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We can start. That's fine. Thank you very much. What I've found is that oh, maybe go back and forth. Good. Okay. That's fine. So if you remember we were talking about uh welcome everybody. We were talking about red eyes and it's, I thought I could do it all in one lecture, but it's been two lecturers and I'm still not finished. So I think we left off on uh this, this is interactive. So please unm ute and speak. So patient 11 was this page three pictures. So that's uh front of the eye. What, what if you remember we talked about this? What is, what can you see here? Uh Please unm ute and speak rather than sending messages because it's difficult to uh to look at the messages and talk at the same time. It's a big tub. It say say that again. I couldn't hear it. Uh a little bit. Yeah. Well, next year I'll be the eye is what? Sorry, I can't hear you very well. Uh Yes, that's right. Yes. So the cornea is a bit cloudy and uh is not clear as you can see the light reflex, which is here is all broken up instead of it being nice and sharp, the light reflex is broken up suggesting that the surface of the cornea is not regular. And that usually happens when there's corneal adama. You can still just about see the features of the pupil and the iris, but they're not clear as you say. So that's the first picture. Hopefully it'll move. Come on. Oh, it doesn't move to the neck spurt. That's the problem. I have to get out. Sorry about this. I have to get out of. Damn, that picture. I think I I just have to show you in these pictures. So what do you see in that picture? Anybody? Uh anybody the thickness. Yeah, that's right. So the corneal thickness is increased. So you can see there's their front reflex from the front of the cornea. There's a reflex from the back of the cornea and that whole thing is thickened. And if you can see these folds as well, these are folds in the decimates membrane of the cornea. Remember the cornea has five layers. Uh the endothelium, the decimates membrane, the stroma, the Bowman's membrane and then the epithelium. So in this case, the stroma, the thickening has red led to Bowman, not Bowman's membrane to decimate these folds folds in the decimates membrane, which is the basement membrane of the endothelial cells. Okay. And then the second thing to note is that there's a mid dilated round pupil and it's not very small, despite the fact that there is a bright light shining on, on the eye suggesting that there is ischemia of the constrictor pupil, a muscle. So it's unable to constrict that pupil. Um The third finding in this picture is that there is some lens opacities just underneath the capsule of the lens. So, anterior capsular opacities and the fourth finding is you, if you look at the iris features, there's this spiraling of the iris iris. So the iris is not straight and fresh, it's spiraled. All of these are suggesting that there is some sort of ischemia going on to the eye. Both the iris, the sphincter pupil, a the lens and the corner. Yes. Sorry. No. Did somebody have a question? No. Okay. Yeah. So uh yeah. So that's the second picture and then this is the third picture later on. And does anybody want to tell me what they say? See here? What are the abnormalities? There is three a normal? Yeah. So there's an abnormal pupil shape. There is a little of Peking of the pupil in this corner and there is a little bit of peeking in this corner. Yep, that's abnormal pupil shape. Yeah. Anything else? What about the tear, uh the side of the uh virus? This one? No, no, not at the top. Yeah. So do you know what that's called? So that's a hole in the colored part of the I uh that's been made. Do you know what it's called, it's called a peripheral iridotomy. So, as somebody has surgically removed that part of the iris, that's right. And that's as a treatment for the underlying condition, which we'll talk about in a moment. Just some more abnormal features on this thing is you see the, the white nous of the pupil in this area and this area they're wipes. What do you think are these white areas will be sclerosis? Uh It's not sclerosis but it's fibrosis. So uh formation of fibrous material as a result of what do you think? So this is fibrosis of the iris. Uh due to what process do you think has caused this fibrosis? Uh Yeah, it's scarring secondary to do surgical procedures. No, it's not secondary to a surgical procedure. The only surgical procedure is this peripheral uh iridectomy. Is it the second into infection? Probably inflammation, confection? No, it's not inflammation. Uh In this case, it's related to the other three condition. Three