Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole, and we have three expert panelists for you today to discuss the management of tumors that compress the optic nerve. Joining me is Dr. Preeti Thyparampil, she's an ophthalmic plastic and reconstructive surgeon; Dr. Adam Baim, he's a neuro-ophthalmologist; and Dr. Stephen McGill, he's a neurosurgeon. And Dr. McGill will be moderating the discussion today. Dr. McGill, I turn it over to you.

Stephen McGill, MD, PhD (Moderator): Well, hello, everyone. Thank you, Melanie, for that introduction. In thinking about the roles of tumors that compress the optic nerves, it can often be difficult to understand what the different subspecialties of Ophthalmology are. So, I wondered if both of you could talk a little bit, you know, if a patient presents losing vision in their eye, a blurry vision, they typically go to Ophthalmology first. So, Preeti, can you talk a little bit about the start of that?

Preeti Thyparampil, MD: Absolutely. I am an ophthalmic plastic orbital and reconstructive specialist within the field of Ophthalmology. And how I explain it to patients is I take care of everything around the eyeball. So, I take care of the orbit or the eye socket and all the structures within. So, I take care of the eyelids, the tear drain, basically everything around the eyeball. And in the context of what we're talking about today, I would be the person who would help, probably surgically, possibly medically if there are lesions, tumors, growths that are growing within the eye socket or into the eye socket and potentially compromising the eyeball or the vision.

Stephen McGill, MD, PhD (Moderator): And as a surgeon there, you know, you trained in Ophthalmology, but your practice is mostly surgical and intervention feeling, correct?

Preeti Thyparampil, MD: Correct.

Stephen McGill, MD, PhD (Moderator): And how about you, Dr. Baim? So, the patient has the tumor or something, they're losing vision, do they see a regular ophthalmologist? What is your role? When do they get referred to you and how is your training different than a standard ophthalmologist?

Adam Baim, MD: Sure. So, I'm a neuro-ophthalmologist, an ophthalmologist by training. You can do neuro-ophthalmology as a neurologist or an ophthalmologist. My role is principally defining the deficits related to one of these tumors. They're often diagnosed incidentally on neuroimaging, or they're evaluated by another eye doctor. My role is mostly to define what the vision deficits are, peripheral vision loss, and then also eye movement and eye alignment abnormalities that can be associated with tumors in the orbit and the skull base,

Stephen McGill, MD, PhD (Moderator): And compared to Dr. Preeti, what is the breakdown of your practice from a diagnosis to an interventional type of practice?

Adam Baim, MD: Yeah. So, we're often ordering visual fields, which are representations of the patient's peripheral vision. And then we're also obtaining tests that are looking at the retina and the optic nerve inside the eye. And that allows us to characterize with a lot more definition the areas of the optic nerve that are affected by these tumors. And that's important as a baseline for monitoring as the care of these lesions evolves.

Stephen McGill, MD, PhD (Moderator): Yeah. And when I think about orbital tumors, tumors compressing the optic nerves, I think of kind of two general categories. The first being tumors that are intraconal, so within the eye socket deep to the muscles of eye movement behind the eyeball. And then, outside of that are extraconal tumors, so tumors that start on the skull side or me, as a neurosurgeon, on the brain side typically, or even in the nose, that can then grow and compress the orbital structures. Dr. Baim, what do the tumors do to the optic nerve and eye function? And can you talk a bit about the signs and symptoms that a patient would see that would suggest, "Hey, we need to work this up a little more for an orbital tumor. Get neuro imaging," that kind of thing?

Adam Baim, MD: Well, from the optic nerve standpoint, this is principally a concern about compression. And so, the optic nerve is very delicate and any kind of force applied to it from the orbit or from the area behind the orbit can cause loss of axonal function. And that can cause vision loss. Often with these tumors, patient's central vision is preserved, their visual acuity is preserved, but they may have visual field deficits that patients may or may not be aware of. And so, these are often very slow-growing insidious processes that really wouldn't be identified unless someone was doing a dedicated visual field test.

