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Hi, guys. Thank you for coming. We're just gonna wait a couple of minutes and then we'll start soon. Okay, guys, thank you very much for coming today. We're gonna make it start now, eh? So today we're gonna be doing on a set. Medical Siris progressed, especially. These are not from ology on. There's a lot to get through. So hopefully myself on a beer can get through everything. So I'm safer past. You might have seen me before. Um, I'm a 50. A medical student. Carly Integrating on Be if you want introduce this office. Will I be our before with your oncology? Yeah. So I'm gonna start often, and a beer is gonna take over. So just a quick recap of the sessions so far. So we had a little change in the schedule, Just in case you wanna make note of that to the rheumatology and pediatric sessions have searched around. Um, se are still a few more sessions to go before PT. So there are also topics to cover in ophthalmology on down there, not taught that well off in our medical school or not that in depth. So we're going to try and go through the main things on on, but also just to kind of focus on the key elements with lots of images along the way. So this is no in order of what we're gonna do, because I don't want you to second guess the questions. Um, Andi, I'll do the first half in there. Very well. Take over midway. So just a quick summary of some of the drugs that are important and we'll we'll come back to that later. So we're gonna start up with an SBA If you could, um, have the polyp on D if you just want to first start by labeling this structure. So if someone could start the whole so just labeled structure, choose the best one. So a College Slam be said, Everybody says eat. See surgeries on your D Iris would be choroid. And if we could have the results of that one SA most people went for be celery body. So it's actually see. So it's this celeries on you, so I know it's a bit mean. If I go back to the question you can see it's quite they have to always look at the end of the arrow, so the end of the area. The arrow is actually went into the zone. You'll of the body and the reason why include this is because sometimes it progresses. Thinking one of the ophthalmology questions could just be a simple labeling one on the ones that I would focus on knowing our, um, knowing about the structures that relate to the different, uh, conditions that we're gonna talk about. So some important things to remember all the for Vera, which is the blind spots, which is at the back here and also knowing what they do so the retina as well. So the retina contains voter receptors, which how the rods for night vision and cones color vision. Also the choroid, which is here. And that's the vascular layer that supplies nutrition to the posterior layers of the retina. And then maybe lastly, knowing the sclera as well as that's the output and they're here that protects the I. I never say maintains the shape of the eye. So just another picture here, if you guys to go away and have a low cats. Sometimes I'll ask you to label the choroid right now on Baby the severe on also knowing this picture. So this is a fun this picture off the retinas of just knowing where the optic disc is. The macular area on weather for beer. Sometimes they might ask you to to answer, to label weather for years on that picture, so we'll do another SPK. So Lee is an 18 year old. He comes to the clinic with a unilateral acclamation, excess tohr excess tears on a watery discharge. He has grittiness, stinging burning, but it's not too itchy. His left eye is red on. D hasn't had anything like this before. He is sexually active, but the cultures you're dry. Negative. So what is your first line management Difficult of the hole. Thanks on. Do you make use of the Q and A function? If you have any questions, it's so most of you went for me, which is topical Plan Fenical. Okay. And some of you went for a or B on glass of, um for C or D. Okay, so I can see why you've gone for that. So, um, the cause of this year is actually a case off. Conjunctivitis on. We want to know. Is it bacterial is a viral or is it a lot, and there's some key questions in the weeks, Um, here is the fact that he's not had it before rule anything up. So we also talked about the fact that sexually active is mentioned. So is this an infection? So the answer's actually be on will come to the management for and the the Nice Guidelines. But the reason that it's B is because you know it says that it's burning but not too itchy, and it's watery discharge. So in this case, it could either be allergic or it could be a viral cause. But we'll look at it more in depth of the guideline in a moment. So in this case, it's actually a viral cause. And that's why, even though it's a viral course, the first line management is still giving a mast cell stabilizer or antihistamine drop on dust looking at blepharitis. So what is that right? It's that's inflammation of the eyelid margin due to infection, and sometimes it can be due. Teo member me in Greece gland blockages. And those are the glands which decreed annoying, which helps the tears to not dry up quickly. So the symptoms of it are burning prettiness, miles, photophobia crossing and readiness of the lid margins. As you can see here on the the test for this are actually usually conservative. So if you would first manage before, you actually did any further tests like a live biopsy, your lid margin culture that would only be if it's chronic and the patient is not recovering from management. So the most common management for this is actually live hygiene or a warm compress followed by antibiotics on you can either give the topical antibiotic like sodium for stomach acid or chloramphenicol on Ben. You can give further antibiotics at this posterior infection such a systemic tetracyclines. In some cases, they might give a week topical steroid, but that's not as common until replacements are usually given for many of these conditions that we're gonna talk about anyway. So then moving on to conjunctivitis. So this is what the question was about on How are we going to discern what type of conjunctivitis that it waas? So just looking at the this table here, in this case, in our nice be a we had some you had unilateral involvements, so it's most likely to be a viral In that case, in bilateral cases, it's most likely to be allergic, and that might be for indication of why this case was not, um, allergic case. Also, the bacterial cases would have had a positive culture, which we didn't have on the discharge, which was name was specifically mentioned to be watery, a swell on. That's why it's most like a viral. And as you can see here, the actual first line management for viral is still anti histamines. And what, plus artificial tears on Ben, you would add topical called cortical steroids. Chloramphenicol is not going to do anything for a viral infection, but in primary care, you will note that a lot of the time the first time management that's given is bacterial management, which is top book prevent occult. So just don't fall into that trap in the nest day. There's also no mention of pollen or seasonal effect in the stem of the question, and that's why it's not like it's a logic. Another interesting thing with the logic is you can see this cobble stoning effect here. They might show you a picture of that as well, and that's comparable stunning Chemosis came OSIs is a demon or swelling off the margin. So next SBA. So a 40 year old patients are head comes to the any department off for a car accident. He says that he hit his head during accident and he has a known past medical history of hypertension. So the globe is seem to be protruding at eight millimeters on there's a visual disturbance and reduce motility. What is the definitive management for this patient Giving the polyp, Please just give you a bit of time. You think about this question. Great. Say so. Yeah. So most people went for a 39% of you. Um, on do Yeah. So is the right answer. Um Onda next, most popular was B or a. So it's very CT scan or perform. Oh, Doctor. Me Good. I'm glad that the second most common trace must be because we'll talk about it now. Sorry. So So yes, this is actually a retrobulbar hemorrhage on that's an orbital compartment syndrome. So there's a hemorrhage into the space behind the eyes of the retrobulbar space on that causes the proptose ist that the patrician of eight millimeters, it can be mawr about maybe 8 to 10 sometimes, Um, on the reason this is actually a medical emergency. So 60 to 100% of people will have, ah, chance off limits, Right? There's a 62 100% chance of visual loss if it's not treated as a medical emergency. So if the question asked you to take a A B C, the approach about probably will be your first time management. I think you have the option here. Um, but in another in another s. Yeah. So you might actually see blood filling up in the I after the trauma. And that's if you can see down here. It's called a high FEMA. So the first like the management, which is definitive for this. So if you notice I didn't say first line, I said, Definitive management in the intestine. The question stem is a natural can talk to me and what that does is that s so that's basically cutting the tendon here. Actual camp in tender on that immediately releases the pressure in the eye on. Then the patients will then have further management too rigid to prevent infection or to reduce swelling in the questions. They're my mentioned that he had a known possibility history of hypertension. And and that's a common cause off the erectile bobblehead marriage. But also, trauma is probably the most common cause. Yeah, so next question. So Bichir has a painless red eye with no visual disturbance. You think you know what he has? So you decided to give him some phenylephrine drops which improved the red nous. So what condition does he have have? The whole No, I hope that was enough time. Great. Yeah. So most of you've gone for a like over 50% with you just is good on. But second, most common choice would be right. So I'll explain to you why I say not be so. Yeah, The answer is a well, then of tea. Today's Have you got that? Correct. So the important things in this question are, um, that he has a painless red eye with no visual disturbance on the reason why I have talked about phenol, a friend. That's because this is the way that you a differentiate at this for right. It's from slow writers on in whenever, when for not for nothing. Drops are given on the readiness disappears. And I that indication of the Scleritis Robbins. The Rituxan will come on to the differences between them in a moment, but it's a common cause off, painless, painless, of a painless red eye. So another word for this redness that you seen the eye is called Contrave teibel injection of this one on. The reason why it's not a subconjunctival hemorrhage is because, um, because of this, because the phenylephrine drops have removed any cause and the fact that it's if it was, if it was painful, then you might think that it