Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

That's great. Right. Mhm. That's good thank you last night. Mhm I or ok excellent. Ok. Yeah. Mhm. All right. Too expensive. Ok. II want you to the mhm. That that you do not have thanks but they leave the house so you know in the house. Ok he is it? Oh I'm sure come in. Oh what about good and ok it's ok. Mhm. All right the left, the left I know you fine. I good. No, just 10 a lot. You live nearby one I mean I don't feel thank you so much. Thank you. Thank you but even when you have. Ok. Mhm. How about you? My wife um that's it 25 minutes walk I walk. I like it in. Yes so I think me. Mhm. So that's a good thing that will make my business. Mhm. Is that what you only need right to kind? Mhm. I don't I don't know. Mhm. Ok. Mm so ok. Ok. Mm take time um thank you very much once again if you're joining us uh just right now um you're welcome and the doctor is already here so um very soon we shall hand over to her. So I'll just quickly go through the house first. Mm mhm I see. All right. Um Please mute your microphone unless you asked to unmute um and turn off your vi unless and you asked to turn it on, you asked to raise your hand face if you want to ask a question or you, you want to make a contribution and you're also free to type in the chart if you feel the need to And on that note and if you haven't logged in with your full names, please do so as well as your drop your contact details, your numbers in the chart so that it will be easier for us to invest with data. Uh Please do not speak over each other and let us respect other people's opinion. Mhm So uh this is a notice from the V doctors. We are excited to announce that we successfully transitioned from the app to the new app. So what does that mean for us? You're instructed to stop sending the cases on the app. You can now submit real cases through the new app and our doctors will promptly respond to your queries. If you haven't already downloaded the app, please do so at your earliest convenience. Should you encounter any uh issues or require assistance? Feel free to uh contact us. You can inbox us or call us. We'll be here to uh respond to your query and please take this as an official address. Um So this is the performance summary for the month of June. We had 199 cases which was submitted for consultation and out of that, uh the three clinicians consulted out of these events to over top up with data. All the consultations came from 26 districts out of the over 82. So we have a chart which dep depicts the summary like, oh, we have 199 in ra, we have 63 clinicians who consulted in ra 52 are topped up in, in green and also 26 districts that consulted um the V doctor's recommendation. The DH O through the CC O should engage and encourage the service users to embrace by using the V doctor. Uh Secondly, the V doctors, the DH O through the CC O to collect and distribute by devices that are not being used. The service users should send sufficient information on the cases. When they consult on the platform, the service users should report all challenges concerning the device and the service to the CC OS and the virtual doctors. OK. Uh uh Please take big or recommendations from the virtual doctor. Ok. So um today's presentation is coming from doctor Hannah Bo. She's uh an ophthalmologist uh coming from the United Kingdom. Uh She's going to talk through uh uh talk to us about the emergency eye assessment. So I'll just speak with her to her so that she may do the presentation So it, but. Mhm. Ok. Ok. Ok. All right. Doctor. You go ahead with the presentation. Hi. Good afternoon. Can you all hear me? I'm assuming that they can, please let me know if you can't hear me, um, or if you want me to slow down, um, if you have. Ok. Ok. Hello? Hello? Oh, that's better. Ok. So did an, did, did any of that go through? I didn't think you did. Ok. So, hi again, everyone. Good afternoon. I'm Hannah and I am an ophthalmologist from England and I'm actually in Zambia at the moment. So it's nice to be here. Um, having a break from the UK. Um, and as you can see my presentation is about, um, and basically what to do about them, how to reach them. Um, and I want this to be interactive, um, as possible for you guys and the main aim is for you to learn whatever you want really. So hopefully you'll get something out of it. Um, so on that note, if you have any questions, um, if you want me to slow down, if you don't understand something or to go through it in a bit more detail, you can just raise your hand and ask or you can save your questions till the end. I'm going to have, um, try to have a bit of time at the end as well to go through a few cases. Um, so anyway, let's see how we go and Yeah. Yeah. Ask any questions along the way if you want. So I thought we would, how do you do this? Um start by considering the body. And in my experience before I was an eye doctor and now that I am an eye doctor, I feel that many people hear the body and the eyes are separate things. Yeah, the eyes, when it comes to them, people don't really know much about them. They're separate entities. They call the ophthalmologist and they give them vague description, history and they, they seem like they seem to be quite, quite of the eyes as well because they're quite unknown. They're very delicate. People are worried about picking them out and about touching them too much. Um So I first of all want to say that the eyes are actually part of the body, they're inside you, they're part of you. They're a very important part of you and just like any other part of the body. There's a lot of general police books that you can apply to that. Um Things can if your eyes are red. Well, what would you do if your arm was red or your finger was red or if your eye is swollen, what would you do if your foot was swollen or you have swelling on your stomach? So just like that, you can apply a lot of general principles. And if the eye felt is swollen and red and it also feels warm, then maybe it's infected, for example. Um I would definitely encourage you to start off by looking at your own eyes in the mirror. I know this sounds weird but I've done it myself. Um Look at your own eyes, look at how your pupils are reacting and look at each other's eyes as well. Look at how they move, maybe feel your eyes. You can actually pick your eyes fairly hard and it doesn't hurt. Um But obviously you pick them too hard or if the patient um has had an injury, su suspect there may be a penetrating injury to the eyeball, then you need to be careful. But in general, you can be fairly firm and it's really important. Um because when you're examining the eye, getting a good look and having, you know, seeing whatever information you can gather, really help the ophthalmologist will be to gain a bit more idea about what might be going on. So they outlined my talk basically, as I've already said, how to approach the eye, we're going to go through some common conditions and then um went to the ophthalmologist. And what did he say? So, first of all, going back to the general principles, does the patient look normal? Are they happy? Are they smiling? Are they completely conscious? Do their eyes look white? And as a normal eye should, or maybe the patient is looking a bit more like