will support you because you know what? They've also cried. And then it was just a big train of people just supporting each other. And we're all, before you know it, the whole office, the whole hospital is just having a great big cry together. See, that's what I would love to see. Instead of pizza Fridays, let's have crying Thursdays.

Why not? You know, like, let's just, let's be okay with this. It's not unprofessional. Oh man. One of the things I hate the most is weaponizing the, the idea of professionalism against people like that is unprofessional. Like, like sure. There are things that are legit unprofessional out there. You can't like take your clothes off and streak through the hospital. Like that is unprofessional as an employee.

As someone who works really anywhere, that's never okay. But it's taken to such an extreme where people like myself, whenever I started as Glock and Plug, I was like, I got to be anonymous because I can't tell jokes. Like, come on, what is that? That's awful. And it's changing, though. It's changing. And what helps change it is putting ourselves out there, I think. Seeing a physician talk about the times he was crying.

or just telling jokes and all the things that everybody else does too. It's just, it's a, I think it helps. It helps move the needle, change the perception of professionalism to what it should be, which is like, you know,

you know be respectful of of others be respectful of patients uh do the your job well um show up on time dress like you're supposed to dress uh wash yourself you know this is what professionalism professionalism is not like don't talk about your emotions but somehow

That's what medicine for a long time just morphed into. That's just what it was. It's like that was professional. Like be a robot. I don't want any of my doctors to be robots. And I've had a lot of doctors. I've had some good ones. I've had some not so good ones. And the good ones, they're real. They're real with me. You know? That's what I like. I like that.

So anyway, thanks everybody. Um, all right. So for today, I've got a hodgepodge of little things to discuss, talk about a couple of really cool. I related things though. So, uh, we're going to get to the eyeball stuff, uh, which is the meat of the episode after our first break here in a few minutes. Um, today, uh,

was an interesting day. So I had a patient, a bit of a pretty easy mystery to solve, but it was a new patient that came in. It was a mystery nonetheless. And so I'll take you through my mystery patient of the day. And also I saved someone's life. No, not really. But in an ophthalmology way, I saved them by confiscated eye drops. I confiscated two bottles of eye drops today.

I'm so proud of myself. I confiscated a bottle of clear eyes. No good. Just as bad as Visine. All right. Visine gets the brunt of my ire and ridicule, but clear eyes is right up there. Roto is another one. Don't do the Roto. I know it feels like menthol. It feels like this weird cooling sensation. That's just what it feels like when a little bit of your eyeball dies. That's it.

And, uh, but the other thing I, so I, I confiscated and I have a drawer in my office at work, uh, of all the confiscated eye drops. That's it's growing. It's a growing pile over the last eight years. Uh, and in addition to clear eyes, simulation simulation is, um, it's less, uh, actually, you know, in a way I think it's more nefarious. It's, it's more, the homeopathic drops are like, in my opinion, uh,

Maybe even worse than like Visine because Visine, it doesn't try to lie about what it does. Like it gets the red out and does it? Oh, sure. It does. Yes. It will make your eyes less red until it wears off and then it makes it. And then they become more red than they ever were before.

And then you got to use more Visine. You got to use more clear eyes to get rid of that redness. Oh, well, then it wears off and it comes back even more red than before. And then you got to use more Visine. And before you know it, you're buying another bottle of Visine and you're hooked on the Visine. This, I told myself I wasn't going to turn this into a Visine rant, but here we are. Similacin and other homeopathic brands of eye products, they're more nefarious because they lie.

about what they do. They claim to treat all these different diseases, conjunctivitis and styes and all these things, and it's just tap water. All the list of these homeopathic ingredients that they put on the back of the bottle, they're in such low concentrations that it doesn't, even if it did have some kind of effect on the eye,

it's in such low concentrations that it won't do anything. You won't notice any kind of effect. Not to mention there are no studies that back up any of the eye of newt or whatever the hell they put in these bottles that it does anything for any kind of eye disease. But it's so incredibly diluted that you're just putting tap water in your eye. So that, in my opinion, is like

kind of worse from just like a sketchy marketing and like getting people to kind of scare tactics and, and preying on, on people's, you know, uh, fears of chemicals that, that social media has tried to, to foist upon us. So anyway, stay late, stay away from simulation. That's like the big one, but you know, it's bad stuff out there, bad stuff. So anyway,

saved some lives today. Uh, this is an exciting time tomorrow. I am on my way to my favorite country on earth, Australia. I get to go back to Australia. I'm so excited.

