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And so, yeah, I think we can get started. So um welcome everyone to. This is actually the first lecture of the term three of the Ukraine Medical School UK Elective program um by CRF. Um And I guess I'll hand over to your doctor. Thank you very much. My name is Came a New Cherry. Okay. Ho Strong Monetary. I'm a consultant of Tomic in vitreoretinal surgeon in the UK. Welcome everybody. Uh I have given four lectures before I was asked to do one on basic anatomy and uh and red I at this time and then I'm doing another one on basic anatomy and trauma in two weeks time in two Thursdays time. So this one is going to be quite interactive. There's 12 of you on here. So please can you all uh mute yourselves? I mean, if you want to don't do it now, just try to see if you can on mute and talk because we want it to be. So I wanted to be interactive because there's lots of, then you need to talk about workers. So just start by, let's see. So uh just start by going through the anatomy. Uh Why isn't this changing? Uh, my slides aren't going forward so I'm just going to stop chair and see what the problem is. Sorry. And, uh, okay, I might have to have it in this, uh, setting, um, a screen because it doesn't otherwise seem to go forward. Right. Okay. So, can you see that? Yeah, that's fine. Yeah. Ok. Sorry. It didn't go forward when I was in the other mode. I don't know why that was. So I tried it again. I'll just see if it, if I go to the other mode, whether it goes forward. Yes, it does good. So basic anatomy of the eye, eyes like a camera and just like a camera. The image is upside down when it goes through the convex focusing system of the eye. So you can see the candle upright being upside down on the retina and they hold uh so the images upside down on the retina, but everything's turned upright as it goes to the cortex. So the cortex turns the images the right way around. So the focusing system of the eye up front, I'll use my mouse to show you. This is the cornea cornea is the clear part of the front of the eye through which you can see the iris, which is the colored part of the eye. It's either blue brown or green as the iris between the cornea and the irises. The anterior chamber that contains acres and acres is constantly being made and it's, it's made kind the eyeball here in what's called the pars planner to part of the retina. And it seeps forward around the zone mules which holds the lens in position and underneath the between in the space which between the lens and the iris and it goes out into the anterior chamber and it cleans out of what's called the angle of the eyes. So there's a 360 degree angle of the eye where the cornea meets the iris. That's the drainage angle of the eye, which has the trabecular meshwork which actively secrets uh uh Chris. So because it's a bit like lymph elsewhere in the body, it's clear fluid and it takes away this constant making and raining away, it rains away unwanted chemicals that made during the process of seeing by our eyes. So yeah, in the iris is called the pupil through which the rays focus. And again, there's another convex biconvex lens, natural lens that focuses. So the cornea is convex outwards and uh externally convex, internally cave. And then the lens has by convict surfaces on the back and the front, the front being much more on the next and the back and then he's focused the light through the vitreous humor on the retina. So the vitreous humor is the jelly of the eye and it uh lines and back of the lens and it goes around on the surface of the retina right around there So, and it's clear again that you can't see it except when it catches. So people vitreous liquidize as you get older and eventually jelly peels off the retina at the back of the eye and then there is constant condensations in the gel where it was attached to optic nerve or their vessels and people can see these as floaters. Um So we'll come to that. If you get sudden change in floaters, you need to be seen to make sure you haven't torn your retina in the process of the jelly detaching from the eye. So the white part of the eye is called this clearer. Uh that's the wall of the eye that's continuous with the cornea. Uh This clearer has also a covering called the conjunctiva, which lines the inside your upper and lower lid and it goes back in the fornices and is reflected on the clearer down to the limbus. The limbus is where this clearer Boynes the cornea. So where the white of the eye comes clear, that circle is called limbus. And a lot of things happen at the limbus. So the angle of the eye is that limbus, uh celery muscles are at the limbus. And a lot of measurements during our surgery is made from the limbus because then we know where we are inside the eye. Um say that lens itself has got a capsule, it's got an anti. So it sits inside a bag, all the capital, the lenticular capital. Uh there's the anterior part of that, it's called the anterior capsule. And the posterior part of that is called the posterior capsule. During attract surgery, we remove the anterior capsule to scoop lens out of, out of its bag. And then we when we face an implant implant goes inside the bag and it's