When we're looking at efferent abnormalities, so abnormalities of eye movement and eye alignment, things that are taking up space in the orbit or in other parts of the skull base are interfering with that motility. And so, patients can develop double vision, which is often one of the presenting features of these lesions. Then, the double vision is often evaluated first by a general eye doctor, and then referred to me as a neuro-ophthalmologist.

Stephen McGill, MD, PhD (Moderator): So when we think about presentation, loss of vision, blurry vision, double vision, when do you suspect a tumor or that you need to do additional things? Like how do you tell the difference between just a strabismus that's, you know, a kid's going to grow out of, or an adult has that's benign versus, "Hey, we need to escalate this, we need to see a neuro-ophthalmologist, we need to get an MRI," what do you do for that?

Adam Baim, MD: Absolutely. So, it's about pattern recognition in large part. With eye movement disturbances, the direction of gaze tells you a lot. If someone has a misalignment that is more pronounced, looking in one direction than the other, that often signifies a particular weakness of one of the extraocular muscles or one of the cranial nerves involved in the control of eye movement. And those patterns often trigger neuroimaging in our practice. With vision loss, there are certain patterns on visual field testing or looking at the structure of the optic nerve in its areas of damage that signify there could be something in the eye socket or in the skull base, as opposed to something like glaucoma, which is a very common disorder that affects optic nerve function.

Stephen McGill, MD, PhD (Moderator): And I know you talked a lot, like when we think about, okay, you have blurry vision, one of the things that the patients often surprised me when I was in training and learning is the loss of color vision that we don't always appreciate. Why do some patients lose color vision, some patients get blurry vision? Is there a sequence of that progression or what do the patients see?

Adam Baim, MD: There can be. So, color vision is subtended by the papillomacular bundle, which is a very high metabolically intensive part of the optic nerve and the retina. And so, it's very vulnerable to compression. Patients with a compressive optic neuropathy will sometimes have color vision loss, but not always. It can also be a feature of disorders like optic neuritis, which are inflammatory conditions of the optic nerve. A color vision is an important benchmark though. And so, a patient that has relatively preserved acuity, the 20/20 number that also has color vision loss, you really want to think about something that could be compressive or inflammatory beyond the eye itself and the optic nerves pathway.

Stephen McGill, MD, PhD (Moderator): So, oftentimes color vision loss is a sign of compressive optic neuropathy and then kind of that blurry vision.

Adam Baim, MD: It can be.

Stephen McGill, MD, PhD (Moderator): I remember too, you know, a lot of times, the really important thing is those formal visual fields, because they can pick up deficits that patients won't even realize they have.

Adam Baim, MD: Absolutely.

Stephen McGill, MD, PhD (Moderator): I remember a patient coming to my clinic who had just moved to Illinois and they were getting their driver's license and they could only see-- like, they had a complete temporal hemianopsia, loss of vision bilaterally and they had no idea and were driving and didn't realize it, just because it happened so subtly. In addition to the visual fields, what other testing do you do?

Adam Baim, MD: Yeah. So, the visual fields are of course very important. The structural testing, it really does guide a lot of our management with these tumors though. So, we're looking in particular at an area of the retina called the ganglion cell layer. So, this is where the cell bodies of the retinal nerve fibers are, the 1.2 million fibers that comprise each optic nerve. And you can actually see, based on the pattern of where that layer is thinning in the retina, where along the path of the optic nerve and insult may be occurring. And as we're looking at these tumors and maybe first identifying them, there's often a question about whether there's early evidence of optic atrophy. Maybe the visual field deficits are quite mild, but we're seeing early structural changes, looking at the retina as an indicator of optic nerve function. So, that's a very important part of our testing that we follow longitudinally. We can see whether there's thinning over time and that can complement the neuroimaging and then the functional studies that we do.

Stephen McGill, MD, PhD (Moderator): And you measure that with the OCT, correct?