this, they're not very well in some way and that's the first thing, as I'm sure you're all aware, life vi if the patient is dying or their life is in danger, then that's more important than the side. However, if they are going to survive, ideally, they don't want to be bright. So if they're dying and they're going blind then to address their lives, um, threatening emergency and then have a look at the eyes as well. So your eyes are very important to life. Um And again, if they're systemically unwell, that might give you a clue as to what's happening with the eyes, maybe the eyes are being affected by the systemic condition. But if it's in the last slide, they're looking fairly well, it just their eyeball or either one or both eyeballs, they're a problem. Maybe it's a more isolated condition. Um Yes, just the eye look normal. If you ever see a nice normal eye you can see. So I don't know how much you know that eye it's got. So if I'm being too basic, then please let me know. And if you want to go into more detail, just tell me, I don't know how to, can I just look at the chat if I want, if they have questions or will they make their hand? I think they can raise their hand right? You can make your hand, I think, can't you? So just raise your hand if you want anyway. So there is a nice eye. So you can see the skin. If there's no redness, it's nice and opposed to the globe, the white bit of the eye, that's the flower and then the clear part of the eye, that's the cornea. Um And then that color part is actually a very thin um, disc with a hole in the middle. So that's the Irish, the hole in the middle is a people. It's not a thing like many people think it's just a hole. And what you are actually looking at here through the people is the lens of the eye. So unless you've had your lens removed, which is what happens when you have cataract surgery, we're actually looking at the lens. So if that pupil, if it's not black, but it looks white, then probably they either have a cataract or they have something behind the lens which is showing white and you can see it in people and then what is the most important thing in eyes? So, going back to general principles, if you see a patient or a person lying on the floor, what's the first thing you would do? You would go check their lives, right? And how do you check they were alive? You'd feel their pulse and maybe check their breathing. But yeah, the main thing is their pulse, you got a pulse, the heart is beating and they're alive. So the vital sign for the eye is the vision and that's really important. So if they can see the, the most important thing to establish is if they can see and if they can see anything, even light and dark that shows the eye here lights and, but if they can't see anything at all, it's complete darkness, they can't even hear the bright light shining in the eye. Then that, that's a bad sign that shows the eye might be either dead or temporarily dead ie, you know, in a severe state. Um, so that, that's really important and while there's light that it's definitely worth saving and again, hopefully go to later, even if there's no light, it's still worth shaving the light. Um, but beyond that, get an idea, an idea. So they can see like, great, get an idea of their vision acu is really helpful, especially for the ophthalmologist. And you don't need to have a vision chart. You can actually download them now on your phone. So I think it's fairly easy just to download Stellen chart or similar, um, vision chart and just check their vision, they give you instructions how far away to stand from the patient. Um, essentially if you don't have that or, you know, um, you want to just quickly do a vision and just ask them, can you see my fingers, can you pick up a small object off the table? Can you see this pen? Um, you know, can you read the paper and do that with each eye individually? Ok, then you'll get an idea if one eye might be completely blind and they might be relying totally on one eye. She do it with each eye individually. And many people call the ophthalmologist and say I couldn't get a vision because I couldn't open the eye because the eyes swollen shut, the patient is too much pain. They won't let me open the eye and they are too worried basically to open the eye. And I would say that in the majority of cases, you can't open the eye. So the number of times is it the or they manage to get vision? And they tell me the patient can only see my hand that the only detail like everything is really blurred. And then I go to the patient gently open their eye and actually, they can get nearly to the bottom of the vision chart. And that makes such a big difference as to what I think the condition is how I'm going to treat the condition. And the reason why I get a much better vision is because I push the patient and I really, I very carefully open the eye. Yeah, one tip actually is to not touch. So I mean, obviously the patient has a painful eye, injured eye is going to be very dumb. So you want to try and open your eye without putting any pressure on the eyeball itself. And the way to do that is to put the pressure, is that a question or is she want to have that right now? I can't see any hand out. So I'll continue you. But please do put your hand up with your. Um So I was saying yes. So unless you suspect they have a fracture of the orbit and even then it's probably safer. Basically, you lift the eyelid up gently and then use the orbit. You can find it in yourself or your colleagues use the, the bony rim around the eye to anchor the eyelid open. So then you're not putting any pressure on the blow. And in that way, you should be able to open the eye wide enough for them to heal and also for you to get a look in the eye. And yes, it might be a bit sore, but it shouldn't be that bad that you can't open the eye. If you have any anesthetic eye drops, then definitely feel free to put them in because that really helps put a patient overnight. Um And sometimes if you turn the light down in the room because some often they're photophobic and the light is gonna be painful for them. So if you turn the light down just, you know, enough so they can, you know, not so much that they can't see, but you know enough that it's not so painful for them, then you might be able to get a vision as well and just basically try your best and often patients will complain and say, oh, it's too painful. I can't see anything. It's all blurry. Yeah. I can only see the top letter and then they just give up. But I really push them. I tell them look, you know, it would be really important. I don't know. You can see and please have a look at that letter. Can you hear that letter? Can you hear that letter? And I really encourage them and often you can get them to see a lot more than they think they can and you think they can. And that's really important because it dictates the prognosis of um the eye. And also, as I say, gives you a better idea of what might might be wrong with them. So sorry, I've spent ages on that, but that's a very important thing. And I can hear later when you're calling ophthalmologist. If one of the first things you say is this is the vision and straight away, the ophthalmologist will think, oh, this person that what I talk to you about and then make the