the bag that's held by the zone yowls the eyeball. So that's why the plastic implant does not move around after cataract surgery, it's going to the back of the eye now. So retina is the photographic film at the back of the eye and it's got 10 layers. Um So there's a potential space between the ninth and the 10th layer of the retina. And when your retina detach ear's, this is where it separates, it's in that potential space that separates uh retina, anterior part of the retina is fed by the blood vessels from coming through the optic nerve, the retinal blood vessels that you see and photographs of the fund assess that only feeds the anterior one third of the retina. So first three layers of the retina, three or four layers of the retina rest our our nutrients and oxygen from uh underlying Polaroid, which is a very vascular layer underneath retina. The last layer of the retina, the uh potential space between being between the ninth and and uh sent layer of the retina is called the retinal pigment epithelium. That's uh the stock, the thyroid, the choroid has different part as well, but we won't go through it basically. And then after the choroid is this clearer. So, um all the nerves uh of the retina adder up optic disc and leave the optic disc is where the optic nerve points, the eyeball. And that's what causes the blind spot because there's no photoreceptor in that ring Reich area, which is away from the center of the vision center of the fovea. The center of the retina is called the fovea. That's where you only have cones. If you remember, there's rods and cones are the two cells that do uh the photo receptors. If you like the primary cells that are stimulated by light, it cones operate in bright light and rods operating dim light owns our what you see fine vision with. So they're concentrated mainly around the macula, the center of your vision. And then the center of the macula is called the fovea where there's a dip that you can see even on this picture is where the 10 layers, eight layers, sorry after retina have moved away, uh create space just for the bones which are stimulated by the uh light coming in the incipient light. So that's the center of your vision that all you're fine vision is. So all the reading is done by that little pinpoint other fovea or four viola uh in your vision, right? So uh that's just a very, very basic anatomy. We can go into much more detail about the anatomy of the retina, the choroid etcetera. It's fascinating, but we probably won't have time for this sector, which is mainly the red eye. So that should surprise it. This is just a neuro anatomy and it's important. It's the light reflex. Okay. So it's got an afferent limb and an different limb. The Afrin limb is where the optic nerve. So if you can see if you shine a light into the pupil of one eye, uh stimulation, the light stimulates the optic nerve. In this case, it's on the left eye, it stimulates the left up nerve which goes backwards into the mid brain at the level of the superior colliculus. And there it's uh synapses with the different pathway which goes uh are sympathetic nucleus of the different pathway is the Edinger westbound nucleus. And that goes to both sides that stimulates the different pathway. The parasympathetic which runs through the third cranial nerve. The ocular motor nerve goes to the eye and that constricts your pupil. So that's the reflex, the light reflex where you shine a tort through the up nerve, the second cranial nerve, the level of superior colliculus. It's um uh synapses with the different pathway, which is that level of the Edinger uh finger westbound nucleus, which is the uh parasympathetic nucleus of the third nerve or the oculomotor nerve. And they're, it stimulates both sides, both fingers. Both of those ocular motor nerves are stimulated because constriction of this finger on both sides. And that's important because when you go to uh when you do a swinging light test, if you sign a bright light on one light and then swing it to the other, right, should be a little bit of dilation and then immediate constriction again on both sides. So if you swing it from the left to the right and the pupil starts to dilate up and you're on the right eye and that right optic nerve isn't working very well. That's a sign that the visual uh decreases due to optic nerve problem or is beyond the I if that makes any sense. Um Any questions on that one? Okay. Um So uh just to go through the cranial nerves, as you know, I think six out of the 12 cranial nerves have got are somehow involved with the I. So uh second cranial nerve is the nerve that goes from your globe to your brain and helps you see, the oculomotor nerve has the person pet Ickes supply to the eye. And it also supplies four of the six extraocular muscles, try ocular trochlear or the fourth nerve, uh supplying superior oblique, which is an extraocular muscle. Again, uh the trigeminal nerve supplies the sensation to the cornea. So if your contact lens where and uh sometimes you get itchy or scratchy eye, it's because you've got a micro abrasion and because your cornea is so full of nerve endings you feel it as being very painful and it can help to heal over the next hour or two, that's