All right. Good morning. Good morning, everyone. Welcome to our first sub specialty grand rounds of the year. We're very pleased to have our neuro ophthalmology department here presenting to us. Just as a reminder, for those who are relatively new to the department, we do sub specialty grand rounds. Each division is responsible for one day each year. And this is really an opportunity for your division to get in front of the faculty, update us on what's new, if there's new procedures, new staff, new medications, new surgical procedures that we should be aware of as faculty. This is a great opportunity for you to update us all on those. And then really a great opportunity to showcase some of the interesting cases that are coming your way and utilize your fellows to help us learn. And so with that, I'll turn things over to our neuro ophthalmology division. Thank you. Thank you for the kind introduction. We're just going to go ahead and get started. Our first presentation is a clinical presentation from Riley Philbin, who is our pediatric neurology resident rotator. I'm sure that all of you, many of you have worked with her and she was awesome. Thank you for the videos from the screen. Cool. I don't need them. Hi, my name is Riley Philbin and I'm a child neurology PG by three. And I'm going to talk to you guys today about an ocular movement disorder case that I admitted while on service with PCH neurology at primary children's and then was able to see during follow up in Dr. Bagunta's pediatric neural neuro ophthalmology clinic. So this is a previously healthy six year old who presented with difficulty moving her eyes for the past two weeks. Two weeks ago, the right eye began appearing isotropic followed by one week later, the left eye appearing isotropic. There had been recent suspicion for a GI illness with vomiting and sore throat prior to symptom onset with no other major changes. The patient began bumping into objects frequently, having more difficulty navigating the stairs was growing has a tete amulet. There were no reported falls or concerns for head trauma during this time. But her mother also noted new slurring of her words and avoidance of eating social history was significant for a recent move from Hawaii. In the primary position her eyes were notable for isotopia bilaterally left greater than right after an examination revealed 2030 vision visual acuity in the right eye with 2025 in the left eye with normal color vision bilaterally and no RAPD present The front examination revealed equal pupils with risk reactions minus five adduction deficits bilaterally minus two adduction deficits bilaterally intermittent vertical nystagmus will motility on up gaze and down gaze Intermittently able to briefly adduct each eye with significant effort and the ability to adduct on convergence with the oculosephalic reflex being absent neurologic exam was otherwise notable for Possible dysarthria but preserved deep tendon reflexes stereo acuity was zero for three and animals and zero three for circles. Now I'm going to play some videos and this was once the patient was admitted. This wasn't her first presentation. The one eye at a time good all the way up and it has sound too. So in the first vision video, you can see that the right eye has full super reduction and in production with minus five adduction and minus three adduction. Little bit there. Good job. Okay, switch eyes for me. And then on the left eye, you can see are also full with super production in production with a minus five adduction deficit and minus three adduction deficit go down towards your toe. Way down. Good job. Now we're going to do right and left. I know that's the hard one. Good. Good job. Okay, she's very cute. Now the last thing uncover your both eyes. And then this next video. Good. One night at a time. Good. All the way up. Good job. Yeah. There we go. This next video just highlights the component of her vertical nystagmus and up gaze. Good. Go all the way up again for me. Good job CC. Good job. And then this last video highlights her overcoming her adduction deficits with convergence with some significant effort towards the end here. Good. Perfect. And I go all the way. Okay, so initial exam was concerning for possible bilateral accommodative spasms and she was discharged with very close outpatient follow up. Exam three days later in clinic grew increasingly concerning for bilateral horizontal gaze palsies and she was subsequently directed admitted to the PCH hospitalist service with neurology and ophthalmology consulting. At this point, her differential was most concerning for a demyelinating lesion either something acute like a post infectious syndrome or the initial presentation of a more chronic condition. A brain tumor that particular localization most concerning for diffuse midline glioma are formerly known as the infamous DIPG some sort of active ongoing CNS infection as well as nutritional difference deficiencies such as B12 or folate deficiency. On admission MRIs of the neuro access were obtained with pertinent findings noted within the brainstem as you can see in these pre and post contrast images. So this demonstrated confluent T2 flare hyper intensity and enhancement within the peri aqueductal region dorsal midbrain dorsal pons and dorsal medulla extending to the region of the OBEX with a geographically separate lesion highlighted by the arrow. At the right ventral cervical medullary junction this involved the facial colliculi and abducens nuclei bilaterally and the presence of the geographically separate lesion suggested that this may be more representative of a post infectious or inflammatory demyelinating process neoplasm at this point was considered less likely but not entirely excluded. And then this is just the axial views of the same lesion right through here and right through here and on the other one you can see with these arrows this kind of more extensive lesion at this point as well as this separate satellite lesion at the junction. Perfect. Thank you. There we go. Perfect. And of course now it's gone on the screen. So thorough autoimmune inflammatory and infectious workups were initiated following MRI with pertinent findings outlined in red including positive aqua porn for and glial fibrillary acidic protein antibodies as well as a strong lung cancer. The rest of her workup was overwhelmingly negative with the workup results that were available at the time neurology and ophthalmology both felt comfortable treating this as a post infectious process with a five day course of high dose methyl prednisone. Unfortunately there were minimal improvements in her speech and eye movements during this time. She then underwent a two day course of IVIG. With rapid return to baseline of speech and significant improvement in her eye movement abilities. She was discharged on 60 megs per gig or 60 megs per day of prednisone with a taper with further considerations for IVIG treatments if her progress plateaued. And then she was discharged on 60 megs per gig or 60 megs per day of prednisone with a taper with further considerations for IVIG treatments if her progress plateaued. So final diagnosis still to be determined or hopefully maybe probably not her aqua porn for and you've had titers were very low and likely represent Paul false positives. These same antibodies were also tested for separately on her erupt demyelinating disease panel and were negative on that panel. Pete's autoimmune neurology was unable to send any repeat testing on her CSF studies as it was rejected by Mayo Clinic for add on due to degradation of the sample in storage. This patient was last seen August 10th and Dr. Vaguntas Pete's neuro ophthalmology clinic with improvement in her bilateral horizontal gaze palsies disarthria and isotropia and is now wearing glasses and isotropia. Unfortunately, the family had to cancel their first Pete's autoimmune follow up appointment, but this has been rescheduled for today, September 20th with Dr. Lou. So hoping to be able to attend that this afternoon and see how she's doing. So this slide serves as a brief anatomy overview for anyone like me who doesn't know what to do. But bilateral horizontal gaze palsy is a rare presentation caused by bilateral interruption of the medial medial longitudinal fasciculus, abducens nuclei, or paramedian pontine reticular formation, or a combination of the three. This lesion, the lesion in this slide serves as a brief anatomy overview for anyone like me who doesn't have all of these memorized, but bilateral horizontal gaze palsy is a rare presentation caused by bilateral interruption of the medial medial longitudinal fasciculus, abducens nuclei or paramedian pontine reticular formation, or a combination of the three. This lesion, the lesion in this patient appears close in proximity to the abducens nuclei and to the PPRF containing the excitatory birth cells for horizontal gaze. Bilateral involvement of projections from the PPRF or the abducens nuclei would be able to explain her horizontal gaze palsy. The key difference, kind of theoretically, in differentiating between these lesions lies in assessment of the oculospallic reflex. In the most simplified version of this arc, angular rotation of the head causes endolymph in the horizontal semicircular canals to rotate opposite to the direction of the head, causing activation of the ipsilateral vestibular nucleus with inhibition of the contralateral vestibular nucleus, causing the doll's eye reflex that we've come to know. Both vestibular nuclei then activate or inhibit both abducens nuclei, which send signals to the corresponding ipsilateral lateral rectus and contralateral oculomotor nucleus through the MLF. The abducens nuclei are imperative in this reflex arc, and the absence of the oculosophallic reflex in this patient would theoretically localize this lesion to the bilateral abducens nuclei. The oculosophallic reflex is often preserved in an isolated PPRF lesion due to a direct connection from the contralateral medial vestibular nucleus directly to the abducens nucleus, which can bypass the PPRF entirely. So while there's not a whole lot of literature of pediatric horizontal gaze palsies, I did want to briefly highlight this case of an 86-year-old male with left internal capsule stroke who could not initiate horizontal saccades to the right with preserved oculosophallic reflex consistent with super nuclear right horizontal gaze palsy. Anatomically the frontal eye fields are located between the premotor and prefrontal cortex and crucial for super nuclear control of horizontal conjugate gaze. Descending