could be slow writers. But if it's painless, it could also be some kind of title hemorrhage. Dry eye is not likely to present like this, so it'll be about subconjunctival hemorrhage since we mentioned already. So that's when you have first blood vessels between the conjunctiva on the sclera and the symptoms of which are a painless red eye so similar to what we just saw. A note Awesome vision, similar to the question on it can be asymptomatic. The cause is our most CEO pathic, but it can be after and I injury or head injury. If you have severe coughing or vomiting eso patients that were that have pneumonia or even in cases of covert where patients were coughing a lot. They actually might develop subconjunctival hemorrhage all the patients with hemophilia and a hospital history of hypertension as well. And for this year to make sure you check the patient's BP doing FBC LFTs and also clotting. So the management. Actually there's there's no treatment required. It's conservative on often they're the I will turn yellow before improves. And that's just the natural healing process. So on to, obviously writers and sclerosis, which is what RSP was about. So obviously, ritis is the hepatic inflammation off the vascular connective tissue layer that lives between the sclera Onda content typer on. In both of these conditions, you're going to get a red eye. Um, you'll get a tenderness and pain in some cases of Episco ritis, but it's usually painless, but it will be very severe for school writers and scleritis. You'll also get photophobia and vision loss, which we didn't have in the SBA that we just did on in Scleritis. All those are sometimes get a blue issue is what the question might describe it as so the management does defer for the two So for Evista Ritis, you would give them artificial tears on if it doesn't go away or it did improve. You would then give topical steroids for a factory cases. And for slow ritis, it's an urgent ophthalmological referral, so you should refer to the ophthalmology department. Um, Andi. Usually steroids would be given or release of all prednisolone on. Then they sometimes give a landsend's with or without antibiotics, but I think it's uncommon for them to prescribe antibiotics. So especially if the cause is not bacterial. Um, so the most important thing in terms of investigation, which I haven't included on the slide, is because this is done. This diagnosis is done through the use of the phenylephrine drops, most commonly to differentiate between the two conditions. But you can also tell whether it's scleritis or not, um, or flight. A pistol right is by doing a slit lamp examination on insulin rises, your CBC little modules, which is the common occurrence. So if that comes up in the question and they mentioned nodule is, you know it's the writers, so the next a condition we look at is chalazion and stye. So now we're looking at a condition that affects the aisle. It's not the actual globe itself on it's acute, swelling off or on the eyelid, but they have different causes. So if it's, um, Obama England blockage, which is, as we previous talk briefly talked about is a blockage of the oil oil secreted gland, which stops tears from evaporating quickly or drying up with the eye drying up. That's called a chalazion on. If you get infection of an eyelash follicles, that's called a stye. So I've got some pictures here. Style is also called a cardio, and that's another word friend on going to see the difference between a stye on to chalazion or ah, my baby, um, gland obstruction. So a chalazion will typically be painless, actually, even though it looks a bit worse on, patients will be able to notice a chalazion on when they look in the mirror more obviously. But it can slowly become uncomfortable and painful over time as it swells on. When the patient feels that they, they might mention to you that it's a hard bump felt on the outside and the inside, so when they ever had their lead, there might be a little white dot, which looks like a stye on the inside. But it'll be. It'll be hard and rough. Stye is usually painful when it comes up, even if it's small, so the management for both of these are quite similar. So the start of the management would be a warm compress on Let hygiene on. That could be a lead scrub. Or you can get these things on my bags, which patients can put on their eyes on also just making sure that the areas kept clean. And then, in both cases, chloramphenicol might be given his boat, which is a broad spectrum antibiotic. If, in the case of a chalazion, if it persists, which they can, sometimes they might need excision. But the danger with that is that they can, uh, then I think they might sometimes require really construction. Or they might leave a scar. So patients are the best thing is to try and avoid having to go to surgery on nice guidelines. Actually, only say the antibiotics should be given if it's associated with conjunctivitis. So just be careful of that, that your first management is no clinical. It is didn't let hygiene and warm compress to until the next SBA. So reserve has a sudden onset unilateral pain in his eye. He has photophobia blood vision, floaters, red eye on an irregular people. So among other presentations that we can see her in the image. He has a past medical history of and close and spondylitis. So what is your first time management for this patient? So if I could have the polyp, please? Thank you. Great. So most people went for D. Okay, So IV dexamethasone. Right. Great. So, yes, that's the correct answer. So why is it the correct answer? Well, in this case, it's anterior uveitis on the key things in the stem of the question which which mean that this is on two uveitis are the irregular people on the past medical history off and closing spondylitis. The fact that it's unilateral and the patient, obviously as you can see in the photo, has a red eye hard red. I've, um now another thing, which you can see in the photo which I I didn't wanna name here and draw attention to Is this this layer here, which is a hypopyon, and that's a possibly build up, um on. This is a medical emergency. So you need to get the patient IV steroids. You can give cycloplegic eye drops a swell, but that's often given alongside later on. So, you know, cyclopentolate for a trip in, Um So arguably, you know, you could say that if you're taking a B c D approach, you know, you should give the patient I'd be paracetamol. What some sort of pain relief on? I think that that is a that is ah, acceptable answer. But in this case, really, you're not going to treat the patient unless you give them IV dexamethasone. That's the most important. And, munchkin, so just a little bit about anterior uveitis this summary. So the symptoms are sudden onset unilateral pain for a phobia, blood vision, floaters, red eye, irregular people and the hypopyon on the management is cortical steroid treatment. So I'll be dexamethasone. Second line is deMars and then the third line is an anti muscarinic spectrum PJ Such a cyclopentolate um, some associated conditions, which are really important to look out for Teo in SBA, is, um so that you can sort of have an idea that this might be anterior uveitis are spondyloarthropathy. So I'm closing spondylitis like we just talked about On also other HLA b 27 related conditions Also IBD onda sarcoidosis. Now you might sometimes see this picture where it looks, uh, sort of you can see this bumpy area here on. That's an irregular people don't get this confused with FHP. So in patients that have FEP, which is, ah, the amyloid disorder, they get a, um, a Lloyd deposit in the land's and that causes what we call the scallops people not slightly different. So it might look a bit like this. But if the question stand talks about this'll past medical history on on these symptoms, it's more likely to Teo Uveitis if you've seen a regular people so on to chemical injury, so this's a cause off. This's a common common occurrence that happens in the workplace at home. The most common group of patients that actually get chemical injuries are young men who work from the age of 20 to 40 or Children from the age of 1 to 2, which get which are commonly affected by household feeling products on. But, uh, you know, other acidic substances in the in the household, so the symptoms of This would be a painful red eye watering a decrease in visual acuity. They might get a skin burn a swell around the area around the of the orbit. Blistering on the signs that you can see on examination would be a corneal abrasion. So we've got a I got a fatal in a moment off a corneal abrasion which can have a look at, um well, they might actually have a larger hole in the U. S. O. Or in the in their office surface of the eye. And there's also launching of the limber, So I don't think is that clear here. But the limbus is the outside area around the iris, so it's actually quite expanded. Here on that area, which is around the iris, is that white area, which you'll see that becomes launched. So that's an important thing to look out for. Now your management. The first thing to do is take a culture, a history or a history from the patient if they can give you a history because you need to find out whether it's acidic or alkali burn so acidic burns are less common than Uncle I burns on, which almost twice a skomal on on some of the other products which cause alkali burns. Are castle cleaners that have ammonia in them specifically in the workplace. It could be lyo meant, um on dure. So what would you need to do? So the first thing you need to do is figure out. Is this an accident, or is it a deliberate? Um, if it's a deliberated attack, you you could think that. Okay, this might be an acid attack. Um, you need to admit the patient, test the pH and irrigate them immediately with a with a solution. Irrigation solution Might be sterile water on. Do you can give them topical steroids? Antibiotics? Cycloplegic switch paralyzed the iris and reduce pain on. Then on top of that, sometimes that your gas eccentric or a score Percocet is given. And that's for increasing the speed or recovery time on that, the healing and then also it's important to make sure give the patient and easier. So until the next test, be a So you do a slit lamp examination on the J with a florist and stain. Because he has been complaining about discomfort and rubbing his eyes a lot. How would you describe what you see in the severity they're going to pull up. Great. Okay, interesting. I came. So? So most people have gone for a epithelial tear. Okay, um, the second that then there's a bit of competition between B and C. So dendritic pattern defect on 0.8 A PPO or erosion? All right, So this is something which might be useful for placement as well if you have an ophthalmology basement coming up. So the answer is actually see punctate epithelial erosions, and I'll explain why I think I know why people have said there might be a time. So, um, this could have been caused by a number of things. Firstly, before we go on to why, this is the answer. It could be in this, but in this case, the