effort and they will be impressed and more and trying to listen to you and help you. Um So yeah, there we go. So, um just one important point if you think the globe is ruptured. So if you think the eyeball has a full thickness injury, so right through the sclera or the cornea into the inside of the eye, then basically the eyeball is like a football, it's blown up and if you puncture it or like a tire or anything that's sort of blown up it without a, you know, make a hole in it. It's going to be all soft and then you press on it, then it will squash and the contour will start coming out. So, yes, if you think that's happened, you need to be very careful. Um, but even then, yeah, you, you should still try to open the eye and just take great care. Um Second of all, um 80% or third of all, perhaps I can't remember. Now, 80% of the diagnosis is in the history. Have you ever heard of this? Um I don't know about you, but I think that's very true. So again, without even touching the, the scary part of touching and examining people of your eyes, you can take any type of good history. And if you relay that good history to the ophthalmologist, often you can come to a diagnosis. Um, you know, mainly on that. Um And again, I don't, obviously it helps the more you know about our easier and ophthalmology, the better, you know what question you are. Um But even if you just take a good history based on your general medical principle, if you lay that to the ophthalmologist, then that will give a lot of important please to the ophthalmologist as to what might be going on, you don't underestimate that. And that's before you even touched the army, which is really good, I think. Um, so then touching the eye, I'm afraid you're going to have to touch it and examine it the best you can. So I thought we just go through the eye from front to back and I don't know, as I said, how much you know about the anatomy or, or how much detail you want to go into. So I think, should we just start and then you can stop me or ask me full information. How did that sound? Um So you're starting from the front, what you can see the external eye and this is the eyelids, the orbital septum, which is basically this sheet of connective tissue which um divides the um the tissues in front of. So the font of tissues like the lids and some of the fat on in the lids, some cleans fat, the eyelids, the eyebrows, um and divide that with the um contents of the orbit. So I don't know if you know the orbit is like a bony cone shaped um hollow in the skull. And that's where. So the eyeball sits in there and then the optic nerve connects the eyeball to the brain and then around the eyeball, there are six muscles which move the eye and then the rest of the orbit that cone, the bony cone is filled with important nerves which um innervate the eye, blood vessels which supply to the eye and orbital fat. And I, you, we will see that's quite important to try and distinguish um between in front of the eye and in front of that and behind. And then as I said, we have the extraocular muscles. So just looking at a few photos here, um this is the sort of thing maybe that you're seeing in an emergency setting um on the external eye and it's mainly so um the eyelids um and around the eye. Um, so if you need something like this, then um there's key things to establish. First of all, what's happened to the actual eyelid or the front part and then if the eye itself injured. So in this top left picture, it looks like quite a small cut here, but it's very important to find out what caused that cut, um, and take a bit of a history and then examine the eyeball because if it's a small thin sharp piece of glass, for instance, it could have gone all the way through and penetrated the eyeball. Now, looking at the eyeball here, it looks fairly white and normal, but you can see, I think you're likely, but you never know sometimes, um, patients come in with a fairly normal looking eye, but they have an injury further back. So the eye, the eyeball has actually been penetrated, but it's quite far back into the right part of the eye. So that's why history has been important. And if that happened, you would expect the vision to be down. Um So if, if something had pierced into the back of the eye, then for example, you might expect the patient to say I can't see very well. And there is, there's lots of black spots into my in my vision now or misting. And that's because there's blood floating around inside the back of the eye, even though the front of the eye might look normal to you, then there might be blood blowing up on the back of the eye, which is what the report in the skin with black spots. Um If it's something like this, we get on hole, then again, this looks fairly superficial. The eyes look a bit red implies that there might be a cut to maybe on the on the conjunctiva. Yeah, the conjunctiva is the white. So it's a clear, very thin skin which lies over the white part of your eye and that not your blood vessel and can very easily be injured. Um I want to irritate it will swell up and look sort of a bit funny like it isn't the hip so this eyeball could be injured, but it might just be that it's a bit bruised, a bit red from this. Uh So again, very important to just very gently have a look and look at for the extent of the um of the injury. Um And then here that's obviously quite severe injury as well. Now, in terms of emergency management these sort of injuries. So, I don't know if you know about the, um the lacrimal apparatus. So you actually have a tiny little tube. I think that might be it here actually. And when you try your teas or just, normally your teas are produced in your lacrimal gland, which is somewhere up here, they flow into the eye and they flow into these two tiny little holes and down these tubes and then into your nose and they drain it away. If you have a cut full thickness through the eyelid, you're basically cutting off the tub. So you won't be able to. So basically, you're going permanently affect that sort of injury, ideally should be repaired properly by an ophthalmologist. And they put this little stent in and they preserve that tube. So, um hopefully the patient, you won't get all to the eye. They'll have a proper, yeah, it won't heal properly. Um Well, if it was maybe a cut more to the side of the eye here, um or just, you know, around the eye or maybe a holy open carpet like this superficial, then often that heals up by itself, you can just clean it. You can just put some steri strips or some um antibiotic ointment and just leave it and often it heals quite well. The skin around the eye is actually very good at healing. Um And if you just oppose that you do the wound, the antibiotics, then often in a couple of days, it would heal up. Obviously, something like this needs further attention. And that, well, I mean, both of these to be should probably be sent to um, an ophthalmology to be repaired. But I don't know, I mean, depending on your skill with some um, eye lacerations, eyelids, lacerations, rather you might feel comfortable just suing yourself even in England often if it doesn't involve the eyelid margin. If we just maybe down here, then we just get the A&E general doctors to suture it. Um And then these are just two, some other front of the