frontal eye field fibers project to the PPRF in the brainstem, and lesions of this circuit at the PPRF abducens nucleus and or the MLF can produce various horizontal ocular deficits. The majority of stroke cases with conjugate gaze deviation are seen with cortical lesions affecting the frontal eye fields, as opposed to this case which demonstrated disruption of frontal eye field fibers in the anterior limb of the internal capsule. The intact oculosophallic reflex and rapid resolution of this gaze palsy in this case is more consistent clinically with frontal eye field super nuclear lesion compared with a pontine lesion. Neuroimaging did not end up identifying any sort of pontine lesion in this patient that would otherwise have explained his deficits. This case just further highlights the anatomic localization of these various pathways as they exhibit control over components of horizontal gaze. So once bilateral horizontal gaze palsies have been identified, there's a wide differential to consider. It is most important to note that the likely etiologies differ significantly depending on the age of the patient. In adults, bilateral horizontal gaze palsies are highly concerning for multiple sclerosis, and cerebrovascular accidents represent the most common unilateral cause of horizontal gaze palsies, together with MS accounting for more than 50% of cases. In pediatric patients, post infectious etiologies are thought to be the most common presentation of horizontal gaze palsies followed by brain tumors. Other etiologies considered in pediatrics that would less commonly present in adults include cure email formations, nutritional deficiencies and metabolic conditions. There's also concern that this may represent an initial presentation of a more chronic demyelinating lesion in this patient, particularly since repeat antibody testing could not be performed. So one last note I wanted to touch on is why did it look like this patient had accommodative spasm in her initial visit to the ED? So it turns out that this phenomenon has been reported during attempted ABduction in patients with horizontal gaze palsies. These paradoxical movements are theorized to be part of a near reflex substitution in which meiosis and myopic shift in refraction accompany the convergence movements. This has been well described in a pediatric patient with right-sided facial colliculus syndrome due to a pontine AV malformation, which manifested as near reflex substitution and convergence spasm on attempted rightward gaze. The authors proposed that the lesions of the version system, which are located in the ponds, would result in overactivity of the virgin system located in the midbrain, and this clinically may present as accommodative spasm. The mechanism of this rare ocular movement disorder is still not clearly understood, and there's ongoing debate regarding whether this is secondary to a peripheral infranuclear mechanism or a central super nuclear mechanism. But regardless, this article was helpful in explaining why her depresentation very did closely resemble bilateral accommodative spasm. In conclusion, bilateral horizontal gaze palsies in pediatric patients are rare, but the differential is broad, particularly within Peds. Involvements of cranial nerves, other cranial nerves can help guide level of concern for the localized lesion versus a more systemic process. And like in our patient, we may not confidently identify the ultimate cause of onset. While we hope this represents a one-time event most consistent with acute disseminated encephalomyelitis, she may end up having some sort of relapsing, demyelinating condition that will need to be followed more closely over time. For now, follow-up will be most pertinent to monitor eye position and response to treatment, while in the long term the patient will need to be followed to evaluate for any new neurologic symptoms. And that's the end. Those are some sources. Yep. They did the MRI at the subsequent when she was direct admitted. So yes, she really did not get a scan of the first visit. So we were called initially at our easy ED visit and her exam wasn't quite as profound as it was the next day. Her lethargy and her poor speech and all of that. But yeah, probably should have gotten that scan the first time around. I can also comment on that because I actually was the one who saw her in the ED when she first presented. It was a really tough exam. I see a lot of kids in a lot of different stages of life in the ER. And when we first saw her, she was old enough. She couldn't read the eye chart to do like the near chart to do numbers. So she didn't know numbers. We were doing visual acuity with the tumbling ease. I tried even having her do the color plates to kind of boost her ability in the exam. And so I wasn't really sure if she was just like super shy. She was in the ER. She just had this huge move. And it was really hard to get her to participate. Now looking back, it's very obvious that those were symptoms of what was going on. And so I reached out to the neuro ophthalmology service and was like, I'm actually not sure. And we elected for prompt follow up. So I'm going to have to get it down first. Sorry, what was the question? Dr. Long. Oh, sorry, did did she have those abduction deficits when she was first seen? She did. And and now, I mean, looking at those videos, right? It looks really obvious when she's in the ED, but she was almost so flat. I was like, if she's just like not and then given how she participated with like visual acuity exam, confrontation, visual field testing. I was just like, is this girl just like, is there actually something wrong? Or she's just like not participating in the exam. And so I was, I was really unsure what was going on. Yeah, I mean, I think there's a good learning there with the new abduction deficit. I mean, I am baffled as to how she didn't get a scan in the ED. Even if you are convinced of accommodative spasm. I mean, we could have dilated her to and see what that did with the with the with the accommodative spasm, but often a lack of information from the patient to means that we need to dig a little deeper. No, easier said than done. I know, but yeah, interesting. How is she now? Is she still isotropic? Is she still over a month ago? How come we're patching there? The answer was yes. She's still eat. She was still isotropic, but that was a month ago. She was closing one eye a lot because because of our isotropia. So we're patching the contralateral. I did encourage her to use it. Interesting. Okay. Do you have any thoughts? Do you have any thoughts, Bob? Bob just took a giant bite of food. So of course he got called on. Okay. Dr. Katz's presentation is is the main the main show here. And so we're going to I'm just going to breeze through this because his presentation is downloading. I just wanted to briefly mention a an addition to our temporal arthritis protocol. Which should shortly be on pulse. As you know, we have a current temporal arthritis protocol. You can search under GENSA arthritis or temporal arthritis. As you know, this is a condition of inflammation of the medium sized blood vessels, which mostly affects the older population. And the constitutional symptoms are somewhat nonspecific, often associated with polymyalgia rematica. I wanted to mention a scenario in which a 65 year old woman with a diagnosis of fibromyalgia, presents with a new headache, but specifically not jaw claudication. She has no visual symptoms. Her said rate is just a titch elevated. Her C reactive protein is two platelets at 240, which is normal. Her primary care physician who just went to a CME program on temporal arthritis calls for an urgent temporal artery biopsy and started steroids immediately. So one of the things that you can do is you can go to Dr. Ings. Really amazing normal gram online where you can calculate that the risk of GCA in this scenario is about 8%. So not super high, but not zero. Dr. Harry is out of town. And so what are you going to do?  Well, I want to ask you to consider adding this to your regimen for this type of situation, especially vessel wall imaging is a high resolution MRI technique where you use gadolinium to enhance the wall of large and medium size blood vessels. And there's a protocol available through our radiology department and Scott McNally is the point person and can be phoned, paged, called at any moment, day or night. Just mentioning the literature. There was a study in 2017 prospectively of lots of patients, many of whom had biopsies, some of which were positive. That's actually a pretty high positive rate on biopsies. But the MRI was abnormal in 60 patients. And my favorite statistical useful thing is the positive and negative predictive value, the negative predictive value. So a normal MRI of the blood vessel wall predicted normal temporal artery biopsy in 98% and a positive predictive value of 48%. So not super specific, but quite sensitive. And there was a second study out of Germany, which is extremely granular in comparing radiology and skip lesions and all that kind of stuff. But it's similar type of results. And so both studies showed a loss of sensitivity after about five you five days of corticosteroid use. So you do have less than five days of steroids to get this done. Temporary biopsy, you have several weeks probably temporal artery ultrasound, according to Dr. Harry, you can lose a positive in a day. So we ask you to add that to your regimen. It's not necessarily inexpensive. It's not necessarily easy to get, but it can save people a temporal artery biopsy. It can also make a diagnosis in a patient in whom a biopsy may be contraindicated because of medical issues or gadolinium sensitivity can sometimes be an issue. We had a really great patient for this, but she was truly allergic to gadolinium, so couldn't get this test. So she I believe ended up with a negative temporal artery biopsy. So I just wanted to put in a plug there and the updated protocol should be on pulse. Thank you. Brad, I think is next. Oh, Kathleen, I think is next. I don't know how to do this. So. What's new. Press the right button. Yeah, thank you. Well, I, I want to bring up three things that you should know about idiopathic intercranial hypertension in 2023. Our treatment goal to start with is really to prevent visual loss and we have a great protocol for fulminant progressive visual loss with papillodema and you should all be aware of that. And we all know that we do medical therapy first for patients with IIH, but if their vision progresses, we do a surgical procedure. And I'm going to talk about a new procedure that's gaining traction. The second thing is we want to reduce the headache because we've really found that headache is what drives the visual quality of life. So as your headache worsens, your visual quality of life also worsens. So we want to improve vision and we want to improve the quality of life. That means we have to take care of the headache. So the first new thing is that IIH is now being considered probably a metabolic disease that abdominal adiposity can affect venous pressure and then venous pressure can increase the intercranial pressure. And we're finding out that there's an increase in insulin resistance in women who have IIH compared to BMI and age match controls and there are also inflammatory markers. And this brings up a new treatment that is being proposed for IIH in addition to lowering the intercranial pressure. And that's a glucagon like peptide or a GLP1 agonist. This is in the news. I'm sure you've heard about it. But this is a gut neuropeptide secreted in the small intestines and it's been used for diabetes and weight loss. And it does a couple of things. One is that it inhibits glucagon release and lowers the blood glucose.  