Knock Knock Eye: What Happens When a Virus Decides to Eat Your Retina
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Knock Knock High

Uh, I've got some, some announcements. First of all, right off the bat. First, I, I'm, I, I just had my lunch. This isn't really an announcement. It's just something that popped into my head. It's a, it's a Thai place that I've been going to for, for years and it's fine. It's just, it's really close to where I work at one of my offices. And, um,

Uh, I, uh, I was disappointed a little bit this time and it's just because the last time I had Thai food was in Sydney, Australia, and that was the best Thai food I have ever had in my life.

in Sydney. And I have to assume, I don't know, maybe it's just like Sydney is just one of the biggest cities in the world and it's very multicultural, but also like it's the Thai food is from that part of the world. I wasn't in Thailand, but there were a lot of Thai places to choose from. And then, so I had that amazing food and then I came back and just,

I don't know. I guess I've been eating like an Americanized version of Thai food and it's, I don't know, just disappointing. It's like, are we really that good at food here in the U S like, like certain things like barbecue were amazing. It's awesome. Uh, uh, got some good seafood around, but I don't know, like things like Thai food. I don't know. I was just disappointed.

It's like, I just, I want to go, I want to go back and get that Thai food. That was so good out there. I miss it. I miss it already. Um, so anyway, disappointing start to my lunch break. I do have, here's a real announcement though. We have ortho bro stickers. So we've been working on some merch. Uh, you can, I'm showing you this on the, if you're watching this episode right now on the YouTube channel, um, I have, uh, uh, this is a, here's a picture of me as ortho bro. This is a sticker. It says, what up, bro?

spitting image, I believe. I think the artist did a great job on this one. There's a kettlebell, Ortho Bro kettlebell. And then one of my favorite stickers is just, they made a, you know, I had one of those videos like Ortho was trying to admit a patient to medicine, but he said, well, he couldn't admit a patient to medicine because he ran out of stickers or he ran out of punches on his

admissions to medicine punch card. And so we made a sticker version of the admissions to medicine punch card. I love it. It's the wackiest thing. And it's just one of my favorite gags that I've done for ortho. Last thing we have new pediatrics socks. All right. On the top of the sock, it says adults are terrible.

Love it. I don't know. It's got unicorns on it. It's colorful. It's great. All right. So check it out. Glockenflecken.com slash merch. All right. You guys ready for some eyeball stuff today? We're going to get into it after the first break because I have...

I saw something during one of my clinics recently that I have never seen before. It's one of those things you learn about, you study, you're tested on it as a resident going through your board exams. But it's just like, am I ever really going to see this? I saw it. I saw the unicorn. Speaking of unicorns, I saw it.

It's actually not. So what am I talking about? Zebra is not. There should be a third option. So there's horses and zebra. Those of you are not in medicine. Like, what the hell are you talking about? What are all these animals? So it comes from the term like if you hear hoof beats, think horses.

Basically telling you, okay, don't just automatically think this is some rare thing that this patient has. What are the most common things? Common things are common. And so you think about horses, not zebras. For some reason, I guess unicorns from the unicorn socks popped into my head. So maybe there should be a third thing, though. You have very common things that are horses. You have very uncommon things that are zebras. And then you have never-see-them things.

Like sympathetic ophthalmia. That's probably the one thing that pops into my head, which would be like a unicorn. That's a unicorn thing. You only see one of those, if ever, throughout the course of your career.

sympathetic ophthalmia by the way that's a wild diagnosis that's that's uh you have either a a trauma or surgery it can happen with surgery basically something penetrates into the eye whether it's a surgical instrument or just a trauma a projectile whatever it is a stick a thousand things can cause open globes but you have some kind of thing enter the eye and that

incites this autoimmune reaction that causes your immune system to fight the other eye. Your body, all of a sudden, because you have this open globe injury, recognizes your eye as foreign and unfortunately will start attacking your good eye. It's

A horrific thing that I've never seen it. I've just just read about it. And it's it's it's like one of those things you're just so scared about. It's extraordinarily rare. I mean, it's a unicorn level. It doesn't happen.