I am speaking to the Royal College of, of, of, of surgeons, the surgeons of Australia, like the big surgery conference of surgeons in Australia. I get to experience, I've never met the surgeon. So in Australia, I've been twice before the last two years, uh, people in Australia keep inviting me back, which is awesome. I love it. Um, and, and, uh, the first time I went, I spoke to the infectious disease doctors, which is great.

And the second time I went was the anesthetists. Also fun. Awesome. They were exactly as you would expect from my content. A lot of them had shower caps on and some of them brought their own blue drapes to the event. It was great. Well, this time it's the surgeons. I get to find out if Australian surgeons are like us.

all the other surgeons. So, so if, if surgeons are the same throughout the world, so we'll, we'll find out. Uh, so I'm excited though. It's, it's a long trip, but, uh, what a wonderful place it really is. It's great. I'm going to be in Sydney for a whole week. This time I'm going by myself. Uh, I brought the family, um, the first time, but this time by myself. So I'm going to do some like

Grown up things like, um, go eat at restaurants that, that have something more than like chicken strips and pizza. I might try to actually go. I'm the only one in my family that has like a, an interest in eating seafood and it's Sydney. It's like right on the water. So, so I'm going to, I'm going to, I'm going to take this opportunity when I'm by myself to go to restaurants that like, there's no way in hell that

I could ever convince anybody in my family to go to. So I'm excited about the Asian foods. Another one, like, you know, noodle places. I don't know. There's just like, there's so many different cultures in Sydney. It's such a, as it's so multicultural, like I gotta take it. I'm going to be eating a lot. I'm going to eat good. I'll be good in Australia.

Uh, so I probably put something out, like I'll post on social media to try to get some recommendations for, for restaurants. Um, before I go, by the time you see this or, uh, uh, listen to this, I'll probably be back. But anyway, excited about that. And as part of that trip to Australia, I'm getting two talks. One is going to be my, um, uh,

My story, talking about the cancer diagnoses, the cardiac arrest, which, by the way, the five-year anniversary of my cardiac arrest is coming up. So next episode you hear, I might actually just spend the whole episode talking about that event in my life. And we're also going to do a similar thing over on Knock Knock.

Knock, knock. Hi. We won't go into as much detail, I think on that one, but we'll, we'll have a little thing on that one as well. But this one I'll probably do my, just by myself, talk about my personal experience. And, and the other talk I'm giving in Australia is called Dr. Glock and Fleckins, incredibly uplifting guide to us healthcare. This is great. So the Australia, they, the, the, the people that run in the conference, they, we had a meeting and they're like, listen,

Here's a, like, there are some things happening in Australia that are basically like trying to increase the amount of privatization in the healthcare system. And, um, of course, like I was like, oh, I strongly suggest that you don't do that because look at where it's gotten us. And so part of what they want to do is, Hey, can you just like

They wanted me to come in and be like, can you just tell us about U.S. healthcare?

And, and I am more than happy to oblige. I, so I put, I'm, I'm putting together a talk, um, all about us healthcare, uh, loosely based on my 30 days of healthcare series. I'm just going to, I'm just going to go through everything. It's like, what is a copayment? What is a co-insurance? Uh, we're going to talk about pharmacy benefit managers, private equity, by the way, another big hospital in, um, I think in the, I want to say Delaware, uh,

uh, that serves a lot of rural areas, uh, got shut down because it was bought by private equity. They realized it wasn't profitable enough and then it closed private equity strikes again. All right. So yeah, all this stuff, I'm going to, I'm going to tell the Australians everything. And so hopefully it can influence their, or maybe temper their desire to move, uh, toward more privatization than they already have.

