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Okay. So welcome. Any everybody. Uh It's good. We have small numbers today so we can have a really interactive session. So this one is about the basic anatomy of the eye, which we have done every time. But it's so important that we do it every time and uh trauma uh go through uh nine came a new cherry consultant of time, the Can Victoria retinol surgery. So you've seen these, the eyes like a camera and those are uh basically remember the anatomy for those who are present. This is interactive. If you have, if you remember the anatomy, we can skip through it if you don't because I don't know what level you're at. So please let me know if you want me to go through this or if you know it, we can skip to the actual slides of trauma. Any any answers. Hello, someone in the chat has said yes. If you could please go through it again. Oh, yeah, I can't chat. So you can unm ute and uh if you can unm ute and talk because it is an interactive session uh this session because it's all about pictures and asking questions. That's how I found it best to learn. So I think it's also best for you to learn it that way. So please unm ute and talk when there's a questions asked, don't put it in the chat. I'll never see that. Um So uh basically uh their eyes like a camera, it's got the front cornea which is the clear part of the eye through which you see the iris, the colored part of the eye. Um It's connected to this clearer which is the white of the eye. And the junction of the connection between the two is the uh is the list is called the limbus, which is just here. If you can see my arrow, that's where the cornea becomes the white of the eye and it's where it's joined. A lot of things happen at the limbus like the drainage angle of the eye is uh there where the acquis drains out of the eye. So we all have a quiz being built all the time and drained out of the eye. And this is like the lymphatic system that drains away all the uh waste material of vision. Um Behind the cornea, the cornea has five layers. We won't go through that, but there is an endothelium on the inside of the cornea that keeps the eye, the cornea clear. And that's why we can see if those cells don't function properly. Then the cornea becomes opaque and waterlogged. Then you won't be able to see, we are all born with a certain number of endothelial cells and these endothelial cells, uh we lose them as we get older. And then other things clutches, cataract surgery, etcetera can damage the endothelial cells. And if we go beyond a certain number of cells per millimeters squared, then the cornea again, decompensate or becomes cloudy and that's again important in the setting of uh of um trauma. Uh The other thing to note is that the limbus, uh there is a covering that covers the clearer and that's called the conjunctiva. And the conjunctiva is the kind of clear uh clear covering that covers the uh bulb, er, part of the eye, the bulb or conjunctive, I'd conjunctive covers the eye and it goes inside the fornix, which is the upper and lower legs at the very bottom and it reflects off the tarsal plates of the lids. If you remember that anatomy, unfortunately, it's not on this picture. Uh the fluid inside between the lens and the cornea is called the Acquis. And it's produced by the Pars Planner uh here in the back of the eye and the fluid comes forward through the zone mules through the pupil and drains out of the angle of the eye. That's the aqueous humor. Um We have the iris which uh has a hole in it. The whole is called the pupil where the light gets to the back of the eye. And the pupil obviously changes size depending on the light conditions. Then behind the iris, we have the lens of the eye that when you're young, it can change shape and focus. But as you get older, you lose that ability. And therefore people need reading glasses as they get older. Um Then there's the vitreous humor that covers that is between the lens of the eye and the retina. The retina being the photographic film at the back of the eye that you do the scene with the retina lines, all the 360 degrees around the eye coming forward from the optic nerve, which is at the back of the eye. The retina comes forward to just almost 60% of the way anteriorly where it meets the powers planner uh which produces the acres humor. Uh Again, the anatomy is a bit more complicated than that. But this is the basic anatomy and retinal detachment, obviously, because the retina gets its nutrition and oxygen from two sources. The anterior third of the retina gets its nutrients and oxygen's from uh the incoming blood vessels through the um optic nerve, which is called the retinal blood vessels. So that's the anterior third of the retina gets its nutrients and oxygen from there. The posterior two thirds of uh