You know why I'm talking about that. Anyway, oh, because I saw, I wouldn't say unicorn that I saw. It's probably more like a zebra, but it was a zebra that I had seen for the first time. So we'll get to that here shortly. But first I've been working on something lately. You know, I do a lot of speaking. I go around different conferences and different specialties. I usually do like a version of a similar talk that I give. I've got several different talks that I can do, but

I'm, I'm working on something for a cancer center. I'm speaking at a convocation and, uh, first convocation I've done, I've done like commencements. I didn't do a commencement address this year. Part of that was purposeful, uh, because I've done, I've done a commencement every year for the last like four years and inevitably every single time it ends up on social media, uh,

People generally like it, but I am having a difficult time finding new inspirational things to say. So I'm afraid of like, like people are going to compare, uh,

you know, my, a commencement address from like three years ago that I gave. And it's like, well, you're just kind of saying the same thing, but a different way. You're just adding new jokes to it. So I was like, let me just take a break from commencements, um, for, for at least a year. And so I didn't do one, but I am doing a convocation, which is something I learned about. It's, it's like a, basically it's for faculty typically, uh, or you, you give out promotions, uh,

uh, awards for the year. Uh, and so it's not a commencement. People aren't leaving, but it's for people that are still in the department. I want to say, you know, I don't quite know. I don't think I've ever actually been to a convocation, but I'm speaking at one and it's for a, a very large, um, very well regarded cancer center and the background of this. And the reason this has been so difficult for me to write this, this speech is

which is about 20 minutes. It's, it's because, um, morale has never been lower in this part of medicine, which is a very, you know, academic part, you know, people that rely on research grants, research funding, uh, uh, and also take care of patients. So lots of translational research, people that do both clinical and research. And, um, after talking with the

people that, that are bringing me in to do this. Um, it's, it sounds, I'm, I'm, it's, it's, it's challenging to, to try to, to figure out the right words to say, uh, to try to inspire people and, and give them confidence that things will get better because man, the, the, the, all the stuff with, with RFK Jr, with Doge, with trying to, um, to, uh,

basically just cut back funding across the board for so many different people and doing incredible research. They just like, people don't know what to do. And it's, I don't know what I can say, honestly, to, to help them. I've got a lot of inspiring words I can give. Fortunately, it's oncology. And I, I've been in that world as a patient with my cancer diagnoses and I've had lots of different

personal experiences, you know, with being diagnosed with testicular cancer at 26 and then again at 30 and losing both of my testicles to cancer. By the way, now riding a bike has never been more comfortable. And it's, so I'm certainly going to speak to that, but I really feel for these people who don't know what the future holds for something

that they're passionate about, which is trying to cure cancer, trying to make the lives of cancer patients a little bit better, a little bit longer, a little bit more fulfilling. And if that's not worthy of research money, of taxpayer money, of NIH grants, I don't know what is. And I'm just not speaking for myself because I had a very curable cancer, testicular cancer. I just had to have orchiectomies and I was fine. But

I know a lot of people, a lot of young adults with a lot of different types of cancer. I've known people who have died from their cancers, especially through the First Descents organization, the nonprofit that supports young adults with cancer. And this stuff matters. This isn't just a number on a ledger, the amount of money that people get to do research. That

It's not just a number. There are lives at stake here. There are people that really benefit from the work that these world-renowned researchers do. And it's not something you could just tick off as a cost-saving measure. It pisses me off. And so I'm going to go. I'm going to speak at this convocation. I'm going to try to help these people feel better about where we are.

in the world, in the US. There's only so much I can do about that. At least I can make them laugh, right? I've got a lot of testicle jokes I could tell, that's for sure. Those of you who have heard me talk or been to one of our live shows know I have no shortage of testicle jokes. It's the beautiful thing about testicular cancer. Oh man, the jokes. So many jokes.

But it's just a hard time. So, you know, reach out to your friends in the research world because they're scared. They're nervous for their jobs, their livelihoods, but also just their ability to keep doing what they love. And that's really disappointing, you know. Hopefully it gets better. And the people that have lost research grants, get them back in some way. We'll see. All right, let's take a break.

Hey, Kristen, if I could give one piece of advice to like brand new physicians or even like med students, early career folks, it would be to get yourself some life insurance. Yes, that is the time to do it before you start having all sorts of health issues. Like a cardiac arrest. Or cancer. Yeah, the cancer scares. You never know what can happen. You don't. Right. And so having that peace of mind.

It's so helpful. And so let me tell you about Pearson Rabbits. All right, tell me. This is great. So this is a physician-focused, physician-founded company founded by Dr. Stephanie Pearson, a former OBGYN, and Scott Rabbits, who's an insurance expert. They understand the unique needs of physicians and can help physicians improve.