called a corneal abrasion. Uh So the trigeminal nerve, the uh deuces nerve is the lateral, the, uh, that supplies the lateral rectus, which is an extra ocular um, uh muscle and then the facial nerve, uh innovates the facial muscles including uh orbicularis, which is what closes and opens your eye eyelids. All those nerves have uh which is basically six of the 12 have something to do with the I just remember that for the next bit. Okay. So now we're entering the second part of the talk, which is the red eye quiz. So there is 22 patient's of gods and they all have got red eyes okay? And we're going and some of which are painful and some of which are not, I'll tell you which is which. So I'll show you the pictures and I want you to a mute and tell me what you see in the pictures and some patient's have got one picture. Some patient's have got more than one picture. So we go through it and then you can tell me what you see in each pictures and we can come for diagnosis and talk a little bit about the condition. No patient one, this is what you see. So anybody tell me what we're seeing here, what's happened? Yeah. Anybody man don't be shy. It's the picture of an eye, I'll help you. They give you this, uh, go ahead. Uh, Azad. Come on. Uh, the cornea is, uh. Mhm. Yeah, there's, uh, there's other infantry, uh, infiltrates or the, uh, that's our inconsistency. Be called me cocaine operation. Right. Yeah. First of all, the cornea isn't clear. So you can't really see ulceration at this stage because you haven't, you're sustaining there. But it doesn't quite show ulceration. What color is this thing that we have put in? Anybody? One interactive. It's not uh it's not I D it's rose Bengal actually. No, it's not. Floors. Floors in is yellow. This one is incorrect. Read called rose Bengal. We don't use it that often actually. And rose Bengal uh stains something red. So, what is that something that's sitting on top of the cornea? But you're absolutely right. The cornea isn't clear, is it? It doesn't have the normal shiny reflex it normally has. There's all these mucus I told you it's mucus stuck to the eyelid. Okay. So, is it like a micro operations? Is it caused by microbe oration? Yes, it can be. My, you can say there are micro operations or what we call punctate epithelio opathy is what we term we give it. So, yeah, Micropal theology, I'll show you some more pictures of the same patient and you can um it the diagnosis. So that's her eye and both of her eyes are like that. Okay. The red sore, uncomfortable, stinky. And you rose Bengal and they stain with this thing. It shows mucus being stuck in the cornea. The corneas are not very clear and yeah, and she's got really dry mouth as well. This is her hand so anybody can talk to me about her hand. What you see there, Claire? Oh. Uh, pop it scleroderma like that. Clear. A derma. Not quite that bad. It's quite a common condition. Look at the joint and look at the finger arthritis closest. Uh That's right. That's right. Arthritis. What type of arthritis? There's many types of arthritis. Uh Yeah, rheumatoid arthritis. So, can you think of what I condition and mouth officially? Right. This episode? Clear itis. No, it's not episcleritis, right. Yes, you're right. Harry, you've I tease not uveitis either. No, no idea. Idiots, tight litis. Uh anterior uveitis. No, it's not anterior uveitis either. All of those can be associated with rheumatoid, but it's not the thing, the most common eye condition with rheumatoid arthritis. So I gave you a hint. Um Why do I have that picture there? Oh. Uh So he's got dry mouth as well. She's got very dry mouth, dry eyes, dry eyes, dry mouth. Yeah. What's that called Sharga Sharga syndrome? She grins. That's right. Shogren syndrome. Shogren syndrome is associated rheumatoid arthritis, isn't it? A lot of rheumatoid patient's have got severe I uh dry eye syndrome and that's dry eye syndrome. But the new reason you have new case on that on the cornea is because there, if you remember your tear film is, you know, it's not Candida, just dry eyes, that's just mucus, just dry eyes. So it's Shogren syndrome secondary to room without arthritis. So the reason you have mucus stuck to the island and the cornea is not here is the tear film breaks up and it's like having drizzle on a windscreen when you're driving. If you're tear film isn't regular, I can't see very well. So the vision goes blurry and then the vision clears if they think that generates very quickly again, because it's so dry. If you remember, there is three different layers to your tear film. So we have the mucus layer that's closest to the cornea mucus layer, makes the tear film stick to your eyes. So each time your eyelid goes up and down, basically wets your cornea and make sure that it's kept kept moist. And that's why there's a nice uh sparkle to your eyes. When you look at it, everything is clear and the cornea is clear. Um there's a second layer which is the watery layer or the liquid layer and that's in the middle and then on the surface is a fine layer of lipids produced by, by the Meibomian glands. And if any of those three components are in different ratio is the ratio of those change, the tear film breaks up. And when the