Which honestly, I don't get. They got a good system going on there. They really do. They have a very robust, well-funded public option like Medicare, Medicaid, except keyword well-funded. Like they're all supportive of this thing rather than trying to gut it every single chance they get.

which is obviously what we do right so uh key well funded but they also have a private option so people who are willing and able to pay a certain amount of money for their health care they they are have the ability and it sounds like this two-tiered system and um that would be the case i mean you

Your concern is that like the public option is just like crappy healthcare, you know, but because it's, it's much better funded by the government that that does raise the standard of that public option.

And I think that's actually a really good way to do it because it decompresses the public option, right? It makes it to where it's accessible. Not only does it need to be like affordable or free for people in some cases, but you want it to be accessible, which is a problem that some countries like Canada has, right? I mean, we have that problem too, but it's just hard to access the healthcare system.

So I don't know. I feel like they've got a good balance going on in Australia. I'm trying to learn a little bit more about it. Maybe I will during this conference, and I'll report back. So I'm excited to talk about the incredibly uplifting guide to U.S. healthcare in Australia. All right, let's take a break. We'll come back with eyeball stuff. ♪

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okay first thing i want to i want to talk about is um something that came that i that someone sent me one of our producers actually sent it to me shout out aaron um on instagram from this guy who had a cancer of the eye i'm not sure what he had it might have been a melanoma um but uh he lost his eye and he's a he's a he's a machinist

He's like a kind of an engineering type. His name is Brian Stanley. So on Instagram, BS machinist. And he did something that is probably the coolest thing that I've ever seen someone do who has lost an eye. His prosthesis, he like engineered it to have like a light. It's like a flashlight.

Oh, by the way, I didn't mention when I talk about Australia, that's the reason I'm wearing my United healthcare, my no United healthcare scrub cap. For those of you watching on YouTube, uh, I think I'm going to bring this with me. I'm going to, I'm going to, I'm going to wear it to try to be one with the surgeons, uh, during my talk. Anyway, Brian Stanley, Instagram, um, this guy, amazing, amazing. So his prosthetic has the brightest flashlight. You can, uh, it like it say, say you wake up in the middle of the night.

And like, you need to, um, you know, go to the bathroom, but the lights are off and you don't want to try to find the light switch. It just, he just turns his, turns his eye on. It's amazing. It's like the Terminator. It's like the simultaneously scariest and most incredible, awesome thing I've ever seen in my life. Like, can you imagine seeing that talk about Halloween? Oh man, that would be like haunted house. You come across a Brian with his, with his, uh, with his, his, uh,

You can make it like a black light. He has all these things. You should go check him out on Instagram, Brian Stanley, machinist. Fantastic. I love it when people get creative with their prosthetics.

And you can like, there's a, uh, I've met people in Oregon that, that do incredible work and they're like bejeweled and you can really get individual and, and show off your personality with your prosthetic. I love it. You know, as opposed to like, and it's fine to have like, just to have a prosthetic that you try to make it match the other eye. Some people want it, want it that way. But then there's also some people that just like being

um, kind of wild with it and, and have it really reflect, um, their personality. And I think that's cool too. So I, I encourage anybody, everybody to, to, without an eye to experiment with their prosthetic. Um, as long as you're doing it safely, uh, with people who know what they're doing in terms of making prosthetics.

So real quick, actually, since we're talking about prosthetics, um, I, yeah, I think some of these talk, you might hear me. If you've been listening to knock, knock. I now for God, the year and a half we've been doing this. I don't know if it's been that long. It's been probably at least a year. Um,

You might hear me repeat some topics. That's okay. Like we could always hear it. How often do you just learn something and hear about something and you just never forget it ever again? Obviously, probably all the time when you're hearing me talk. But in reality, you probably need to hear it a few more times. So prosthetics, let's talk about prosthetic eyes. A lot of people think a prosthetic eye is like a full-sized eyeball that you're putting in there. But that's actually not the case.