Adam Baim, MD: OCT, yeah.

Stephen McGill, MD, PhD (Moderator): So, optical coherence tomography, and that wouldn't be standard, a typical. Like if I go to the eye doctor, I need to get my contacts adjusted, that's not part of the normal screening, correct?

Adam Baim, MD: Usually, OCT is used for a lot of things in Ophthalmology. The analysis that we're doing of the ganglion cell layer is often not part of the standard OCT that a general eye doctor is doing. So, it's somewhat specialized.

Stephen McGill, MD, PhD (Moderator): Yeah. So, I think that that's really important as we think about the types of tumors that can compress the optic nerve. So, things within the orbit, like hemangiomas, things outside of the orbit, I think the most common one we see is either meningiomas that grow and can thicken the bone and compress actually the whole orbit causing proptosis, the eye being pushed forward, or pituitary tumors that can grow next to the optic nerve, just intracranially, and then also cause thinning of the optic nerve, which you'd pick up on the OCT imaging, the Humphrey visual fields.

So, thinking about tumors that can compress the optic nerve, we can often think about tumors within the eye socket, intraconal ones deep to the optic nerves, things like that. What would you think about for intraconal tumors, Preeti?

Preeti Thyparampil, MD: There are common benign tumors within the intraconal space. Vascular malformations, proliferative vascular malformations versus more abnormal vascular connections between venous and lymphatic channels, for example, so venolymphatic malformations. And depending on the nature of the tumor, they're all managed differently. Some vascular tumors are managed. If they're the result of dilated venous and lymphatic channels, and they're growing and causing symptoms that would be best managed perhaps through embolization procedures with Interventional Radiology, for example, some benign vascular tumors are left alone. If the imaging is confirmatory and supportive, that they're benign in nature and they're not growing, we might just follow these with serial scans, for example.

However, if it's a tumor that is causing compression, that has been shown to be growing, and that's where Dr. Baim and his colleagues really help us to guide the management. Because obviously, this is a very high risk area with a lot of important structures that we want to intervene surgically only if it's really indicated. And so, if there is evidence that it's growing or compressing the optic nerve, causing motility deficits or causing proptosis or bulging of the eye to a degree that's causing ocular exposure, then the risk-benefits would favor intervening.

Stephen McGill, MD, PhD (Moderator): Yeah. And from the neurosurgery side, we see a lot of meningiomas, which are tumors that grow from the lining of the skull and can actually thicken the bone and that pushes in on the orbit. And then, they can grow from the skull side, from the brain side out towards the brain, but then also down into the orbit compressing the optic nerve.

And I think when we're trying to think about what to do, that's really where it's important. Once you have the diagnosis that you've made, Adam, where you know, hey, we've got compressive optic neuropathy, the patient may or may not have a visual deficit, but if we're seeing thinning on the OCT, thinning of that ganglion cell layer, we know the patient's getting into trouble, that's where we kind of say, "Hey, this is symptomatic" or the alternative, something that's not yet symptomatic but is growing.

We've had a couple of these patients where we were following them, their tumor was growing, they hadn't yet had a major vision loss, and then now it's time to do something. So, when we make that diagnosis and now it's time to move forward with surgical treatments, can you talk a little bit about how we work together, when you get me involved, and when we do surgeries together, and also when you would do things on your own and say, "Hey, you don't need a neurosurgeon"?

Preeti Thyparampil, MD: Often we're working together when there's a dual component to the lesion, to the tumor when there's a skull-based component and there's an orbital component. And obviously, we have trained to have a level of comfort with our own areas. And it's very nice and it really gives me, as a surgeon, a level of comfort and confidence that we can do the most for the patient, but safely when we're doing it together. Because the preoperative assessment to begin with, we go into it with a lot of very specific knowledge about the extent of the tumor, where to expect to find disease, what the deficits are, and so how aggressive we can be, and how much to weigh the pros and cons for the patient, depending on how much damage has already been done versus how much is at stake. So, those combined lesions, certainly.