tear film breaks up, you start to get symptoms of dry eyes. So it could be any of those components. And then the other problem is that mucus starts to increase induction and that's why you get whites like material in the corner of your eyes, like sleep. That is just by mucus. Uh And with this patient, what do you think is the treatment for this patient? Anybody tears? Yes. Artificial know note, give them steroids first know start with artificial tears. Yeah. How often would you use the artificial tears, would you say as optimists necessary all the time? Yeah. What's all the time? How often would you say to her? He's got severe. I, yeah, Arley. Exactly. Yeah. Yeah. Can't really damage the cornea. What artificial tears. So, the more you use the better. So, hourly every half hour and some people are so bad they need every 15 minutes. And when it gets to that level, what we then do is put until plugs in, it's like a sink bug that stops the water draining out of the sink. It's the same sort of thing. You put it in the lower think Thai and it stops draining of the tears. Okay. Um, there's different types of punctal plugs. Hourly drops is the key thing. And anything else apart from our hourly dropped, you would advise the patient to do or have the color of the eyes cover the eyes yet. But that they can't see if you got, it's a good idea, but they can't see if they cover their eyes. So, hourly drops during the day. What about nighttime is what I'm getting at? What lubricants at nighttime? Yeah. What type of lubricant? The artificial tear? Okay. For nighttime use when they go to bed? Mm. What do you think? Probably not enough. Just the loop because drops are usually these days. Hyaluronic acid just wears off. So, you need something much thicker than that. It's a bit like Carafate, uh medically. It's, yeah, it's an eye appointment called Saline Night or it used to be lack re loop, there's lots and lots of them and you don't need prescription for either artificial tears or the ointment just giving them these things can really uh soothe their eyes and improve their vision quite a lot. And sometimes you just got to encourage them. They don't worried about using something every 15 minutes. They might be over doing it, but you can't overdo use of artificial tears because they're literally just lubricating. So if it's soothing to the eye, they use it more and more often. And sometimes they say when they, when the drop it stings and the reason it stings is because it's so dry that when you wet it, it starts to stink. So you don't need to use it more, not less. So that's important. And sometimes somebody says steroids, it's true. Sometimes in severe eye disease, I uh actually becomes inflamed cornea and uh this clearer, become inflamed secondary to that And so if you use your artificial tears for a week or two, they're still symptomatic with really a sore eyes. You might give them one or two months of a very mild steroid called FML drops once or twice a day that just dampens the information for that time. But really for steroids to be used on the eyes, you need to have it, have an ophthalmologist present because it give rise to other side effects such as high pressures and track. So you just need to be careful, you can't come them out as a generalist. Okay. So that's dry eyes. There's a lot more to be said, dry eyes and it's a very, very common condition. What percentage of people over the age of 80 do you think suffer with some sort of dry eye condition centers? Which is a probably around 50 to 60% and more than that 80 to 90% of God. Yeah. Yeah. So often when they come to, um, um, to have their cat tracks because any surgery on the eye will worsen the dry eye syndrome. So often they have concurrent cataracts and dry eyes. And sometimes in fact, people come with what's referred to as cataracts, but you find out that it's their chair film and you just give them artificial tears and they don't need the surgery because their vision actually improves with just doing those, those things. And the third thing you can do for my eyes is lit hygiene, which is basically hot water from the tap. About 50 degrees. You put cotton wool in it, you put it on the closed eyelids and you leave it there for two minutes. And what that does? It melts, the oily secretions inside the eyelids. Inside the Meibomian gland. You remember the Meibomian gland. Each if each of our lids I've got plenty Meibomian Gland in the applet and about 20 in the lower lid which produce the oily or the lipid part of the tear film. Sometimes they become blocked and having the heat on them is like having a fat fat in a hot pan. It becomes more runny as you heat it up. So if they leave this hot out on their eyes for two minutes and then clean the lashes, it often helps regular rise their own natural tears. So it often helps. So you can tell them to do that about four times a day if you do it more than that, the problem is it can affect skin temperature can affect the skin. So about four times a day is the right number and they get a lot of relief that you may remember that in the past, they used to talk about hot e and areas, compasses and cucumbers, they all do more or less trying to do the same thing which