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R-A-V-I-T-Z dot com slash knock knock to get more information on life insurance for physicians. All right, folks, let's do some ophthalmology. How about that? So I did something that now you're going to not maybe not believe me when I say this, but I was in clinic on Saturday. That's right.

I, an ophthalmologist, worked on a Saturday. You hear that universe? It happens. It exists. We do that. The reason we do that is because it's a good service to our community. We're a community practice. We're all over the state of Portland. We have like 20 locations. I'm very proud to say we're 100% physician-owned practice. And we...

There's enough of us that we have like three different MDs around the city of Portland that have a clinic of, of every Saturday morning from eight to noon. So that for a couple of reasons, number one, uh, it just, we, we have enough patients. We see enough of the Metro air, the Portland Metro area, which is like almost a million people.

That, um, I think it's just when you have enough coverage where you don't have to, like, I, I have three Saturdays a year that I have to do because we have so many doctors who can do, who can work these Saturday mornings.

that it's not too onerous on us, and it's very much appreciated by the community, because there's a lot of people that need to have an eye exam, but they just can't get in during the business hours. We all know ophthalmologists have a severe allergy to working at nighttime. We don't have evening hours. We can't do that. We turn into pumpkins after 5 p.m., but Saturday morning is doable. So I had my Saturday morning clinic

And, um, and it's, uh, don't let that get out to the rest of medicine. Cause they're not going to believe me, but, uh, it happened. It did. And it actually was fine. It was fine. Except I had, uh, this is one of these, these are, these are clinics where you typically they're not your usual clinics because usually it's, it's all patients I've never seen before.

As opposed to my normal clinics where people will come in, like I have a relationship with them. I've seen them every year for the last eight years sometimes with a sprinkling of new patients thrown in. But these Saturday morning clinics, it's just all comers. It's just...

It's usually it's people I've never seen before. So that does make it a little bit more challenging because you have new patients, they're new to you at least. And so you're having to figure out their medical background and their, you know, and it's a busy clinic too, because you're technically also the on-call doctor.

for your area of the city. And so if people call in, they say they need to be seen, we have a handful of spots available for those urgent appointments that need to be taken, urgent issues that need to be taken care of. So I was chugging along in my Saturday morning clinic recently and

And we get a report of a call from a patient who's in her late 80s who had progressive onset blurry vision in both eyes. So the way triage works on these Saturday mornings, because I could get very easily just inundated to the point where I'm seeing 35 patients in a morning.

and can't give patients the time that they need and just overwhelming the staff. And so I take care of triage myself. So a call comes in, our staff, they take the call, they write down the reason, they get all the information, all the history, they bring it to me, I read over it and I decide, yes, this patient needs to be seen, tell them to come right in.

uh, no, the patient that can be seen in a week or two weeks or three weeks or next available, or, okay, let me call the patient and get a little bit more information. Those are the three decision points I have to make. So a, the, this, this, this, uh, woman in her eighties calls progressive blurry vision that, that over the last two weeks, uh,

So that could mean a lot of things to a lot of different people. Some people feel like blurry vision is just a little bit of blurriness, maybe just for reading, but they can still function. Sometimes that can be devastating for people. They can be very concerned about that, but it's typically not something that's here. It could be just dry eye. It could be something that's very minor.

Some people can tolerate a lot of blurry vision, and so they wait until their vision gets really bad before they call. And so this is one of the situations that I had to get on the phone and just try to flesh out exactly what progressive blurry vision in both eyes exactly means. And so I talked to the, it was the family member of the patient, and they're

Turns out it's painless vision loss, which is usually a good sign. Painful vision loss is often like that's where you get some really bad things like chemical injuries, obviously trauma, bad infections. But this was painless vision loss, but the vision loss sounded pretty severe.

So a patient was no longer able to read a book or see anything on the TV and was actually starting to have trouble navigating around, like was kind of feeling out for the wall. And so it's just a lot more serious sounding vision loss. So I said, okay, and this has only been a couple of weeks. Let's go ahead and get her in. We have a spot open. Bring her right in. Let's take a look. Patient gets there. And the first thing I notice is,

When a patient has vision changes, again, is that pain thing like exactly like, is there any discomfort here? So as soon as I walked in, I saw the patient, she seemed very comfortable. So I was like, okay, well, it's clearly not in a lot of pain. When people have eye pain, I mean, it's pretty obvious that is, that is not pain you want to have. It's, it can be pretty severe. And so this patient didn't seem to be bothered by her eyes.