And then, sometimes there are even orbital lesions where it's the location where it's within the orbit. And there are so many ways we can get to the orbit. You know, the orbit is the ice cream cone-shaped bony cavity of the eyeball. And you can approach it sometimes through the sinuses, sometimes through the eyelid, sometimes through the surface of the eye. But sometimes the best way to approach it is actually superiorly, from the intracranial space because, just based on where the growth is, that's actually the safest approach and that's the most direct approach and where we can get the best excision. And so, sometimes in those instances as well, we're working together.

Stephen McGill, MD, PhD (Moderator): Yeah. I think, also, what would you say are the key priorities? So. Dr. Baim diagnosed the patient. You have, let's say an intra-orbital hemangioma, like the case we had recently. We see compression in the optic nerve. The patient had color vision loss. She was a young mother. When you are talking to the patient, what are your priorities and the way you think about that going into the surgery?

Preeti Thyparampil, MD: As an ophthalmologist, initially and then training in orbital surgery, my priority is the eye, the vision, the function of the eye with regards to the vision and the integrity of the optic nerve, but also with the regards to the integrity of the vessels that feed the eye. The nerves that feed the eye that serve for eye movement, for the function of the eyelid, for the sensation of the eye, all the things that allow us to have a functional and useful eye, and then also, the form, the appearance of it. Often these tumors have become deforming. They've caused proptosis or malposition of the globe. And that is also something that we want to give the patient the best result. So, making sure their eye sees and functions and also that their socket and eye look as they should.

Stephen McGill, MD, PhD (Moderator): Yeah. I think that's so important. You know, how we see our face when we look in the mirror the first thing in the morning, you know, that's such an important part of a person's identity. What do you do to optimize the cosmetic outcome, the appearance of the aesthetic outcomes for our patients?

Preeti Thyparampil, MD: So, and you know, as much as we're taking care around the optic nerve, we're also taking care around the eye muscles. So the alignment of the eye is a big, a big part of function, but also of aesthetics. If your eyes are misaligned, that has repercussions not just for your vision, but also for your social and emotional wellbeing. And so, taking a lot of care to not damage the eye muscles is part of what we do. And I think that's where my comfort with the eye socket and the eyeball in general really serve us well, where I'm able to do surgery at the level of the eye for us to identify where the muscles are, tag them, be able to utilize them during the surgery to orient ourselves, because often these tumors, they've either pushed the orbital structures out of the way or they've even encased them. And the anatomy, it's not like when you look at a picture in a textbook, it's just infiltrated with tumor sometimes. And really to be able to confidently get in there, peel off the tumor and know where you are, it helps to have been able to operate at the level of the eye and identify these structures so that we know where we are.

You know, sometimes it gets to be sort of like you're swimming, you're swimming in an orbit with tumor, and it really helps to orient and be aggressive with the excision while protecting these structures, because you want to tell the patient, you know, when they're waking up, you want to tell them, "We got it. We got it all," or "We got as much as you can get safely while preserving your structures."

Stephen McGill, MD, PhD (Moderator): Yeah, I think that's hugely important. You know, what we do from a neuroimaging standpoint to see your point is so well stated that it's where the tumor is that determines what we need to do. And I think that's where having all the surgical expertise that we need on hand is really valuable in providing the best care for a patient and looking at that anatomy, how the normal anatomy is positioned, determines our approach, whether we can come through the nose to get to the eye, whether we do a craniotomy coming from above, whether we do an eyelid incision and a little lateral orbitotomy or something come around the edge of the eye, you know, all those things are totally determined on by where the tumor has compressed the normal structures and how to remove it safely. Because I think regardless of the tumor, our goal is to get the best resection possible for the patient, the best cosmetic outcome, and have a clear approach for that. So, that's totally very interesting to see how the anatomy dictates the approach. And I think that's really important, and what team members we get involved.