eye problems. So, um does anyone know what this is? Anyone want to write in the chat? What this might be or put my hand up? Go on some, have a guest. Bye. I can't need to tell you. Ok, I'll get to run out of time. This is um cystitis. It's basically an infection of the lacrimal sac. So the drainage operation um apparatus that I was telling you about just now, I hear the communication where the tears flow between the eyeball and the nose. Um There's a little sac here with his collect and basically this place got an infection. He looks quite young actually and it's actually all building up but just like general anywhere in your body. If you have something like this, on your hand, on your arm, it looks like just a big spot, basically like an infected spot that's going to come to a head and then all this pus that will come out of it and that's basically what it is. Ok. Give treated the same way and often the eyeball is not involved in the Sure. So what they need is just lots of gentle compress and some antibiotic ointment. If you think this redness is spreading around and turning into cellulitis, then you might want to give them antibiotics like tablets or other, you know, IM or IV or whatever you have available. Um But if it's fairly mild, then often it will just settle down with um the compress and the um ointment and you'll probably put the o in the eye. So going into the little hole and hopefully help with the infection. And then this, hopefully you recognize this, this is a classic um appearance. This is herpes yil down the, caused by the herpes virus and it's basically shingles on the face. And if you see this, then the difference between shingles here and shingles in another part of the body is that the eye can be affected and you can get inflammation inside the eye. It can actually affect any part of the eye from the front to the back and it can, in w the worst case cause blindness spread to the brain or encephalitis. Um But I have seen that before and it's pretty horrible. Um And you can also get a secondary infection with bacteria. And so in this situation again, you want to assess their s um systemic situation? So how well are they? If they're very unwell, then it's more worried. Um And what, how is the eye? So, are there any, any, my this lady's eye looks quite red but the cornea, the pupil is fairly normal. If her vision was good, then that won't be too worrying. I mean, hopefully it can just settle down without um causing these complications. But if the vision is blurred, if the eye looks abnormal, then they must go to ophthalmology treatment because as I said, it can be quite serious otherwise. Um and then this is um so this is quite important um condition when I talk, you know, when I talk about that or septum, so that connective tissue which divides the chronic section. So the eye tissues and the inner section, so the septum divides the two and there's an infection, you can get called preseptal cellulitis. And there's another infection called orbital cellulitis. So the pre seal is in the front of the septum and the orbital also called postseptal they in the cone. So all the while. So this, I don't know, Zen want to say, what do you think about this? Do you think this patient has infection just in the front part or do you think they have it in the back section as well? Any any guesses? And if so why, what's the rationale for this? I want you to check what the next slide is actually? Ok. So that's OK. So going back to this. So what do you think anyone want to say? What they think? Do you do? Is this basically, is this an infection just in the front section or is it affected the back section too? So the eyeball, all those important muscles and nerves in that bony cone in the, in the skull. Anyone there's no one saying anything on the chart. We can't, there's no stupid answers. By the way, you can say whatever you want and it's fine. Ok. No one's replying. So I'm going to, to me that obviously, it looks like there is an infection, the front part because I think it's red swollen and you feel that patient's face, it's probably quite hot. But the worrying thing is the eyeball. So if the eyeball looked like if it looked like this, but the eyeball looked like a normal eye like this, then that wouldn't be too bad. I would give oral antibiotics and I would tell them it's not improving and come back. However, with this patient, you can see it swollen shut, you open the eye. Very important to open the eye. You can see the eye looks quite red and swollen, right? And then even more worrying when they look up when you see, they can't move the eye, that one's moving nicely, that one is stuck. And if you shine a light in their people, you may find it's not reacting very well and that's very worrying that shows the infection has spread to involve the eyeball and behind the eye. And that is a self threatening and potentially lifethreatening emergency. If you don't treat this, the infection can spread to the brain and the patient can die. Basically. So if they have this, they need um antibiotic as soon as possible. Ideally, the intravenous antibiotics. Um, if you don't have that, I would just start whatever oral iron antibiotics you have and I would monitor them very closely, ideally send them to a bigger hospital. Ok. They may, well, I mean, in the UK, they would need a brain scan to check where the infection is and they often, they have a big abscess in that brain cone and they may have a brain abscess. Um And you can tell you can get an idea about whether the brain is involved by their, whether they're systemically. Well, so if they're not fully conscious or if they, they've got neurological problems, that would be even more worried. Um But yeah, this patient needs emergency treatment and the first thing to do is just start antibiotic as soon as you can. Um and then get, get some advice. But like I said, if the eyeball is white, even normal like this, and you could be much more confident that this all antibiotics will be fine and then just monitor them. And as long as they improve, and often it just settle down. This condition is often healed in Children as well where that septum was, divide the front and the back of the eye is not very well developed and it can have progressed very, very quickly. Actually, my sister had it when she was different and we have had to rush to the hospital and quite panic. I mean, thank goodness you're fine. Um, but yeah, you, you'd have a laid rush your bag quickly. I've seen a child in the hospital who, I mean, within like a couple of hours it was significantly, um, we had to rush him into, I think he had to have a drainage, he had to have the abs an abscess drained on the surgery, surgery, um, in the orbit. Um, and this is another similar sort of emergency. So this patient, unlike the patient, um, in the last side has had a trauma. So they have had a severe trauma to the eye and you can see that it's all swollen up and it's not just the eyelids. In fact, it's mainly the, um, the eyeball and this all the swelling in the conjunctiva, there's blood under the conjunctiva, but then more worrying and you see the eyeball itself, there are people that a normally live. It's a funny shape and it looks all red inside as well. And I think you can appreciate the blood