And, um, so I was looking through, uh, at the, you know, what the technician had done in terms of a cursory exam. And, and I noticed the vision was 2200 in both eyes and was not able to be corrected. So that's, that's one thing that I always have the, our technicians try to do, especially for a new patient with a decrease in vision. Okay. The vision is 2200. Is it possible that the patient just needs glasses?

That might sound silly to think, okay, why would the patient call in with decreased vision suddenly or over the course of two weeks if they just needed glasses all along? You'd actually be surprised. Some people just don't recognize that they have decreased vision until they cover an eye and they look with their bad eye like, oh, wait, why is my vision so bad? Now, that wouldn't apply in this case because it was bilateral, but you can have a

sudden onset recognition that your vision has been bad for a long time. That is a real thing that happens. And so what technicians, well, I'll have technicians do is if the vision is down, it's not what we would expect, then you at least try to see if it'll improve with a very quick, very cursory refraction to see if it could just be a glasses problem. Well, there was no improvement for this patient.

So we know it wasn't a glasses issue. Timeline was about right. She said, you know, in about two weeks, it's been getting gradually worse, but still no pain, no pain. So at this point, I come in to just take a look. I like to do a few things before we get the patient dilated. So one thing I do is I check the pupils.

So I check the pupils. I do a alternating flashlight test where I check the reaction of one pupil and then I go directly over to the other pupil and check that. And I go back to the first pupil. I do that like five or six times. And what I'm doing is I'm just assessing the health of the optic nerves in both eyes. Sure enough, the optic nerves look okay.

The pupils, I should say the pupils look okay because I haven't actually looked at the optic nerves yet. But because the pupil reaction was normal, I felt more secure that the optic nerves were going to be fine. And then I get the slit lamp out and I look. And I look in both eyes and there is a tremendous amount of inflammation in both eyes. What we call uveitis. In this case, it was pan uveitis.

So there was inflammatory cells. It was like it was snowing inside the eye. There were inflammatory cells in the front part of the eye. And then when I moved the focus of this slit lamp into the back part of the eye, the posterior segment, there was also inflammation back there. Now, unfortunately, this

upper 80s patient had not had cataract surgery and had pretty severe cataract. So it was a little bit of a difficult view to try to get through, look through the cataract into the back of the eye. But there was clearly inflammation throughout the entirety of the eye. So what I know now is that there's what we call pan-UVitis inflammation inside the eye throughout the entirety of the eye, and it was in both eyes.

that narrows down the differential significantly. So I started looking at the history. I started asking a little bit more questions about the history, you know, any autoimmune diseases, because when you're talking about uveitis, especially something that's bilateral, you want to find out if there's any kind of history, like things that could do that. Sarcoidosis, you can have what's called HLA-B27 uveitis, although sarcoidosis

That would typically be just in the front of the eye. You wouldn't necessarily have inflammation in the back part of the eye. So that was less likely. But you think about things like syphilis. So I did get to ask someone who is in their upper 80s if they've ever had syphilis or if they could possibly have syphilis. And always it can kind of feel like I've done it enough that it doesn't really bother me now. But I remember just starting out

It's like that would have made me incredibly nervous to like ask that question. You know, it's just something you got to ask. It doesn't matter. You can't just assume. You cannot just assume. And so I asked about that recent travel, recent illness, you know, just all the basic history questions.

no known history of syphilis. No, not a possibility. The family member also kind of laughed it off and she kind of laughed it off as well. And so, you know, it's like, okay, I feel pretty confident. We're still probably going to check for it, you know, get an RPR, but very, very low on the likelihood on the differential. And so looking at a big picture now, what are the possibilities here? Well,

Looking at the history further, turns out this patient also about a month and a half prior had a shingles infection. She had a shingles rash on her shoulder. All right, now my ears perk up because one of the things on the differential for bilateral inflammation like this that's very severe could be a disease called acute retinal necrosis. It's a herpetic disease.

infection of both eyes. So my differential right now at this point, I think autoimmune conditions are very unlikely. No history of it. It's also in her upper 80s, less likely that it's going to present that late in life because your immune system is kind of ramping down at that point, you know, and so you would expect it to be a more apparent a little bit earlier in life. So one thing I have to think about is cancer. Could it be a lymphoma?

Possible. All right. Bilateral. Yeah, it could be. But the patient's been healthy. No recent weight loss, no night sweats, fevers, nothing unusual. Everything's been fine except for this shingles rash. So the other big thing and the thing I have to take very seriously is could this be acute retinal necrosis?