You know, a lot of neurosurgeons will remove tumors on their own without oculoplastics person. what I've really enjoyed about our working together as a team is what you can bring, especially on that aesthetic and the functional outcome. I can take out a big brain tumor that's compressing the optic nerve like a big meningioma. But getting the eye aligned just right, you know, I think having a multidisciplinary team and that working together where you can help me with the eye position.

Another thing that we've been doing to optimize the appearance and cosmetic outcome is creating custom implants. So, a lot of these tumors will infiltrate the bone of the eye socket. And then, we have to remove all that bone and now the eye could be connected to the brain where the pulsations of the brain could give the patient a pulsatile proptosis, or sensation of that where the eye could drift back. In the old days, we would just use a piece of mesh or something to reconstruct that sort of the best I could do with my eye. And you'd see complications of entrapment of eye muscles, but we've been designing these custom implants together that can really help patients have the best cosmetic outcome possible.

And then, working together, you know, one of the things, and maybe you can talk a little bit about what you bring to these surgeries and some of the things that you do. You know, as a neurosurgeon, I just take out the tumor, but when these meningiomas and things start to invade into the orbit, it can be hard to determine where the normal structures are in order to protect them, to prevent diplopia, make sure the patient has a good outcome. Can you talk a little bit about some of the things you do at the start of the case to help identify the normal muscles and everything?

Preeti Thyparampil, MD: Absolutely. And I think this is another instance of where the preoperative assessment and that familiarity with the exam preoperatively and postoperatively, and having some familiarity with what happens to these patients postoperatively, kind of anticipating what happens to someone with slow growth of a tumor, what structures get damaged, what happens after orbital surgery, anticipating the loss of orbital fat, for example, and kind of adjusting during surgery to take that into account, and therefore, sort of give your best prediction for where to set the eye. But during surgery, some of the things we do, I often like to start on the surface of the eye, identify the extraocular muscles, then keep utilizing them throughout the surgery because they track back into that cone, that apex of the orbit.

Using that to orient our cells with regards to other structures like the vasculature nerves, identifying the position of the lacrimal gland so that we minimize the trauma to the gland during the procedure. And then, once we've done a good dissection, setting the eye with our implant and then modifying that based on the position of the eye, really making sure that I'm happy with the position of where the eye is. And that's something I enjoy doing and I feel comfortable doing, because it's something we do in clinic all the time. We're always looking at the position of the globe and using tools to measure using just the clinical exam to assess when the eyes are aligned. And then, being able to do that in the intraoperative setting as well, I think really gives the patient a nice aesthetic outcome because the deformity, that bulging or sinking of the eye, that is a big source of distress to patients and they really want to see that improved upon.

Stephen McGill, MD, PhD (Moderator): Yeah. I think it was, you know, your ability to lasso and get ahold of the extraocular muscles at the start of the case, then lets us go intraorally and intra the eye socket intraconally in between the eye muscles. If we're able to identify them at the beginning of the surgery, then we can give a little tug on it and see, "Oh, there's the normal structure. Okay, now we're on the tumor and we can separate that." And that's allowed us to get some really great results, I think, for several of our patients where who've had tumors that I wasn't sure we could get it all out. And then, when we have that, it's like, "Oh, we know where everything is." So once you have that knowledge of where the normal anatomy is, where it's been displaced by the tumor intraoperatively in real time, really lets you take your resections to the next level. And I think have some of the best outcomes we can for our patients.

When a patient comes into surgery, like, let's just think about some of the diagnosis. One of our recent patients, we had a little picture of this patient with an intraconal tumor here or it was a hemoangioma it turned out to be, that had been growing. On the diagnosis side, you know, let's just walk through the case real quick, Adam. Talk a bit about, you know, this patient comes into your clinic, what are you looking for? Go through the diagnosis and then we can talk a little bit about that case, exactly how we went through it.