patient been rubbing there. I got a lot of discomfort, so it could be probably one of two things it could bought. One of three things it could be. They've got an infection on there, rubbing their eyes. It could be that they've got dry eye on there rubbing their eyes. Or it could be that they got a foreign body under the eyelid and that's causing the irritation on because in it to scratch the surface of the eye. So it's in this case. Can you see those little dots here on the on the surface? It's quite it's quite fine. It's hard to see, but this pattern off dot switch take up the which reflect the the green yellow green. They fluorouracil agree that is known as punk date of birth video erosions. They just think of it as puncturing. So you've got lots of small little pinpricks, which which are reflecting lights on. And the reason why it's not enough material terrors because in the neck feels hair. They should be a big section, like a big sort of like almost like a big hole, which will fluorescent reflect life. Now? I think some people might have thought that there was a tear because of this top part over here. So if you can see my point from the screen on because of this because of this top part him, um on, that's actually not That's actually whether eyelid margin is where the fluorescence day the florist in liquid has accumulated on the on the eyelid. So So if you got caught out like that. Just just be aware that if you're gonna see a little tear, it's probably most likely going to be maybe here somewhere or closer to the center, towards the limbus. Okay, great on pimping. Scarring is not a thing that just that blood just for that. So this is another question. Another SBA so you can have the polyp. So what color is this staying used for? The slit lamp examination is that green is a blue is the orange is it yellow or is a pink? There's any one right answer to this one. But I think this has come up in a nest be before in an exam. So that's why I thought I heard in and just watch for a while. We're waiting for that. If some of you thought that this was the tear on, But why you chose terrorist, Actually not. This is a reflection of the lights and the reason you know that that's a reflection on this because, um is because it's not fluorescent green. So, you know, that's a reflection. So if I could have the results please of the pole. Oh, so you got a hole. Okay, so I'm glad I put this in then. So it's almost a tie between a, B, C and D. Okay, so So Florissant is actually a a Norine. Just the answers, actually see, So the next night Yeah, they aren't so the answer is actually orange. So the reason why this is confusing is because sometimes we'll see the florist and drops on placement and they don't look that orange. They look a bit yellow, but for the purpose of an SBA, the answer is Florissant is orange on the light that you used to look through this little, um that's on the slip down. That blue light is called cobalt blue. I'm not going to go into the really details of the physics of why that happens, because it's you don't really need to know that for for progress test. But basically what happens is when the Florissant that goes in the eye, which is an orange drop, seeps into this into the layer of the eye, and it sort of permeates through the holes, which I made in the outside layer on the blue light, which was shining, is causing the electrons to move to hire orbital's on. Then when they dropped back down. That causes emission off green or yellow lights. So that's you don't know too much, but they don't know the wavelength that which that happens. But that's why you get this sort of green yellow effect. So that's no, actually, the dye that's green and yellow And I could be a bit confusing because sometimes on placement to see the to you and it looks yellow. Okay, great. So let's we want one next condition. So carrot itis so characterize this is inflammation off cornea. Um, and it can be It can be of uninfected course, so it could be viral, bacterial or protozoan. So there are some symptoms which are common regardless of what time it is. And that could be a painful red eye photophobia a decrease in visual acuity. A small people discharge which could be watery or past like dendritic branching, which was a sign that we that was in one of the S. P s earlier on, then an epithelial defect, which is a tear in the lining on, then a corneal clouding so the cornea just might be clouds, liver and your minor bills get to see too much of the center of the other people or the iris. Now, what are the causes? Well, this is where you need to to differentiate between them, and you can do that based on history. So the patients that have, uh, that where contact lenses, it's most common that they have an infection by pseudomonas, um, on patient that I've seen. So maybe a child that's been playing in the soil, or some be that strong, contaminated water. They go on a hike or if you live in an area where there access to clean water is not not. Not readily available, then can't remember is a common cause. Also, patients who've had trauma. If they've had conjunctivitis, which is unsettled, then it's refractive, and it keeps coming back on, then bacterial causes. So the most common ones are strep staff, or pseudomonas would be just talked about for contact lens bearers, Um, on also happy simplex. So if we just go on to the test, so the test that you should do are the floors and stain certain lamp examination. A corneal scraping cytology so empty nest on a PCR viral ones on an F, B, C and HIV test is Well, so the patients that have, um, herpes simplex, we'll get this dendritic cutter. And so that's what I meant earlier by dendritic pattern. It just looks like a lightning bolt. Or by the name, a dent right s so you can see, like, the little the head of the den dry here. And that's where the tail, Um and that's a really easy thing to Teo. Identify if you see it. So what is the management? Well, that would vary on what the cause is, But often it's a topical anti viral such as acyclovir. So, uh, in the vial case, like an H S k case or ah, chloramphenicol for a bacterial case so on to our next condition. So end up form itis so end up from, like this is via inflammation of the interior on or posterior chamber of the eye on the symptoms are a painful red I a sudden decrease in visual acuity country titled Infection, Past Medical History of Ocular Surgery. That's really important for this condition. If you if your patient has had surgery, there's sort of two conditions which we think about which they might develop after this one is a cataract, which we'll talk about in a second, and then the other one is end up for my test on, then the infection or trauma again. Here you'll get a hypo pee, and so that layer of white cells that we talked about the possible the past. They're of white cells that build up in the eye Onda corneal edema as well, so you can see the cornea swollen on. The two main causes are you have to figure out. Is it is it endogenous there is it from within the body, so it could be a result of infection in endocarditis? Or it could be exogenous. So a cataract surgery it could be post intravitreal injections, which is the management for some other conditions that we're going to touch on. And then the test you do are a set up examination, especially to look at the hypopyon, a full infection screens so F b CS Bs on a viral culture. On the management is intravitreal injections of antibiotics, so that's into the vitreous. So it's not very nice, but I never ask for the patient. And if you're squeamish and you you see it in person, maybe not be nice to yourself, but they literally just inject straight into the eye, um, into the vitreous you about Onda. Then we'll do a biopsy of the vitreous for a culture and then over track to me. So a trick to me is a type of eye surgery with which which they basically remove the vitreous inside the eye and replace it with another solution on. It's a gel like substance, and it fills the middle portion of the ice. That's what the vitreous is. So until next, SBA So Jar for is on the ward and tells you that he's waiting for surgery for his glaucoma. And that's made him feel that the glaucoma that he had has made him feel sick. And I gave him severe pain and his eyes were red, so it had come on acutely on his visual acuity has been affected at the time. He can't remember what type of glaucoma he has, but he tells you the name of the drug that he's using in the meantime, on that it makes his pupils small. So what medication is he using on what type of glaucoma does he have? And so you could have a polyp. Bit of a mean question. Two questions in one great case. And the results. Okay, So most people went for be superior car bill on closed angle. Glaucoma on do the second most popular choice was a circular copy and aren't open angle glaucoma. All right, so for going to the answer. So the answer is indeed it is be so well done. Everyone who got that on for everyone who got a well done for getting the drug on. But we're gonna talk about why it's be so This patient has acute angle. So I didn't give you the word acute in the question, but they have closed or acute angle glaucoma, which is the same thing on, but they have a red eye there. They were acutely on. Well, the time they felt sick on their visual acuity was affected. I haven't given you too much information, actually, in this question about to sort of disseminate whether it was acute all for open angle. But you can tell from the fact that he is on the ward waiting for surgery because, uh, on the fact that his you know, he had severe pain at the time. So the reason why it's, um, Benicar Penis because it's, ah, it uses. It's a muscular neck receptor antagonist, so it must run it receptor agonist on that construct the pew that constricts the people and causes my OSIs. So it's not too low because that's a beauty blocker. It's not tropicamide because that's an anti muscarinic, and that causes dilation of the of the eye on my dresses. And that's actually used in examination of patients who have really small people's. And you can you can do for endoscopy on them so well done to have one you got a copy. So I want to the next SBA before we talk about glaucoma. So a seizure comes to the clinic and has gradually got worse over the last few weeks, with a history off frequent changes in her vision, she was referred by her optician because the intraocular pressure was 16 16 in us Oculus sinister and 25 in Oculus. Dexter. Based on your investigations, you think that she has primary open angle glaucoma. So what is your first line management for this patient On some of the terms of new to you, we will just go through the turns. Well, the moment be on to the question. All right, so good results. Okay, So most people went for option B. So prostaglandin analog and 10 across on, then the second most common choice bars D so carbonic anhydrase inhibitor the town of prostate. Okay, so I think you guys know or you kind of know what drug you want to choose. Um, but we need to know what type of drug is. So