CRF 09.03.23 Ophthalmology Part 2 Dr Kaykhosrov Mancuheri



This on-demand teaching session is tailored to medical professionals interested in diagnosing red eye symptoms. Through a series of patient examples, the lecturer will review the common symptoms of red eye conditions, such as mucus staining with rose Bengal stain or follicular conjunctivitis. They will also discuss systemic autoimmune disorders and treatments such as artificial tears, ointment, hot water and cotton swab, and topical antibiotics. Upon completion of the course, medical professionals will be well-trained in the diagnosis and treatment of red eye.
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Learning objectives

Learning Objectives: 1. Participants will be able to distinguish between a painful red eye and painless red eye. 2. Participants will be able to identify the components of a healthy tear film. 3. Participants will be able to understand how to treat a patient with dry eyes and Earl Claire Itis. 4. Participants will be able to recognize signs and symptoms of systemic autoimmune disorders and collaborate with a rheumatologist for treatment. 5. Participants will be able to recognize and differentiate between common causes of a red eye, such as allergic eye disease and a viral infection.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Buddy. Uh Hello everybody. Welcome again. This is the rest of my lecture on the red eye quiz that we never finished last time. So I'm just going to go through some of the patient's we've already done. But I'll answer this uh the ones that we have done myself just to as a refresher. And but for the rest of it, for the new cases, I think it's from patient six onwards. Uh if you could a nude and answer questions. So it's really looking at the picture, seeing what abnormalities you can see and then try to come to a diagnosis together about the red eye. So uh yeah, in eyes, as I was saying that there is very few symptoms, patient's with our eye problems, either lose vision or they get a painful i or a red eye or sometimes those things are combined. So you can have a painful red eye or you can have a painless red eye or you can have painless red eye with reduced vision or painful red eye with reduced vision. So you can combine those. But it's basically my more or less three or four symptoms, of course, double vision is another uh symptom that people can complain of. And, but double vision is to do with the extraocular muscle. It's not an internal problem of the eye. It's the problems of the muscles of the eye that's been ocular double vision, which we won't go into today. So I'm sorry, I can't have my picture on. It's because my internet is quite unstable. So I hope you can see all of this. So I'll just start with the eye quiz. And we had the first patient who was staining with rose Bengal stain, a red eye with rose Bengal stain. And you can see that there's blood vessels from the upper limbus trying to grow in. And this patient has got severe dry eyes and those things that are staining or mucus uh from the tear film layer being stuck to the cornea and that's pathognomonic of a type of dry eye syndrome. So mucus on the eye, it's not puss, it's mucus because it stains with rose Bengal. Um and that mucus suggest abnormality of the tear film. That's probably one of the commonest cause of dry eyes or Epis Claire Itis. If the eyes are very dry, then you can get inflammation of the epis clearer where, which can cause redness of the eyes. And the treatment of this is really to treat the symptoms of dryness with lubricating eye drops, which are called artificial tears. And there are hundreds of these on the market. They can be, get got over the over the counter, they're not prescribed in the U K anyway. And if the patient's are complaining of pain on waking up, first thing in the morning and their eyes are comfortable when they open them, they probably need an ointment overnight as well. So they need to put in a Zaillian eye appointment is the one that we currently use. It's called Saline Night Eye appointment at night times. Um They also, I always tell them to do lid hygiene, which is basically hot water and cotton wool, which they place on their eyelids and leave it there for two minutes that melts the oily secretions that are produced by the Meibomian glands. Uh These are the openings of the Meibomian glands. 20 of them, about 20 of them on the upper lid and about 20 of them on the lower lid and they produce an oily secretion which starts, stops the tear film from evaporating. And sometimes these Meibomian plans become blocked and hence why uh the hot water about 50 degrees on a cotton wood wood be like allowing that this oil to melt, heat up and melt and become more fluid and flow out a lot more freely. Uh So you leave it on for two minutes because just like a fat in a hot pan that takes time to melt the oil in the upper and lower lid also take time to absorb the temperature and become liquid and runny and uh so you leave the hot pattern for two minutes and then clean the lashes by rubbing down up on the upper lid downwards. You're encouraging the secretions to come out of the meibomian glands. And then that fine oily secretion on top of your tear film stops the evaporation of the Acquis part of the tear film. If you remember, our tear film is made up of