Plus it causes nausea. And the other thing about this is these receptors is they are in the chloride plexus. And in laboratory animals it was found to reduce the intercranial pressure. And this drug is in the news. It's being touted to improve diabetic retinopathy, glaucoma, you name it. But for IIH this is what we're looking at right now. You're going to hear different names for this drug. Exenotide also goes by biata. And then semi-glutide is wegovi, wejovi, and ozimpic for diabetes. And it's the same drug, but it's got a different trade name depending on what it's treating. And it does lower the weight by 15%. It has been studied in IIH. In Birmingham, England they inserted little sensors to follow the intercranial pressure. In 16 patients who were enrolled, it was a prospective trial. They all had this pressure reading at two and a half hours, 24 hours, and 12 weeks. And this drug did lower the pressure at all of those time points. And then there was an open label trial of 39 patients. 13 had received the GLP1 receptor agonist. And 26 had usual care. Weight loss was definitely increased with the GLP1 group. There was no difference in the visual outcome at six months. The headache, it did improve a little bit more with the GLP1. And the big side effect was nausea. The second study for weight loss is the bariatric surgery trial that just came out. This was a trial that randomized 66 women with BMIs over 35 to a weight watchers program or a bariatric surgery. And it did lower the intercranial pressure. And the RU&Y procedure was the best procedure for weight loss. And they lost a lot of weight. Their quality of life did improve. Their headaches did not improve. And remember that weight loss surgery and weight loss alone is not going to fix the vision right away. So we still have to follow the vision very carefully. So there were no deaths, but there was one bariatric surgery complication of obstruction. Okay, the other new thing that I want to touch about is venous sinus stenting. We have known for many, many years that as the venous pressure goes up, the intercranial pressure goes up as well. And you can see this graph from 1934 where the CSF pressure rises as the venous pressure rises. And this brings up the fact that as our venous pressure rises, you can get venous outflow obstruction because the vein will reduce itself. And then you get venous hypertension. You get decrease in CSF absorption. Then you get increased intercranial pressure. And then you get more stenosis. And many times in our patients with IIH, we see this venous sinus stenosis, either unilateral or bilateral. So the new kid on the block for treatment of IIH is venous sinus stenting. And the indications are usually when you have a big large arachnoid granulation, as you can see, I think my arrow is working or maybe not. But anyway, you see the big arrow there at the arachnoid granulation. And also the septi are also present. And you can stent across these. Here's a stent going through the septum. The indications are it has to have greater than eight millimeters of mercury, pressure gradient across the stenosis. And the pressure really has to be elevated at 220 or 2020 millimeters of mercury. And these people have to be on clopidrogel and aspirin. So there can't be any contraindication to that. And it has been used for severe disabling headaches associated with intercranial hypertension, focal neurologic deficits, rampant papillodema, and visual changes. There was this large metadata meta-analysis that came out on 49 studies, 250 patients. And you can see that the pressure improved in almost all of them. The transient visual obscurations also improved, pulsatile tinnitus improved, headache resolved in 37% improved in 41%. But of all the parameters that again was the least likely to resolve. Papillodema did resolve in 41% and improved in 38%. But there are complications. And the main one is thrombosis. There's been subdural hematomas, intracerebral hematomas, cerebral edema, stent migration, and even death. So if you're going to look at all of our procedures, you can see that in this review, it was a wonderful review that looked at all of them. You know, nursery fenestration really is very helpful for papillodema. But the other procedures do treat at the stents, the shunts. Visual fields improve in all. Most of them have some headache improvement. Maybe the optic nursery fenestration is the least. And then you can see that all procedures have complications and shunts. The problem is about half of these can fail. And so we kind of shy away from shunting. So in conclusion, IIH is most likely a metabolic disorder. Definitely more work needs to be done. I think it behooves all of us to know about the GLP1 agonist about weight loss. We don't really know what the effect is going to be for headache or visual loss. Weight loss surgery is a treatment for weight loss, but not for visual loss. And stenting may play a role in treatment of some patients that don't respond to medical therapy or some of our other even surgical therapies. That is all. Do you have any questions? Yes. How long does it take to see the results of the stenting? So from the papillodema to go away? Well, the pressure will go back to normal almost immediately after the stent. And as you know, papillodema is very variable from person to person what actually happens. But the pressure will lower almost immediately after the stent. And then the papillodema usually gets better within a few weeks. But 30% is the female preponderance. So the question is about women and metabolic disorder and the female preponderance. Well, we do know that obesity, diabetes and this metabolic syndrome is more frequent and women all by itself. People with IIH are more prone to, let's say, polycystic ovarian disease. And so there are these metabolic and endocrine abnormalities that are being thought to be more prevalent in women than in men. You know, the answer is definitely not out there. But you know, we have a lot of obese men and we don't see that much IIH. It's got to be the hormones. So apparently there's going to be a fire drill at any minute. So it is a drill and we're not supposed to evacuate. So I do some medical legal consulting as a side hustle. And it's actually very interesting. I learn a lot about how doctors think, how lawyers think, and also really see some interesting medical things go wrong from which one can learn. And so I got permission from a plaintiff who had sued her ophthalmologist because they missed the diagnosis of the tuatary tumor. I got her permission to present her case here just for an example of like what not to do as an eye doctor and also kind of get a little insight into how the medical legal system works. These are my financial disclosures. They're not relevant to today's presentation. I was inspired by this article by Noble David in 2006 where he also did some legal consulting and he presented six cases in the Journal of Neuroothemology where ophthalmologists had been successfully sued for missing the diagnosis of pituitary apoplexy. For those of you that didn't read the presentation that I sent by email, this is a 55-year-old patient with two weeks of decreased vision and one day of headaches. On examination, she's got hand motions, vision, and atherm pupillary defect and a pale nerve and one eye. She's diagnosed with ischemic optic neuropathy, told to come back in six weeks. At six weeks, her exam was unchanged. The eye doctor told her to get it evaluated for sleep apnea because she didn't have high blood pressure diabetes or high cholesterol. At 12 weeks, she went and she was supposed to come back in three months, but instead she came back in 12 weeks. No, anyway, she came back early. Now she's got 2,200 vision in her previously unaffected eye. To make a long story short, she went to the emergency room, had an MRI scan which showed a pituitary tumor that was resected, and then she ended up being no-light perception in the one eye and 20-30 in her previously unaffected eye with a dense temporal defect. She was left with just a nasal crescent of vision in one eye, and she ended up suing her the vitreo-retinal surgeon who misdiagnosed her with ischemic optic neuropathy. I was going to ask Dr. Kennedy if the retina doctor deviated from the standard of care, but he's in the OR at the VA. Oh, brilliant. Do you have a microphone? I do, so I can answer for Brandon. I was thinking about this question earlier this morning and I found it a little difficult because we get such good neuro-ophthalmology training here at the program, and so I'm not sure of that skews how I see this, but I personally feel like he might have deviated from the standard of care. There were two big points that stood out to me, and this actually goes to my own question, I think number three, is that when we all learn in general medicine, even through neurology, that if you have a headache with any of these red flag other things, like this patient was over 50, I don't know if it's her first one, but then it was also, it could have been a new headache, but really it had visual symptoms and exam findings along with it. Usually when that happens, it's like a straight way to get imaging right away. And so I think that's a first point, but the other thing that struck me too was that he sent the patient back to the optometrist and there was more vision loss. And that was also another huge red flag that we should