So, yeah, so the answer is be So it's a plastic it prostaglandin analog latanoprost on. I'm just going to go through the question with you because there's some a couple of things in the question which may be some people might not have seen. So, um, and I opiates intraocular pressure on. In this case, the patient has an IOP off 16 in the ocular sinister, and that's, uh, the left side. And a good way to remember that I'm I'm sorry to other people that are left handed, but sinister is the reason it's called similar stairs. Well, I'm not sure this is 100% true, but I You might have heard that, you know, back in the day, people didn't want to use their left hand cause they said it was the hand of the devil on. That's why it's called ocular sinister. Eso it just That's a good way to remember it and Oculus Dexter, because most people are right handed, and that's the side that you were dextrous with. So that's just a quick way to remember that if you see that question on, but we're looking at the intraocular pressure in the right eye. Opulus Dexter at being 25. That's quite high. Often, when you look at intraocular pressure, you want to look at the difference between the two because the patient might have high intraocular pressure anyway. On the intraocular, pressure can range from anything from 10 up to about 21 usually or 22 sometimes. But you often want to look at the difference between the two. Obviously, 25 is very high anyway, so you know that there's something wrong there, Um, and yes, so in this case, the answer was a ton of process, the first time management, but open angle glaucoma, and it's a a prostaglandin analog. So just a quick run through, we're going to, like, discuss this. I think This is a topic that a lot people find quite difficult to get the head around. So coma is the optic nerve, which there where the optic nerve, which connects the eye to the brain, becomes damaged. And it's usually caused by a fluid building up in the front part of the eye, which increases the pressure in the eye So you can see here. This is a normal optic nerve, so it's a bit dark and this is an optic nerve. With low coma. You can see it's swollen and it doesn't look the same. Um, sometimes, if you haven't seen a couple of these fighters might think that's normal. But it's when you compare them, you could see the difference. So some of the causes off a coma or their risk factors are city. So if you're African, Caribbean or Asian orange, any more likely to have it? A family history of diabetes, hypertension? If you've used cortex steroids, family history, so sorry, uh, farsightedness. So I put a trip here that's for acute angle glaucoma, and we'll talk about the different types in a moment. The risk also agreed increases with age, and it's estimated that Norco 5 to 2% of people over 40 have one type of glaucoma grates on to the next section. So yeah, So the investigations you do forget came are visual fields, a slit lamp examination applanation to mama tree for the intraocular pressure on gonioscopy, which we'll talk about the movement. So the two main types of glaucoma are open angle and closed angle. I'm gonna compare them first and talk about how they actually happened before we go into depth. So the first one is open angle glaucoma, and that's caused by a slow block. Which of the drainage canals, which results in an increase of intraocular pressure. Now the in the open angle one. The angle of the cornea on the I rest is poop into this angle over here. But the trabecular meshwork here is partially blocked on. That means that you keep getting this a quist flow into this front area on the pressure slowly build up, and that's why it comes on slowly, um, on often the patients don't notice that they're having problems straight away, and it's insidious on, but this is actually the most common type. So here you can see a comparison So in an open angle glaucoma situation, the patient will. They will complain of a headache and I but it won't be. It won't come on. Suddenly they might have a scar tamer. We'll talk about that in a second. Um, they'll have frequent changes in their price biopic lens and as that's in their comment, in their vision Onda. They'll have a delayed dark adaptation, and I lost vision and blinders now in closed angle glaucoma here, and that's caused by a blockage of the drainage canals in the Canal of Slam. So when the when the pupils dilated, the irises attracted to relax here and that and it also thickens as well. So when it retracts and thickens, you get a neither really narrow angle here or you'll get no angle at all, and we'll completely blocked off. And that blocks the canal of slim between the iris and the cornea. So this canal is completely blocked off on. That means that there's no aqueous outflow. Um, on the pressure build up really quickly on the canal, A slam is, um, sort of a circular canal that lies, um, that lives in these flare, a corneal junction of the eye on. That's what drains aqueous humor from the anterior chamber into the veins and drains the eyeball. And that's how your pressure stays normal. Um, on your get severe pain, nausea and vomiting. Readiness of the eye black, you know profusely. Acclamation photophobia on. Um, this might should come in attack, so it might not be constant as well. So just some of the features of primary glaucoma in more detail, which is really useful for excuses. Well, so the features. We'll have our profile field loss and you'll get this nasal scatomas, which is also called in our cure rates for the germs for two months. So in the knees will get a nasal step, they call it, But you might also get this back you ate. Pattern is well, they'll get tunnel vision, a decreased visual acuity, that intraocular pressure will increase way beyond 24 above 24 when you do Goldman affirmation to monetary and the normal should be around 10 to 21. As we discussed earlier, you should also do a colonoscopy examination to assess the interior of the anterior chamber of the high and the configuration on the depth. This but now open angle. Glaucoma can be confused with presbyopia, which is an age related farsightedness that patients get. So make sure that you don't confuse the two. Now, this is, I think, really interesting pictures. Maybe some people haven't seen or, um but this is a way that when you look at the actual disc of the eye, we talked about how it doesn't have the same as it should. These are the four steps to, in my opinion, the best ways to diagnose, uh, to look at this picture. And the first thing is to look at optic disc, uh, Ping. So the optic disc up toe up to disgrace show should be more than normal in seven. So a normal cup is no 0.42 point seven. Although the caveat is in clinical practice. You know, sometimes then these things are not exact. So there's no cutoff sort of. This is exactly the cutoff, which you have glaucoma. It's more of you to look at the overall picture on what that means is if if you see this cup, here is a little raised area, this lighter area, and then you can see the other, the the largest circle. So the largest cycle of the disc and this is the cup. So if the cup fills attempt of the disc, that would be a ratio of 9.1. If it feels seven tens of the disk by that means it would be a ratio of 9.7. So the normal cup to disc ratio is less than open. Five on a large cup. Just ratio tells us that there's something wrong, so that's the first sign. The second one is optic. Just power on. That shows that there's operative a trophy so you can see that it's a bit lighter and shave. Second one is bare netting of the vessels. Now, if you follow this point up here and you see how this vessel jerks and bumps that you should be going from the middle so it comes out and then it jacks and bumps over the cup edge. So that's when they appear to have a break and they go down into the cup on. That's because of the raised edges of the cup. Another one is cut. Nothing's. That's usually where the vessel entered at the desk here on, but that could be a result of ah discovery. So the management for this is as we rightly going the SBA. The first time is a prostaglandin analog, so PGA I remember as primary open angle, almost proagro and then use a PGA A prostaglandin analog. That was hard for, um, second line. You can use a beat blockers or just below carbonic anhydrase inhibitors that does Olumide or a sympathomimetic I dropped like the monitor. Now, if it's advanced or chronic, the nice guideline state that you should do a selective laser trabeculoplasty. And that's a short pulse. That low frequency, which they target the melanin rich cells of the eye in the trabecular meshwork and that induces, uh, white cells to clearly affected cells on. Then rebuild the meshwork to reduce the Are the IOP so going on to your primary acute angle or closed glaucoma? The features of this we've already discussed, we said, you know, severe paying decreased be a symptoms worse than my dry eyes. Worse with my drive system watching TV in a dark room. Ah, hard red eye halos around light. So this is a really great way to look at it so you can see these halos that you might see it when you look at a directly the barb on. Do you have a semi dilate of non reacting people? Systemic upsets? They might be really sick. Now this is Ah, emergency. So you need to refer you to the ophthalmologist. Give IV. I see it is Olumide start to reduce the increased secretion and then you want to induce people reconstruction with the topical pilocarpine. But the definitive management is a laser eye surgery on. That's the peripheral iridotomy. So that's when they put a little hole in the peripheral area of the iris. So maybe, like here, maybe they would do it through a little purple hole in the iris on then that causes the aqueous humor to flow back into the angle. A Z discussed that. So here's I'm going to go through it now. But here's a list of all of the drugs and also the adverse effects. So this this really comes up often in SPS, so make sure you know what the adverse effects on the mode of action of each of these drugs are on day used. So on to the next question, Eso Shamma is a 45 year old female with a history of type two diabetes who presents for a routine. I check out her optician endoscopy produces the following image on the optician refers her to ophthalmology. What stage is her condition? Seven clubbing. It's quite a messy picture. On also be prepared that sometimes in SBA they might not give you a picture is Well, they might just described things to you. So it's important to know all the terminology as well that we're going through. Great. So see the results. Okay, so yeah. So most people went for a so proliferative diabetic retinopathy on a few people went for options. About a quarter of you went for shouldn't be severe. Pre preoperatively diabetic retinopathy. So I'm glad. So most of you got the answer. Correct. So well done. S Oh, yeah, it is proliferative diabetic retinopathy. Now, some of you might be thinking Okay, I can see it's proliferative on. I can see this So you can see here on this new vascular