pictures. So, to this picture and this picture, these are all the same conditions, all these three pictures except that the last picture, the one you see now is after treatment. These are before treatment. So what do you think has caused the scarring this fibrous tissue to be here soon. Isha Senecio of the sorry senecio of the virus and Australia Sinek, you know, it's not Sinek information. No, okay. So the fibrosis is stimulated by ischemia of the iris. So uh lack of blood supply to the iris. Okay. So um what do you think is the diagnosis here and here and then this is the treatment, the peripheral iridotomy. So, what do you think is the diagnosis anybody? So what's happened that's caused ischemia of all these things and corneal adama and lens opacity and the ischemia of the sphincter pupil. What do you think has caused all of that lack of blood flow or ischemia? Okay. So I'll tell you what's caused it a very high intraocular pressure. So this is this is called acute angle closure, glaucoma. Okay. So some people with very small eyeballs usually hyper metropolis. Patient's people are who are alongside ID or hypermetropia have got small eyes and therefore the drainage angle of the eye, the angle that drains away the acres fluid out of the eye is quite narrow. In other words, the iris and the cornea or the anterior chamber is shallow. And in these cases, what can happen either would exercise when the pupil dilates or in low light conditions. When the pupil dilates, they can go into acute angle closure, glaucoma because as the pupil direct lates, the uh occurs gets trapped behind the iris and it produces kind of a thing called iris Bombay. Have, have you heard of Irish Bombay where literally the acres which is made in the in the parts planner part of the eye? Let me go back and show you the anatomy. So uh here we are on this picture. So, Pars Planner is here uh in front of the retina, that's where acres fluid is made. The acres then goes through the zone you als goes between the lens and the iris through the pupil and drains out of the angle of the eye between the cornea and the iris is called the angle of the eye. Okay. In these cases where the iris is very close to the cornea, the fluid build up back there when the pupils dilated, it's like a dilated pupil is like the curtains are drawn so that uh Iris can trap the fluid underneath the between the lens and the iris and it's bowls forward and closes the angle and suddenly you have the pressure inside the eye going from a normal anything below 21 millimeters of mercury is normal. So if the pressure suddenly goes up to 50 or 60 millimeters of mercury, the blood supply to inside the eye is compromised. So there's lack of blood flow. So this then can cause infarcts of the fink terp you plate. So the pupil is unable to close properly because the sphincter has been ischemic and has had a kind of a strong, there's lack of blood supply to the front of the lens. So you start getting lens opacities in front. Like you saw the high pressure compromises the function of the endothelial cells, which you remember it's the endothelial cells pump acquis or pump the cornea clear of water and make the cornea clear because if the, if it's waterlogged, then it's not clear. So because the endothelial cells are compromised, then the cornea becomes a damage pissed and unclear. And all of that can lead to a subtle loss of vision because their optic nerve can become ischemic as well and get an infarct because of the high pressure inside the eye. So that condition is called acute angle closure, glaucoma acute because it happens over a few, a few hours, an angle closure because the angle of the eye becomes completely closed off and they get a uh they get trapping of the acres behind the iris. Hence why the treatment of this condition is either surgical irritate artemis or nowadays a yag cup yag laser is used to make a hole in the iris. So that's called a laser peripheral iridotomy. So an opening in the iris would allow the fluid come forward and escape and breaks the cycle of acute angle closure. Glaucoma. Okay. Does that make sense? Any questions on that? So I put you to see uh sorry, I didn't hear that because of the echo. Let me turn off and then to turn my microphone up. All right, I said, well, you should be the treatment. Uh doctor me. So something about an iridotomy, you asked, I was saying, could you speedy treatment again, the treatment, the treatment is, first of all, you have to lower. So if somebody is actually an active acute angle closure, glaucoma, you will not be able to see the iris clearly enough to be able to do a laser iridotomy. Uh So the prophylaxis, if you