be investigating more instead of just chalking this up to a new, or like a refractive error. And so for me, yes, I think he did deviate from standard of care. Okay, yeah. No, I agree with you. And I think this case was settled. It didn't actually go to trial, but I think the defense attorneys were also convinced that maybe their client had deviated from the standard of care. So the question is, did the retina specialist order a sedrate in a CRP? He did not. And you know, I don't know, the patient's 55 years old, her risk of giant slarditis is pretty low. That wouldn't be the first thing on my mind, but he didn't order any tests actually that I know of. Dr. Sauer is going to tell us if the optometrist who originally saw the patient deviated from the standard of care. Maybe, yeah, no. So I think one thing that the optometrist realized is that he didn't know what was going on and that he needed to refer the patient to somebody else who might be able to figure it out. But in terms of did he deviate from the standard of care, I think yes as well, because we all know that to get into retinal specialist, it takes some time. And this patient, as Tony mentioned, obviously had some red flags and needed to be examined and seen a lot sooner. And I think the correct way for the optometrist to refer this patient would have been to the emergency room right away because there was an optic nerve, a pale optic nerve with Audi Dima and that warrants imaging, especially in the setting of vision loss and the new headache. He should have sent the patient not to retinal specialist that can't see them for six weeks, but to the emergency room to get imaging and be seen the same day. Yeah, so I think Dr. Sauer brings up a good point and that is that everything in medicine is kind of black and white.  But everything in the legal system is gray. Nothing is black and white in the legal system. And so this is a gray area because the standard of care for an optometrist is different from the standard of care for an ophthalmologist. And so as an ophthalmologist, I actually can't testify to the standard of care for an optometrist. You actually have to get an expert witness who's an optometrist to express that opinion. But I actually think the optometrist did the right thing. They knew that they didn't know what was wrong with the patient and so they referred them on. I mean, they should have referred them to an optometrist, but at least they knew that they didn't know what the diagnosis was and needed some help. Whereas I think the retina specialist also didn't recognize that they didn't know what was wrong and didn't recognize that they needed to ask for help. Dr. Etheridge, was the ischemic optic neuropathy diagnosis reasonable under the circumstances? Is Tyler here? Okay, so I will answer for him. So I'd say the sine qua none, that means like that with which out one, it doesn't exist. For ischemic optic neuropathy is a swollen nerve. So if you see a pale optic nerve, you cannot make the diagnosis of ischemic optic neuropathy. Now, you could be right that that was what actually happened, but you actually have to have seen a swollen optic nerve in order to make this diagnosis. And the swelling should resolve within about six weeks or so. So I think that the retina, I really fault the retina specialist. Again, you can't assume that just because ischemic optic neuropathy seems like the most likely thing in a 55 year old with no risk factors, then you can't make that diagnosis. Okay, so Dr. DeSautel's was going to talk about posterior ischemic optic neuropathy and its prevalence compared to a compressive optic neuropathy. Yeah, so the short answer to this is no, posterior ischemic optic neuropathy is not more common than a compressive optic neuropathy. There's not a lot of incidence data out there about this for ischemic optic neuropathy on the aggregate comprising both anterior and posterior ischemic optic neuropathy is the overall rate, you know, you're looking at something on the order of like two to 10 per hundred thousand in the US population. But series that have looked at posterior versus anterior ischemic optic neuropathy within ION as I've been seated about only 4% of ION cases are actually P-I-O-N. So the incidence is probably somewhere closer to 0.08 to 0.4 per hundred thousand. So it's certainly much, much less common and compressive optic neuropathy has a rate of about one to two per hundred thousand. Thanks for looking up the epidemiology. But yeah, I think you're absolutely right. Posterior ischemic optic neuropathy is extremely rare and it's actually a diagnosis of exclusion. And so one would never want to make that diagnosis without first chasing down the other more common ideologies like a compressive optic neuropathy. Thanks. We do have a chat question. If the patient is seen in a delayed time frame after the referral and the optometrist didn't specify the time frame is the liability of both parties. I'd say that's another gray area. I'd say, again, as an optometrist, they might not have realized that this is an urgent situation. If the patient then comes to you and there's been a big delay between the time that you see the patient and the time that the optometrist specified, as long as you do the right thing, you're not going to be liable because this is not actually your patient until they appear in your clinic. And so I would say that in that case, the ophthalmologist is probably not liable if they do the right thing after the first visit, not after the third visit. And the optometrist may or may not be liable. Again, that's going to be a gray area. Dr. McCurry was going to talk about whether or not the vitriol retinal specialist should have been expected to diagnose a compressive optic neuropathy, because I mean, like a pituitary tumor, that's not part of being a vitriol retinal specialist. That's diagnosed by other specialties. And I just couldn't, like I actually read that, and this was an actual thing that was written by another ophthalmologist in a report that they filed for the defense. And I was just, that really got my blood boiling because I think that we're doctors first, ophthalmologists second, and specialists third. And as an ophthalmologist, you should, even if you're specialized in vitriol retinal surgery or cornea or glaucoma or pediatrics, you should be able to hear this story, see this patient, and know that they either need to be referred to another specialist, which is fine. You don't have to make the diagnosis yourself or you need to work the patient up. You can't just assign them a diagnosis and let it go. Okay. Dr. Muhammad was going to talk about what missing piece of information caused the defendant to miss the correct diagnosis. Wait a little bit. But in terms of missing piece of information, I feel like in this case, an optic neuropathy of uncertainty in biology, in addition to neurological symptoms including headache, you know, pretends additional workup, particularly brain imaging. So just with those two kind of exam findings and in history, I think it's pretty obvious in our case that that patient should have received a scan or at the very least, sub-stratiality referral to neurophthalmology. Yeah. So this again was a sense that I read in a letter filed by an ophthalmologist in the defense of the vitriol retinal specialist that said that because the patient did not report vision loss in her left eye at the initial presentation, that that was their fault. And because she was a poor historian, that that's what caused the retina specialist to miss the diagnosis. And to me, that's victim blaming, you know, like I'm not even sure that the patient, I mean, the patient probably did have some vision loss in her left eye at the initial appointment, but she was aware of it. Her visual acuity was normal. So to say that the patient is a poor historian and make that as an excuse for somebody missing the diagnosis is inexcusable. No, that's a question for one of the residents. Dr. Polsky was going to opine on whether or not pituitary tumors are slow growing and if the patient had had surgery after the initial presentation, it would have been the same. This is another argument made by the defense. Yeah, I guess a couple things. So it's true that generally most pituitary adenomas are slow growing. Some of the things I read were around like one to three millimeters per year, which first of all, I mean, if someone has a large pituitary tumor that's abutting the optic chiasm, then very minor changes can potentially cause devastating visual changes. The other thing is to not to bring up visual fields again, but if a baseline visual field had been obtained, then they could have objectively, potentially objectively shown if there was any change over time, but they didn't do that. So there's no way for them to show that there was no progression. The other thing is, that's kind of crazy to me about this argument is that they went from hand motion vision to no light perception in the right eye, and they went from, I think it was like 2030 in the left eye to 2200. And so there was objective changes in the visual acuity, which can be explained by what was ultimately found, the pituitary tumor. So I think this argument is not great. Yeah, no, I agree with you. And this is a little bit more gray area, because Dr. Polsky is absolutely right. These tumors are very slow growing, but the fact that the patient had vision at her initial presentation had vision loss of only two weeks and had this new headache tells me that she probably bled into the tumor. And when you bleed into a pituitary tumor, that's pituitary apoplexy, you have rapid expansion of the tumor. And if you deal with it right away, if you decompress it right away, you can save the vision. And if you don't decompress it, then as Dr. Polsky said, even that little additional compression of the chiasm in the optic nerves can lead to irreversible vision loss. That's hard to say. Actually, I'm going to actually push that question off. Dr. Kirsten was asking, because the nerve was pale at the initial presentation, isn't that proof that her prognosis was poor? I'm going to push that off to one of the residents, because that's another question we've got coming up in the time we have left. Dr. Wilkinson, currently rotating on neuro-othemology, what ophthalmic testing at the initial visit would have best predicted the potential for visual recovery, which directly addresses Dr. Kirsten's question. So an OCT... Sorry, saved by the bell. So an OCT-RNFO would have been really helpful in this situation. Excellent. Because thinning of the optic nerve head would have been predictive of worse visual outcomes. Yeah, so that's actually... that there's some literature on this. A retinal nerve fiber layer scan at the initial visit would have best predicted her visual recovery. And I think Dr. Kirsten's right. With a pale nerve, your prognosis for recovery in that eyes might be guarded. It's another gray area, because none of these tests were done. But I think the prognosis for the other eye, which as far as we know was uninvolved at the initial presentation, was much, much better. And so I think we could have preserved vision in her left eye if action had been taken at the initial visit and not delayed by 18 weeks. And then Dr. Wertz was going to address my question. What do we do when we encounter patients who are poor historians? I'm over here on the side. But I think there are kind of two things that come to mind. And one is that you... if you have reason to believe that this patient might be a poor historian, you have to expand your differential and you have to rely more heavily on your exam. So I think in terms of... there are a lot of things you can do in terms of doing more extensive chart review, get more of a sense of what's this patient history, what risk factors do they have.   