ization. And that's what we're looking at. It could be any stage off diabetic retinopathy, but I haven't given you a stage. Um, there are the things you can see here, such as the dot, dot hemorrhages, You can see the tortuosity of the vessels. You can see cotton wool spots will talk about all these things in a second, but the main. You know, once you see this new vascular ization around, here's these extra blood vessels. Then you know it's proliferative. Now this is actually a a laser scar from treating diabetic retina up with these air. Sometimes you might see the answer would be treated diabetic retinopathy on. That would be the correct answer. If, if I gave you the option on and that's in the area of ischemia or perforation, they might use a peripheral scatter laser treatment. And that's what these little dots are out here. So a quick summary of diabetic retinopathy. So the changes on the retina are often noted during a routine screening or prior to symptoms. So in the in the ANA test screening in the UK is for patients who have diabetes over the age of 12 is it's routine screening on some patients might have visual loss, which is when they have a maculopathy. So that's, um when the macular area said this sort of area here would be affected as well, or they might have a tree is hemorrhage. And then we'll get to the, uh, visual loss in a beer is gonna talk about in a moment. The cause is off Are almost all patients with diabetes. Type one will have some degree of retinopathy within 20 years of diagnosis, but many patients with Type two will also have her some signs of retinopathy after going through a symptomatic period of hypoglycemia. Um, Andi? Yeah, so the investigations you do art would be an agent HBA one c You do in ocular computer toe CT Florissant angiography, which is especially good for seeing bleeds on. Do the management is if you have pre preventive, um, it should be monitored at 4 to 6 months, or you can do you know, in some cases they might even do a perfect scatter days of treatment. If it's mild or moderate, it's, um, they diabetic retinopathy. They would monitor annually and maintain good control on for high risk proliferative retinopathy. We do the physical violation, and they might give antibody Jeff injections, which may be used to minimize neovascularization. So just a quick summary of all the different things you might see two before I go on to how you stage it so you might see micro aneurysm. So the just dots they're little red dots, which are local localized capillary dilation and small red dots in clusters or alone. Then you might see intraretinal hemorrhages. So there's a slightly bigger ones within the nerve fiber. Or that might be called the dot. All blocked, shaped or flame shaped range is well, they might be this hard exudate little yellow dots, which are resting on Lipit deposits. You might see the grades white Willie areas. That's what they called, causing little spots. And that's patches in the nerve fibers tear, which indicate chronic low cholest you mia. Now, if they have venous abnormalities like this, like a dilation or beating or duplication, then you know that it's widespread ischemia. And then finally, neovascularization. So these little extra vessels that you see everywhere So just for the staging of that diabetic retinopathy, you This is the way that this is that I would use this state. There's a couple of different ways you can do it, but this is the one that I would stick to on Miles nonproliferative. You have more than one micro aneurysm have a moderate nonproliferative. You'd have micro aneurysm plus dot um, for 10 ridges of these ones. Hard, actually, date says you could be here. Um, and then sometimes unconscionable spots. So I got a spot here, and then sometimes you might also get, um, you miles to get Venus stimulation or perforation. But we only a small amount on then. In severe non proliferative. You have lots hemorrhages and my karate in all four quadrants. If you split the iron to four quadrants in all four areas, you'd have those. You have venous bleeding in atleast two quadrants on then i r m a n a least one quadrant. And then proliferative we already talked about you. Get any of us is Asian. So on to an excess. Be a SoMa is a 65 year old male who really visits the hospital. He knows that his vision is not normal and he's been to rating over time. He has a BP of 150 over 95 on fundoscopy. You see the following image? What grade is his condition, but okay, so between C and D said third or fourth stage so yes. So it's quite tough to see actually from this image, But I'll explain to you why the answer is third stage. So for those of you got fourth, you know, it could have been forth, actually, but you see the cotton. So this is hypertensive retinopathy, so not the same as diabetic. So you see a cotton wool spots, you see a flame and blocked hemorrhages around here, and then you might see the start of a demon. But I don't think that's that it damages yet. And that's why this is a third stage picture. This is a photo is actually was taken it with diagnosis that stage on fourth day, you'd have more obvious a demon. So in hypertensive retinopathy, use a Keith Whiteman staging on So first would be anterior narrowing and tortuosity eso the tortuosity me just sort of curly lines. Silver wirings. This photo shows it really well. That's your little silver. So it's almost fluorescent like interior. Be off the inside of the blood vessel that's called silver wiring to Is it our to Venus nipping? So that's when you see the school notches and then Stage three is costing world exudate it's flaming. Body damage is on. Finally, you'd see papilledema. So this is what I would say is more obvious to be stage for when you get something a picture like this so papilledema and this could be caused by hypertension or space occupying lesion, a medic, idiopathic intracranial, hypertension, hydrocephalus or hypercapnia Onda. You might see Payton's lines elevation of the optic dissipated lines of these concentric radial retinal lines that come out from the center on blurring of the optic margin. Now there's loads of different causes of this, so it's just important to know the differentials. So until next day. So a 70 year old man Jeremy's investigated with blood vision discopy reveals a 70 year old swelling of repeating myself there. So if endoscopy reveals drusen Restinal, epithelial and macular neovascularization and Angela Graders, test is positive, What is the most appropriate next investigation? So you guys were going to run over slightly, but if you just stick with it, um Mm. And the results. Okay, so, yeah. So, um, so yeah, so about a bit of a mixture so kind of equal. Of course, all of them, actually. So the answer for this one would be splitting sit up examination because we've seen a fundoscopy already. But the first examine you to do after endoscopy is a slit lamp just so that we can assess, um, the outside of the eye. And, you know, that's probably usually our first line investigation for most conditions. So in in related macular degeneration is the most common cause of blindness in the UK, and it's usually bilateral. It's a bilateral of degeneration off the off the macular and voter receptors in the retina, which caused bruising build up, and we'll just have a picture of what trees. And there's the risk factors are smoking age over 65. It triples, actually, if you're over 75 family history off increases your risk times four. If you've got first degree relative with it, and the investigations are slit lamp microscopy. California's photography Florissant stay in angiography, so ct on an anti grid. So this is the and the grades, and if this, But if it paciencia is this, then that's a clear indication off of it related macular degeneration. So veggies is a potent might Egypt in, and that's it drives increased vascular probability in patients with wet a R M D on a different footing. Wet and dry is that in wet you get in choroidal neovascularization So in a choroid and rapid loss of vision caused by blood and serious fluid or a Dema pooling here on the macular on you can also get a retinal, the Tuchman. So in another city or season for bump here and dry, you'll get bruising, which is yellow of these drugs and yellow spots. And they build up around what's called Brooks membrane on. This is the most common one, actually, Atrophic, um, I called. So the management for this is an anti bedroom. So when um is, um um, a laser for tickle ago actually can be used, but people get visual loss on then photodynamic therapy, smoking cessation, education, reading, reading, AIDS and diet or important. There is some evidence that zinc and vitamins may reduce progression of the disease by one third, but, uh, but the main management would be anti better. So 71 woman's our our comes in with the juice vision, free to call a vision and halos as well as some blurring lights. Since you find it really easy to use, not Thomas cope. You confidently look for the red reflex, which is defective. What condition do you suspect crave? Have the answer, please? So you can see the whole Sorry about that, guys. Okay, Yeah, So we'll just have you have the answer, just so we could just leave things on it that great. So he has to see most of you got that one. It's a bit easier question, so we'll discuss that. Why? So the answer is see because they also see cataracts because the patient doesn't have a red reflex, and that's really a clear indication of cataract. So it's going to the next SBA. We discussed cataract on the Maybe it's come here talking to have been more of a neuropathy form. So a 30 year old female re A from Japan, recently gave birth to a boy last on holiday in the UK She recalls having a vaccination 15 days before pregnancy, which was which was confirmed, but she's unable to remember the name of the condition. The baby was born with skin lesions on a low birth weight. Further test suggests sense in your old deafness. Bilateral cataract, Payton doctors, arteriosus, salt and pepper retinopathy is we can see here on. So what condition is this child Heart? Can you please call? Uh huh. It's a bit of a mean question, but so, yes, these mystical about congenital rubella it's been doing well dot So that is the answer. So this is potentially as a result, off MMR vaccination. We should not be offered to women planning to get pregnant within 28 days on. Children have a 43% risk of being affected if the mother becomes unwell 28 days before. So yeah, and create a shot. It's an office in on that, because that's the cream is a fight. Peter Leash. So just a quick summary of cataracts. So it's an age related a pacification of the lens, most common cause of visual impairment worldwide. It's not just in the UK on its build up on the crystalline lens, and these are some of the causes of cataract. But age is really the main one of the most important ones, so the teachers are reduced vision, faded color vision, a glass of like severe, brighter, a halos around the lights. But this is a really great diagram, I think, to visualize it on your investigation