There's two components to a quote-unquote prosthetic. One is the globe, the meat of the prosthetic. That's a weird way to describe it, but you know what I'm saying. The majority of the volume of an eye that you're trying to replace is not actually ever seen by anybody.

So when you take out an eyeball, you're removing it from the orbit. All right, that's a space, a physical space your eye is sitting in. It's protected on all sides by bones. And so you take that out, it leaves the space unoccupied.

And if you don't do anything with that space, you know, it's going to fill in with scar tissue, with fluid. But more importantly, you're not going to be, if you don't fill that space, it's going to look a little bit more abnormal in terms of the shape. You won't be able to actually have a normal appearing prosthetic or any kind of prosthetic because you need the support for the prosthetic.

You need the support of a large, a globe, an actual sphere behind the prosthetic. All right, so basically you take the eyeball out, you have the space deep in the orbit that the eyeball is supposed to be in. And so the first thing you do is you actually put a replacement sphere into that space and you suture the conjunctiva, the skin of the eye,

that's kind of you you try to preserve as much of that as you can but so basically you keep that part and you suture it over that sphere that's sitting there back in the orbit you let that heal and then that's when you get the prosthetic that goes on top of that all right so the the prosthetic that you see for from people that that have one of these it's not a circle it's what's called a shell

It's literally like a shell of a peanut or a pistachio shell. It's curved, but it's got a... Basically, you can imagine fitting a marble in the shell. That's kind of what it's like. So you fit the shell, which is the actual physical prosthetic that people see, and that sits right on top of that sphere.

um and underneath the lids and so it by doing that you can make it look like a normal eye if you want to so it's really cool honestly and uh so i have people that come in they i see their prosthetic sometimes they have some problems with it it doesn't fit quite right so then i send them back over to the ocularist who's uh can polish the the the things and as a whole um uh it's a whole

Whole thing. So it's not just like, even if you have lost an eye and you have a prosthetic, there's still things we need to monitor for that, um, with that thing. But anyway, it's, it's really awesome. It's really cool that we have that technology. We have that ability to give people the chance to, to be themselves and to feel whole, um, in whatever way they want with their ocular prosthetic.

um and man i've seen some cool ones you know and people lose their eyes in all different ways too you know i'd say as far as like reasons someone would lose an eye obviously trauma is a big one so um trauma um cancer you have to take it out uh there's uh also like so you can get severe glaucoma chemical burns um reasons basically what would happen is

you end up with an eye that is chronically painful and blind. A very common reason to take an eye out is because someone has what we call a blind, painful eye. It's an eye that will not see anymore. No light perception. And also it's causing them pain because when you've had something severe, some kind of severe disease process to the eye,

It can become chronically painful. The source of that discomfort is not totally clear, but at that point, it's like, well, let's try to relieve that person's pain by taking the eye out. And it works, right? It helps them. And then we can give them something that looks more natural for them if they want.

Um, so kind of interesting stuff, the, the whole shout out to my oculoplastics colleagues, cause I have done an enucleation before. It's not, it's, it might sound easy to just kind of pop the eye out, but it's, it's not quite like that. Uh, it's, it's, it is kind of a fun surgery to do, to be honest. Um, because you, you get a really good, uh,

you get to see all of the anatomy of the eye, both behind the eye, which you don't normally see the orbit, all that, all that space. Um, and, uh, it does really does help people out quite a bit. Uh, oculoplastics, you know, they do a fellowship after residency to be, to be able to specialize in that. We have someone in our practice that does that. All right, let's take one more break and we'll come back with my mystery patient. Yeah.

Hey, Kristen. Yeah. I've been, you know, grossing you out about these Demodex mites, although I'm not sure why they look like adorable. Well, these are cute, but it's the real ones that kind of freak me out a little bit. Yeah, but I have some new facts to share with you about Demodex. Oh, great. All right. These mites have likely lived with us for millions of years. Oh.