of the retina gets its oxygen and nutrients from the uh from the choroidal layer and the choroidal layers sandwiched between the retina and this clearer these are a layer of very vascular layer. Uh and then there's different layers to the choroid, which is the Korea capillaries and the larger vessels at the back behind that. And that feeds the posterior two thirds of the retina with nutrients and oxygen, as I stated. So, if the retina separates from the choroid, then uh the retina does, this retinal cells do not get the oxygen and nutrients they die, they need. And uh the retina, their retina can stop functioning. And therefore, people lose sight in case of retinal detachment. Um So the, if you remember the there is the photo receptors, which is the rods and cones, uh they're actually the ninth layer of the uh retina. So they're right opposed opposite the retinal pigment, epithelium which lines the choroid corridor vasculature. Um And this uh there's a potential space between the our pe the retinal pigment, epithelium and the photo receptors, the rods and cones. And that's the level where the retina check when it detaches, the photo receptors come off the R P and they don't function because of lack of nutrients and oxygen. Um There is also uh six extraocular muscles that move your eye about and they are, they are supplied by the cranial nerves. And in fact, six of the cray 12 cranial nerves actually supply the eye. All right. This is another one. So I'll just go through the crane nerve's first. So, optic nerve or the sec, the first nerve result factory nerve, which is for smell. Nothing got to do with the aye. The second nerve is the optic nerve where you see most. And that's the one that you can see here, that's the chiasm and the optic nerve coming forward. Um, and that's the optic chiasm, pituitary's underneath that. Then the third or the ocular motor nerve supplies four of the six muscles, extraocular muscles and it also supplies the parasympathetic supply to the eye. Uh, and the constrictor pupil, a in particular, which makes the pupil small, smaller comes through the oculomotor nerve. Um Then the fourth or the trochlear nerve supplies one of the smaller extraocular muscles called the superior oblique. Uh and that gives rise to uh double vision, vertical and torsional, double vision. When you have a superior oblique policy or the fourth nerve policy, the fifth nerve, the trigeminal nerve, of course, supplies the uh the sensation to the cornea. And I, and that's very important because trauma that causes corneal abrasions can be very painful. But the good thing is that that's a break in the epithelium of the cornea. You remember, I told you there's five layers in the cornea. So the utmost anterior part is the epithelium. Then there's the bowman's membrane, uh then there is the stroma, then there's decimates membrane and then there's a one line of cells, one cell thick, which is the endothelium. When you get trauma to the eye causing the a scratch on the epithelium, that's called a corneal abrasion and it's very painful because all the nerve endings from the trigeminal nerve and there. But the good thing is it heals quite quickly within a few hours. Usually it's healed on this. It's very big. In which case, it can take one or two days to settle, but it heals itself and the pain settles upsides spontaneously. So that's the fifth nerve or the trigeminal nerve. And the sixth nerve is called abductions nerve and the abductions nerve uh uh or the sixth cranial nerve supplies one of the other extraocular muscles called the lateral rectus. And again, in terms of head injury, if you can get lateral rectus policy, if the intercranial pressure is raised, and that usually gives light to bilateral lateral rectus policy. In which case, you really need to scan people to look for causes of raise in chocolate pressure, especially if they've had that after trauma. Of course, trauma directly can as severe or damage the lateral uh six ab juices nerve or the sixth cranial nerve. And that can lead to 1/6 cranial nerve policy as well. So, um that's where the importance of it is. The seventh nerve supplies their facial muscles and the trigeminal uh the trigeminal, no, sorry, the facial nerve and the branch that supplies the uh orbicularis muscle. Obviously, it helps you to blink. If you have a visional policy, you're blinking rate goes down, you're not able to wet your cornea properly and you can end up having reduced vision because the cornea becomes opaque if the tear film doesn't regularly wet the front of it. So that's very important. Um, that's the seventh nerve. And then from eight onwards, they don't have anything to do with the eyes. So those are the important cranial nerves for the eyes. Right? We go back one. Uh, there we go. That's very important. Again, this