the mucus layer, which is the first layer that sticks the fluid e part to the eye itself. Then there is the liquid part of the Acquis part in front of the that and then there's a fine oily part of the tear film and that keeps the cornea moist and stops the cornea from becoming unclear. So any time that the the cornea becomes dry, the clarity of of it is affected as you can see from this cornea. Yeah, if you look through it, the features of the Irish are not very clear and that's because the cornea itself has become unclear because of the dryness of the tear film. So the tear film is extremely, extremely important and the various percentages after three components are very important to be in the right proportion. If there's any change in that the tear film can break up and patient's can get symptoms of dry eye eyes, which is the first patient. There's a lot more to it than that, but I don't think time allows. So we'll go to the next slide. Oh yeah. The next slide, my eyes can be secondary to a systemic disorder, especially systemic autoimmune disorder. So that's the other thing you need to look for as well as treating the dry eyes. You need to. Yes, sorry. Did you want to ask a question? No, it was. I was answering like secondary. I thought this was Chardon syndrome. Oh, yeah. That's right. Very good. Yeah. Yeah. I'm going to run through these first six patient's quite quickly. That's right. That's Shogun syndrome, dry mouth associated dry eyes and Shogun syndrome, which is an autoimmune disorder can be associated with room arthritis. So the dry eyes, you need to look for all of these in patient's who present with my eye. So this is obviously uh small joints affected by rheumatoid arthritis. 50% of these patient's have positive rheumatoid factor if you remember. So then you need to collaborate with the rheumatologist on treatment of this. So, and then treating systematic uh systematic systemic condition such as rheumatoid can affect the tear film because the tear film is also reduced because of uh an autoimmune attack on the lacrimal glands. So, by reducing the auto immunity or controlling that sometimes with uh you know, stronger drugs that reduce their immune response, then you could get improvement of the symptoms of the dry eyes and dry math as well because of this. Right. So the patient uh was this patient? And we said that this patient has got quite a lot of follicles in the lower lead. Uh This is in the conjunct type of the lower lead and follicles. So it's a follicular conjunctivitis. And the two things that can cause a follicular conjunctivitis. This is allergic eye disease. So allergy to something in the environment or it could be a viral conjunctivitis as well. So a viral infection, but the viral infection tends to settle after a week of to they have a history of flu like illness and it comes in the two hit hypothesis. So they're ill for a week first, then they get better and then they get a bit worse. And viral conjunctivitis is quite contagious. But this one is not viral conjunctivitis. This is allergic II disease and they can be allergic either to the contact lens or their solution or they can be just allergic to something in the environment. And of course, I allergy goes with asthma and history of a to be eczema, asthma and allergy goes altogether. So you always have to ask about those other systemic problems and work with colleagues if they're patient's have other problems such as that. So these are giant pill a again, there are big follicles on the upper lid. Again, that's pathognomonic of allergic eye conditions. And if it's very severe, you can get these dots around the limb biss. Uh the limbus being the place where the cornea joins the white of the eye, which is called the sclera and these are TRENtal as doc dots named by Mr Trent. Trent has who first described them and they're just allergic response to something. And usually this is pattern pneumonic of Verneuil character contouring to Vitis, which is an allergic condition and they, this patient definitely needs steroids to control it. Usually the younger Children in there five or six and as their Children get older, they tend to settle down. Uh the eyes in these Children can become very itchy. And if they are rubbing their eyes, they can actually cause a condition called Kurata Conus later in life by just rubbing their eyes too much. So it's very important in Children to give enough drops, steroids to control the itchiness so that they're not rubbing their eyes all the time. Otherwise, they can have, as I say, this problem called keratoconus appear in the later life, which causes irregular stigmatism of the cornea. And indeed corneal graphs later on in life if they keep rubbing their eyes. So the treatment of this is with mild steroids, usually either F M L is the drops or another week. Steroids are just dexamethasone, but dexamethasone is a bit stronger. So we usually start with FML and they're very steroid sensitive. So they respond to FML which is the weakest, weakest I steroid we have okay. So patient three was uh this patient who's got this plus sitting there and there's nothing, no other organisms that produces so much plus as gonorrhea. So that's got gonorrhea, carry the conjunctive itis and you need to swap, the patient, treat it with topical antibiotics. Usually a penicillin. If they're