So let's talk about acute retinal necrosis. So this is a disease. It's a pan, it's a viral pan uveitis. So, so far bingo, like it, it affects, it causes inflammation in the front and the back of the eye. Just like, you know, we're thinking just like we're seeing, but

And so you get a tremendous amount of vitreitis, inflammation in the vitreous cavity of the eye. You also get a vasculitis of the retina and the choroidal vessels. So you have a couple different layers of vessels in the back part of the eye. Some are deeper than others, but with this disease, acute, what we call ARN, acute retinal necrosis, you get inflammation surrounding all of those vessels.

And it preferentially affects the periphery of the retina. So the central vision can be relatively well maintained as this infection and this inflammatory response gradually migrates from the periphery of the retina, like the outer part of the bowl, into the center of the vision. That's kind of the story I'm getting, right? The vision was gradually, over the course of a couple weeks, getting worse and worse. Now,

This is fairly uncommon. Again, this is the first time I'm ever seeing this. But most cases of acute retinal necrosis are caused by a reactivation of a latent herpes virus. It just so happened that her viral infection happened like six weeks ago, but it could have been years. And so herpes virus is

In this case, herpes zoster, which is the more common cause of acute retinal necrosis in somebody who's immunocompetent. So I have to assume she's got a normal functioning immune system. And so you can get this in patients like that. And so the virus was laying dormant and then it started, it reactivated.

It reactivated its spread across the nervous system. It spread along nerves through the optic nerve to reach the tissue inside the eye. So it's very rare for you to have acute retinal necrosis as a primary herpetic infection. Usually it's a reactivation of virus that you've had. And guess what?

So many of us have herpes virus sitting in our nerves. I don't want to scare you because again, this is extremely rare and usually happens six, seventh, eighth decade of life. But God, if you've had like a cold sore, if you've had, you know, herpes is extremely common and it just, for most of us, it's kind of lives in our nerves and doesn't cause any problems throughout our life until it does. Um,

The retinal necrosis, the death of the retina occurs through two mechanisms. It causes, obviously there's infection. So you get viral replication within the retinal cells. There's lots of different types of retinal cells, horizontal cells, bipolar cells, there's amacrine cells, there's ganglion cells. You have rods and cones, photoreceptor cells. So you get retinal

intracellular viral replication in all these cells, and the cells don't like that, right? And that's what causes and induces necrosis of those cells. And that necrosis and just the presence of these viral antigens, these virus particles, that provokes a massive inflammatory immune complex mediated response. And then you get lymphocytes that come in there.

And that causes more inflammation and just you get into the cycle. You just more infection because the virus is replicating, which causes more inflammation from your competent immune system trying to fight it off. And all of this is very delicate tissue in the eye, so it starts to cause damage. And when you start killing off cells, you start losing blood vessels. That causes ischemia, which results in even more inflammation.

as the body tries to repair the ischemia. And it's just, you get in a spiral and it doesn't end. And so how do you treat this? Well, you got to treat it. You know what? Actually, let's take a break. We'll come back and we'll finish up with treatment.

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, wow.

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.

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Let's talk about treatment.

So what do you do? You got to start antivirals. And I think I made a mistake earlier. I said herpes zoster is the most common virus that causes this. Actually, it's for older adults. It's varicella zoster. That's the most common type of herpes virus that causes this. Now, this patient had the shingles rash. So this one might have been herpes zoster virus, but we don't actually know that yet.

So we got to start antivirals. Now, there have been a lot of studies on how you should deliver antivirals to a patient like this. Do you do it IV? Do you do it just orally? Do you do it intravitrally? Do you inject medicine into the eye, which always freaks people out? And there have been some studies, and basically there's really no difference in efficacy between antivirals

Oral and IV, and they both will get very good penetration into the eye. So you don't have to do intravitreal injection. In fact, that's probably not what you want because the virus has been traveling along nerves.

And so even if you inject the medicine into the eye, well, you probably still have active virus that's along the path of the optic nerve. That's how it got into the eye in the first place. And so you really have to treat systemically. Even if you decide to do an intravitreal injection, you're going to need to either do oral or IV. And we know that those are about equivalent.

And so the easiest thing to do, especially in an outpatient setting, just start high dose oral valacyclovir. So that's what I did for this patient.

I started valacyclovir one gram three times a day, which is our typical dose for zoster, and also started some topical steroid. Yeah, I'd be a little bit careful about that with herpes infections, with viral infections. But as long as you're not doing steroid monotherapy, you're also treating with an antiviral, usually you're going to be okay.