is the, uh, light reflects the light pupillary reflex, the Afrin limb, if it is the second cranial nerve or the optic nerve, and that's when you shine a light, it stimulates the retinal cells, the photo receptors in the retinal cells, which synapse eventually through the optic nerve. And they have a synapse with the heading arrest file nucleus, which is the parasympathetic nucleus of the third cranial nerve. And they sign ups the optic nerve from one side synapses with both heading arrest file nucleus. As you can see from that picture and therefore stimulating both of those nuclei stimulates the parasympathetic pathway which runs through the oculomotor nerve or the third cranial nerve to the uh constricted pupils muscle, which is sitting uh just around your pupil on the iris and it constricts the iris. And therefore, when you shine a light on one eye, both pupils have an equal reaction and they constrict at the same time. And so this brings to uh uh our mind, uh swinging light torchlight reflects where you can pick up damage to optic nerve by swinging a torch from one eye to the other eye. The pupil, when you go from one eye to another, I should dilate a little bit but immediately constrict on going to the second. I, if the pupil going from right to left starts to dilate when you're on the left eye and then when you go to the right eye and it constricts even more, then you have a right sided, um, relative, afferent pupillary defect, which means that your optic nerve is not, uh is not conveying information as it should. So there's an optic nerve problem. So that's the swinging light torch. Everybody knows about this, right? I think you do have you any questions on that part before we go on to the trauma, which is the interactive part. So that was just a quick summary out of the anatomy of die. Any questions on that? No, sir. Oh, hang on. Let me turn up my volume. No question. Sorry, no questions, no questions. Good. Okay. So we'll just go through the trauma and this is the interactive part because there's lots of slides and we're gonna talk about it. So, what's that? Anybody? What is that? What's that picture? Okay. So I pick names. So Serie A, do you want to tell me what that is? I'm not entirely sure it's an eye, isn't it? Yeah, good. You start with very basics. So it's a nice. So what do you see there? Accumulation of bum blood. That's right. So where is that blood? Where is it sitting inside the cornea? It's not quite inside the cornea. It's behind the cornea. Remember the cornea is clear? Okay. It's five layers. Yeah, I will show you pictures of it's very rare to get bleeds inside the cornea. You can, but it's really rare because normally that cornea doesn't have any blood vessels. Of course, that's why it's clear and we can see through it. Um, if there's abnormal blood vessels growing from the conjunctiva onto the cornea from the limbus, then you can get intra inter corneal bleeds in cases of corneal scarring, et cetera. But that's really, really rare. So it's not the cornea. So, where do you think it's sitting there? Syria? Um, is it between the cornea and before the virus? Absolutely. Yeah. Absolutely. And what's the name of that? From the anatomy lecture? It starts with anterior, the anterior chamber. Have you heard of that? Yes. Yeah. So the blood is sitting in the anterior chamber? Okay. Uh So do you know what the name given the medical name given to that is blood in the anterior chamber? No, it's called a hyphema. Have you heard of hyphema? H Y haven't added that. No. Okay. So it's called the hyphema. Lots of terms. But yeah, it's quite specialized. Very good. That's excellent. What's that before you go? What's that black thing? Above the, above the blood? It's colored black? Yeah. The pupil. Yeah, that's where the life goes through. Excellent. So uh in lights, trauma or blunt trauma, you can often get a hyphema and that usually you have to be careful because it me it means the the angle of the eye maybe damaged in these cases of trauma. The angle remember is where the fluid of the eye drains out of the eyes. Uh the acquis strains out of the eyes and if you have a damaged angle, long term, it can give rise to problems with controlling your intraocular pressures. And if the intraocular pressures which are normally below 21 millimeters of mercury, if they're raised over a long time, they can cause damage to the optic nerve, they can slowly kill off the nerves. And there's 1.2 million nerves that goes from your eye to your brain through the optic nerve. So it slowly kills those nerves and that condition is called what I'll go to the next one, Azad, what's that condition called? You do pizza? Uh What's the condition where the optic nerve is damaged by having raised intraocular pressure? What's that called? Uh Madama, sorry papilledema. No