not resistant to it, if they're resistant, then you need to see what topical antibiotics they need and they need systemic antibiotics as well. And this is a sexually transmitted disease. So everybody within that sexual, uh, circle needs to be treated. So you need to refer them to sexual health to uh for everybody all partners to be treated and Children to be treated. Um And uh the uh diagnosis is by taking a swab and sending it to the labs for both gram stain and culture and sensitivity, as I said, and depending on that, you give the systemic antibiotics needed, but usually it's treatable with penicillin. Of course, now there's a lot of resistance coming to that. If not, then you have to see what they come up, not being resistant to. So that's gonna really character conjunctive itis. It's quite rare but it's just important to pick up because you have to report it uh in the UK at least you have to report it because it's a communicable disease patient for uh family in, in a tore. Um that's a newborn baby that has picked up an infection of the eye while going through the birth canal normally. So both the baby and the mother need to be treated for this condition with both systemic and topical antibiotics and I forgot to say the topical antibiotics are usually every hour on the hour or every half an hour, even through the day and night until the past settles and then you can slowly reduce the drops. Hi, doctor, can I have something? How could a difference yet between, tell me a new Metro, um, meat and, and the doctor problem, which is benign. All right. Yes. So this happens on the first day of birth. So this baby is just born and usually they have that or within a day of birth. Whereas a blocked tear dot is usually, I mean, a lot of Children can have pla blocked tear dogs, but it's not post that comes out of there. I it's mucus, so that's different. So you need to take swabs of that and send it to the lab and it comes back at positive. Normally. I mean, there's so much pasta eater that it would definitely be positive on both gram stain and drops. But with the blocked tear duct, you don't get the inflammation around the eye as much. It's just mucus and the eye isn't puffy and red. So that's another giveaway because there's no inflammation in the blocked tear duct. And of course, in a blocked tear duct, uh most of those 99% of does open by the year by year one, as the child grows up, that membrane breaks down and uh it opens up. So you just need to reassure parents. And if they haven't opened up way year, about 99.9% open up by two years. So it's rare that they need anything doing before two years of age. But for this condition, you need to treat straight away because if you don't treat, they can get very, very sick and it can spread to the meninges and get, it can cause death actually. So that's reportable and you have to treat it. Yeah. So they would probably have a temperature as well. Whereas with a blocked tear, doctor patient would be feeding perfectly well, would be happy. Wouldn't be sore or crying or inflamed or have a temperature or anything like that. So those are all important pointers. Okay. I'm going to patient six quickly and then at six, we slow down and ask the questions. So patient five, this is what you see and this is classical of a corneal burned. So this patient was probably hammering an ale or working underneath a car drilling or grinding without wearing eye protection. And a hot piece of metal has fallen and Estonia and burnt and produced that black dot uh which is a bit metallic looking. So there might be a piece of metal on top of that and then it's casting a black shadow on the iris as you shine the light on it and this hasn't gone through and through. But you never know when, whether there were other pieces that could have penetrated the, I usually the, I would be very sore and the vision affected if it's, if they uh foreign body has entered I, but you never know, you have to do a full proper examination. And of course, you can do X rays of metal bodies inside the orbit if you, if they look up and down, because sometimes even with dilated pupils, it can't see enough of the back of the eye to make sure that there is no uh metal foreign body. So you could do X rays with the patient's looking up and down. And if the metal body moves, moves on, looking up and down, you know that it's inside the orbit and then they need an operation to enter the eye and remove that. Because if it's iron or worse copper, they can lose their vision within 24 hours because of the inflammation because and they're very toxic to the retinol retinol uh cells. Basically, um they're neurotoxins. So they need to be removed straight away if, if there there. But most of the people would just have the corneal burn. In which case, you just use a needle to flick the metal off the bride, the burn of rust and then the epithelium grows over it. You then treat with chloramphenicol appointment four times a day for five days and that's all they need. But you do need to do that full examination of the eye to make sure nothing's penetrated inside that I which is quite rare but important to pick up. Otherwise patient's can lose vision. Uh The patient six was this one. And we said this is a typical keratitis. It's a bacterial keratitis usually. Uh and a hypo p in hypopyon is puss inside