here. So basically this patient had severe trauma in the eye. And if you were to. So I don't have the other photos. But if you were to ask the patient to move the eye around, they wouldn't be able to move the eye. And if you were to um, check the pressure of the eye, then the pressure is really high. And this patient has something called a retrobulbar hemorrhage. It doesn't always look this dramatic. But um, this is when, um, trauma or sometimes eye surgery or sometimes match back on surgery causes bleeding inside that cone, that bony cone. And of course, it's a bony cone with a thick connective tissue in front of it, it's like a compartment. So I don't know if you know about compartment syndrome in the leg where you have a bleed in one of the muscles and the blood builds up and then the muscle dances because it cuts off blood supply. So it's the same thing. If you have blood building up in the brain cone, it will start cutting off the optic nerve between the brain and the eye and then affecting the muscles that move the eye, affecting the nerves that innervate the eye and basically, the eye will die. So if you have a situation like this where a patient comes in with a trauma, the eyes are swollen. So poking out basically, and it's really painful, they can't see anything and it's when you touch the eye and it feels hard compared to the other eye, then you need to act quickly. Now, I don't know if you were trained in this, but there's something called a lateral Campho and canit where you basically have to cut one of the main tendons of the lateral corner of the eye. And that's the topic of another talk, which we can do actually in the future if, if you would like that. Um And you basically, you don't need to like, you basically don't think about anything. Don't worry about your eye, basically, make a big cut to make a big cut and massage of the eye and then you find the tendon which anchors the eyelids to your bone and you cut it and that will relieve the pressure and you might see the blood coming out and then you'll save the eyeball. Yeah, if you want me to, in fact, I can share a patient I've done with that if you want me to share that with you. Um Please let me in the comments and I can send it later. Um And then now we did. Yeah, we so we went into this but didn't we with the um do the eye movements look normal? So I don't expect you to tell me if they've got further palsy or a brown or all these complicated eye movement problems or a Dune syndrome. In fact, the only time, the first time I saw syndrome, by the way, in Jamia, it's very cool. I didn't know what to watch this week. Before I was an eye doctor, I later came to know what it was, um which is very helpful for my ophthalmology exams. So, basically, if you just have a look at the eye open, both of them and look at how they move, you can see this patient's eye movements are clearly abnormal. That one's out there, that one's out there that is not normal. Basically. And I think hopefully you can appreciate that It's this eye that's the abnormal one or is it? I think so, I that's the abnormal eye, but essentially I'm not going to get into what the problem is because I think that's very complicated. And if you can just describe so the eyeball is not moving outwards or the eye move, the eye movements are completely abnormal. The eye is just not moving properly. Then again, that will give me an important clue if you're going to, yeah, you want to call the on. OK, lean on. We bring back, I quite high up. What time is it? How many have left? Ok. We have 13 minutes. OK. So you're on the anti your eye. Um So the anterior eye, basically, what I what I mean is that clear window of the eye, the cornea, the white part of the eye and the overlying thin transparent skin Tiber and then the anterior chamber, which is between that clear dome, the cornea and that thin colored disc, the iris like the anterior chamber and I think the main thing to say for this again is to describe what you see. So for example, this is, oh, I don't have something to ask you. This is a subconjunctival hemorrhage where there is blood under the skin of the eye, the conjunctiva, but the eye is otherwise normal and this actually looks horrendous, but it's not very well. And you can most likely reassure the patient unless you're worried that there's a full thickness laceration. Obviously, in this area, you can most likely reassure the patient when the second out be fine. This is your, this is where the eye is just a bit red. But you can see here the sign of infection, the eye a bit swollen. So again, upon general principle, it looks like the infection with us on the eyelids. This hopefully, I don't know if you will know this. It's fairly combinations as well as your growth of the, the conjunctival of young vegan. It starts, it does start growing over the cornea. And as long as it doesn't look too inflamed, it's not painful a lot and it's not over the central part of the eye, we tend to just leave them alone. And then this is your foreign body. This patient has been grinding metal and they've got this little um bit of metal in their cornea basically. And while it doesn't look like you've got all three, which is really good. Can you see the eyes quite red and around that metal is a tiny little whitish finger, anything whitish on that clear cornea is bad. That's a sign of possible infection. So when the cornea is infected, it often goes white. Sorry, I made that by mistake, it often goes white. So that um you need to get that out if you can and then give the patient antibiotic. And the main thing, if you give them antibiotic, if you can't, if you're worried, you don't start poking them in the eye because there is a danger that you might, you know, if you would try to get that out and you poke them all the way inside the eye, that would be even worse. So the main thing is to sort out the infection in this case. Um, and then this eye is generally red and this is one of the ophthalmology conundrums and it often, um, is a conundrum for non ophthalmologists as well. Someone's got a red eye and they don't really know why and they can't really get to the bottom of it. And sometimes I see red eyes and I don't really, yeah, I'm not really 100% sure why the eye is red and there's a few possibilities. Um, in fact, there's many possibilities and you tried to narrow it down to a few and if you can now and if you can narrow down to a few and make sure it's not, I felt right problem then that's the main thing. Um but what I would say mainly for this anterior, I describe what you see. So describe where the redness, where is the redness? And does it affect the whole part of the eye or is it this part of the eye or does it affect the um white part or is the blood inside this part? And that is all those sort of things are really helpful, please. If you have access to something called fluorescent, I don't know if you have a lot. It's a, it's an eye drop. Do you have access to it? Mhm. Do they have this flues? Mhm. So you probably don't. Which is very sad because it's really good for showing up scratches on the front of the eye. So this patient you can see they've got an abrasion and they've got scratches on the front and this, I don't know if you, anyone knows what this is. This is a classic, this