is make the my bony in function. Uh Meibomian glance function easier and secret a lot better. So I'm noticing that it's, uh, 10 30 we have done one patient. So we're definitely not going to get through this, which is good, which means that I have picked quite a few. Uh, it's, uh, much rather than too little. Okay. So, addition to so here it is. What is that, what you think that is? Anybody wants to tell me what you see. Yeah, it's a cyst. No, it's not the cyst. It's the conjunctiva. You're right. So that brown thing is the cornea. The transition between the white and brown is the limbus that I told you about that the things happen and then the white is the bulb are conjunctiva, the conjunctiva that is on the bulbous and it's reflecting back. This is the for nous. Fornix. Fornix is where the Kulbir conjunctiva and the uh Palpebra conjunctivum eat each other. So it's the bottom of if you plural it at, it's the bottom of that which sometimes contact lenses go and lodge there. Uh uh Fornix lower. Fornix. There is some material that's deposited there. And anybody guess as to what the material is that white fluffy material? What do you think that is? Go ahead. Christy. I can see you haven't muted. I I was going to say, is it when the Acquis humor, uh you know, if you get a aqueous humor out of the eye, that's really bad to talk about trauma because that's Yeah. No, no, it's not. Nothing like that. It's just mucus. Again, it's just a bit of mucus in the lower conjunctiva. Okay. So dry eyes can give rise to mucus and this condition can give rise to extra mucus. This is, what is that? Can anybody tell me what, please? Ok. Rough. So again, the conjunctiva. So which part of inflammation that the upper upper lid? Yeah. So the, it's the upper broken junk diver. Exactly. What do you see on it? It's inflamed. Yes, it is. How do you know it's inflamed? Uh Great know. Do. Yeah, there's these white nodules on it. That's right. Okay. Very good. What do you think? Are those white nodules? Lymphocytes perhaps in few tricks? Blows. Actually, lymph nodes. Yeah. Uh lymphatics basically large lymph nodes basically. Yeah, we call them follicles inside the upper eyelid. Okay. So this is a follicular conjunctivitis we call it. So we want to know what's causing this filic conjunctive itis. So I'll show you the next picture. Uh That's again, the follicular conjunctive artist. This has become giant to play. So these are much bigger you see like full stop and the opera let again. Yeah. And we'll just go to the next picture. Okay. What's that? What they see for this? Clearer itself? Okay. It's clearer. And what else is the so konia and clearer the junction. So this is the limbus where the bound ends and the white starts what you see the limbus of this patient. So these are all the same patient. The last three pictures, they could be the same patient. But would it be mucus? Uh It some mucus. It's not jules, it's not jewels exactly like that. It might be inflamed. Uh Yeah, it's inflammation. So it's the same as up there except that this one is on the limbus. It's actually got a special name because it's pattern pneumonic of a certain condition. So, what do you think if you see that? You know that's the condition and then you can treat it. So do you, do you know they're called somebody's buts because they look like bites, but I was going for something viral. But uh it's, it's not this, once you see these white dots, they're not, it's not a viral conjunctivitis. But you're right. You can have a follicular conjunctive itis. If you saw this thing, it could be junked Vitis, viral follicular conjunctivitis. This condition. This one is called Lantus stocks and they're at a pneumonic of allergic conjunctivitis. Ok. Seasonal allergic conjunctivitis are called Santa's E R A N. The A S I think that was the name of the guy who described. So if you see this, this is severe allergic conjunctivitis. Normally you see them in young people, they do need to be referred and treated with steroids in young people because they have got severe allergy. Eventually people can grow up out of them like they grow out of asthma and hay people because they're all related OK. Tranter starts so, Swan, it's not quite the same patient. It's, uh, another allergic conjunctivitis and is a giant popular. A, what do you think the patient might be using? Let's cause this maybe immunosuppressant. No, no, no. If you get immune suppression, you won't get the follicles because there's nothing to react to anything. You're suppressing them be contact lenses. Yes. Thank you. Very good. Okay. So the older contact lenses were much more allergenic in the past. And so people got this giant what's called giant play, which caused, you know, I'm very junk divided secondary to wear of contact lenses. So you have to leave off the contact lenses, but it's much, much, much less common because the other thing, the material will lose contact lenses now are very different. I haven't seen them for quite a while. I used to see them 20 years ago. Very commonly. Very good. Okay. So that's follicular conductive eyes is very good and this is the pneumonic tran test us for the conjunctivitis. So, follicular conjunctivitis has different call