the anterior chamber. So you can see that there's a fluid level inside the cornea between the cornea and iris and you can't see the iris very well. And all the features are not clear because the cornea has become edematous and it's not clear anymore. And usually there's a history of contact lens where so and nowadays we are gone. Most people are using daily disposable, which is a lot safer because they throw it away. But the days when it was monthly disposable lenses where they put people would put their contact lens in cases and use solutions to clean it. Uh the solutions themselves could have the bacteria, the contact lens case could have the bacteria or the contact lens could have the bacteria. So you have to send all three for gram stain and culture and sensitivity as well as taking scrapings of the cornea to send it for culture and sensitivity. And this patient would need to be admitted and started on hourly or half hourly. General drops, usually kept your oximeter vancomycin to cover everything. And then once you have your sensitivities backs in 2 to 3 days, then you can taper the treatment to what the organism is most sensitive to. Um So, uh in this case, there's a lot of puss and a lot of corneal uh uh edema and uh stromal opacities there, which suggests that it's a bacterial infection of the cornea. But you can also have an A Canton IBA infection with contact lenses. In those cases. Usually you don't see features like this so much as the I becoming very, very painful. So the ulcer doesn't look as bad as it does with a bacterial one, but it's very painful. And they again needs special treatment for uh anti acanthamoeba treatment, which is quite specific and I don't remember what it is because it's quite rare these days because we have gone onto daily disposable contact lenses instead of monthly disposable ones. Right? And then patient seven, this is where we start. Okay. I think we stopped there. So anybody want to hazard a guess what we see here. Tell me what, what is the structure, what you see? And if there's any stains or anything like that. So who would like to start? There's nine a few on the car or eight, a few. Yeah, please don't raise your hand. Just say because I can't see your hands. Just a mutant talk. Uh There is an over dilated pupil. That's right. Yeah, there's a dilated people. Okay. Anything else I can see those red lines or the pupil on the cornea itself? But I don't know. Uh Yes. So what do you think? Do you think that's a stain has been used here? I don't think so. It's a stain. Steyn doesn't, uh, fish spread like this. I don't know whether it just ain't, but I don't think it's a stain. Yeah. So basically it is, we use quite a few stains. So, the two typical ones are Phlorizin we use and rose Bengal and they rose Bengal is especially good for, uh, staining mucus that's stocked to uh to uh the cornea and uh flourishing is very good for epithelial defects that you see. So, yes, this thing is uh staining in epithelial defect after cornea of this patient. And you're right, the pupil is dilated, but I don't think that's, that might be because the patient has had drops to make sure that they don't have any other problems in the back of the eye. So, do you have a diagnosis for this? What type of an ulcer do you think this is paraparetic and Matilda, maybe foreign body scratching or something? Uh No, it's not a scratch because of the way it looks. Somebody said something else I didn't hear and it's not a foreign body either. Is somebody pick some. Uh Yes, yes. So it's called the dendritic ulcer. Very good. And it's, this is typical, you see the way the shape of it is like a dendrite or just very wiggly like that. That's typical pattern. Pneumonic of hurt based simplex keratitis. So, what's the treatment for this patient. Acyclovir. Yes, Acyclovir. And we're finding it difficult to find acyclovir, uh, ointment, ointment five times a day. So we sometimes give ganciclovir because there's no Acyclovir three times a day. And also, if patient's a resistance to acyclovir, you can give ganciclovir, which is a bit more toxic to the corneal cells. But yeah, we use it. So, Acyclovir, how long would you give the Acyclovir eye appointment for usually for two weeks? So you've seen that two weeks, but you see them at one week to make sure that the cornea has healed because after a week, it heals. But because sometimes there can be resistance to Acyclovir. If you're using it, it's best to see the patient at one week to make sure it is actually healed. Otherwise, if it's not healed, despite using Acyclovir five times a day for five days, you then think about resistance and can switch to Ganciclovir three times a day for the following week. So it's a two week course of it and they should finish the two weeks because even though the cornea has healed that one week, the virus, of course, stays in the ganglion cells of the fifth nerve. So you need to treat it for two weeks to get rid of as much virus as possible. But beyond two weeks, we don't treat because of course, the treatment itself is quite toxic to the epithelium of the cornea. So you don't want to overuse it. Uh So five times a day for two weeks is the standard treatment of Acyclovir. And if it's ganciclovir is three times a day for two weeks. Do we need to treat system systemic treatment of Acyclovir