Yeah. Does that make you feel better? No. Like they're passed down through close contact, especially between mothers and babies. Oh, wow. Such a special gift for our daughters. They're born, they live, they crawl around, and then they die on your eyelids and in your lash follicles. Their entire life cycle lasts about two to three weeks, all spent on your eyelids. Well, thank you for that. This isn't helping, is it? No. How do I get rid of them? Well, it's

It's fun to gross you out, but we do have all of these. It's really common, but there is a prescription I drop to help with these now. Okay. That probably excites you. That makes me feel better. Any way to get rid of them, right? That's right. All right. Sign me up. Visit Mites Love Lids to learn more about demodex blepharitis, which is the disease that these little guys cause. Sure. Again, that's M-I-T-E-S Lids.

Love Lids, L-O-V-E-L-I-D-S.com to learn more about Demodex and Demodex Blufferitis and how you can get rid of it. All right, here we go. So last week I talked about on Knock Knock Eye about, you know, a TikTok I saw where people were blaming doctors for being so late in clinic. And, you know, we'd go back and listen to that. And it's a bit of a nuanced discussion.

Um, but in, in doing and having that conversation, I talked about, you know, all the, the different reasons why a doctor can come back, all the, the potential chaos that can occur in a clinic resulting in a doctor not calling you back for 45 minutes after your appointment time, which is not ideal. We don't want to do that last thing we want. Uh, but one of those things happened to me today. Now, fortunately, uh,

Um, I had a little bit of a lighter schedule, so we didn't get really too far behind, but, um, this was a patient that came in with, um, I think I've mentioned this before, all of us in our practice, uh, you know, as, as kind of a benefit to the community, we leave a spot open in the morning, a spot open in the afternoon on our schedule that will not be filled until the day of that clinic.

And that gives people a chance if they call in, they have a serious problem going on, then we can more easily fit them in that day. And usually those spots do get filled up. Well, today, this morning, the spot was filled by a patient who had worsening ptosis. Ptosis is a droopy eyelid. Now, a droopy eyelid. So I'm the ophthalmologist. And as soon as I saw a droopy eyelid on the schedule,

What did I, what was like my first thought? My first thought was, oh man, I hope we have some time because this could be something that can take a while. All right. So at first I thought, okay, well, how are we doing in clinic? I was like, is this, do we need to let patients know that this might take a while? How are we doing? And we were doing okay. We were doing okay. And so, um, uh, you know, made sure the staff was aware. We got the same. This is what we want to check is what we want to do.

And then I was thinking, okay, what could this possibly be? This is before the patient even got there, right? What could this possibly be? So droopy eyelid, like new onset droopy eyelid. So first thing, first and foremost, is this a third nerve palsy? Like that's the thing, potentially life-threatening, something you don't want to miss that if that's what it turns out to be, patients whisked off directly to the hospital, all right, for the emergency department for imaging.

And then treatment if necessary. So third nerve palsy, Horner syndrome, that's something that damages the sympathetic chain. There's a whole host of different things that can cause a Horner syndrome, but you get a droopy eyelid, what we call ptosis again, also meiosis, which is a constricted pupil.

And anhydrosis, which is not something I've ever, that's like lack of, lack of a sweating on one side of your face, which I've never diagnosed. I'm not sure how you would do that. So really it's the, it's the smaller pupil and a droopy eyelid that makes you think Horner syndrome. So those are two things. The other thing is could just be a, um, it, it could be sudden realization that they have a droopy eyelid. Maybe someone told them, Hey, your eyelids droopy.

Have you ever checked that out? It's amazing. People sometimes don't look at themselves very often, and maybe they've had a droopy eyelid for a while. So it could just be like age-related ptosis. You have a couple of muscles that are responsible for raising up your eyelid, and one of those muscles, over time, the insertion of that muscle can degenerate.

and so you get what's called a high eyelid crease so you can look at your eyelid crease that you have if that eyelid crease starts elevating up and up and higher that means that your that muscle is becoming weaker one of the muscles called the levator that elevates your eyelid and so if that muscle is weakened which happens naturally over time it causes a gradual ptosis

But this patient was like 50. And so I was like, oh, we don't usually see age-related ptosis that soon. It's possible. But anyway, that's on the differential as well. Another thing would be myasthenia gravis.

which is a disease that affects the nerve terminals and the acetylcholine receptors. And basically, you just get this weakness, this muscle dysfunction weakness throughout the body. But also, you can just get ocular myasthenia, where the eye muscles don't work as well.