causes. One is viral. You can get this giant papillary papillary conjunctivitis if it's contact lens allergy and then if you see the trend test starts, it's seasonal allergic conjunctivitis. Very good, well done, everybody. Uh Well, we don't have much more time but we'll go to section three. Okay. So just one picture. What do you think that is anybody you can describe what you see? That's a lot of oh and say it uh is it a leakage of a quiz humor? Know definitely occurs. Isn't white like this occurs with a lot of mucus. A lot of, for me situations. Yeah, this is not foam and this is not mucus. What is like mucus, what uh something else? It's not mucus this time. It's what you normally say. Uh It could be tears, it could be tears. It's not, there's no what's white and everywhere else in the body. Limp. Hurry. Uh It's clear. Uh what's white? You know, if you see a white thing in a wound, what do you think it is? Uh Thank you. Yes, it's pass. It's pass. Yes, that's right. This is pass. So this is a pussy conjunctivitis. Really the worst you can get. You can't even see the cornea. So if you see that much pus in and I there's only one diagnosis. Anybody tell me what it is and what bacteria cause it would it be? Bacterial? Conjunctivitis? Waiters. Yes, it's a bacteria. Conduct devices very good. And what bacteria do you think that might be any stripped streptococcus? So not quite strep. Strep doesn't cause that much passports like chlamydia Neisseria. Yes. So it's not chlamydia. Chlamydia doesn't have much puss, but it's got the conjunctive itis. You have to have to be aware of it. It's, it looks like allergic. So if somebody's within this sexual age, you need to get a special chlamydia all swabs. But it's not like this. So this goes with chlamydia. What other thing, you know, bacteria do you know? Gonorrhea, gonorrhea, that's it. Gonorrhea, conjunctivitis. That's it. There's only one thing that gives you so much person and I, and that's gonna really conjunctivitis and you need to put this patient on both, uh, oral and, or intravenous and, uh, topical antibiotics every hour on the hour for this. Otherwise they lose their eyes. Basically, it's that dangerous. It melts the konia and allows the contents to come out. So that's gonna real conjunctivitis. And you have to, it's an inform, you have to inform whoever it is the authorities about this because it's a disease that needs to be informed. Okay. So that's pattern pneumonic of gonorrhea. Conduct providers patient for. Okay. So, what's this one look like it's pass again? Yeah. And M osis Key Moses. Exactly. Yeah. Most is of what part of the eye periorbital edema. Yeah. Uh huh. Eyes completely closed. So, that's right. Yeah, eyes completely closed. And it's a baby just born. Yeah, that'd be, again, bacterial, uh, conjunctivitis secondary to gonorrhea. Yes. It could be gonorrhea, but it could be any of the STD AIDS. Again. This is, uh, and, uh, to me and, you know, tore, um, it's a notifiable disease and it took any of the things. Basically the baby's picked it up during birth, uh, born in the birth canal. So you need to treat both baby and mother and I think it's intravenous in this case as well. Uh And this is the day that baby's born, obviously. So if you see that you need to treat both baby and mother. Very good. Ok. Shall we go to the next one? Okay. What's that red eye again? Yeah. G C Melanoma. Not quite. Yeah, it looks like a Melanoma. But what? See a brown ring, don't you are a arc ring? Where is it? What structure is it on? No, no, it's on the cornea. Absolutely. The cornea is clear. So you can't see the cornea. It's not on the iris. If it was on the iris, you would be in big trouble because it is an intraocular foreign body and it's a completely different thing. The reason, you know, it's in, it's on, on the cornea is because it's casting a shadow, you shadow act thing. So this is the shadow, this ring. You see my mouse. Yeah, you can see my mouth. So this thing is sitting on the cornea. Is it some kind of a deposit on, uh some kind of a lipid deposit? Of fact, it's not a fat deposit. Uh, okay. It's an occupational hazard. Patient is a mechanic. He said led, it's not be led for unlikely to be for everybody. What sort of a foreign body could be metallic or it's a metallic corneal foreign body? Nope, it's a metallic corneal foreign body. What was the patient doing? Do you think when they got this scraping or, uh, drilling or maybe drilling or hammering. Yep, drilling or hammering. And they weren't wearing what I protect the eyeglasses or, uh, they need to wear eye protection when they're, uh, either drilling or hammering or doing anything. Yeah. So, this is a corneal foreign body. Uh, it's a rust ring. So, it's a hot piece of steel that, or metal iron that fell on the cornea and it's printed, That's why there's a ring around it and what you need to do with a needle, ophthalmologist on a slip and removes that and you scrape it and you have chloramphenicol ointment. So that's a corneal foreign body. Very, very common. It hasn't, you have to make sure that there is no, uh, what do you have to make sure this is the question? Yeah. One Christie. Come on. Right. Protection. That is the one thinking too. What