for these patient's uh diagnose uh, profile FCV? Should I think for prophylaxis? Yes. Well, that's very good. So, for a normal treatment of patient's know, because it's just like a cold sore. So they're usually run down. So you tell them to, uh, you know, just rest a little bit, you know, make sure they get all the normal nutrients in their foods and uh rest a bit and also use the ointment. But you don't normally need to give acyclovir unless you see that this is occurring 567 times a year. And then if it keeps on coming back, then you might have to give once a day, uh prophylactic dose. Uh Sokolov a once a day, 400 mg once a day or 800 mg once a day as prophylactic against this thing coming back because the more the pay, the problem comes back, the more it causes another problem. Anybody know what that other problem that's having a hepatic keratitis can cause sit, is it to do with uh, no, it's not hypo P in you don't with pay simplex. Don't get a hypopyon. Definitely not. What did the other person say? Somebody else was saying something? And so no, again, it's very unlikely unless the patient's are immune suppressed, which is unusual with a normal day to day things. They don't get to incur fly this from this, but in the eye itself, sorry, cat, cat track. No, it don't, don't get a cat tracked. But what they do get is an aesthetic cornea because, you know, the trigeminal nerve supplies the cornea, especially under the epithelium. And the herpes simplex virus lives in that, uh, in that nerve, the fifth nerve, that's why it comes out on the eye. And so the nerves that supply sensation to the eye can afterwards not work very well. So you get what's called an anesthetic cornea. So if somebody's had hep, it's simplex in there. I even once before, if you touch a tissue to there, I, they don't blink. Whereas if you touch an eye that touch a piece of tissue to an eye that has normal sensation, you would quickly jump back and blink. So the corneal sensation goes down. And if it goes down very much, those actual nerves have an effect on the sticking of the epithelium to the uh to the stroma of the cornea. So they can start getting um corneal ulcers secondary to the anesthesia, which can lead to long term problems with vision. If it, if the cornea become, you know, if they get recurrent, have a simplex keratitis, that just damages the sensation of the nerves. And of course, there, it's much more danger because the whole point of feeling pain is that you avoid things that cause the pain so that it doesn't damage your eye. But if you have no sensation, people can get things in their eye and it can damage there. I without them realizing or feeling the pain. So these are the problems that can happen afterwards. Okay. So this is another picture of the dendritic ulcer. You can see it being stained again, that's flores seen. That's used to make a diagnosis and you could just put Phlorizin in and shine a blue light and you'll see a yellow streak like this. And that's uh pathognomonic of helpers, simplex, keratitis energy. That's the blue light. And uh so patient eat. Is this patient diagnosis, please? Shingles. Yes, shingles. What's it called when it happens in that part of the head? Which nerve is it affecting? No, no. Oculomotor supplies. It's a motorcycle trigeminal nerve. Yeah. And which branch of the trigeminal? Cursed. Yeah. The trigeminal is the fifth nerve. What? Which branch? Remember? It has three main branches, doesn't it? The magazine area? No, not the Maxillary. It's not over the maxilla. Is it uh uh Yeah, that one branches month. Um I think it's the first one. Yeah. The first branch which is called, what lecture are we in? Yeah, it's the ophthalmic branch. That's right. Very good. So there's three branches to the trigeminal is the author Lamic, the Maxillary and mandibular branches. And this one is affecting the opthalmic branch. So the diagnosis herpes zoster ophthalmicus, that's what it's called. It's basically shingles of the academic branch of the trigeminal nerve and the rash is one sided because you remember it just respects the midline and that's how you can diagnose it. But sometimes they just have a headache or pain and the rash is very difficult to see and you have to look carefully among the hairline to diagnose it. It's very, very important to diagnose early. Why is that? Because the novel be dead? Yeah. And more than that, not just dead. What happens to the nerve afterwards degenerates. So you can get post hepatic neuralgia, pain in the nerve afterwards. And apparently that's one of the worst pains anybody can have. It's absolutely horrible and people are put on amitriptyline for it. And even that sometimes doesn't touch things so that pain that post hepatic neuralgia is much more frequent if you don't diagnose within three days after the onset of the symptoms. So you need to diagnose very early. And as I say, sometimes the rash takes times to come out. So you have to look carefully for it and you have to always think about it about people coming in with headaches. So tell what's the treatment for this, please. IV, antiviral, it's not quite IV you can get oral most of the time unless you think that there is super infection of the rash, which sometimes people can cap. So they can have a secondary bacterial infection of the skin on top of the shingles rash. In which case they need, uh IV antibiotics. But the treatment is what it's just. Yeah. Again. Yes. So, how do you give it? Is it ointment a cycle or? Exactly? It's oral cycle. 