will show it reflex. The red reflex is defective on on slit lamp examination will see a clouding over the front of the eye. On the conservative management is prescribing stronger glasses, encouraging use of bright light Ng'andu surgery, which is probably the only effective, definitive management s o They'll do a small incision or they can do a faker milk, A faker in most in multiplication. Um, so this is some of the examples of different types of cataracts. So cortical pap sealer, you clear? I wouldn't worry too much about, but just I think the red reflex is important and being able to recognize that it's a cataract on this is just you can read that you're in time. This is just a little summary of the different types of cataract. So I think it's, uh that's the end of my section. So beer is gonna take over now and she's gonna talk to you a bit more about some other conditions and some neuro ophthalmology. So if you wanna share your screen, I'm sorry that we should stop sharing my screen Very good. What can you say? Sorry. I can see your whole screen so I just want to see I can see your nature. It didn't seem representatives note for that. Yeah, No. Can you see? Fine. Yeah. No, I can see you. That's great. But, um thank you for saying with us for selling on guys. I'm gonna be focusing more like your ophthalmology. There's some other road topics. So if we start with the fast question on, But the question is on 84 year old man presents with loss of vision in his left eye since the morning he's otherwise asymptomatic and has had no associated eye pain or headaches. His past medical history includes ask you a cart disease, but he's otherwise fall on on examination. He has no question in this last time, the left people responds poorly to light, but the consensual like reaction is normal. Lost a very reveals a bright spot over a pail in a pink rash in a what is the most likely diagnosis? We can get the pole going, please. Thank you. Um, affected. Then we'll stop the polls. Okay. We'll stop the pill now. Um, a lot of you have gone for option we on, and that is in fact, the correct. Answer on. We'll go over. Why? That is right now. So in the question, you notice that the sorry in the question you notice that they talk about rest, Got over a pill and a pic right now. That is the significance in terms of central retinal Restinal artery occlusion, and I'll go over about in a second. But firstly, we need to know about acute visual loss on cute visual loss could be divided into into, like, so many ways, So you can think of it like, isn't transit? I didn't go for a few seconds and then come back again. And usually we think off ta in those cases. Is it painful? So have we know safest talking about a huge click home or or optic neuritis. And obviously the other associated sometimes with them would also help you find out, um, narrow it down further. Do you have an associated red eye with, uh, visual loss of that? It's a cute look, Homer, that you can divide it into it. Further things, whether it's on one side or is it on both sides? If it's unilateral, it's more likely to be these options. If it's bilateral it could be a t I A on is there are EPD present, which I know a lot of us have a seat with optic neuritis. But there are other options as well here, um, which could give you an RPG with an acute measure loss. So those are things to consider a slob. We're going to details, Um, all of these in a second. So a t I A. Is to find a sudden, sudden onset hum in a home of nine. Official feel lost. It's usually playing less, and there are other neurological symptoms. So a transient ischemic attack is usually when we think of it in terms of the brain. When you got loss of blood supply for a few seconds and there is no transient, there's no long term damage to the tissue of the brain. There are certain risk factors as we would associate. The way of strokes of well, is cardiovascular risk. Factors like hypertension prefer muscular disease, diabetes, that factor. One thing to be considerate off here is over. Um, your says so guess which will go over again. But this is something you need to consider in like gi, see a So if a patient comes in. If talks about like a temporal headache and then says are that point? You are particularly worried anyway, but if they say to actually, um, my regiment for a few seconds, but it's back now, then you really need to be concerned about that. So, um, and then management is as you want with the stroke. You want to refer to the stroke teams just so they can rule out everything and make sure we're on the right medication. So I'm Marissa spoke last. Like I said, it's trying to a loss of vision due to compress blood vessel to the restaurant. So how do you differentiate between a central western or wale occlusion and central retinal artery occlusion? And it's depended on the symptoms, So you get in both of them. Acute Spano Ocular, painless central visual loss. But when you do the endoscopy, it's the significance of the spine. Oscopy findings not tell you what ISS So if you look at it here, if you can see my mouth's moving in a central Restinal vein inclusion, you've got hemorrhages on how you know it's a central vein. Being inclusion is the fact that you'll have hemorrhages in awful quadrants. So if you were to divide the I, uh, this is like a very simple basic way I'm doing it, but basically, we'll see, um, hemorrhage and awful quadrants. However, if you only see it in one quadrant, then it's called a branch. Retinal vein occlusion. Yep, on D in times off other findings and on your friend this would be a dilated touch. Torture. Spain's cotton wool spots on already said about claim hemorrhages. How you gonna manage this one? So in most cases you don't actually need to do anything because they're uncomplicated. And so what you want to do is just allow them to settle, and they should settle within about 3 to 6 months. But you should be keeping a close eye on these patients because there are certain things that you want to keep a look out for, and that includes macular edema. So if you see like a fluid buildup, like a little fists build up on the macular region, and the first line option for that is by Jess and the other thing that can happen as it doesn't diabetes, you can get neovascularization on any time you've seen your vascular ization, the management is always the same. And photocopy elation. So that's your central retinal playing exclusion, the central retinal last three occlusion. So are the the main arteries blocked? You'll see like a pail rest in ER as you do the out. If this this looks a bit prices, usually it's poor wife, and then you'll see this cherry red spot on that Should if you see that in the crash in in your head, it should be like Central artery occlusion and you are concerned about the nation's. They should go to the stroke team for assessment, and then that will give them prophylactic aspirin. So as you went managed with stroke and also a lot of these cough that come from your carotid artery. So then they will do like a carotid scan, and if it's more than 70% blocked, then you're thinking of like a direct and are track to me. Sorry, some of these words I can't say to save my life. So, um, I and again like with central retinal vein occlusion, you can have a branch, retinal artery occlusion as well on the causes, as would be with strokes. It's strong, but, um, Bolic, that's one of the courses. Well, the other could be basket lighter. So because if you remember, I was talking about amorosa for guess it comes under the same branch. So, like, you could have a stroke in the eye, which can be central retinal artery occlusion central. Sorry. Brand tractor artery occlusion or amorous is for grass, so you can have a vasculitis off the big. So the main office. Okay. Dokey on leaving on to the next one. Sorry. This for, like, moving of it too fast. Um, okay, on, then the rest a little detachment. Um, retina detachment is defined as a visual field loss progressing towards the center. So if someone says, well, I feel like there's like, I was hit on the head or I fell down the stairs, and now I can't see in the corner of my eye. You're sort of thinking about retinal detachment. So, um, and other things you're gonna see the retinal detachment is lots of lots of flashes and floaters because you might also seeing a mattress hemorrhage and how you differentiate it because you've got more than hundreds off that in restaurant attachment you'll also see are you might see our EPD loss of red reflex and a pill Retinal falls. And how you're gonna treat these patients is, um, is the fact that you need to remember, if you forget anything, I'll give you a prep the details. But if you've got anything, it's an emergency, and they need to be arrested. But the specifics off you need to be admitted. One is that if you know that patient with suspected our ENT have a visual field loss or decreased visual acuity all, they have fundoscopic signs of detachment. They need immediate referral, whereas people everyone else can be referred within 24 hours on again on philosophy. Feel of that you'll see, like sort of. The rest are coming away. And usually what happens if the reason these happen is YouTube? Like I said, the main number one cause of trauma, but also if you got richest attachment or just say, for example, diabetes causing scarring. And it's so the so the pulls away at your retina. Um, and people who are my own pictures of cooks motorized, I manage. It sort of pulls away. Sorry, bigger eyes and then it pulls away. Um, so should we have a go at this question? After everything I've told you so far? What? You know, I'll let you guys read us. Thank you for the pool. I read the craft show in in case you guys some where you can't see it. Ah, 66 year old women Mom Task presents to the e. D. With pain, less measure loss in her left eye Her vision suddenly disappeared in the left eye two hours ago while she was walking a dog. There is no history of two or more. The patient was apartment must medical history, poorly controlled diabetes mellitus and partner effective diabetes, diabetes, diabetic retinopathy. Over the past month, she has noticed appearance of cobwebs, partial obscuring her vision in the left eye. On examination, the visual acuity fix out of 12 in the right time. On there is complete ritual. Awesome. The left eye. So what is the most likely diagnosis? You know, it's a lot of information to take it. So if we start the pole right there, Perfect. So we've got a split between D and E on. We'll look at the answer now, Mr Why it is what it is. So the answer is bitterest hemorrhage on. We'll go over. Why, that is that just from the question is the fact that I was like particularly trauma? Um, you'd be thinking of retinal detachment and, yes, diabetic Russia, I said. Diabetes are more prone to getting a retinal detachment, but before they get that, they get the scarring off their interests, and that's what pulls that away. So you get richer scarring, which was going away, and then that eventually pulls away as the right now Onda. Therefore, the