And that means that you might do a more extensive workup than you would do for another patient. But that's kind of your job as the physician is to figure out what workup do I need to be not just anchor on one diagnosis, but to convince myself that I'm not missing something else. What are the... the can't-miss things that I need to be ruling out? What are the more serious things? And then kind of as a side note, you know, it's impossible to say whether this was truly part of this particular encounter, but I think anytime you start to think to yourself or consider the possibility that the patient in front of you is a poor historian, you also kind of have to think to yourself, why do I think they're a poor historian? Just because I think sometimes it's easy, you know, if we as physicians often have some unconscious biases as well that might cause us to not take patients seriously or not believe them, or to maybe not consider the things that they're telling us as seriously maybe as we should because of something else that we're thinking about, either we're anchoring on a diagnosis or there's some other factor. And so I think that, you know, before you assume that somebody is a poor historian, you have to be considering that as well. Yeah, I think you're exactly right. I think your point, the thing that I would take away from what you just said, Dr. Wirtz, is when we all encounter patients who are poor historians and in that case we can't rely on the history, we have to go the extra mile with our exam and testing. And so if you want to go down the road of saying that this patient was a poor historian, then you need to go the extra mile as the examining physician and do additional testing, go the extra mile to really figure out what's wrong with the patient because you can't rely on the history. It's not an excuse for not getting the right diagnosis. And in this case, a visual field, absolutely, I'm sure that if the vitriol retinal specialist had done a visual field at the first visit, there would have been a small temporal defect in the left eye and they probably would have tumbled to the right diagnosis and gotten an MRI scan. One neuro ophthalmologist has commented to me that visual fields are the most underutilized test in ophthalmology and I think I agree. That was certainly the case in here. Okay. We have one other chat question. I'd make a case for a visual field whenever there is something funny about the history or exam. That's absolutely true. I agree with that 100%. Visual field tests should always be your go-to when there's unexplained vision loss. That should be your knee-jerk reaction. Dr. Warner has a comment. I just want to add that sometimes the reason why a patient is a poor historian is because they could be afraid of what the diagnosis might be and they want to minimize things and brush things off perhaps even more than the clinician and because they're afraid that they've got a brain tumor, they don't want to mention that word. If they do, they need a scan. Brad, can I ask you something? Yes. It's hard. You should already scan it but before the deal is completed, how would something like this have been worked out and figured out? Dr. Kersen's question is how would you... How would you work this up if you couldn't get a CT scan or an MRI? Let's say you were working in an under-resourced country where that wasn't readily available in the next building over like it is here. I think you can still do skull x-rays just about anywhere. Sure. Yeah, you might see an enlarged cell atersica on a skull x-ray. You could do endocrine testing. If you were suspicious of a pituitary tumor, you could do endocrine testing. You could certainly do a visual field. I think visual fields were around before the Beatles. Even confrontation fields. I'm sorry. A red ball. We're doing fields with a red ball. Yeah, you definitely have to be a little bit more resourceful and when you don't have an MRI scanner in the next building. So I'm sorry we're out of time. Dr. Patil and Dr. Sanchez won't be able to get to the questions that I had sent you. I apologize because it's 9 o'clock. I am red. Circling back to your comments for the end on the timing of the consultation. The highest dollar amount suits in ophthalmology now relate to retinopathy prematurity. And ophthalmologists have been held accountable both for failing to get the patient in in a timely manner. So the time, they've looked at it from the time that it was scheduled, not when you met the patient. And so that you are responsible for that. And the other issue is that ophthalmologists have been found accountable for failing to recognize that the patient didn't show, failing to track the patient down and successfully get them in. In all these circumstances involving bad outcomes with everlasting light, long visual impairment. So be careful with that and make sure your staff is aware of what they're doing because some of these are a bit gray areas. And unfortunately the courts have come down leaning on the ophthalmologist in that circumstance. It's a dangerous world out there. Darn right. Okay. And with that thought, have a great Wednesday. Cheery day, right? Have a delightful day and career.


The MMPREDICT study is a Horizon 2020 project started in November 2016 and is funded by the European Commission on the Horizon 2020 program. It is a team of two clinical partners. We have the Erasmus Medical Center and the University of Turin. We have a biotech company, Scott and the X. We have the Erasmus University, the economic partner within our team. And we have the Miloma patient's Europe as a partner representative in the project. We aim to develop a diagnostic tool which can predict the most effective treatment for each Miloma patient. Scott and the X is a specialized company in the development and validation of diagnostic tests. We have put already a test on the market for Miloma, the MMPREDICT. And it's a test which can distinguish patients from in a high risk group or a standard risk group. Currently we're now focusing more on the treatment side. If we can also predict which treatment is best for which patients and that's where we can implement our knowledge in the development of such tests. So we will measure genetic information from different multiple Miloma patients throughout Europe. We have recruited 800 patient samples and we hope to get some genetic information and from these patients look at their treatment and see if there's any correlation between those. In that sense we can implement this in the future to predict which patients is most suitable for which treatment. We hope that every patient gets the optimal treatment they deserve and in that sense focus on the most effective treatment for each individual Miloma patients. Also we hope to provide this and improve the care of these patients so reduce the side effect and directly get the right treatment for these patients.


This week in the rundown, we discuss how you can protect yourself in cyberspace, the redesign transition assistance program, and more opportunities for you to earn a Navy-funded postgraduate degree. First, the recent security breach at the Office of Personnel Management underscores the need to be aware of online threats, such as identity theft and hacking. OPM is notifying the estimated four million government employees who may have been affected by the cyber security breach. Here are five tips everyone should follow to help prevent identity theft. One, check your account information regularly. Two, keep an eye on your credit report. Three, verify the identity of anyone asking for your information. Four, do not reveal personal or financial information in email and do not respond to emails asking for this information. And five, keep your documents in a safe place. For more information, check out this week's wire. Next, the Navy has redesigned the Transition Assistance Program, or TAP, to prepare sailors for the civilian sector. The changes include a new curriculum called Transition, Goals, Plans, and Success, or GPS. It's a five-day class that goes in-depth in financial planning, VA benefits, and includes an employment workshop all designed for preparing sailors for a civilian career. The Navy also announced more opportunities for you to receive a master's or a doctorate degree. More than 1,500 quotas are available for officers and enlisted. These will include programs at the Navy Postgraduate School, the Naval War College, and various other service grad schools, as well as the top civilian universities. Remember, these are Navy-funded programs intended to help us educate and retain our best and brightest. So don't miss out on the opportunity, contact your detailer for more information on an academic career path, or visit npc.navy.mil and click Education under the Info tab. Next week, we'll look at how the Command Advancement Program, CAP, is transforming into the Meritorious Advancement Program, MAP. Beyond a name change, the new program will give commands the opportunity to petition for extra quotas or return unused ones. Among other things, we expect a NAV admin to be out this week. That's all we have this week on the rundown for any questions. Shoot us a tweet at usnpeople or you can find more information in this week's wire. For the Chief of Naval Personnel, I'm Lieutenant Ryan Benitez. Thanks for watching.