notice on your examination that shall somebody's got shallow anterior chamber, a lot of times we would do laser peripheral iridotomy and that acts like a truck door. They basically, there's a communication between the behind that fluid, behind the iris and in front of the iris and that prevents acute angle closure. Glaucoma happening. The other way you can do it if you don't want to do a peripheral iridotomy is to do early cataract extraction. So if you remove the fat lens and put a thin plastic lens in, you almost never get acute angle closure, glaucoma. If somebody has gone into acute angle closure, glaucoma, they're normal symptoms are nausea and vomiting because the pressure is so high that they get a headache and they get nausea and vomiting. And there has been many, many cases of misdiagnosis where people have gone into a and e complaining of a headache and nausea and vomiting and been vomiting. And they were told they had gastro entra enteritis because nobody bothered to check the pressure inside the eye or check their vision. So acute angle closure, glaucoma can, can be a diagnosis that can be very easily missed in general practice. So, um so the thing to do is if somebody comes with a headache over the eye and reduced vision as well as nausea and vomiting. Then you need to suspect acute angle closure. Glaucoma check their intraocular pressure with, with by a friendly ophthalmologist. And if it's high, they need emergency treatment, admission to hospital and they need to begin given intravenous acetaZOLAMIDE in order to reduce stain chocolate pressure and prevent visual loss. So the first thing you have to do is lower the intraocular pressure and once you lower the trochlear pressure to below 21 then the cornea starts to clear and then you're able to do a laser iridotomy, um which is the safest thing because you don't have to enter inside the eye to do a laser iridotomy. Its hold on by light and you make a hole in the iris as shown. But if your vision is not as your, if your view is not clear, then sometimes you have to resort to doing a surgical iridotomy. So take them to theater and make a surgical iridotomy like was shown on that picture down here. Um Where is it that we are on this picture? So that's a surgical irritable to me. And that allows the fluid to come forward from behind the irish to the front and drain out and stops the bowing of the iris forward that could cause acute angle closure, glaucoma. So this condition, acute angle closure, glaucoma is very important for general practitioners to know about and not to miss the condition is becoming much rarer nowadays because a lot of people are having cataract surgery before the age of 80 or 70. And if you have cataract surgery, it's almost completely makes the anti your chamber deep and makes this condition not happened. So it's becoming in the last 20 years that I have practiced. This has become rarer and rarer because as you increase age, what happens is your lens gets fatter and that can shallow the anterior chamber. So again, if you can imagine um this lens, this lens, the fatter, it's natural lenses, the more shallow down to your chamber will be. And that was one of the causes by removing the lens and putting a plastic implant, which is what we're doing cataract surgery, then you deepen the anterior chamber and it nullifies the risk of acute angle closure, glaucoma. So doing the early cataract surgery can improve vision as well as reduce the risk of acute angle closure, glaucoma or okay. Any questions on acute angle closure, glaucoma. So the first line of treatment is ascertain is dolomite, intravenous and you might have to repeat it several times and keep checking the intraocular pressure and use topical drops also to lower the intraocular pressure. Once it's lower than the cornea is clear, you could do the laser treatment, which is laser iridotomy, which is the definitive treatment for this condition, right? Let's go to patient 12. So this is patient 12. What do you think this is all patient. 