papilledema is swelling of the optic nerve. So this is where the optic nerve uh cells that transfer the information from your retina to your brain starts dying. As I say, there's 1.2 million of them. Uh And if your pressure is a bit raised, they can start dying. That condition is called glaucoma. Have you heard of glaucoma? Yes, sir. Ok. So that's what glaucoma is where abnormal pressures inside the eye can compromise or kill off slowly over months or years, the optic nerves and you get what's called Colonel vision. So you're not aware that anything's happening at the beginning until it's too late. And unfortunately, if the optic nerves start dying, we can't bring them back. Therefore, all we can do is check the intraocular pressures and lower them if they're high to prevent future optic nerve. Because if you lose them, that's it. You can't bring them back like most other nerves in the body. Uh Does that make sense? Yes, sir. Good. Ok. Lovely. So we'll go to the next picture. So that's hyphema. Okay. So who's next on my list? Let me ask questions now that there's only 10 people, I'll ask questions. Uh Irene, your next on my list. Are you there, Irene? Do you want to unm yout? No, she's not gonna on mute. Okay, Azad. Are you there? Can you keep telling me about this picture? What, what do you see on this picture? Azad. Uh I see in the anti chamber that is uh pool of a small pool of uh red fluid. It could be blood. It is blood. Yeah. And that's called what we just mentioned it. That's called hyphema. Hyphema. Hyphema. That's right. H Y P H A M A. Yeah. Hyphema. Very good. And what else? Opposed as opposed to other conditions. So, what's the difference between this eye and this? I, there's a difference apart from the hyphema, they both got the hyphema, but there's one other difference here. What do you think that is? I think it's the, yeah, Richardson. The, what the iris? Yeah. What about the iris? It's muddy. Yeah, exactly. It's not clear. Is it the Irish doesn't look clear. You can see the details of the Irish very well here, but you can't see the details of Irish very clear. And you see that reflex, light reflexes quite sharp, light reflecting back here, it's quite sharp, whereas when you go here, it's all broken up. So the right light reflex isn't great. So what do you think is happening here? What structure is the problem do you think? Why can't you see the iris clearly? And of course, you know, the blood is quite heavy. So it all floats downwards and gathers? That's why there's a fluid level of blood at the bottom there. So why do you think this, what structure is making you not see the iris clearly? Is it the iris itself, do you think? Or is it another thing clearer than sorry, clear? Uh No, this clearer is the white of the eye that's not in the picture. So it's the clear part of the eye. What's that called from the anatomy? The clear part through which you see the iris at the very front cornea cornea. Yeah, exactly. So, this gentleman or lady has got compromise cornea, his cornea is becoming waterlogged and not, therefore not clear. That's why his reflex isn't clear and that's, he can't see out, you can't see in because the cornea isn't clear. And you know that because that reflexes all broken up and then also you can't see his iris clearly because his cornea isn't clear. It's like a, you know, look, look through a window and the window isn't clear. So you can't see the structures beyond the window. Very clear, like a misted window almost. What do you think would have caused the cornea not to be clear? If, if you were listening to my lectures, anatomy lectures, you would have uh come up with that be a bunch. But uh I don't think so. Punch can call the inner uh inside the bleeding. Yes, it can, it could be a punch and it can cause bleeding inside, but the punch doesn't directly cause the cornea to become a damaged Tisdale. Something else happens. Why do you think? What do you remember why we said the cornea has become opaque or a damn? It is. It's to do with one of the layers of the retina. Do you remember from the anatomy lecture? No, anybody I don't want to put you out to on the spot as a very good anybody want to help us that out. Why do you think cornea isn't clear? Okay? I'll tell you that you remember, we said there is five layers to the, to the cornea. The innermost layer is called the endothelium, which is these cells that sits just inside your cornea. And the function of your endothelium is to, it's, it's got a proton pump and it pumps out actively using a T P. It pumps fluid into the acres and therefore keeping the cornea nice and clear. If the cells become compromised. For any reason, they start not to be able to act properly as a pump and the cornea becomes waterlogged and becomes opaque, starts going to, things start going blurry. So it's