Adam Baim, MD: Yeah. Well, the mass is fairly large and it is situated in an area where it's causing mass effect on the optic nerve. And so, it's important to characterize exactly what the vision deficits are. And then, its location is displacing the globe, of course, and then the extraocular muscles. And so, there's usually going to be a misalignment of the eyes. A patient may well have double vision in this case. That's important to obtain baseline measurements of because with the resection of these tumors, even under the best of circumstances, with the best of technique, there can be some residual eye misalignment. So, it's important to characterize that.

Stephen McGill, MD, PhD (Moderator): Then, when we go to surgery, this was one, it was too big to get from around the eye socket there with like an eyelid incision. So, we actually did an incision behind the hairline that let us look from above. And I did a craniotomy, opened up, get an orbitotomy so we could see there, we were able to leave her orbital rim intact. And then, for your role, you came in at that point, and can you talk a little bit about the steps you provided?

Preeti Thyparampil, MD: So, this was an intraconal tumor. Like you were saying, Stephen, it was positioned in a way where approaching it through the nose or the eyelid, which we like to do whenever possible to, you know, do a less large approach, but it just wasn't in a position where that was safe. We'd have to sort of operate through the optic nerve in a way to get through those approaches. So, actually doing craniotomy and getting that nice exposure was the best approach.

So once that exposure is provided, then it's a matter of opening up the intraconal space. So,, the orbit is well protected by the periorbita, and then opening that and then starting to dissect very carefully through the layers of orbital fat until we start to identify critical structures. And that's where identifying the muscles at first really helps because tumors displace everything. Things are not where you necessarily would normally expect them to be. And so, I start by opening the conjunctiva on the ocular surface, just, you know, a little bit posterior to the limbus of the eye. And then, hooking the extraocular muscles similar to how a strabismus surgeon would do if they were going to do eye muscle surgery for eye misalignment. And then, tagging those muscles with sutures, and then labeling them so that we know which is which, and then proceeding to the orbit.

And then once we start to open up that periorbita, you have this kind of sea of orbital fat. And then, slowly, the tumor starts to become visible. And the question is, well, where is everything relative to this tumor? And how aggressive can we be? How much more based on our preoperative imaging do we expect this tumor to extend? So, it's just really about having as much knowledge going into it as possible, and then periodically checking those muscles to see, "Okay, if this is where we are, then we know we have more medial or we have more lateral. And we should proceed in this direction or that direction."

I also like to get all our preoperative imaging. I like to do like reconstructive-type imaging where the imaging engineers that we work with will highlight the large vessels and sometimes you want to know there's this large branch off the ophthalmic, for example, feeding into the tumor at its posterior aspect. And so, we'll be looking carefully for that vessel and anticipating it, and kind of dealing with it as we go along. We know which important nerves are onto the tumor, for example, and keeping an eye out for that and dissecting carefully. So, just having all the information, all the comfort going into it really allows us to get a better resection.

Stephen McGill, MD, PhD (Moderator): And that was a fantastic case. I remember it very well, just working together. And I think where we have a team, that's what really gives us an ability to do a resection. I probably couldn't do on my own, and I don't know if you could either, you know, because we have to work together. But certainly, I'll never forget walking down along the optic nerve actually bringing the tumor right down to the orbital apex. That was a great case. We were able to get all the tumor out.

You know, I was thinking of another case of ours and you mentioned also the advanced imaging you get that's so helpful for planning. Going to the extraconal tumors like meningioma, we've been using this specialized dotatate PET imaging. That allows us to see the extent of the tumor so we could plan a preoperative custom implant that fits right where we want at the end gives us a perfect reconstruction for the globe. And then, that was a tumor where we were able to use the implant. But when we got down towards the orbital apex, you know, working together like that, the PET showed us where the tumor went, but we weren't able to remove it all because it was invading some of those muscles.

Preeti Thyparampil, MD: It was just too deep into the apex.