Hi, welcome to today's webinar. My name is Kirsten Vandetta. I am a senior product manager at LinkedIn And I'm excited to talk to you today about two of my favorite topics user empathy and Enterprise products. So a little bit about me before we get started I've been in product for about seven years now I started at a company called simple view which creates technology for destination management organizations and travel and tourism and They were a startup and I did that for a few years before moving into Higher education So I work with a great team at the University of Arizona to modernize The student experience and really create digital tools on campus and now I'm at LinkedIn which is a larger firm and Working specifically with building technology for sales as a senior product manager And most of my B2C experience really was in higher education And so a lot of my experience across from simple view to LinkedIn is in the enterprise space So when we talk about user empathy today that applies for regardless of what product you're in But when we talk about empathy in action, I will sprinkle some flavor on that When it comes to enterprise products, so the first section we'll talk about create how to create a culture of empathy Not only within yourself, but how you build up with your team and even up to leadership And then when we talk about empathy in action, we'll talk about how empathy is not just listening and understanding It's also doing and so what can we do to prioritize our user needs in enterprise products? And then the last thing just we'll talk about the effects of empathy Especially as you're building empathy within your team In fact, there was an article recently that came out in Forbes and it was talking about Satya Nadella the CEO of Microsoft And how he says there's one psychological trait the most innovative teams and that turns out to be empathy and so empathy can really create Innovation by truly understanding your users and putting yourself in their shoes. So that's what we'll talk about So let's start with creating a culture of empathy. Well first. What is empathy? What is user empathy? user empathy is Understanding something from your user's point of view from their perspective not yours So if you're listening to someone they're telling you a story about something and you're putting it in your own frame of reference that is Not empathy. Empathy would be listening to someone and actually putting yourself in their shoes why they may feel the way They do, you know, their goals. Why are their goals that way? What do they need to do to accomplish their goals? What are their pain points? What are the struggles that they're dealing with and understanding them coming from a perspective of understanding them instead of judging them? And so that is user empathy Walking a mile in someone else's shoes really so how do we build empathy for ourselves for our teams? Well, I'll start with just in general how you can be empathetic And then we'll talk about how to build empathy in our teams and then with our leadership teams and our internal stakeholders for our users specifically so First thing listen listen listen If you're not listening and you're doing more talking than they are you're going to miss something About their pain points their motivations and anything you need in order for you to truly understand What problems need to be solved because at the end of the day product is about finding the right problems to solve, right? And really understanding those problems And another thing I just put this as a some bullet I think it's really important to allow for silence When you are being empathetic and you're really trying to understand someone if you are Not prepared to sit in some silence while they process and you process You might miss something and our knee jerk reaction might be to fill the silence with our own perspective So an example of that might be if somebody says well, it's really frustrating for me because X And you say can you tell me a little bit more about that and they pause and you you know Maybe you're counting like 10 seconds 15 seconds. I mean, that's a long time actually sitting in silence And then you respond with is it because would it help it? Now you've switched roles Now you're talking about your perspective You're truly trying to be helpful, but you're not listening to them anymore You know put yourself in the situation and it's not about right so Allow for that silence, you know, if it's too long, you know, maybe that 20 seconds, you know jump in there But allow for that and during those silent moments process put yourself in their shoes, you know Instead of thinking to yourself well, why wouldn't they just do it this way think okay, so if I was them I'm doing it this way because and that leads you to better questions To be more curious and ask the right questions and again, don't ask those with prompts Would it work better if and definitely don't solution when you're being when you're just being an empathetic ear Definitely don't solution. You're still listening to them and it's still about them and not what you can do for them yet The next thing is speak their language, so it's really easy We're all you know, we were as product managers. We work with engineering. We work with UX We work with leadership work in the industry and there's a lot of jargon floating around Leave your jargon at the door Unless it's jargon that your users use don't use it use their jargon learn their industry terms Work to understand where they're coming from and use words that they identify with versus what you identify with The last two kind of go together Using empathetic language and avoiding judgmental language and in order to avoid judgmental language You have to avoid thinking judgmentally. So let's let's do an example of what that might look like So we have a user who says I would like to accomplish task X in fewer steps It's super frustrating too many clicks. Okay, so a judgmental language and judgment looks like Well, that doesn't you know why I mean, it's not that hard Just few clicks Then they're done so that's pretty common probably in any product forget enterprise I like that's pretty common in any product and Where that judgmental language comes in you've lost your empathy You've already decided they're lazy It's not that much and they're being sort of way So your judgmental language is nowhere close to empathetic Empathetic language flips the script and we think to ourselves. I wonder why it's frustrating for them. How many clicks is it? What are they trying to accomplish or could they do it? You know, I guess not could they do it a different way? But you know, how frequent are they doing that because that would be really frustrating if they're doing like, you know This many times a day, you know, we could look at that Now you're using empathetic language. I understand that that it's frustrating I could see how that would be frustrating Especially if it's this many times. So the difference is Judgy not judgy, right?  It's seriously is a couple clicks. We have other things to deal with and That can be helpful, especially if you're in a setting with your users where you're talking to them, you know Not having that judgy language where they come with something to you and you immediately Solution for them and basically tell them like they're doing it all wrong. You can do it this way everybody else is Another way to build empathy within your team is with your personas and your user stories now personas. I'm going to say broadly Lots of people build personas depending on the size of the company you're in and what roles you have in your product team So if you're in a large company, it might be you wax that builds personas. It could even be product marketing If you're in a smaller company, it could be you as the product manager Regardless of where those come from use them as much as you can because it puts a face to a name in the bowl The second thing is is using user stories as a way to build in an empathetic language So not just you and anyone you're talking to is is taking in those stories from the user perspective But you're getting that into anything anybody's reading, you know, engineering is gonna read it Scrum master is gonna read it everybody that's working in JIRA basically is gonna read it or your spreadsheet or whatever you're using So our example is on the left. We have faceless dude Who wants to export data because he's gonna manipulate some data offline from other reports?  What do you mean the reporting tool? But skip that On the other side we have as a data analyst So we have a we have a persona I need to apply custom calculations monthly board reports We need this because we we should exist to our board In our community so we can keep our funding the difference is no persona versus a persona I haven't generalized why and Nothing for my engineering team to even tie themselves to they there's nothing for them to connect to Why are they taking data out of the system? We have a reporting tool Whereas the other one they can empathize they kind of see what's happening. Okay monthly board reports, you know The solution is not anywhere in here. It's just I have something to connect to I have someone to connect it to and Clearly the product manager has done a little more investigation to if I know enough to put that much detail in there So that helps using your empathetic language in your user stories The second thing Actually, I don't know what number one But the next thing is that sharing user feedback with your team is super important You can also share it with leadership. You can share it up. You can share it out But definitely with your team Specifically UX and engineering. I feel like get forgotten a lot and I speak from experience So when you get positive feedback something whether it's from a stakeholder a buyer a user or whatever that might be Share it share it share it share it. They built it. They're building the tool. They're maintaining the solution They were the ones that that really innovated and tried to think of the solution along with your expert problem definition and your why But it helps them connect with users more. Let's say they worked with your product champions Or your user group or something and now that it's rolled out and users are using it and they're blown away. I mean Man, you know for your engineering team to be able to say, oh my gosh, I worked with Julia on that and she loves it Like this is so cool On the reverse side, don't protect your team from negative feedback Now I put a like a tiny caveat on that in that We want to share we want to make sure our teams are hearing what's important to our users but if you get something that's just like you know Really negative language Make sure that when you forward that on that you are Adding narrative somehow to say what the negative impact is versus the negative language Ignore the negative language and look deeper again in their shoes What is the actual pain point and problem they're bringing up and that can really help your team connect To your users both positive and negative. So you got to share the negative feedback It's how you get to the positive feedback The next thing is actually four things. These are not small things. So it's kind of funny that I put them all in one slide So you'll see a little disclaimer at the bottom once you get these slides if you want to download load them You're welcome to read that But basically these are really big things. They take a lot of management time From you From whoever else on your team might be helping with these but they are invaluable Ways to create feedback loops and connect your team to your users in order to build that empathy So the first one's a user advisory group Call it whatever you want a user group a focus focus group But are really a group of maybe product champions or product users that you get together And they partner with you on really digging in with how they work And what they need and what their goals are And bringing your team to meetings with this group Make sure your team is embedded in these conversations your team UX Engineering whoever else is on your team They're going to hear different things than you do in those meetings And you all coming out of those meetings with those different perspectives Gives you just such a leg up when you go to create solutions Yeah, and you can be really innovative because you truly understand What's going on with your users the next thing is Sprint demos i put sprint slash feature demos, but it's really sprint demos So if you have this probably works better with a smaller company, but if you have Say your user group or your user advisory group or you have some product champions that are helping you With building a specific feature set invite them to the sprint reviews where your team is demoing what they've built Because not only does it help them give immediate feedback, but you start to build empathy both ways They see all the effort your team is putting in they see how the progress is coming along And they can give you feedback But also understanding where you're coming from and then also engineering can hear immediately like oh I thought that was going to include this or oh my gosh I can't even oh we asked for this and you gave us this and this is amazing and I can't wait to use it It was really a really important piece I found in In connecting my team to users And we got that idea from a fabulous agile coach. So if you watch this, I hope he knows who he is for feedback sessions What I mean by that is really I mean it really is a focus group But invite your team to those and so you're probably thinking right now like wow That sounds like a lot of meetings