because of the compromise of the endothelial cells under this person's cornea. Now, those endothelial cells can be compromised just because of the trauma, could have damaged some of them and you could have lost some from just some endothelial cells beyond the exact limit that you need to keep the corneal clear. And that would be irreversible if that happened. But that's not normally what happens. There's another reasons why the endothelium cells start to give up and don't work properly to pump out fluid. Can anybody think of what other way apart from reducing a number or dying? There's another thing so they don't function. Does anybody else know why they might not function? Especially in cases of trauma, they'll be obstruction, uh not quite obstruction because these cells are literally lining all inside your cornea. So the bottom but might be obstructed by the blood but not to top it. Okay. I'll let you know it's, if the intraocular pressure goes up, the cells don't work as well as efficiently pumping out the fluid. So this patient who has had a trauma to their eye and they've bled inside there. I that blood is stopping the drainage of the acres properly out of the eye. And it's often the case that the intraocular pressure can go quite high. And when the intraocular pressure goes high, it then compromises the functioning of the endothelial corneal cells and therefore, the cornea becomes opaque. But luckily, that's a reversible thing because if you lower the low intraocular pressure that the cornea can clear out quite quickly. Does that make sense? Excuse me, sir? Yeah. Would that be considered as a closed angle? Glaucoma then uh not quite because closed angle glaucoma is kind of what the pressure can go very high up to 60 but closed angle is to do with an gonioscopy. I'll show you a gonioscope. What structures of the angle you can see and how much is the distance between the iris and the cornea. So it's a structural function of each eye and every individual's in different. So it's more common in hyper metropolis alongside of people because they've got small eyeballs. So it's not quite called angle closure, but it's just as a result of trauma and the blood going in the, even if it's an open angle, the blood can cause the pressures to go up. Does that make sense? Yeah. So angle closure is a particular term that's, that's applicable to only one thing when they're sudden raise spontaneous, raising pressure because of a narrow angle causing Irish Bombay. And the pressure can go very high, slightly different. It's not to do, it's usually doesn't have to do with trauma that's spontaneous. Whereas we're talking in terms of trauma. So in trauma pressures can go very high, they can go to 60 or 70 which can also knock out the blood supply to the optic nerve or the retina and knock out the nerves. So you have to lower very high in chocolate, pressure's very quickly. Otherwise, patient's can have complete loss of vision from optic atrophy or infarction of the optic nerve which causes optic atrophy. Does that make sense? Yes. So, is this some reversible at all? Um So this this trauma if for example. Yes. Yes. So most of the corneas that appear like this is because the pressure is high and we give either oral Diamox or intravenous Diamox. If it's very high Diamox or acetaZOLAMIDE might and that lowers the pressure and the cornea clears when the once the pressure comes down. Does that make sense? Yeah. Good. Okay. Any other questions on that? I, before we go to the next picture. So just to recap, in summary, this patient probably has had a punch from somebody. He has bled from the blood vessels inside the angle of the eye and the angle of the eyes between the iris and the cornea, that drainage angle of the because it's got blood vessels and that's uh made the blood come into the anterior chamber. It's called the hyphema. The hyphema has compromised how well uh the occurs can drain out of the angle of the eye and therefore put up the pressure and the high pressure has compromised the working of the endothelial cells. And therefore, they're not able to pump the fluid out of the cornea and keep the cornea clear. And therefore the cornea has decompensated. So in this case, what we do after measuring the blood, the intraocular pressure, we treated with topical drops or and Diamox or acetaZOLAMIDE. And that lowers the pressure when the pressure is lower, the cornea tends to clear itself because the function of the endothelial cells comes back. The only time where the cornea wouldn't clear up is because if the trauma has actually caused death of the endothelial cells beyond the critical number needed to keep the cornea clear. And if that happens, then that's an irreversible cornea corneal edema. And then you're into the realms of giving corneal graphs. So using somebody