Stephen McGill, MD, PhD (Moderator): Yeah. And I think that gets back to, you know, having the whole team together, the preoperative diagnostics, the preoperative imaging, advanced imaging, advanced reconstruction, like what you're talking about, looking at, you know, where's the vessels, the nerves that we can see with some of these segmentation algorithms and things that you had brought in where with the meningiomas, the PET imaging can help.

And then, I think, we can provide really the best outcome for the patient and getting back to the fundamentals of let's preserve function. So when that tumor was invading into the sixth nerve or the lateral rectus, we cut right down to the edge of the muscle and then said, "Hey, let's stop." And she's done phenomenal. She has normal vision. Her eye came back to the right position. No double vision. In the postoperative period, as we close up here, what are some of the things that patients can expect if you have a tumor invading the orbit? You need this multidisciplinary team to really optimize your outcome. What do those first few months look like?

Preeti Thyparampil, MD: The first few months, preoperative expectations and really giving patients the reassurance that they're going to be managed with experts with regards to each aspect of their care, really gives them peace of mind, because it is a long road and there's a lot of patience involved. There's an incredible amount of swelling to begin with, that just if they're counseled and reassured and watched closely during that period, I think they can have peace of mind as they get through that.

They should expect double vision initially. And just being able to reassure them that this is completely normal and expected and just a gradual process of recovery, and be able to say that with certainty, really gives them peace of mind. There might be lid function that needs time to recover. But having that confidence going into it as to where we were and what functions were preserved, really allows you to just reassure the patient that, over the next few months, we will give everything time to recover.

And that if there are deficits, they can be addressed. They're already plugged into ophthalmology to neuro-ophthalmology. And with regards to eye misalignment can be corrected. Deficits with regards to lid position or lid function can be corrected. And, you know, it's a long road. And initially, it's just focusing on that immediate postoperative period and being able to get them through that, but then also being able to help them as we get to the fine tuning. Way down the line, once the big tumor is out, which was the main objective, we still care about the details of the function and the aesthetics, and then we're able to help them through that as well. And then, with the vision, I'm sure Adam, does a lot of postoperative follow-up and care.

Stephen McGill, MD, PhD (Moderator): Yeah, absolutely. I think that it's important that first couple months, often double vision, but that usually gets better. And then, in the long-term, monitoring of these patients, can you talk a little bit about that, Adam, and the role of the neuro-ophthalmologist?

Adam Baim, MD: Yeah. So, we're using many of the same modalities that we're employing before surgery. So, we're following the visual fields. We're following the OCT. Looking for any sign of recurrence, in conjunction of course with neuroimaging. The eye misalignment is an important piece of this too. In many cases, that double vision will improve. Patients often are very appreciative that they've made it through the bulk of their care, but they often need a little bit of reassurance about the double vision.

In those cases where the double vision does persist, one of my other roles is as a strabismus surgeon. And so, we're able to reposition the eyes to mitigate that double vision. That often has to wait for several months until we see exactly where the eye misalignment has leveled out. And there are things that we can do short of surgery to help ameliorate that double vision as people are continuing that recovery process, but it's an ongoing monitoring. These are patients that require longitudinal care and, you know, we love providing that for them.

Stephen McGill, MD, PhD (Moderator): Yeah, I think that, just to wrap things up, I think, you know, it's really important to have that multidisciplinary team with both the surgical expertise to do these complex operations, whether it's through the nose, whether it's craniotomy, whether it's around the orbit to get these difficult tumors out. Working together as a team with the diagnosis beforehand, advanced imaging to guide our surgical planning. And then, careful monitoring postoperatively to help the patients through that care and then monitor their vision and any adjustments that might have to be made down the road. But I think it's been a pleasure to work with both of you. I look forward to it and I really enjoy all that we do together. So, thank you both for coming and being on the podcast today.

Preeti Thyparampil, MD: Thank you.

Adam Baim, MD: My pleasure.

Melanie Cole, MS (Host): Thank you all so much for such an exciting discussion today. And to refer your patient or for more information, you can visit breakthroughsforphysicians.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.