800 mg five times a day. And you have to, I think it's a 10 day course of it. So you shouldn't give less again, the same thing. And if you can restart Acyclovir before the third day of symptoms, then the incidence of post hepatic neuralgia is much, much less. And you'll be really um doing your patient a favor if you diagnose early. And so these patient's can either get eye problems or not. And would this current patient, do you think would have? And there's a sign that tells you if they're likely to have, well, it's supposed to have told you in the past, it's not always work, it doesn't always work. But if this part is involved, then it's much more likely that the, the eye is involved. Does anybody know which part of the body and what the name of the signs is? No. Okay. So it's called Hutchinson side. And basically, if the rash goes to the tip of the nodes, then the likelihood that the eye is involved is a lot higher. At least that was the teaching when I was in medical school. But I think people have found that not, that's not quite true. So, everybody who has this rash should see an ophthalmologist because how do you think the herpes zoster virus can affect the eye? And which part of the I can it affect difficult questions? You're not ophthalmologist. So, I'll tell you, uh, somebody you say, say that again, can it affect the retina and also the optic nerve? Absolutely. Yeah. So, disaster is much more serious that simplex infection, which gives the dendritic ulcer. It can affect any of the tissues in the eye and it can affect it not straight away when the rash is there but months afterwards. So you can get in from the front going backwards, you can get micro dendrite on the cornea leading to corneal opacity. Sometimes later on, you can get an inflammation of the I called uh I rightists or anterior uveitis, which is inflammation, that's quite a common presentation of her exhaust. Er So some patient's who don't have the rash yet can come with inflammation. And later on we see the rash coming and realize it's secondary to shingles. Um so they need to be treated with steroid eyedrops, then they, they can get, the iris can lose its pigment in patches. So they get what's called iris, atrophy and the pupil muscles that constrict, the pupil can get affected. So they get a mid dilated, non reacting pupil. So one of the causes for a non reacting pupil on one side is a previous history of eye involvement by the herpes zoster virus. So also as my colleague said, their retina, but not usually the retina, mainly the optic nerve. So you can get up inflammation of the optic nerve causing optic atrophy. So patient's might come in with normal vision at the time. They have the rash, but you find that 4 to 6 months down the line, they have lost a lot of vision in that eye and they're, they're nerve, it looks completely paid. And that's because the virus has affected the nerve. So if you see, so every time you see herpes zoster ophthalmicus, you need to refer to an ophthalmologist and we need to follow for three or 456 months to make sure that none of these complications of eyes are there, there isn't much you can do. And the other big complication is that it can rise cause a trabecular litis inflammation of the trabecular meshwork, which can put up the intraocular pressure. So they can get very high pressure and pain because of that. So every time you diagnose that you should get an ophthalmologist to also review the patient to make sure there's no inflammation in the eye and you need a slit lamp for that and that the pressure hasn't gone high. And again, the pressure can go high a few months down the line from when they have had the shingles rash. So you have to be careful. So, yes, it's a nasty virus. Um, and you know, it's the same as the varicella virus. So, herpes zoster is causes both disease. So all of us have it in our body except that when our immunity goes down, the shingles can come up in different places like this and cause uh effect. Uh Mila. Do you have a question? Yes. Hello doctor. I just want to add that is very common to see it with cellulitis at the same time. Yes. Yes. So the rash itself can cause swelling but you can get super infection of the rash which then is diagnosed as a bacterial secondary bacterial cellulitis in which case, they need to be admitted. But the rash itself can give lights to swelling. So like this chap doesn't need the IV antibiotic. But if he his eyelid was really puffy and red and tense, then I would diagnose that it's a cellulitis and would need to be admitted for IV. Otherwise I would just treat him with the oral acyclovir. So yes, you can get, as I said before, a secondary bacterial cell, a light is around where the rash is. Yeah. Any other comments or questions on this patient before we go to the next one. So again, the corneal sensation can get affected in this virus as well and that can lead to long term problems with uh in Europe neuropathic corneal ulcers which can cause visual problems long term. So yeah, so that's that Asian nine is this one. Anybody want to describe what you see, maybe your bloody missiles, the missiles might be disproportionately paralyzed