else's donated cornea to take away the bad cornea and put a good cornea in. Okay. So we'll go and to speak. Who's going to speak next? I have Irene. Are you there yet? No, no, she's not. And then there's somebody called iphone. Do you want to unm ute and uh tell me what you see. No, anybody, can anybody tell me what they see here in this picture? There's a hematoma on the anterior chamber. Yeah. So that's a complete hyphema. It's a complete eyeball full of uh full of blood. Ok. So, do you think there is more damage to other structures or not? Yes, there is corneal damage because you can see the light is not very clear. So, so the reflex is quite sharp, the cornea, this case hasn't decompensated yet. Okay. So you can see the reflex of the mirror of your slit lamp very clearly there. But you can't see any other structures inside the eye because it's full of blood. So you always have to be suspicious. You never know it may be just a big bleed, but you have to be also very suspicious that there is more damage that needs the eye. So other things could have been damaged or they could damage to the iris. Yeah, there could be, you can't see it because you because you can't see, you have to presume the worst thing. And also this I could be a globe rupture. So sometimes when you get a punch to the eye, the front of the I can appear normal, but the intraocular pressure would be very low. And if that's the case, you always worry that this clearer has ruptured behind where you can't see it. So in those cases, you always have to explore the eye to make sure that it hasn't ruptured at the back where you can't see it. So you have to cut away the conjunctiva, um called Perretta Me 3 60 Perretta Me and look at this clearer to make sure it hasn't ruptured. I'll show you pictures of that uh in the future. And again, in this case, you need to watch the intraocular pressure. If it's too low, you're worried about the ruptured uh eyeball. If it starts going very high, which it can do because there's so much blood in it, then it can damage the nerve. So you have to watch this patient very carefully. Okay. So this is not the greatest picture in the world, but anybody would like to hazard a guess as to what they see. Shall I give you a hint? It's the front picture of the front of her eye, of the anterior chamber basically was, that's right. There's pass inside the eye. Yeah. What's the name of that? Anybody know pass inside the eye. It's called a hypo P in. Okay. So in this case, the cornea is also not clear because you can again see the reflex which is very bad, but this patient has got pus inside the eye and that's often bad news. Usually it can be either ineffective, causing pass inside the eye or inflammatory. So inflammatory means just the fact that somebody has had trauma to the eye has called the eye to become inflamed, producing lots of white blood cells which some of which have leaked into the angle of the eye and have settled on the bottom causing a hyphema hypopyon. Sorry hypo P in. Um So that's called the hypo P in. Let's go to the next one. So who's next? Who would like to have a goal here about what's happened to this side? What are the things you see? Yeah. Anybody come on somebody cannon mute and tell me what they see. It doesn't matter if you have talked before. Am I lied? Yes. Please wash it go. I think it's something. Sorry, I didn't hear that. Am I lied? Yeah. Yeah. Yeah. Keep going. What did you say? Um I Lloyd Milo. Oh myeloma. You mean it's not a myeloma? I know my Lord doses. Sorry, I'm amyloid, amyloid, amyloidosis. Not quite. No, it's not that rare. Amyloidosis is quite rare. Remember the topic is trauma? Okay. So tell me what you see. Wash it in this picture. Just describe what is it? First of all? Okay. We can see maybe hemorrhage over there. It's not hemorrhage. Just tell me what you see. What's the structure in the picture? Gornje? Yeah. So it's the i the front of the eye there is a cornea. Is the cornea clear or not? No, it's not. No, the cornea is actually clear because there's a nice, nice reflex and you can see the color of the iris pretty clearly. Okay. What else can you see? Tell me what, what is, can you see the iris? Yeah, on the back. Yeah. The irony. What color is the iris in this case? It's brownish. Said no, the iris. Uh, it's great, great gray. Yeah, gray blue. Okay. And, uh, is it normal, is the Irish normal pupil opening is not normal? Yeah, pupil opening is irregular. Any other bits that's not, uh that's not normal. Is it Irish detached from the? Yeah, the, that's right yet it's torn on one side, you see it's torn from its insertion. Uh So that's called an irritable. Dialysis. Irritable means iris, dialysis is a split. So there's a split and if you could look beyond it, you can see the edge of the. So has this patient got a lens, a