12. So that, and that, what do you think of this patient? What's the diagnosis? And what are you going to do anybody? Very orbital, uh peri orbital, okay. Not quite erythema. Peri orbital. What's it called? Uh, right. Information. Information of somebody said that. Yeah, blepharitis. No, it's not blepharitis. Blepharitis would never be so swollen. I wouldn't be so swollen closed in blepharitis. That's just the lashes. So, not blepharitis. Who else? Somebody else said something else? So, peri orbital is pretty good. Uh It's not quite a pair orbit abscess. It's called peri orbital cellulitis. In fact, in this case, because you can't see the eye itself, you can't call it preseptal cellulitis. You have to call it orbital cellulitis. Cellulitis, preseptal cellulitis. Yeah. So it could be preseptal cellulite but, or it could be orbital cellulitis. Now, what is the difference between preseptal cellulitis and orbital cellulitis? And which one is more dangerous and why anybody little cellulitis is more dangerous? Yes, that's right. Why is that? Is that uh, optic nerve get compressed? Uh Yeah. Well, if it was only the optic nerve getting compressed, it would and the globe and the globe. Okay. What's the worst thing that can happen to somebody with orbital sal itis? If they're not treated septicemia, they can get worse than septicemia, vision worse than that worse than vision. What's worse than being blind, being damaged, being dead? Very good. Very good. Somebody said that being dead. Uh subperiosteally lapses can go into the cerebral venous. That's right. Exactly. Exactly. If you remember the roof of the orbit is very thin bone and if you get a abscess inside the orbit, it's very easy for the pressure of the swelling to make that orbital apex bone to break. And then you have an abscess going into the brain causing a bacterial meningitis and death. So, orbital sal itis is extremely dangerous and it usually happens in younger Children. Um It can happen to adults as well, but it's mainly young Children between the ages of 1.5 to 3 that it happens to. What is the cause of orbital cellulitis? Normally anybody sinusitis. Yes, that's right. So they have sinusitis and that leads onto the orbit being affected. It could be preseptal or orbital. Okay. Let me just show you on the anatomy book and the anatomy of the eye. So, or this doesn't show the globe. So you see where this eyelid is just behind there around the orbit, there's the orbital septum. If the infection is in front of the orbital septum, it's very unlikely that it would spread behind. So it's not life threatening if it's a preseptal cellulitis. Whereas if the infection has spread to beyond the i beyond the orbit, beyond this septum, it's called orbital cellulitis and then it's really, really dangerous. Now, in this child, the problem is uh we can't tell which one it is. Why do you think we can't tell, we can't tell whether it's preseptal or orbital, why, why uh solution of the, that's the pill side of the island. Yeah, I cannot, cannot openly can't see or can't identify elevation. Exactly. So, there's five things that would cause you to diagnose orbital cellulitis. And those five functions are the functions of the optic nerve. If there is any pressure on the optic nerve, then your diagnosis goes free from preseptal to orbital cellulitis. So in preseptal cellulitis, the eye itself is usually not red, it's white, it's just the surrounding tissues that are red and edematous. In this child, you can't open the eye. So you can't assess that the uh function of the optic nerve. And there's five functions of the optic nerve that we assess. Anybody can tell me. What are those functional things of the assessments of the optic nerve that we assess. So there's five things, it's probably too difficult for you because it's it's postgraduate stuff. So the first one is visually cutie. If the optic nerve is affected, the vision will not be normal. That's one. So in preseptal cellulitis, vision is normal in all riddles, cellulitis, the vision is not normal. In this case, the island is so swollen, you can't even assess the vision. So you have to assume the worst. You have to assume this is orbital until it's proven otherwise. So, visual acuity is the first function of visual optic nerve function. The second function of the optic nerve function is color desaturation. And the most uh the most uh noticeable color defect is red desaturation. So if you show somebody who's optic nerve is damaged or uh not working as well as the other optic nerve, if you show them a red box, they see it as much darker red. So the brightness of the red goes. So if you just go from one eye to the other eye, the colors are much more dull with the one that the optic nerve is affected. Of course, you can also do color testing with Ishihara plates. But Ishihara plates are made for congenital color defects. They're not really good at picking up optic nerve abnormality. They can, but it's not as important. So just a matter of showing somebody a red box and comparing the the tone of it or the brightness of it from one to another, I they'll notice a much dollar read with the eye that has got the optic nerve affected. So the second modality of optic nerve function is color defect, reduce color perception. The third modality is