so that the pupil is not. Yeah. So it's not, it's not the pupil. You're right. There is an abnormality. So always start off with what you see. So what you see is a dilated pupil which isn't fully dilated in our directions, there is three points where it's not dilated and it seems to be stuck. So one is here, one is here and one is here. So in those places, the pupils trying to dilate but it's actually stuck to the lands. Uh So that's the iris. The colored part is actually stuck to the lens capsule. In what condition do you think that might happen? So, okay, that happens in when you have inflammation of the iris. So uh I writers, inflammation of the iris causes the irish to become sticky and it sticks. So anti UV ITIS or I writers is the same thing really is the name given to inflammation inside the anterior chamber. And uh they, those patients' then need a lot of steroid drops. Now, why there are some patient's get inflammation? Well, again, there are some associated diseases that can cause this and you have to look for all of these and it could be from various systems. So the common one is ang closing patient's with HLA B 27 who have enclosing spondylitis who are more likely to have that can get recurrent anterior uveitis just because they're predisposed to it. You can get it as a Writer's syndrome. That's the triad of uh, your arthritis, conjunctive itis or I rightists and something else, I can't remember. That's a sexually transmitted disease. So, uh, those things can cause anterior uveitis and there's a whole load of different illnesses that got a very small chance of causing anterior uveitis, which you need to exclude. There's, there's quite a few of them, but they're all much rare than these two things that I talked about. Um So if you diagnose anterior uveitis, you need to treat it with topical steroids. And usually we start off at hourly drops and then reduce it over time. And then you have to tell the patient that usually in 50% or more patient's, this is a recurrent condition. So sometime in the future, again, they can get the same thing and it's very important. They realize the eyes becoming red and painful and come and see the ophthalmologist to get a diagnosis and treatment with topical steroids. So the treatment is topical steroids hourly and to dilate the pupil once a day or something with a not a long acting. They used to give atropine, but atropine can make it stick down in a dilated decision. So it's much better to use something like cyclopentolate where it's much less longer acting and it would cause the pupil to go up and down. And if it's stuck it make sure it doesn't stick to the lens. Okay. So again, as a, do you want to ask your question? Uh Yes, yes. I wanted to know the name of this condition. Uh Sorry, I forgot it. Yeah. Yeah. So it's called either I rightists inflammation of the iris or another name is anterior uveitis. So, inflammation of the U V L tissue in the front of the eye. So you can have anti UV itis posterior uveitis and intermediate uveitis. There are different conditions, but let's just talk about the anterior uveitis, which is the only one that gives rise to a red eye and a painful red eye basically and can cause the Irish to stick down to their lens. And that's called the. So these points where they're stuck, the irises stuck to the lenses called posterior Sinek, a posterior Sinek a formation and there was one there as well, but that's torn off. So there's a bit of pigment from the Irish. They're suggesting it was stuck there before as well. Okay. Any other questions before we go on? No good. Again, I'm not going to finish the lecture. But anyway, it doesn't matter, right? Isn't 10. So this one, what do you see? Can anybody tell me what you see here? You can see some pigments. Yeah. And, and where is the pigments? Which tissue is it on? Get up? Which one uh this clearer is the white of the eye? Okay? And not quite conjunctive that covers this clearer. It's again the white of the eye. So that's on the cornea. Okay. Cornea is the clear part of the eye. So the blue thing you see is your iris that you see through the clear cornea and that light of the slit lamp is showing you the outline of the cornea. Okay. So, and the first place where the light hits is called the epithelium of the cornea. Then below it is the stroma of the cornea there. And then the last place where the light lid leaves is the endothelium. You remember we talked about endothelial that you get a certain number of endothelial cells on the cornea. And their function is to keep the cornea clear by pumping away fluid from the cornea. And you're born with a certain number of these endothelial cells. And as you get older, they get reduced in number. So if you go below a critical number, your cornea gives up and becomes waterlogged, then you lose vision. Remember we talked about that before, maybe not. But yes, that's what happens. So, which part of the cornea do you think this, this pigment is on, is it under endothelium, the stroma or the endothelium? Anybody both in the trauma and and uh yeah. No, it's it's endothelium. It's on the inside and these pigments are pigmented inflammatory cells. So they are leukocytes that have been deposit in the anterior chamber on the cornea because again, and this diagnosed again chronic anterior uveitis. So once you see these