So you get dysfunction of the muscles of the eye, including the eye muscles that affect eye movement. So you end up with like strabismus, double vision and droopy eyelids. So that's probably the, those are, those are all like the big ones. All right. So that's what I'm thinking. That's, and it, you know, two seconds, I'm just thinking through all these things. So patient finally comes in and do the evaluation.

I go in, um, vision's okay. All right. Um, so I ask, I look at it. Definitely there's ptosis there. All right. The page, the left eyelid is like bisecting the pupil. Like it should be way above the pupil, but it's like right across the pupil. And so, um, uh,

And so I check motility because what I want to know, is there double vision? Because double vision goes along with a couple of these diagnoses. It goes along with third nerve palsy. It goes along with myasthenia. And there's no double vision. So I'm kind of breathing a little bit of a sigh of relief because there's no double vision. Okay. So it's like less likely to be third nerve palsy, less likely to be myasthenia gravis. Could just be age-related changes.

Um, and so next thing, a very important thing to check is pupils, right? Because a third nerve palsy, you'll have a dilated pupil on the affected side, a Horner syndrome. By the way, this also could be a Horner syndrome still because Horner syndrome doesn't involve strabismus. The Horner syndrome, you know, so I'm looking at pupil size. That's a very important point. So with, with a droopy eyelid, you're looking at motility, double vision stuff.

or, and you're looking for pupil abnormalities. And so I checked the pupils and here's where it gets kind of interesting. All right. Because in case it wasn't already interesting enough for you, I think it's fascinating. Some people might be taking a nap right now. That's okay. That's all right. Hey, if I can at least help you get a little sleep, I'm all for that. All right. So I checked the pupils and the pupil on the affected side where the droopy eyelid is,

it it's it looks like it's normal i go i look at the other eye and there's a fixed dilated pupil again this is a new patient never seen this patient before and so i'm starting i'm like whoa what's going this is like threw me for a loop like wait a second this is it's on the wrong side like that if there's a pupil abnormality it should be on like the same side that the ptosis is on

So what's going on here? And so I go into the history a little bit more. Apparently, this gentleman had a big trauma to that eye, had a traumatic cataract removed, and had glaucoma for years that didn't get treated very well. And he ended up with a blind eye. So you see his hand motion. Generally, he just forgets about that eye.

So I think that's why the pupil was fixed and dilated because the eye was blind from glaucoma and just the pupil doesn't work well whenever you've had really high pressure in the eye for a long time. And the pressure was like 50 today, but he was not in any pain, no discomfort because it's been like that for years. But this also makes it a little bit trickier when I'm trying to figure out pupil abnormalities.

Because you really want to compare one side to the other, right? So something like Horner syndrome, well, how can I tell if this eye, this pupil is smaller than it's supposed to be if I can't compare it to what the other eye is, right? So now it's getting a little bit more challenging.

I'm still relieved that I don't see any sign that there is a third nerve palsy. All right. Yep. We got the droopy eyelid, but there's definitely no dilation of the pupil. The pupil is not, it looks totally drop dead normal to me. It's not even a phrase. I don't know. Anyway, totally normal. Um, if anything, maybe it could still be a Horner syndrome, but, um, so anyway, um,

And the other thing it could still be is technically still be myasthenia is like, okay, well I'll check myasthenia gravis test. Nothing, you know, that's what it's going to be. So the easiest thing to do to test for myasthenia is just have the patient look up with a sustained gaze. So I'm just like keeping your head still, just look up at the ceiling and I give him a little target, hold my finger up there, keep your gaze up there. And sure enough, after like

five to 10 seconds. I watched, I watched as his eyelid just gradually got lower and lower and his eyes, he was unable to keep his gaze up because the muscles that were keeping the eyes up started to tire. And so the eyelids started to go down, the eyes started to drop and he could not keep his gaze up. That's fatigability. And that's when I know, oh,

okay, this has got to be myasthenia gravis. A very high likelihood that this is myasthenia gravis. So, and I'm reassured that it's not going to be like a Horner syndrome. It's not a third nerve. I have nothing that's consistent with a third nerve palsy. So ordered acetylcholine receptor antibody tests, also some thyroid stuff because thyroid and myasthenia can go together.