there what's called the relative Afrin pupillary defect? So rapd, I don't know if you've heard that that's where you swinging shine a light torch. So you should swing a bright light from one pupil to the next pupil. And then as soon as the light shines on the pupil, it should constrict a little bit and then start to open a little bit. But when you have a relative afferent pupillary defect or a defect in the optic nerve, uh, of one side, then the Afrin limb of the pupillary reflex doesn't work as well on one side that as the other. And so when you shine a light, the pupil starts to dilate rather than constrict. So do you remember that this is what we showed you? So there is the Afrin optic nerve. When you shine the light, it stimulates the optic nerve on both sides, stimulating the etiquette of Westphal nucleus, which is the part of the the parasympathetic nucleus of the third cranial nerve, the oculomotor nerve and that stimulates the oculomotor nerve, which then stimulates the pupil to constrict. So if you swing the tar slide from one eye to another eye, the eyes should constrict a little bit and start to dilate a little bit, not dilate too much. But if you go from the right eye to the left eye and the pupil starts to dilate, then the left eye has got a left relative afferent pupillary defect. And that's a sign of optic nerve defect on that side. So that's the other modality of function. The fourth one is brightness desaturation. So we talked about bread color desaturation being down with the optic nerve uh compromise optic nerve brightness of lights are also reduced. So if you shine a bright torch in the normal I'ts, somebody is dazzled. But if you shine it the same torch on the eye, but a compromise optic nerve, it, they don't see it as bright. So that's the fourth function of the optic nerve and the fifth function, fifth way, you know, the optic nerve can be. So, uh compromises either if it appears swollen like a disc, oedema or if the disc, the optic disc at the back of the eye appears pain. You remember what the optic desk looks like? Don't you? Let me see if I have any fun this photographs? And can you believe it? I don't have any fun this photographs because these are all just eye problems. So those are the five mortalities of the optic nerve that you need to assess. And if any of those are compromised in a case of preseptal cellulitis, then the diagnosis is orbital cellulitis and you have to admit them and treat them with intravenous antibiotics for three days with broad spectrum until you have cultural sensitivity and you know what you're dealing with. So, what are the investigation if somebody comes in with a preseptal or orbital sal itis, what are the things that you need to do anybody? So you admit them for intravenous antibiotics? That's one. But what are the other things? Uh ophthalmology examination uh by the on called ophthalmology. And then we do a CT Absolutely. Yes. So CT MRI scan of the head just to see if there is any abscess formation in the orbit, which can burst into the back of the eye and there is three specialties that need to work together. And what the, what other thing does the CT look at? So you look at the orbit for abscesses, what other things sinuses? Yeah. Do you look at sinusitis which sinuses in, involved? Absolutely. Absolutely. And it might sign especially so. Yep. That's right. It's from ethmoiditis. And what are the, what are the specialties that need to be involved in a case of orbital or preseptal cellulitis? Optomologist? Ent Yeah. And would that be neurosurgeons? Yes. So if they get a pre orbital abscess and neurosurgeon, but before neurosurgeons, if the only there's an abscess that needs to be drained before that, obviously, depending on the age group, pediatric pediatrics. Yeah. So they're on a pediatric ward. So the ophthalmologist function is just to diagnose and assess the optic nerve all the time. And then uh the uh E N T is to treat the sinus infections. Sometimes they have to do washouts, etcetera, etcetera, depending how bad things are. And the pediatrics obviously looks after the whole uh intravenous administration of the drug and then if need, if the CT is, or MRI scan is worrying about the formation of uh subperiosteal abscess, then they need to be involved to drain it. Yeah. So, for subspecialties, actually, right. Um What other questions shall we ask? So that's pretty. Oh, yes. What are the organisms? Do you think if it's a 22 year old child. What are the suspect organisms that might be causing this? Him? Opulus? Um, awfulest. Yeah, that's a big one. Moraxella Catarrhalis. Yeah. And it could, uh, pseudomonas as well sometimes. Uh, pseudomonas. That's