is nothing else but uh the cold sore virus be on the eye. So straight away you spot diagnosis. So if you do have this floor hit and it can only drop and you shine a blue light on the eye and it just shows it really nicely, then that's really helpful. I don't know if you can manage to get at all. I know they have ae th but I don't know if it's generally available but anyway, maybe I'll have a chat with Daniel about that. Um by the way, moving on, um we need to do some more p pictures. Um So again, this is January red eye and it, but it's more red around the, um just about, well, what we call the limbus, which is the junction between the cornea and the clever and that's often a sign of something called uveitis. Um What's the inflammation inside the eye? And then here you can see there's only a section of the white part of the arteries which is red and it also looks swollen. So if it's just red, then it might be the superficial layers that are affected and, and um inflamed. But if it's a deeper lay, it looks swollen and that's more worrying. It's what we call scleritis. And that's where the deeper layers of the sclera can become a affected. And then this one is again, a generally red eye. Um I'm not sure what they're trying to show you. To be honest, I think maybe the cornea looks slightly hazy. So maybe the cornea might be affected as well and it will be important to check their vision in these cases as well. So that can give an important clue. And then here, can you see that the pupil looks really funny. This is whitish ring and that's because there's a lot of inflammation inside the eye as well as the eye being red. And again that here, that's something called uveitis, which is inflammation inside the eye of the um internal structures and that can, can blind you well. So if you have something like that, but something like that, then can you see the difference? So this is red, but this bit looks quite normal, right? Um If you can, if they can see normally the people reacting, you can be fairly reassured due to infection. But any have this one where it looked genuinely red and this one looks a bit funny and this looks whitish and they probably won't be able to see very well. Then that's, you know, much more serious. And then again, so you can can you see here? I don't need to appreciate that. Have a look again at this photo, I'll show you this, this photo be done. There's blood here, right? Yeah, there blood on the white part, but this part is what's normal. Well, uh I remember the photo, right? If you look at this one, you can clearly see there's blood inside. So that's been fine, but they not they see blood inside out of the chamber. And that again, that's much more worrying than having blood in the eye. And that often happens in trauma. I don't know what this is here. Maybe, I mean, some sometimes the tumor bleeding. Um and then if you wanna get the blood inside that you can get this white stuff, I don't know of anyone what age it's basically pus. So there's pus collecting in the I vi did this patient had this big whitish thing. I don't know if you remember, I said that white on the cornea is a bad side. It's not infection. So this patient has a very bad infection of the cornea and it all part building up in the I VI and that again, you get, that's blinding to the emergency treatment. Um And if, if you, if you see this, you should basically give an antibiotic. So top topical is best, whatever eye drop antibiotic you have put them in every, every hour, at least. So, start off every half an hour and then put them in every hour for at least 48 hours, day and night. So throughout the night, the patient need to be put loads of antibiotics. Essentially, you see this, you need to drown the eye antibiotics. Ideally, you need to take a sample. But I'm assuming you won't be able to do that wherever you are in the um clinic. Um Yeah, it's more important that you drown the eye antibiotic and then probably send them to the hospital to get further treatment. So I was thinking we've done the two sections of the eye. Do you want to do the posterior section or shall we do a few things for more help? Ok. We don't have long left, do we or should we have, do you want to ask any questions or what do you want to do? Ok. Ok. I feel like I get a lot of information and I'm feeling information and you probably won't be listening to me anybody longer. So do you want to, do you have any questions about patients or do you want to go through a couple of patients? Is anyone there to honest to me, there are 28 people here. So I'm sure one of you at least can reply. Right? It's clear. Ok, cool. So do you want, what do you, what that mean? Do you want to continue or do you want to do some discussion or do you have any questions? In fact, we only have four minutes left. We have four minutes. So we can only do one case. Should we do one case or network? Let's continue. OK. Should we continue then? Ok, let's OK. Well, if you continue, we have time, we have time you came back. Oh OK, let's do it. Let's quickly finish off then like, OK, we can do this more detail later. But because basically for the back of the eye. So if you have one of these, which your ophthalmoscope, then that can be very helpful because it might allow you to see the back of the eye like this. Now, this is your normal back of the eye. I don't know again how much you know about the anatomy, but it's these nice blood vessels, you can see the the central area of vision, the macular and this round white thing. That's the optic nerve where it joins the eyeball of the brain and that looks nice and normal. Now, remember that image, if you, now look at that, that looked weird, right? So that what you're looking at is actually optic nerve. So that's the nice optic nerve, the nice blood vessels here, that one, the swollen whitish, it was bleeding. So I might expect you to be able to see that with that ma that device that, but if you can, in fact, I'm sure, I think you can get, you can get like the app on your phone and stuff as well to see the back of the eye. If you can manage to hear that, that can really help after the ophthalmologist. Um So, you know, depending on how motivated you are and what, you know, how much you, how much time you have then yeah, you're much better to be able to tell me that there's something like that happening in the back of the eye or even that's another jumper. However, something like this, I mean, that looks fairly normal to me, right? I think it does to you as well. But actually if you look carefully, there is subtle swelling to hear, there's subtle swelling of the optic disc. I wouldn't really expect you. And there's subtle tortuosity of the vessels. I wouldn't really expect you to pick that up. So basically what I'm saying is now that again, so that you can see these lots of blood everywhere and that, I don't know, you can appreciate kind of a bit of a funny color, kind of whitish in color and that's kind of whitish and the BP is very thin. So you might be able to pick something up and if you have the motivation information and you can get a hold of it, but it's worth having a look and you will, yeah, you will get better over time and then you can just basically describe what you see. Um That's about the best. I actually, I think