Kirsten and engineering is kind of busy. Um, you know, we only have so many resources pool Calling your engineers resources first of all is not empathetic So your engineers are not resources. They can be resources to accounting and finance to you. They're your team and Yes, you want to honor their time you want them to be able to do the work that they need to do But they're going to do better work If they connect with users So It doesn't have to be a weekly thing a daily thing whatever happen come quarterly Even but give them that time to connect ask the questions that they have It makes you guys all Work together in the same way coming from the same perspective or sorry bringing your different perspectives to build this just really excellent massive transform um And then the last thing is surveys surveys are a science be careful with surveys those can be built wrong They can be interpreted wrong make sure you And keep those Maybe hire someone to help you build your surveys first to start Um, but surveys don't have to be long either. They can be short. They can be in application. They can be for a specific feature um But surveys give you the quantitative data in some cases So you'll get your analytics from your product You'll look at your usage your daily active users Whatever that might be and your surveys help sprinkle a little more qualitative on top of that as well So quick breath here Um Before we move into the next section. I just want to do a quick check empathy Is so important Like satya said, it's important for innovation. It's important for really understanding your users But it is a method of understanding and connecting It is not a method of agreeing with or committing to You can put yourself in the shoes of somebody who You know has opposing views than you without agreeing with their opposing views Right to be empathetic is to understand from someone else's perspective So I just want to make sure everybody knows in no way shape or form am I saying Go through all of your backlog be super sad about all the collects have lots of sympathy For your users and make sure everything that they're bummed about gets on the road map. That's sympathy Empathizing is understanding and you can empathize without putting it on the roadmap So our next thing is how do we build user empathy with leadership and our internal stakeholders now? Some of our internal stakeholders might interact with users a lot For example, the sales team Or the support team they interact with users a lot So they're going to have a lot of user empathy already But leadership might not in the and the users that leadership is interacting with might actually be more like buyers And stakeholders and so that connection is missing and you are the missing link So how do you do that? How do you build user empathy? How do you go into a conversation and say yes? CEO or vp a product or whatever that might be You know that sounds like a great idea that solution and that initiative But here's what I could say about These last few meetings we've had with the user group here are the problems that they're up against Here's how we could we think we could solve that Yeah, and here's impact to us and it really helps when you bring empathetic language The wise the background the impact it kind of put a face to a name And so for four things here and actually the last one telling a compelling story is just a given It's down all of them The first one is having a roadmap that outlines your problems that you're solving and not your features that you're building Not all of us have the luxury of doing that. It's really hard for people to move to a bar on your roadmap that says Reduce manual data entry or save users time with blah blah blah, right? Um It can be kind of tough because people want something a little more tangible and so we end up with future roadmaps They're not perfect We end up with them But if you can move If you can move your roadmap to problems to solve versus features to build you get away from a lot of things like you know not having Conversations about why that one feature isn't out yet, you know You get to leave your engineering team room to actually innovate and create solutions without pigeonholing them Already on the roadmap and not leaving them a lot of room to change The next thing is communicating user impact and value often often often So everything that you had in your user stories make sure when you're having meetings you're talking about the why's You're putting your sharing user feedback.  You are the user advocate You are fighting for your users like tron And so you want to communicate that often The next one is communicating user value to business impact when you're prioritizing I'm going to show you what I mean by that when we go through the empathy and action I'm going to give you sort of a A roadmap or a path to how you do that So let's move into empathy and action Empathy and action to me is I have listened. I have heard I understand you um I understand why you need these things Now, how do I decide which of those things to act on and how do I make sure that we actually get some of the User needs onto the roadmap when I have all of these different competing priorities So I want to start with by saying that enterprise products Have a lot of stakeholders. Um, if you're already an enterprise product manager, you're chuckling right now because you know that Um, but you have your users you have buyers. You have internal stakeholders that range from senior leaders to product leadership to You know engineering has tech debt and it needs us to run some updates and dev ops has these other things and There's a lot of competing priorities and there's only so much room on the roadmap And again, don't call your engineers resources. And so when you're looking at well, how do I prioritize All this user feedback I got When you don't when you do all this stuff like I am listening we're listening And then you get to a point eventually where your users are like, but I feel like you're not Because I still don't have that thing you still haven't solved this problem for me And I just saw that you pushed out like nine new features. So where's my stuff, right? We have to be really careful about that because Um, eventually we lose their trust And they just stop talking and then we lose our ability to innovate. So we have to be really careful with that So how does that work? Well? I'm stealing the slide from a previous webinar. I did called b2b enterprise product leadership Actually, I sold the last one too This one just is in general If if you're new to product management, there's a lot of things you have to look at besides How do you put yourself in someone else's shoes? Because if they're reporting a problem or a pain point You need to know how many of those personas are impacted or what work streams are impacted Do they have a work around does it have to be solved? Or is it a nice to have are they just dreaming one day when they submitted that? So I'm binomium saying you don't have to do these anymore you do But when we're looking at empathy and action When we're trying to prioritize our user needs with empathy It looks a little something like this like how we go from empathy to on the roadmap So let's do our university edition So I have an advisor a student and I have faculty Our advisor I mean, so if you've been to to college or university your advisor helps you with your classes They help you pick your degrees. They'll help you with all sorts of things You as a student you need help navigating the university. How do I sign up for classes? You know, what happens if I'm failing one etc, etc And then we have faculty they teach students and they coach them in their coursework So if we look at let's say we have these things reported to us or we're noticing these things on campus So advisors are saying while students are dropping into my office all the time But I'm not available. I'm already booked I have people in my office on the phone whatever that might be And I feel really bad because I can't help them when they need it Then you have the student saying well, I need help and I go to my advisor But they're never available and I have to get registered and I just don't think I'm doing really well in this class And then you have faculty that are like I have office hours and no one comes to see me Right and I can see who's struggling in my class So we have a theme here and I've just picked this theme. You could probably pick other themes Well, let's say we want to connect students to help with the university So we take that theme And in our next evaluation We now have to align it to goals and we're going to align it to their goals We're going to align it to our goals and then we're going to develop a problem to solve Not a solution a problem to solve So the advisor's goal is to retain students and help them be successful The student wants to graduate She went from shocked to very happy the student wants to graduate And then the faculty obviously want to educate and help students pass their class because They want to keep their jobs because they want tenure So they want people to pass their class, right? So we have where this theme comes together Everybody kind of has a similar goal, right? We all want the students to graduate It's just different avenues for that But we have this underlying theme of needing to connect students to help and the right help So the university has a goal. Let's say they want to increase retention rates by x percent And so I can align their three complaints or pain points To their goals and our goal with this theme And create a problem to solve that says we need to reduce the friction and error For students when they're trying to connect with advisors and faculty for course help, right? So we get a very narrow problem that we can solve you could leave it more broad, you know Not necessarily course help could be other things But this is how you align it and you end up putting that on your roadmap with something like This where you are tying in the impact and value to your users To their companies their business To your business and your overall product vision And you align that all together with really empathetic language and that sounds something like this When students struggle to connect with help at the university they are x percent more likely not to return next semester Not empathetic just stated fact we have the data Empathy each semester they have several courses with multiple instructors Office hours to memorize several different applications to use depending on the instructor or college Lions to wait in or outside an advisory store And confusion and figure out who can help them best So one of our key business goals is to increase retention rates by x percent By introducing a solution that reduces friction for students and getting help with advisors and faculty We think this is going to help with our retention rates and you could have some more data in there And you might even be far enough along where you can say You know, we believe that the solution is an app You know, whatever that might be Because that aligns with your business vision because you're an app company, let's say So this is how you bring it all together when you dig in with empathy You get this opportunity To really build trust with your users to really understand them so that you you're solving the problem Because you understand it really really well And your team understands it and when you all come together, you all have a perspective That lends itself to innovating far better I mean, I think in that article that that Forbes came out with Satya's note about empathy being a driver of innovation He talks about teams the most high performing teams are the empathetic ones And the reason for that is it also helps you better align internally with your team So the effects of having empathy the effects of building empathy within your organization and within your team And the effect of building empathy with your at least your user group by inviting them into your space Say in like a sprint review You build trust Your users are going to trust that you listen that you're really going to try to understand them and you're going to do something about it Not about everything but do something about the things that are most important about align It's a whole different conversation about how to tell people you understand, but that's not going on the roadmap It helps your users build a sense of belonging they feel heard they feel connected to you They, you know, um, I've had such good experiences with the user groups And focus groups and bringing my team into it I just can't tell you how how well it just unites everyone And it creates this really transparent open place where we're all really trying To understand each other whether it's our users or cells or leadership It's it it's an incredibly useful thing to have on your team It's going to help you tell a better story. So having a user story like the one that I had early on in our example I mean by the time somebody gets to that Product education or change management can see oh, okay. I can see why we built that What's the solution so I can document it marketing can see why we were trying to solve that thing And what the impact is and you have a better starting point for a conversation than We added an export. Well, why how do I communicate that value? I don't understand what that value is right to you start from a better foundation And like I said, you know high performing and innovative teams better collaboration inside And then you turn your users into brand champions you turn your users into product champions And that word of mouth matters Especially in enterprise products when people are thinking about making large purchases for their organizations Sometimes products that aren't easy to get out of it's you know, it's it's not A one-way door, but it doesn't feel like a two-way door necessarily that you could easily go in and come back out change your mind So I hope you've enjoyed my experience with empathy the things that I've seen work in building empathy with teams And I've been lucky enough to be on several high performing Innovative teams with lots of empathy where we really just connect with our users and Understand where they're coming from and why they need things and I think it helps A lot with making sure that we're getting the right solutions out there. So I want to say thank you Thank you so much. Um, if you have any questions feel free to connect with me on linkedin. Just look up cursing man data It's also on the first slide and we'll make those available. Thank you so much