granulomas on the cornea, you diagnose chronic and to the uveitis. So this is the sort of picture that you see sometimes in shingles, herpes, zoster ophthalmicus and you can get it with other non treated anterior uveitis that's been grumbling on for a long time. And the treatment is steroid drops and all that pigment then clears with the steroid drops 4 to 6 times a day for two or three months. And then all of that settles down. But you need to always find, try to find out what's causing this granulomatous uveitis. So things like sarcoid and various things can cause it as well. So you have to look through a whole load of blood tests and things to diagnose the underlying problem. And a lot of times you don't find one which is fine. So, but it doesn't mean you don't look for it. So that's um anti chronic anti UV UV itis, okay. Uh Those inflammatory cells under endothelium is called keratotic precipitates. And when they are there for a long time, they become pigmented pigment position, pigment gets deposited on it. So this thing has been, this eye has been grumbling on with inflammation for a long time because there and they are pigmented keratotic precipitates which has inflammatory cells deposited on the cornea of the high right issue. 11. This is what you see this okay. So that one, it's another eye but it's the same condition, that one and this is after treatment. Okay. So I want to tell me what you think is the problem. What's the condition called? So let's go through the pictures if nobody can come up with a diagnosis. So what do we see here? Anybody, you just need to describe the picture. That's all. So somebody must be able to describe the picture. There's an inflammation. Yeah, there's inflammation because the eyes red, very good. So red eye is one anything else you see? Is it normal? Is the corneal reflexe normal? Yes. No. Yeah. So you see this white thing is the light reflex from the cornea and you see it's all broken up and it bits. So it's normally very sharp reflex, but it's all broken up. So that cornea is not clear. Again, you can see some features of the Irish are not very clear. So why do you think this cornea is not clear? In other words, when does the clear, not the cornea not look clear? We talked about this before. I'll try to uh sorry, I was going to say infiltrative uh inflammation like fluent information. But yes. So there is inflammation. We said that that's because of the red eye. So the cornea becomes unclear when it becomes waterlogged. So the stroma, when it is not able to get rid of its water, it starts to swell up and become unclear. Okay. And those cells that pump out the fluid into the anterior chamber and keep the cornea clear. I remember our the endothelial cells of the cornea. So something has happened to decide that the endothelial cells are not able to function very well and keep the cornea clear. And therefore the cornea has become waterlogged then cloudy. So lots of things can read to lead to a corneal uh cloudiness. But let's go to the next slide because that gives you a uh okay. So what can you see this picture? Can anybody describe as trauma is? Yeah, stroma of the cornea is what? Enlarged, enlarged. Yes. So it's thick and cornea. So that's all the fluid uh that's been trapped in the cornea. That's making it unclear. So, yes, you could see that between where the light hits the epithelium and the endothelium, there's a lot of stroma normally there isn't that much. And that's because it's become waterlogged. That's one definite thing yet. And the second thing do you see this? That's the lens of the eye that you've got some opacities in the lens of the eye? Okay. And the third thing is that the distance between the reflex on the, on the iris and the endothelium is very small. So that anterior chamber is very shallow. So does that give rise to any thoughts about what the diagnosis be would be shallow? Anterior chambers can cause? What reason? The intraocular pressure? That's exactly right. Yes. So that's the case of Morrison also said that in the chair. All right. Okay. Yeah, you need to not be shy and talk because I can't see the chat. Unfortunately. Thank you for that. That's very good of you. Yeah. So um yes. So that's raised in chocolate pressure leading to the endothelial cells not being able to function very well uh and pump out and keep the cornea clear. So that's a sudden rise in pressure and it's also stop the blood flow to the lens which has caused the cat track and the anterior chamber is very shallow. So this is called acute angle closure. Glaucoma. Has anybody heard of that before? Acute angle closure? Glaucoma. Morrison has modest has written in the chat. All right. All right. Let me get the chat. Can Morris not talk, I'm sorry, doctor, but we have another lecture. Do to stop. Yes. Yes. We'll just do this at and then finished know sudo exfoliation where there was no pseudo exfoliation yet cloney whole pressure. So this is acute angle closure glaucoma which can damage the nerve. The pressure can go up to three times its normal limit, which is 60 millimeters of mercury. Okay. We'll talk about this next time. If there's a next time, I'll have to give another lecture to finish this. Okay. Nice to meet you all. I'll let you go, I'll stop share ing and uh you can go to your next lecture. Thank you for coming. Thank you.