we get to that. OK? Again, that's a bit beyond what I'd expect and then going to the brain. Yeah, the mind's eye actually, it's not in the eye that heats the eye, just receive the light c and the brain interprets us in complete darkness and forms an image which I think is very cool by the way, and the image is upside down the back, the front, but the brain and its amazing ability manages to put everything the right way out. So looking at the brain and hopefully this is more the general conditions um territory. So you wait the ph together at it. But the main things with the brain um with the eye is to check either people reacting to torch and do they have color vision? Now, if you can, you can download an app action from color vision. OK? When the optic nerve is being affected, which joins the eyeball of the brain. One of the first things to be lost is the color vision. So if they can see, but they can't see color or the color is reduced, then, um, that shows that they might have a problem with the optic nerve or if the pee probably is not reacting to light. Again, that shows that there might be a problem further back in the brain, um, or in the optic nerve. And then I don't know if anyone knows what this is. You have one second to guess anyone. OK. No time I want to tell you this is basically um a stroke. So this patient who had a stroke, they want to talk their visual field on both eyes. So you half the they've got he and if you see this in a patient, you should be able to pick this up just by doing a visual field test, like confrontational visual field. This patient needs to go straight away to the medics who have had a stroke. So it's not, you don't need to call the ophthalmologist. They probably have completely normal eyes, but they've had a hemorrhage in the brain or a blockage. Um OK. And then finally when to call the ophthalmologist. Well, basically whenever you want, so most of the ophthalmologists are very nice and helpful and won't help even if they are stressed out when they're busy. They, I mean, well, I personally love ophthalmology and anytime you want to contact me, feel free. Um And I do admit they sometimes give it straight away. Yeah, I don't really, I'm not always able to. Um but I definitely will when I can and all I would say is give me a good history of the one you're very visual and they want to know every detail and everything you can see, even if you don't know the names just describe, you know, there's a, there's blood on the clear part of the eye or there's blood inside the eye and it's forming a fluid and it up to the pupil um and describe what happened to the patient. So the patient, you know, fell over and they struck their, you know, head on a metal, you know, or something like that, whatever, basically just describe it. The more information you can give the more I can help you because often I get cases and it's very lacking in information and no photo and it could be anything because they just give some basic description on die without a proper vision. But the more information you get, the more I can give to you to help you um show history, check the vision and look at your own eyes to get to know what's normal and even doubt all the ophthalmologist. Thank you very much. So I think we will leave case studies for now. But if you have any questions and if you want the presentation about the electoral cancer toy then please let me know or if you do it another time. Mhm. And what's her name? Go back and here here. Ok. Uh Thank you very much for that wonderful presentation doctor I think. Thank you a lot. And is there any questions for uh my left? But I have still here? Ok, cool. Yeah. Sorry. Mhm. I believe we blind a lot and if you have any questions please, this is the time um due to time we will only allow maybe a few questions and then we can close. I think somewhere by 17 days. So please raise your hand if you have any questions or feel free to type in the chat I PPA video by the way. So I can see if you talk. It would be nice to meet you and that my media. I look over. Do you have any questions? Any contribution? Yeah. Go you have to ask at least one question. By the way, I'll be very sad. Am II think we have a uh on eye hematoma topic. When do you say this blood is irreversible? I say do you mean? Yeah, I think you're talking about um that were talking about that one when you have a bleed or are you talking about bleeding on the eye general or whi which type of you bleed the ivers? Is that what you mean? OK. I think if you have all that. Oh OK cool. When you have a bleed. So that's what is really important to find out where the blood is. So, if you have a bleed on the surface of the eye, then that's normally reversible and it will just settle down myself actually. So it's not that serious. If you have a bleed inside the eyeball, then that can settle down actually quite well. Um, it normally it helps in treatment, um, but it can cause complications so the pressure can go up from the eye, um, and it can cause you reverse of blindness. So if it's in, if inside the eye, well, that's why you want to differentiate is inside the eye or on the outside. If it's on the inside, then they should be referred to ophthalmologist. Um And then if it's behind the eye like that to you, um with the uh cut, the can can that or you, you are not sharing anymore, but the, the eyeball don't worry. Well, the, basically, if it's behind, if the bleeding is behind the eyeball, then the main worry is you're going to compress the optic nerve and um and damage the connection basically between the eye and the brain and then they'll go blind as well. Um So those are the two types that with v potentially. So if you act quickly, you um you can save the vision, but if you don't, then they will go by um um, show you right here, basically act quickly. Mhm. Ok. Cool. Anything else? Any other questions one from, from they respond. This one from this one. Hematoma. Yeah, I did. Yeah. Yeah, I did. Oh, nice. You're very welcome, Jessie. Thank you for your question. So I think there's one from what? Yeah, she's saying inside the presentation. Go miss the best part can uh present on, I can present on, on IOP and glaucoma. Thanks for calling. Oh yeah, I, where are you? I can't see that question. OK. Um Go on the chart, let me see chart he wanted about glaucoma. I mean, what do you mean you want to do another presentation on glaucoma or do you want me to tell you about glaucoma? They not to tell you about glaucoma? I think, I mean, yes, the he's actually on it. I don't know if we would be able to, if you'll be able to measure eye pressure in a clinic. Your, that's your, that's true actually is a very important um parameter of the eye that sign, if you can manage to measure the pressure again, it can give you a clue as to what might be wrong with them. Um I mean, glaucoma is basically a condition where the optic nerve is affected. Um and it is associated although it's more complicated than that with high pressure in the eye of the eyeball. Um But yeah, the doctor type of glaucoma secondary and primary glaucoma, but it's basically what you mean. Yeah, the basic thing is when the pressure is high in the eye. Um And the main thing to get the pressure down. So again, I don't know. May I can talk to Daniel