answer is Veteran's hemorrhage on a few more details about with dress hemorrhage. So if you see sudden onset of floaters following, followed by diffuse visual off monitor ocular and it's painless and it's associated with retinal neovascularization, so as you can imagine in diabetes. So one of the biggest risk factor for bitterest hemorrhage is being a diabetic on. We know that in late stages of diabetes, her diabetic retinopathy you get neovascularization on these best wrestles just aren't as good as the normal ones, the more prone to rupture, either. More prone to just leaving every write on there for you just again Get this break it off. The blood on the blood just pulls around all of the bitterest area. So it's blood in that mitral area, and therefore you can imagine the patient won't be able to see. But there's no reason that they should be having pain. You got low test on everything, because that's what the veteran's is. And if it's destructed, then you get floated. So the management is just the fact that blood surgically is from the rest. Rest, however, if there is a rational break, then Chrysler your laser effect of regulations on investigations and through things like dilated for endoscopy, which may show hemorrhage in the vitreous cavity. So we'll sort of look like it's full of blood. It's red, etcetera on slit like last slipped lump examination might show right blood cells and the interior of interest. Um, and there are various other things you can do. And again, if you see any vascular ization, it's never a good sign, and you should always treat it with the question that is a 25 girls male who has a sudden decrease in visual acuity since the morning when he woke up from his left eye, he complains of pain when moving is high. On examination, you observe our EPD optic disc swelling in a central scotoma. He was diagnosed with M s by months ago. What is the most likely diagnosis? Okay, Okay. Trebay, stop The whole how that's Everyone's gone for C. And I think we all know what I was thinking of a mess. We think of my problems. We go for optic neuritis, right? So optic neuritis is defined as swelling of your arm optic nerve. So how do you know that? Um, you're thinking of optic neuritis. You can think of it as you a lateral decrease in visual acuity. So it could be hours two days on the central school. Trayvon's color vision is affected because of it. Affect it being in your macula region and pain worse. And I boom in, which is also known as Obama Pleasure. You'll also see r e p d relative african few pilloried a fact which is defined us with the spring life test. When you do so, when you shine the light give you the actual I you got, um, dilation off that I because of the damage to the optic nerve on the management for this of high dose steroids? Um, yeah. So on other things that can cause it is sorry that one on the other things that can cause it is like diabetes. Cephalexin usually is not just a mess where you can get optic neuritis. So you need to be careful with that. And obviously, your optic nerve can also be affected than things like blue coma. So you need to be You need to consider those options as well, because anywhere where you see absolutely right as you should be good. Think you have things like just do some rise again decrease in acuities a decrease in vision decrease in color vision R E p t um and, uh, pharmacy Just so pain in western I movement. And again the management is steroid like with most autoimmune conditions talking a bit about a scheming Coptic uropathy so Tremfya, which I've already got over most commonly present in patients over 50 years of age. And it's also associate it, which is, um, rheumatological conditions. How are you gonna be thinking the station? I have you see a see if you've got someone with unilateral temporal headache Onda that has your chronic a shin and then say like they described in simple terms, um, telling you guys, they describe like, oh, when I brush my head, my Scott free. Also been 10 days of this. Some of the questions you can ask them instead of because patients don't generally be like I'm around, my Scott feels tender. Some people might not know. So you can ask questions like also, how does it feel when you brought you have, um, Joel Cortication. You can ask them, like does it does. You know they hurt when you like to, you're out that when you choose staff or do you get tired and cheering? Exact Right, Um, and then the proximal muscle weakness of the first patient away the PMR. So the condition, the rheumatological condition, Um, and this, like I said, you're worried about. I mean, this is for you guys as well, so just make sure you always ask them about visual loss of vision loss or any facial defects. Open investigations. You're going to see elevated in your PSA because I got it's an autoimmune sort of. It's a vasculitis, onda um, cause it's really cleared like a also last run to extend across Yeah, Stories on management for the patient is cirrhosis or a steroid. So anything you forget, you please. We come to the rheumatological teaching, but with the auto immune conditions, mostly you want to use steroids to make sure that the sun goes down and you can use a high dose prednisolone or methylprednisolone on which one you use Depends whether you have eye problems and people can use if you've got any sort of I involvement. But if you don't then high dose spread if absolutely fine. Um, make sure to always remember that you're looking for us are in these cases, which should be elevated on. But if they've got associative PMR is well, then that CK should be normal because it's not a rheumatological. Um, sorry it's not. It doesn't break down your muscles. PMO toes okay, on herpes is a start off that on. Uh, I've given up on pronouncing names today. It's getting late on, So in this condition pizza dough. It describes a reactivation of the rice and as you Storace of the area that's supplied by your stomach division. So what you'll and usually see is a secular rash around the eye on the one thing to be very careful office. The Hutchins in size, which is a Russian. That your nose and what that indicates is that there's a high likelihood of eye involvement on treatment again. So think about what's causing it. Well, it's a virus, so we're gonna give the viral treatment on TV. Are old treatment, so it's oral antibodies viral treatment of 7 to 10 days. You don't always have to remember how many days to get it for just consult your local life I've on. Ideally, we should be started within 72 hours. On down other cases, you can consider using topical corticosteroids to treat any like secretary information of the eye. So especially when you see Hodgins and Science, it's a good time to be, like, actually let me in a bit of started it for on. Don't forget that these patients will require urgent ophthalmology or of you as well, because again, anything to do with your eyes of quite important, if it's a very condition like this, you should be referring them in. Um, I just didn't know to touch me. Um, okay, that's what that was repeated anyway. So now we're going to pre septal sash, peri, orbital, um, and orbital cellulitis, remembering that preseptal slash periorbital of the same thing. So before I even describe that to me going to the next stage, which has a better picture. So if you don't see the orbital septum here, the preseptal said he liked us of everything. In front of It's the eyelids, etcetera Onda, the little cellulitis think Who's the soft tissues, the muscles etcetera on. It's very rarely that the Preseptal cellulitis can go into orbital cellulitis flick. It doesn't the barriers ready sex, so it can't cross it. So some things to be aware off in terms of both of these conditions is if you have a child which has got an eye like this, which is a red sole and painful I, which is like painful movement, you should be referring women so they could have a CT with contrast, because it's not sometimes for you to decide whether it is preseptal. I mean, obviously, you might be able to tell from the history because there are certain Zion's, but they need urgent revolver, a CT scan to make that definitive diagnosis because it can be quite temperamental on how you differentiate between the two conditions is because if you could imagine, like, everything behind that area then leads onto your optic nerve Except rest or any information here will cause the back pressure here. So again, you'll get your optic nerve sciences like when you're up to date labs compress, you'll get like Obama, Please. E o r e p t might be present on other things like that. So you got all of the signs you get sort of and preseptal cellulitis plus signs of R e p T protrusion of your eyes Apoptosis visual. Two servants severe severe are ocular pain while she got pain with preseptal sunlight is you've got, like, a deep seated pain that Children complain about on. You can read the rest on your own time. And both of these things are managed with antibiotics, and the type depends on what, like cancer. And so obviously orbital cellulitis will be IV perfect. Um, no, my very funny drawings. My my table hasn't copied over us, so we're gonna be going over cranial love. Polls ease. All right, just give me a sense that you must take a two second break. I'm gonna get up. The other part went to this. Oh, good. Oh, I did have a question for you guys, but in the entrance of time I'm just going to do is the smaller version of the PowerPoint. Because I know it's getting quite late, so I might ask you some soft, um, just joined ready on the tuft. So if we had someone who had say, like, a true true true for what kind of visual field defect do you think they would have? If you someone wants to write it in the trial, bring it up? No. So that was if someone has a pituitary True. Well, what kind of visual field defects will be picking up yet? So bitemporal hemianopia. So I'll explain about visual fields to you guys as much as I can, really quickly. And we'll once we send out the part point, we'll touch the actual visual field things. I just wanted to quickly go over it myself. Um, and annotate. Sit. Sorry. If you could hear a baby crying in the background, you don't get your heart. So if you think of your eyes, then like with anything else, is you need to, like, orientate yourself with the rice and less so in your eyes. If you imagine this, this is your rice on. This is your left on both your eyes has a right visual field on the left visual field. Poor drawing bathroom on my side, but yes, so they have a right visual field on the last rational feels. But you can also think of it as your temporal rest. Oh, your nasal rectus Because this is closer to, you know, have nose less close to your temple on temporal region. And so every time you look at all of their thing, you still remember them on The other thing you guys need to remember is that everything is inverse it. So the right side goes to the left side of the visual field to the red and everything from the left. Go see your right side And that's how it travels on all of the things from