Building a property portfolio is a pretty good route for financial independence. And as always, we are here to help you get going with some expert advice and insight. This is the Private Property Podcast. My name is Tumi, let's unpack. Congratulations to Glenn Majosi for walking away with that 500 grand cash prize from yesterday's show. Thank you so much, Glenn, for interacting with us. Shoot your shot and share this post and tag your friends. And the person with the most shares wins 500 grand cash. Here's some handy tips to get you started off your property plans and strap and get them ready to launch. Number one, to become a truly successful residential property investor, you need to learn everything you can about every aspect of the industry. So the first step is to educate yourself. Number two, people usually have two options when it comes to finding a roof over their heads, either renting or buying. When it comes to residential real estate, your first priority should be to invest in a home for yourself, then start building your empire. Number three, your credit score basically determines your buying power. Before you start discussing how to finance investment properties, you need to take a good look at your credit score first. Number four, it's all about repetition. Buying another property from your first property profits is how you get investment return, the cycle going, and you have to have your portfolio working for you. Number five, any investment involves some risks. Finding it, putting all your eggs in one basket is the riskiest thing you can do. If all your investment properties are in the same type, it will be hard for you when the market drops. Whether you are starting from scratch or looking to grow, we hope that these facts help you to get the best out of your residential property investing. Today we are joined by a former Miss Universe and she holds five degrees and is in real is a real estate superstar, a true combination of beauty and brains. She has been working from Pam Golding since 1994 and she's the area principal for Durban North. Ladies and gentlemen and the private property family, help me welcome our guest tonight, Carol Reylo Reynolds. Carol, good evening. Thank you so much for joining us. To me, thanks so much for having me. Five degrees, ma'am. Five degrees. That is absolutely amazing and truly an expert. Someone we want to have on the seats to have this conversation with as we are talking property and investing. So jumping straight into our conversation tonight, I always mention property portfolios on this podcast. Can you explain exactly what this term means for somebody who's watching us for the first time and wants to start a property portfolio? Yes. So essentially property is a fantastic asset and investment class. So if you can start to build a portfolio, in other words, own a number of properties that you've invested in to secure rental income, then that is a fantastic wealth creation tool. In fact, it's one of the reasons that I'm in property. I'm so passionate about using property to create wealth. Something I've taught my children and it's something that I think everybody should investigate and explore. And if they have the means, they need to get going as soon as possible. And what can a property investor do in order to start building a portfolio? Like someone already has a home. They are looking and they are prospectively looking to go into this. You said one word that I like then you said investigate. How does one investigate this and start building a portfolio? So you need to start researching areas that generate good rental returns. So popular areas where there's good capital growth where you know that your investment is secure because the area has stood the test of time where there's always a demand for tenants. That's the key because when you're building your property portfolio, you actually want to use other people's money to grow your wealth. So you're going to investigate bond finance, which means that you have to look at your credit score and make sure that you've got a good track record so that you can secure bond finance. And then you need to make sure you're going to invest in an area where tenants are in high demand and easy to find so that you can then place a tenant into your property that tenant will then subsidize your bond finance. And the property starts to work for itself, which is what you want. It's always a good idea to get your money to work for you rather than you having to work for your money. And you know when it comes to property investments, right? It has a reputation as something that is really just for the wealthy. And does one need to have a lot of money up front before they start investing and what advice would you give to somebody who wants to start? There are so many ways to do that. One is to form a syndicate. If you haven't got a sufficient deposit, then find a group of friends who have got the same interests in you and who are also keen to get a property portfolio going. Form a syndicate. You can either buy in several people's names or you can form a little company and become shareholders in a company that you use as your investment tool. And that little company becomes your property company and the four of you work together to slowly build an asset base and properties. So you can start, for instance, you could each contribute 100,000 Rand, which means you've got a deposit of 400,000. And then you can seek to acquire a bond for about 600,000. Look at properties that are valued at a million Rand. And boom, you get started. A million Rand is a really nice starting point because the numbers work so well. So if you can gear your property and by gearing, I mean using the bank's money to finance it, you can put down a deposit of say 30 to 50%. So in this case, we're talking about a 400,000 round deposit. So 40% deposit. You gear the balance, which is your remaining 600,000. And then you'll rent normally in the million Rand price band. You will find that you should be able to get a return on your investment of 6% per annum. So you should be able to get 6,000 Rand a month as your rental income, which will pretty much cover your bond installments. And then you've just got a shortfall that you each need to contribute 80% per annum. And then you've just got a shortfall that you each need to contribute every month, which would go towards your rates and levies. Remember that your tenant will pay the utilities.  Property is such a great investment because A, you can use other people's money, in other words, money from the bank. B, you can use your tenant's money to cover your bond.  And you know, we are, we are watched by people from all categories in the property space. And what do seasoned investors and a seasoned investor who's probably watching this mean by diversifying a property portfolio? Yes. So it's a good idea to have a range of properties in your portfolio and to look at different areas to invest in. So for instance, there are a couple of areas in South Africa that are really safe investment wise. Cape Town obviously is very popular. The North Coast of KZN has been a booming market for the past decade. So you want to do your research and speak to state agents all over the country. We're happy to offer advice. We don't charge for advice. And that can help you just do some area research. So I think it's really important to explore the areas that you want to invest in and then to diversify. Maybe you start with a little apartments in Aung Shlonga. And then once you've got your first one, you've built up a little track record with the bank. And then you use that property as leverage to enable you then to buy your second property and possibly at that stage, you look at something in Cape Town. Once you've done those two, maybe Santa's a good area. Maybe there's a lot of tenants there. It's a good place to invest. So you're slowly growing your portfolio in a diverse way with multiple areas factored into the equation and even multiple price bands. So some investors have a strategy whereby they only bar off plan. That's also quite a nice way to build a portfolio because you put your deposit down today to secure the apartment. But the development only registers in two years time, which means that over that two year period, you haven't really had to subsidize the property at all. You've just paid your deposit. You've managed to secure your bond. You haven't parted with any other money apart from your deposit. And in two years time, you might already have achieved capital growth on that investment. We often launch products that we launch at say one and a half million round. And by the time the development is registered, that one and a half million round apartment is already worth 1.8 or 1.9 million. So our purchases and our investors have already built in a little profit for themselves just because property generally appreciates over time. Sure. Thank you so much for that. I'm just talking building a property portfolio and we are joined by Carol Reynolds. And so this is the time for you to share and make sure that you tag your friends to stand in line to win that 500 grand cash prize. Carol, coming back to you, what would you say is one of those traits, right? That all successful investors have in common. And with that also, what advice would you give to somebody who wants to become a successful property investor? I think the key to be successful in anything is research, and planning. You have to have a strategy and you have to have a plan. So as an example, we've got some investors who are serial investors on our development. So their whole strategy is around buying off plan, enjoying the capital appreciation. They will either then flip at the end of the development's period, or they'll hold and rent off. I've got other investors whose strategy is that they are always buyers and never sellers. So their strategy is simply to grow a portfolio and to hold. And they hold and then they rent it out and they keep growing and they never sell. So they try and hold on to all that stock. It's like playing Monopoly, I guess, where you just keep buying and keep going. So that's amazing if you've got the equity to just be a buyer and never be a seller. That's a really nice strategy. Another strategy that some investors have is actually to flip homes. So this is fantastic, except that in South Africa, our transfer duty is quite high. So you need to do your research before you get involved in flipping because you need to make sure that the acquisition costs don't eat away all your profit. But the bottom line is, in order to be a successful investor, you need to understand your product. You need to be well researched and get advice from experts in the field. Make sure that you're investing in an area where there's sufficient capital growth. So for instance, if you do want to renovate, buy an old property and renovate, you know that you're not going to overcapitalize in that area because you've done your research and you know that the price ceiling is really high.  So before you jump in, seek out advice. Advice in South Africa. Like anywhere in the world is free, especially from a state agency. We're happy to help. And we can give you all the steps that you need. And once you're armed with the correct advice, that's when you can start investing and making your money work for you. Speak to your accountants as well. Always really good to look at the tax implications of what you're doing, the financial implications. They can give you advice on what vehicle to use, to purchase your properties. And then, if you don't have the money, then start by buying your first property in your personal name because Sars has given us a lot of tax benefits for acquiring residential property in our personal names. For instance, there's a capital gains tax exemption up to 2 million rand. So you want to really be well-researched so that you make all the right decisions from the beginning. Yeah. No, thank you so much for that. And thank you so much for that. Thank you. Thank you. Thank you. Thank you. No, thank you so much for that. And thank you so much for such an insightful conversation about how one can really build that property portfolio. Thank you so much for joining us and have a great night. That's a pleasure. Thanks to me. Take care. And thank you so much to everyone else for showing us love on Facebook tonight. It's time to announce that 500 rand winner. And that winner is going to be announced in our comment section. So make sure that you keep your eyes glued on the announcement on our comment section. Thank you so much for joining us tonight for an insightful and packed show. Please do ensure that you join us every day 7 p.m. right here on the Private Property Podcast. My name is Dumi and have a great night.