natural lens or a plastic lens, natural natural lens? Yeah, exactly. And you can see the, the edge of the lens through the defect in the iris up above here. So this is the big defect in the iris. It's torn away because of trauma and you're able to see the lens, the edge of the lens here. And these are the zone you als that you can see. Okay. Is there, is the lens normal or is it abnormal? I think it's only the iris which has been detached, men's would be intact. So, yes. So you have to always be very careful because the lens is intact. You're right. But there's another structure, the zone you als which hold the lens into place. So those own you als maybe damaged during the trauma. So, uh, you have surgery in the future, you have to be aware of that because you can end up with a lot of complications without realizing. So the lens itself hasn't been damaged, but is it normal or is there something you see there that shouldn't be there? Okay. I'll tell you, shall I? So you see there's an opacity in the lens, you can see it's like a flower petal, that's a cataract. And the trauma has actually caused cataract has called the lens to be opaque and this type of cataract is called the posterior subcapsular. It's just at the very back of the lens and the trauma does tend these cataracts and they can come on very quickly and affect your vision. So this patient probably would benefit at some stage from cataract surgery and putting an implant because that cloudiness is gonna become worse and worse as time goes on. But you have to be aware that there has been trauma and that Irish dialysis means that when you go to take away the cat tracked the zone als may break while you're doing the cataract surgery. And then you have a lot of problem with vitreous coming forward and retina detach ing and all that sort of thing. So it can be complicated. So you have to advise the patient's that it's not going to be straight quick question. Um You said about uh this patient got a natural lens um with the natural lens you can see on the darker bit the edge of it, the actual is going further than that. Is that because of the trauma that's caused? Say that again, you can see what's going further. So, you know, the edge of the lens, which is that darker side, just that the is going further than the lens is that because of the trauma that's caused to the Yes. So the lens would be here and then there is be all these only als holding it to the to the celery body. This black thing is the rest of the celery body which is black in color. If you remember your members sillier color, your body is black. So the iris has been torn from the ciliary body and you're just seeing the edge of the sillier body. Well, the lenses finished where the Zonule Czar inserting. Yeah. Thank you. Good. Any other questions? It's great to have questions. I love interaction much better than me just giving a talk and nobody understanding what's going on. Anything else? No, we go to the next one. Oh gosh, we have 10 minutes left and we're only doing five, right. So what's difference between this one and this eye? Okay. They both have iris that irritable dialysis, you know, trauma to the iris which is torn from its insertion. But is there a difference between this and this picture who would like to have a go and look at this? I'll just show you something. This is this normal lens. So, let's, uh, predicted as well. Uh No. So this patient has had previous cataract surgery. So that's a plastic lens. You see, that's why it's so, it's so clear because she has had cataract surgeon an implant and that's the lens sitting and that's what you're seeing. It's a optic of the implant. I just show you because this is becoming more and more common because more and more people, people are having their cataracts done earlier and earlier. So it's quite a common thing. So this is just called a pseudo fake kick I or one that has had the cataract Ramiro, okay, we go quickly. So this is the angle of that. This is a special mirror called a gonioscope that shows the angle of the eye. Somebody was asking me about the um angle of the angle closure. So when somebody is referred to us regarding glaucoma or high pressures inside the eye, we always put this mirror on and look at the angle of the eye, which is the bit between the iris, the colored part of the eye, which is here, where is my mouse here? And this clearer, which is the white of the eye. And this line you see this line is the angle of the eye. It's called a pigmented trabecular meshwork and the non pigmented traveler glor meshwork. And there's different structures there any way that drains the fluid of the eye. And when that's very narrow, that can give rise to acute angle closure, glaucoma, which one of our colleagues talked about. Okay. But this angle just to show you this eye has