very, very rare in kiddies, I think. Yeah. That's much less likely. Uh, to caucus, I think. Yeah. Streptococcus, thermophilus. And the other one, I can't remember. What did you say? I just stick with prostatic rash, you know. So I didn't be puppies were going to be them her pace know her pay. So these are bacterial infections that are really dangerous. Hepatic infections give rise to another picture. So her pres astor doesn't happen usually in Children. It's older people. That's her pres astor of Thall Mika's quite a different picture and then herpes simplex would give the dendritic ulcers. So uh they don't give rise to this preceptor. So if you diagnose preseptal or orbital cellulitis, it's almost always bacterial in nature. That's why they need IV antibiotics. Yeah, they don't need antiviral IV antibiotics as a treatment. And oh yes. Uh both of those conditions, obviously, the temperature can be quite high and the Children, if they have temperature, they can get fits. So the reason for fits with could be because of high temperature or it could be because the actual thing is leaking into the meninges. So it's a worrying scenario if the child is fitting okay, any questions on pre orbital and preseptal and orbital cellulitis No. Well, I do have one but I think uh listen times know go on, ask the question. It's fine uh export regarding the, regarding the optic know assessment. Yes. And we check the relative effort people were shining that I just shining the light on the eye which is not affected, right? You know, you shine it from one eye to another. I, so that's why it's called swinging light test. So you go from one eye to another, I back to the other, I back to the other, I keep going back and forth. And what you should have is the pupil should remain constricted at all times. If going from one side to another side, the pupil starts to dilate, then decide that is dilating may have a compromised up Tickner. But how do, well how will be low regarding like if one eye is do anything which is not effective, then the other is, is absolutely closed. Know because oh yeah, if, if the eyes closed, like in this case, you can't assess it. That's why you have to presume it's orbiting settle like this. Does that make sense? Is that what your question was? Sorry? Yes, sir. Yes. So if the eyelid is closed and you're unable to open it, then you have to presume that there's optic nerve involvement. You, you presume the worst case scenario and you treat it as orbital cellulitis until proven otherwise because you can't assess the optic nerve and that's what we said in this case. That's why we call it orbital cellulitis. Stand not preceptor even though it could be preceptor when you do the MRI. That makes sense. Yeah. Okay. So we go to patient 13 and this is the patient 13. This is another picture of another one with the same condition of patient 13. What do you think of these? What's the diagnosis? This is pattern pneumonic of it should get diagnosis away anybody. So it's a red eye with dilated tortures, blood vessels on the conjunctive. Er, anybody. Come on, you can get just conjunctivae. It's not quite conjunctivitis. Yeah, that's why I said it's not, doesn't really look like conjunctive itis because if these blood vessels are quite distinct, okay. So I'll give it away a little bit. The patient has fallen and had a major head injury and then one eye is showing this or sometimes both eyes. It's an intercranial problem. It's not an eye problem anybody. Eight hundreds brain hemorrhage. Yeah. Kind of. Yes, it's a hemorrhage inside the brain. But would that be a trouble? Bar hemorrhage, nothing to do with uh sorry, but the hematoma. The no, not a hematoma. Okay. So it's a corral to the cavernous fistula. Do you know what that is? Do you remember the carotid artery goes to through the venous system at one stage in the brain? Yeah, the cavernous sinuses. Do you remember that from your neuroanatomy? Yeah. So, uh like in, in uh cellulitis. I just wanted to say orbits a light is whether it is uh sinus governess thrombosis. But yeah, of course. Uh so it's not a thrombosis Trumbo sis would look different. Yeah, you can get thrombosis obviously in infection. But this is cover Carol to the cavernous fistula. That's a communication between the carotids system, which is an arterial system and the venous system. And that leads to tortures blood vessels on the conjunctiva. And there is a direct car to the cavernous fistula, which is normally secretary to trauma and they're much more serious and they need surgical intervention because the pressure's you deal with are quite high or, and that's usually young males