whether we can give you? I mean, do they, are they able to measure pressure? Are you able to measure pressure in the clinic? I'm not really sure. Maybe uh madame. Do, are you able to just please open your mic and respond to, to our questions? Maybe that would help us to determine if you are you have that? Um um OK, good afternoon, everyone. All right. Thank you. Thank you so much for that wonderful presentation. I wanted to learn more on raise inter pressure and glaucoma relationship. Uh I have a client who's been having persistent, raise the intraocular pressure and the and the patient is gradually losing vision. So I wanted to learn more on that one. I've referred the patient to Lusaka. Yeah, but the patient seemed to be improving. He's not improving. Sorry, the patient is not improving. There's no improvement. Yes. Is the patient? Is he on any treatment? The patient is on only on drugs? Yes. What eye drops, the eye drops uh on glaucoma uh and the dozol amide? OK. But it's not helping. It's not helping. So what they did, they said since this pressure is not responding to, to eye drops, they suggested for the paracentesis which they did. And then after a week, the pressure again went up. So the pressure is not coming down despite the uh the patient putting some eye drops. Uh what do you mean by paracentesis? Uh paracentesis, they wanted to remove the fluid in the, in the eye because the there was a raised intraocular pressure. But why do they know why the pressure was raised? Uh They don't know the cause. Uh initially the patient, he was the uh managed for, for the cataract. So after cataract, cataract, that's when they the the patient started having raised operation. Oh OK. Yes. Mm I mean, and they said by paracentesis, they just removed some fluid from inside the eye that it. So, so when they did presents, they removed some fluids. Then for two or three days, the pressure came to normal. It was between 18 it was between 1618 and 20. Then later on after, after a few days, it went back, it is above it. It should be 5072 somewhere. I mean, the thing is, but taking fluid out of the eye does not address the underlying problem. So it's difficult to know why the pressure is high. But that's the main issue you need to, they need to find out why. But it there are lots of different causes for having a high pressure. And if drug, if the eye drops are not controlling it, then he the patient might need like a trabeculectomy. You know about that Trabeculectomy or a different type of operation. It's an operation where you basically make a ho. Ok. And then go on, sorry, go on. Ok. So for this particular patient, they did uh all the investigations, the investigations they did and everything is normal, normal, normal. So at the moment the cause is not known. Sorry because he not knowing. No. Yeah. Is that in the where did, is that in the clinic in sa? Yeah, I'm having network challenges here. Sorry, come again. I said who who investigated the patient with this in the shower? In the eye clinic in Lusaka? Yes. And which hospital at doctors hospital? What? Doctors hospital in Lusaka? AAA government hospital? Sorry. Sorry, a government hospital. It's an eye hospital. Yeah. Yes. An eye hospital at doctor A's hospital. Uh I go wow. Ok. Sure. Yeah, I know. II um what they doing now then? Sorry, I said what are they going to do with the patient? I'm having network challenges here. What, what, what will they do next with the patient? I can't hear you. Uh What, what will I do next with the patient? At the moment? The patient is just on eye drops but the pressure is not dropping. Well, the patient needs to have an operation in that case. What operation? Um well, either a trabeculectomy. Um yeah, that, that, that would probably be the first line or there's other options which is similar to trabeculectomy, but they need something to get the pressure down your eye drops here are clearly not working. Yeah. Are they going to go back to the doctor? S ok. Are the, is the patient going back there to the hospital? The patient has been going for reviews to the hospital for years? No, not really yet since last year. Ok. And, and, and is the patient going back then the patient is going back next month? They are ok. Ok. Good. Yeah. Yeah, I think that basically will need to have an operation and the operation is. Yeah, I do, I don't know if you know what a Trabeculectomy. What that is? Ok. Do you know what that is? Sorry you do, you know what a tuberculus? Yes, I know it. Yeah. So I think that's probably what the patient will need. OK? Because this patient initially they were saying what was causing the blurred vision was the the the cataracts. So they did, they did cat ectomy. Yeah. Then af after that, that's when uh the patient started having raised the interocular. Yeah. So it might be related to the operation. Ok. Very difficult to know without knowing more details about the patient. But essentially if you get whatever the cause if you get into that situation where you can't get the pressure down, then you need to an eye drops not working, then you need to have an operation, an operation again. Yeah, to get the pressure down. OK? And he can't leave the pressure that high to say look the eye will, as he check, it will just get worse and worse if he'll leave the vision. Of course, is it possible that we can, we can talk outside this presentation? I'm looking at time. Yes, that's fine. Yeah, just feel free to contact me. I don't know how to contact. Yeah. Feel free to contact me after. Yeah, I think we should finish actually because it's late now. But um, if you want to contact me, feel free, um maybe he can give you my contact details. Ok, I appreciate if you share with me your contact details. Ok, cool. Do you have um Penelope's contact? Ok. I'll take note of the line and I'll share. Ok, your number with her. Ok. That's fine. Pen P will share you my details with you. All right. Ok, cool. Thank you so much. Oh, you're welcome. Do you have anything else in the chart in the chart? So I will check you're saying uh nice presentation. Unless there's any last um question, we have one more question, Tim, do you have any last question before we, we close the show? Ok, I guess silence means uh no more questions. Thank you. Ok. Thank you, everyone. And if you have any feedback or want to do any other topic, then please let me know in the future. Hope you have a good evening. Ho All right, bye. Thanks to. Mhm. Mhm. All right. Thank you very much for your time. I believe it's been a great presentation and we went a lot like she said, if uh you want her to present on any future topics, please let us know so that we can relay the information and we could have another one in the future. But I thank you very much for that wonderful presentation and thank you for joining this presentation and we'll see you next time uh in, in next two. Thank you too. Have a great night. Ok. Thank you. Ok. So at the same time we share your numbers. If you haven't dance over, that's OK. Everyone to share their context. Ok? And then most of requesting for the presentation. Ok. Yeah. Yeah, we can do that. Ok. All right. Thank you everyone. Uh Bye for now. Well, he's not, to be honest, there's not many nights I have more like this. It made me like I was talking.