And then I also called our retina doctor on call, went over the case with him, and set up follow-up for that patient the next day. And so this is a scary thing. Also, the other thing is I did end up dilating the patient and looking in the back of the eye. And what you usually see is you see areas of retinal whitening. So the retina should look like orangish, reddish,

Sometimes a little bit more yellow, depending on how much pigment is in the back of the eye. But if you start seeing big swaths of white in the periphery of your retina,

That's typically not a good sign. And so that is inflamed retina or sometimes even dead retina. So I knew there was inflammatory condition affecting the peripheral retina. Talked to the retina doctor. He approved the dose that I was thinking of prescribing for this patient. And we set up follow-up. Now the prognosis is really guarded in this case. So far, a patient's receiving treatment, vision hasn't really recovered.

Uh, and so it's, it's, um, it's a tough one, uh, to have, uh, again, very rare, but, um, patients getting the treatment that they need. And we'll just, you know, one of these things you do, you just, you keep seeing them back. Lots of, lots of appointments. We get to know each other quite well, patients like this and their eye doctors. And which is still part of the, one of the good things about ophthalmology is you really get

to develop rapport, uh, even in difficult circumstances like this. So it was a fascinating thing. Um, and I hope I never see it again because it's, uh, it's harrowing to look at, to see all that inflammation. And the interesting thing, one thing I didn't realize as I was reading more about this disease, because like, you know, I'd never seen this before. So you better believe like at some point I excused myself from the room. I went and looked at, I got on, on, uh,

on iWiki and like all of our resources we have in ophthalmology. I pulled out my wills manual and even got a textbook out. I was like, okay, what exactly? Cause you know, I, I needed to refresh myself on some of this stuff. It's okay to do that. It's totally fine. I told the patient I was doing that. I was like, I need to go check on the dose of this real quick. This is not something we see all the time. And the patients are, they're great about that. They're like, as long as you get the right answer,

That's all patients care about. They don't care how you get the right answer as long as you get it. And so, yeah, I educated myself in the moment and then afterwards and learned that it's actually really common for there not to be any pain whatsoever with this, despite the incredible amount of inflammation is in the eye. And I still don't know that I fully understand why that is. I guess you're damaging nerves, but you think that would be more painful.

especially in an immunocompetent. There's lots of inflammation there. So I don't know, it's surprising. And that's when I knew something was off about this is when the patient had zero pain when it came with all this inflammation in the eye. So it was a scary thing. But, you know, we, I think we did the right thing for the patient and we'll just

Cross our fingers, keep up the treatment and hope for the best. Sometimes these patients end up with retinal detachments and they need surgeries. Fortunately, that hasn't happened so far. So anyway, there you go. Something you don't see every day, acute retinal detachment.

Let me know what you if you guys have any any eyeball topics. If you've received a diagnosis that I haven't talked about, or even if I have, we can revisit some things. You know, there's only so many things with the eyeballs, you guys. So if you have if you have something, a disease, a finding on your exam, something your eye doctor talked to you about, you're not sure what to make of it.

I'm happy to go into more depth for you. If your doctor was not able to, or, or you just don't remember or whatever, for any reason, that's what we're here for. This is, this is what knock, knock. I is here for. It's for you. So leave a comment on our YouTube channel at Glock and Plekans. All these episodes are up on the YouTube channel. Um, I, I always read your comments, by the way, thank you all for the comments about my, the five year anniversary of my cardiac arrest. Uh,

Um, uh, I, I didn't get a chance to, to get into some of those comments here today, but I really appreciate the love and support. Honestly, you guys are the best. It's, I, I feel so fortunate that we have this, both the greater Glock and Flecken community and the people that have found this podcast. And, um,

It's fun to get into more in-depth stuff about it. I think it's awesome that I can find people that want to hear about bilateral acute retinal necrosis. Honestly, it really is cool. And so spread the word about the podcast. Leave a comment on the YouTube channel. Give us a like or subscribe on any place that you listen to podcasts. That helps. That helps a lot.

And thank you all for listening. I am your host, Will Flannery. Dr. Glockenfleck, you guys know me. Thanks to my producers, Aaron Corny, Rob Goldman, and Shanti Brooke. Editor-in-Chief, Jason Portiz. Our music is by Omer Benzvi. Knock Knock I is a human content production. We'll see you next time. Knock Knock I. Knock Knock. Goodbye. Human content.