who get that direct car to the cavernous fistula and they need referral to the uh to the neurosurgeons. Uh Whereas when you're an elderly female who's in their forties or fifties, they can get an indirect or to the converters fistula and that normally is secondary to hypertension. So you can diagnose that they have hypertension. And usually if you treat the hypertension, the whole thing settled. But that's called an indirect Kara to the cavernous pistol, which can lead to the, you know, and these funny vessels on the conjunct type of both eyes. Okay. So, carotid a cavernous fistula, direct type and indirect type. It's good reading for you to read it and look at it. Any questions on that one. Nope, that's good. So these are all the systemic causes of red eyes. So you have to be aware that sometimes a lot of your uh your diagnosis of systemic problems can have ophthalmic input. Okay. So what's this one? This is an easy one. Anybody? Come on, we only have very few minutes left. It seems like the sister of Children cause the bleeding itself. It's what the resist of structured and the bleeding is. Yeah. So what's that called? So there's bleeding there uh be subconjunctival hemorrhage. Yeah. Very good. That's a diagnosis of subcontract uh conjunctival hemorrhage. Okay. Tell me the cause is what they think and cause this. It could be trauma. Yes, trauma is one definitely okay. Like is uh disorder, I mean, sorry, vasculitis, vasculitis. No, no, no, you should never get this hypertension, hypertension. Absolutely. That's the commonest probably causes undiagnosed hypertension. So and the other common, less common causes is severe sneezing or severe coughing. They can black the. So if somebody comes to you with this and they haven't been sneezing, they haven't been coughing and they haven't had an injury, you can almost rest sure that they have had some spike in their BP. So, what would you do next? Oh, let me ask you the question. Does this affect the vision? Do you think? Not much? No, I didn't. No division is completely normal. In fact, people probably don't know they have it. It's only when somebody looks at them and says what happened to your eye that they find out. That's what the second thing is it symptomatic or asymptomatic. They think it could be both. Absolutely. Very good. Most of the time it's a symptomatic, but sometimes you can get gritty sensation on the eye because the bulge makes the eye dry out faster. So you get dry eye syndromes. Sorry, I just have to tell somebody to be quiet. Sorry about that. Okay. So, um, so subconjunctival hemorrhage is where uh yeah, if it's not due to sneezing, coughing or trauma, you need to be aware of high BP on diagnosed high BP. And what would you have to do in these cases? What's your advice to the patient from the high potential? We need to reduce the hypertension. Uh We need to reduce the BP. Okay. First of all, you have to diagnose the hypertension. So what how would you diagnose the hypertension? The speaker madam Eater just do the BP reading. It appears normal. It's 120 over 80. Are you worried? Uh then we might ask if there's I've been any uh fistfight or haven't fallen if they haven't fallen? No, they're not. Sorry. Like it had some kind of accident or a Yeah. Well, they haven't had any accident. They're completely normal. Nothing has happened. They just come in with a red eye, you check their BP and there's 1 20/80. Are you worried? And what would you do next? I can check for the vision that they can see normal of division is normal. Uh, we might ask whether they've been sneezing or coughing, living. They haven't been sneezing or coffee. Have they got in a, uh, a violent experience? No, nothing at all. Just the normal day. Nothing. We might ask if there are any other symptoms, no other symptoms. We shouldn't be worried this, you're not worried. I, well, I am a little bit worried because if the BP has been high that it's broken a blood vessel on the conjunctive, er, it could do exactly the same thing inside the brain. And what would that be called pain? Ham Bridge? It would be called a stroke. Yeah. Yeah. So, but their BP is normal when you check it. Do you have to do anything, do you think, repeat the BP? Because they have had an episode of examine the profession? Yes. So the thing to do is a 24 hour BP on a drink. So there's a instrument that you can attach to patient's for 24 hours that checks the BP every 15 minutes. Often these patient's get their hypertension while they're asleep when nobody's checking the BP and they can go as high as they can be completely normal during the day 1, 20/80 and they can go over 200 over 100 and 20 at night