And most likely if it's positive, we're going to send them up to the university where they have a neuro-ophthalmologist up there who can help with management of a patient like this. But a key point is that with myasthenia though, there should not be any pupil involvement. The pupils are unaffected because this is a muscle disease. All right. Skeletal muscle disease. You're not going to have, there's little muscles inside the eye that control accommodation and things.

but your pupil exam is going to be normal with myasthenia. If the pupils are abnormal, it's not myasthenia. All right, so it's kind of almost a diagnosis of exclusion. You want to rule out some of the things that could be life-threatening, like a third nerve palsy, even a Horner syndrome for sure, because it could be like a lung cancer or something, or stroke.

uh, before you settle on a diagnosis like myasthenia gravis and myasthenia, it can be hard to figure out to diagnose. This one was actually pretty easy because he had that fatigability that was very obvious. All right. And then I let him rest by the way. Uh, you can, you can let them have like an ice pack and that that'll restore the, the, the activity of the muscle. Um, but, uh, I just let him rest. And then he was, he was open up again. His, his eyelids were higher. So

I'm like 99% sure that's the diagnosis. Going to do some confirmatory tests. Did not send him for neuroimaging because again, I had no reason to think this patient has anything going on intracranially that I'd be concerned about. Obviously, if something else happens, we'll reassess. But that was a tricky one with his traumatic pupil. It kind of made me

you know, think a little bit longer about what could be going on. But anyway, that was the, the, uh, mystery patient of the day. I'm pretty sure it's going to turn out to be myasthenia gravis. I see like a couple, like maybe two of these patients per year, not very often, not as much as a neuro-ophthalmologist. Thank goodness. They'd be much better at managing this than me, but that's why we have subspecialists who can do the things that

Manage the diseases that don't come around very often. They have wonderful expertise in all of these areas. And part of the reason I love being a comprehensive ophthalmologist because I get to surround myself with people who are so much smarter than me. I love it. They're great and they do all the hard things.

I can diagnose the hard things, but they know what to do with the hard things. So shout out being a generalist. All right. I love it. And you should too.

All right. Thank you all for listening. That is Knock Knock Eye for the day. I want to thank our producers, Aaron Cordy, Rob Goldman, and Shanti Brick. Editor and engineer is Jason Portiz. Our music is by Omer Binzvi. By the way, all comments, I look at all of them. I didn't get around to reading any of them today. But on our YouTube channel, at Glockenfleckens, check it out. All the video episodes of this podcast are on there.

You can see me like my, when I'm talking about anatomy, I'm like using my hands a lot and trying to, to explain. Sometimes I, sometimes I break out the eye model as well. So, uh, but you can leave a comment on those episodes on the YouTube channel. Uh, and I do really enjoy reading those. Um, and so thank you for that. Thank you for your feedback. If you have any recommendations of, of, uh, of topics you want me to talk about, you have any questions about your eyeballs.

I'm happy to help. Yeah, just let me know. People are always reacting to the videos, but I haven't been getting a lot recently of questions people have about eyes or about the human body. You have a random question about your stomach? I'll do my best. I'm not an expert in it, but I did go to medical school. How about your testicles? I know a little bit about testicles.

Anybody got any testicle questions for me? I've had both of mine removed, but in the process, I learned a lot about them. All right. So please, all the questions, I'm happy to answer them. We'll see you next time, everyone. Take care. Bye. Knock, knock. Goodbye. You've been talked into.