the contralateral. So I said, from the blue, can you see cross over everything from the last side on this side will cross over and everything from the right side and this side will cross over on how you then decide. What kind of visual field, though, is because we can only ask you very few things so you could have across here. So what you need to always do, it's just remember, and just sometimes, like, drawer out. It really does the laughter, Um, so if you can imagine, you've got across here. So that's your first lesion, then what's gonna happen is that you're going to lose the vision. But it's coming from the side from this side here on with vision that's coming from this side to hear you've lost vision from all of this. I think we just do best. Er, what is it? So you got vision in one eye job visual in the other eye. So this is simply monocular vision loss. That's how that works. Um, Andi. So, for example, and that's why if you look at it here, the lesions here, that's what that would be like. A pituitary tumor. That's why you get bitemporal hemianopia because of the track it back from here, you can see that it's crossing over. It's the blue. Why I support coming from. It's from the temporal side here, braces, right coming from here. Always from the temporal side here. So you lost 10 provision in both eyes. And that's why it looks like that you can Oh, okay. Sorry You got you guys got the idea. That's the one thing you need to know. So what you need to do is just track it like just track it back and be like, Okay, if I have lost it here, what will happen? The other lesion you can get is like one that affects it from the side here. Electricity out of it. So affected. So that could be like a middle cerebral artery in in fast. So the red on this out is affected. And the blue on this altruism factors so that can give you a referral for your vial. Attach one of them and you know which one's which. The other thing that's quite 100 to about the original feels is about, like, what is the name of everything? So they might feel like all this is usually the optic nerve, for example. So what happens is when the vision than confident crosses a right cetera, then travels on your optic nerve on, um, in the cell attacks occur well, just about the secretary took out eight this it crosses over. So that's where the coughing ever happens. It was called the Optic Arizona. Then it goes on to become the optic track. Then go to the lateral genetic, a late nucleus and sometimes five come out of this and do the whole like reflex arc of your, um, construction on dilation or fibers. Congar So but to a sip, it'll low on give you that picture of exactly what's going on. Um, and when it goes back, it can either be go a superior fiber tests, which will go through your parietal lobe or your temp are inferior five s if you just pretend for me, like using a superior fibers are these are you in various? So you can imagine the temporal lobe is that over the parietal so that it will go under here in the temporal lobe? Or it could get over it in the prior to lose on how you So like I said, everything is always inverted, so I know it's the inferior fibers, but they're carrying. So if we then divide it even further, this is your only like this. Everything that comes from above also is reflected on to your eye. This is very difficult to explain on this. I know. So everything from your eye that comes in everything from the top in your off your like what you couldn't see to say. If you're looking at a lab, everything from the top of the lamb will come into your resting at the bottom. So everything is reflected in opposite of an inverted way. Therefore, when it comes when it comes, by the time it comes to the parietal lobe. If you had a visual field defects, let me write this out for you guys. So anything that affects your parietal lobe like a stroke or anything will cause you to have an insert, uh, loss of vision so inferior quadrantanopia still cost you to have a loss of vision in this bottom. How anything that causes you to have temporal visual loss will have will mean that you have superior visual loss. So you have a superior quadrant anopia. I hope that make sense like the pictures will make it more make more sense, then just going down to the innovation of the eye from the muscles. You've got three men. Um, knows that you should know about such a the ocular motor, which is cranial of three. It supplies most of the things, um, in your eye. And that's how you remember it. Uh huh. All of them. Do what? They're namesakes disappear. Erectus courses it to move severity Indirect is in fairly me directors medially it set right cetera, however, in for a plea, does opposite of what it says. So it's the obliques like two opposites it cause it was truly of upwards and outwards. Credit for stroke that's apparently causes it to move downwards and upwards On CNN. Six is a beauty of do sense, which is lateral rector's, and it causes abduction. So you remember, it's laterally. It pulls it out. Medial pulls it in on how I remember a view of juices. Bilateral rectus is like L. A the city, so I don't know Philly way, but that's how you remember that, Then moving on to the polls, these related to them crazy enough. Three. So this is my depiction of the eye, and I hope you guys understand. So with the eye, everything is working in conjunction together to keep it in center. Anything off that's that you could imagine, like all the forces are equal in a lot direction. So if any of the forces are removed or of the other forces will, like, pull it into it storage in. But in the case of cranial nerves, three you can imagine that it supplies so many things that it basically everything is removed while after all right levels appear very bleak. And I said, lateral breakfast move that out on superior oblique, moves it down and out. So that's why you gotta down and out, I on the other thing, you need to be aware off. It also supplies like the muscles for your upper eyelid, and therefore you get a true fist on. You also need to be able to differentiate between a medical, a surgical side left palsy on how your friendship between left is the size of the pupils on in the medical medical course of include, like diabetes, atherosclerosis. If it's set, try and surgical include aneurysm. So this what this box you might be thinking off is your cranial nerves, and this is given. Imagine it like a box on the but it has a dual blood supply. One on the outside. So this these fibers represent the past sympathetic fibers on this represents a blood supply on the inside. If you imagine the blood supply to this area is only damaged, then the price and pathetic fibers are still intact, and therefore the pupils are not affected. So you got like a normal pupil. So you've got the Tosis you've got down and out. I had a normal people in the case of a medical palsy. But if you get a surgical problem, so anything surgical, it's like something that causes compression and pushes on here, or effects of blood supply only out of it. So that's my little depiction of an aneurysm, and you can imagine that's pressing on that. So the price sympathetic fibers, which normally cause constriction, are no longer able to do that. So you then get my dry cyst, which is like big people. That's that in terms of how you differentiate between those three, and that's important. And they these so, um, in tubs off. Then, uh, the Creon of Poles ease and this eye. So then cranial love for supplies disappear of least and around the side that moves. It's down So like, um, it causes the I stay in the middle, so like it sort of pulls it down. But now the down forces are equal and the upper ones arm, Or so you can imagine that in the normal position. And just this is supposed to pick like a normal I. Well, then, sorry and I that's trying to look down. You don't. So the left eye is a normal. I will be able to move down and do everything normally but in the right eye. When it's trying to look down, you won't be able to just fully look down so that I will still be pulled up in this direction and therefore you get vertical diplopia so you see double visions. You'll see vision from one eye off the thing that is. Start on and you'll see from the other. I wear the I still thinks up the fingers down below, like it's not looking at it in the right two dimension. And after you got that diplopia and seven million premium or six, you cannot add up to your eye that for if you imagine, um, that your eyes trying a move out worth. And he can't do that. Then it will say in that fixed position on you will get, like, a horizontal diplopia on um, the image of the eye. Sorry. I was trying to figure out what I've done here is um yeah, so yep. So if you imagine that your trial in the direction off, like of that way, the new eyes not like if your left have broken that it won't be able to look in that direction. So what shows your left, which is in the left direction for the patient. Therefore, you'll still have an eye that Sinemet and that sort of in the middle while the right eye is abducting away. So you got a horizontal diplopia, um, on down the case of like, the palsy is this is just to summarize what you should be looking forward. So the problems, they're like the cranial. If that causes, you, always have it down, and I'll try. You know, the normal position. Look really in there for palsy. If you're looking at the picture directly, the centrality off the pupil is no longer like all. Not all the forces are equal. The one spell again for a slightly higher dose and a normal looking straight position that I would look slightly higher. And then when you try to look to the side, which is look to the left and I will again go up like it won't say in the middle. Yeah, I will look more like upwards because of one of them upwards forces and in your cranial nerve six. Palsy. You have this media deviation, so if you're looking straight, it's not again not central. So then your eyeballs. So that's sorry. That's what the picture was trying to show that if your eyes are trying to be central but like you don't have the force that pulls out words, then it's going to stay like gosh. And then it's going to say slightly to the medial side because that those forces are higher because they upwards and Dyment force of counter each other and the right to left fourth council each other, and you can figure out the rest and off why the other ones happened. Thank you so much for sticking with us. These are some of the key conditions, like cheat sheets on house. You tell them in a question because I know we've learned so much information at you, but it's good to know how to be able to front of these conditions on, like on exam SBA type scenario. Thank you so much. Thank you guys. Most of the feet. But for now, copy of pace. That's a Tuesday. Don't leave without putting in. I have, um some of that made sense. And please do Ah, message us. If you've got any more questions, then I'll be happy to explain it to you guys. You guys, if you could feel the feet but form on, then leaves start with Yeah, Ideo.