had trauma again and this angle is not normal. You can see that here. Can you see my my pointer? You can Yeah. Okay. Uh So you see the angle is that black thing, black line going there, it's going there, it's going there, it's all normal and suddenly it widens up and then it becomes a line again. Okay. So when it widens up like that, that's not normal. So that again means the root of the iris has been torn away from the angle uh because of trauma. Okay. So that's called angle recessions. And if you see that, it means that in the future, the prob the patient may develop has a high chance of developing glaucoma. So they need regular follow up every six months or a year to check their intraocular pressures. Because again, blunt trauma can damage the angle. Even if you can't see this, you should always bear in mind that they need to follow up for glaucoma because people who have had trauma to their, I are at more risk of developing long term glaucoma even if, when we examine them everything looks normal because you can't see things on a micro cellular level and that's where the damage can take place. Okay. So long term follow up for all those trauma patient's right. Again, that's another view of the bony, a scope of the angle of the eye. And in this case, what you see is this brown pigment that's released from the back of the iris and deposited in the in the angle of the eye. And that's called uh pigmentation of the angle which you can, you can see them spontaneously in very rare illnesses. But um but it it usually is draw, it's very common in trauma, blunt trauma to die. Okay. So I was at the time, let's just have a look, five minutes to go. Do we, do we have another lecture after this Hannah as a lecture right afterwards at 10? Okay. What time should I finish? Have I got five minutes or shall I finish now? Um If you can, if you can quickly finish? Okay, shall I do this slide and then we finish? So you can go to the next lecture. What time should I finish at 11 or, or exactly at 11? Yeah, that would be fine. Okay. So I have four minutes, right? So this picture would anybody like to tell me what's abnormal about this picture? And where is it a picture of there's an accumulation of fleet in the uh and so your chamber, you already know it's the retina. Yeah, that's the retina, first of all. And what kind of fluid is accumulated there? Uh, blood, uh, blood, yeah, blood there. And where is the blood? It's trapped blood because you can see the periphery. Where do you think is the blood trapped? In other words, what's the back wall of where the blood is? And what's the front wall of where the blood is? I think it's the lens, uh, the lens know the lenses too far forward. This is not the lens trapping it. So sorry, would it be the optic nerves or something? So, the optic nerves is on the left here. That's the optic disc. So that's the optic nerve. Okay. So, just to reorient it, this is a fund ist picture. That's the optic nerve, the outline of it. These are the retinal blood vessels. This is the retinal vein, retinal arteries. That's the fovea or the macula. And that's where the blood is. It's right in front of the macula and look, the blood is actually obscuring the retinal blood vessels. So, where would the blood be? Would it be in front of the blood vessels that is obscuring it or behind it should be in the front? Yeah, exactly. So it's in front of the retina. So this is a pre retinal hemorrhage and then there's a fluid level isn't there like in the long x rays, you get fluid levels because the fluid is sitting there. So what structure do you think is making the blood, the blood not go any lower down that this uh trees chamber? Yeah, that's right. So it's actually the vitreous. So it's called Sub Hailo. It hyaloid is the back of the vitreous is another name for it. Uh So the back of the vitreous has detached from the retina in a circular fashion and you can see the outline of this there it is. So it's if you can imagine literally a bowl of jelly. But at the bottom of the bowl, the jelly has lifted forward and it's been filled with blood. It's bled from this blood vessel here which is bled and it's dripped down and the gravity has made it look like a fluid level. So this is a pre high Lloyd know pre retinal or sub high Lloyd hemorrhage because of trauma. Okay. So we've only done about six pictures and it's 11 o'clock, we will carry on. I'll give another the rest of the pictures another time. Hopefully we'll set up. Okay. Thank you all for your contribution. It was very, very good. I'll stop the pictures and you were very good. I hope it was useful. Thank you very much. Thank you very much. Thank you all for coming. Take care and see you next time. Thanks Hannah. So I hand over to you, I'll just leave and then hand over to you. Ok. Okay. Thank you very much. Bye.