when they're asleep. So, if they have that. It's really important to diagnose that because that's the time they get strokes as well. So you go to bed, get this posture, night hypertension and then they have a stroke and wake up with half of their body numb in one side. So it's very important doing one or two readings of BP doesn't tell you your BP is normal because your BP is, we're varying all the time. Now. a lot of GPS don't like to do this 24 hour BP monitoring because the treatment we have to lower BP lowers the whole average BP. And if somebody is completely normal, most of the time it's going to be very difficult to treat them because you would have to really lower the whole of the BP, which could have other dangers of hypertension. Um, if you're trying to control these spikes in blood pressure, but at least if you know about the spikes, you know, know that there's a problem. Whereas if you just ignore it, then the patient doesn't know anything about it. It's not a great idea. So sometimes a lot of times exercise and changing your lifestyle, losing weight can be helpful in these cases rather than taking medication. Okay. Any questions on that one? Oh, we have only five minutes and five patient's to go. Right. We'll quickly run through the okay. So, what's this? Yeah. Anybody, uh, there is a blood feeling, I think Yeah. So there's blood in behind the iris, behind the virus and between the lens items. Not quite, it's in front of the iris because you can't see the iris at the bottom. So there's the iris and the blood is in front of the iris. Between, between what and the iris. What's this? The chamber? The cornea? Uh Yeah. And the iris. So it's in the anterior chamber. That's right. So what's the name of that medical name of blood in the anterior chamber? What's that called? It starts with A H O P ana. No, that's posing the anterior chamber. Hyphema. Hyphema is blood in the anterior chamber. Okay. So is there anything else abnormal you can see on that iris? Are these things? Can you see my cursor are these blood vessels, blood vessels, dilated blood vessels, dilated blood vessels? Is it normal to have so many big blood vessels on the iris? No, no. So what, what do you think these blood vessels are? What are they called collaterals? They're not quite collateral, they're actually abnormal. They like collaterals but they're nasty, horrible things. They're called Rubio's era. This, have you heard of Rubio? Sis Air? This Erie, this means of the iris. Rubeosis means redness. So these blood vessels grow abnormal blood vessels grow on the iris and this happens and they are very fragile and they can bleed and cause this hyphema. And this happens if there has been an ischemic event in the eyes such as the central retinal vein occlusion or it can happen two diabetics where they can get abnormal blood vessel grow because of the abnormal amount of oxygen reaching the eye. And then once you see these ruby ah tick blood vessels, then you're very worried because they glow into the angle of the eye and can cause the pressure of the eye to go very high like the acute angle closure and they patient's can lose vision if you don't treat it. What do you think? Sorry. Uh which, which uh central retinal arch, vein occlusion. Usually it's a vein occlusion. It can happen with artery occlusion as well, but it's much rare, but it's usually central retinal vein or branch retinal vein occlusion or diabetics that get this. What's the treatment in Jane? The first of all is blood and the occlusion need to do much that medicine. Yes. So the occlusion has happened probably 100 days ago. So you can't do anything about that. But in order to get rid of the regression of the blood vessels, you do panretinal photocoagulation. So you put laser burns on the retina. I don't know if you've seen that being done and that gets kills the peripheral retina, you're trying to save central side. So you kill the peru prefer a retina with laser and that reduces the need of the eye for oxygen. And therefore these blood vessels which are abnormal regress and you get regression of the blood vessels, the hyphema settles down, drains off the, out of the eye itself automatically if you get regression of the blood vessels. So that's Rubio's area. This, what's the time? Oh my God. It's two o'clock again. Should I stop now? Is there another lecture at two? Yes, there is a lecture starting. Okay. So, patient 16. Let's see how many patient's there are 18, 19, 2021 22 23. Okay. I will do another lecture then if that's alright, Hanna, I'll tell you another day to finish off this lecture if that's all right. Yeah. Sure. Okay. Thank you very much everybody.