was the question? The question is, what else do you have to examine in this patient? You know, you've removed the corneal ring and everything's okay. In other words, in these patient's hammering, you have to make sure nothing's actually inside the eye because if they get any corny of any foreign body inside the eye within 24 hours, they can go completely blind. So it's the biggest emergency is any foreign body inside the eye, you have to remove it. Otherwise you get infection and that's the end of the I do. You have to put dilating drops into the people, dilator people and have a good look at the back of the eye and the lens to make sure nothing's gone inside, nothing's damaged the lens, nothing's on sitting on the retina or inside the vitreous. So, so you have to do the vision and do the full examination to make sure the patient's all right. Okay. So we'll go to the next patient. Patient six and we have five minutes. Dude, it's not only does. Okay. So what's here? Yes, that's very good. And where is the past? Um and the conductive er uh yes, there is a little bit of us in the conjunctiva mainly. It's where inside the chamber. Yeah, it's inside the anterior chamber chamber. Yeah. So what do you call that in the anterior chamber? It's called a hypo P in H Y P O P I O N. So that's a side anterior chamber there, pass anywhere else on this picture. Uh It could possibly go beyond the people yet. It's not quite on the pupil. Is it the pupil is the opening in the iris that's inside the eye? So, were dishing, is that as you're right? Um And the highly the conduct um higher lead conductive er hurry, say that again, conductive a of the high leader. Uh No, it's not the conjunctiva. It's actually what's the clear part of the I called scone. Yah, the clear part cornea cornea. Thank you very good with the cornea. That's why you're seeing the pupil, you see the pupil through the clear cornea that is sitting on the surface of the cornea looks like it's on the pupil. But the pupils inside this is on the outside. Uh, it's a corneal ulcer. What do you think that corneal ulcers, what's producing that? Us? And the hypo p, um, what's, what do you think this and how would you treat it? We have to drain it bacterial. Know you there's a bacteria. Yeah. So it's a bacterial infection of the cornea. So it's a bacterial keratitis. So when you have a bacterial infection of the cornea, it's called the keratitis inflammation of the cornea. So it's a bacterial keratitis with a hip open. And how do you think the patient has picked up this material? Keratitis? What's the commonest cause of bacterial keratitis or what used to be? It still is probably infection. Yeah. So it's an infection. We all know it's an infection. But why do you get the infection, do you think? Okay, in contact lens? Thank you. Very good contact lens. Where, so if you're not, so it doesn't happen and this is why people are moving to daily disposable contact lenses. So it didn't happen with the gas permeable or hard contact lenses. It was only when people moved from harder gas permeable contact lens. The uh disposable contact lenses where they had contacts out with 30 hands dirty. Think the cleaning solution itself could be dirty and they kept putting it in their eyes and sometimes they have money to buy new ones. So they carried on wearing the same thing for 46 months. Then they get a spectacle keratitis because it comes from the contact lens or the solution or the case. And how would you treat it? So, what are the things you need to do before and how would you treat it? Uh What kind of, what, what kind of bacteria usually causes? Exactly. How are you going to find out what kind of bacteria causes it? We train the bus and we don't know. No, you don't need to drain the. So I woke up. Yes. So you, you scrape, you do what's called a corneal scrape. So you get a, a small beed and you scrape off around the edge of where some of that us and you send it the lab, you scrape it normally straight onto a agar plate because if you do a swab, most of it buys by the time it gets to the lab. So you directly culture it onto an agar plate and they grow it and then they can tell you what organism it is and what antibiotics it's sensitive to. So you must take a corneal scrape. Uh, then you start them on what, after you've taken the scrape antibiotics, how, how often often, how would you give the antibiotics to be? Topical drops? Has to be topical. Absolutely. Because if you give it through the blood, it doesn't normally come on the cornea. It takes months and months from, because there's vessels on the cornea. So it has to be by drops. And how often do you think we would give it antibiotics? Every six ali, oh, no, every hour or even every half hour at the beginning. Uh, you give it every six hours that will be completely blind. So you have to treat it every hour, every moment. Count. What kind of antibiotics would you start with? Probably a broad spectrum. Like you want something cover everything. What's the one, uh, Harry an incident? Nous Ilin is good if you have the sensitivities back and know what you're dealing with. So, if, if it's a staph or strep, yes, it can be sensitive to penicillin. That's probably the best thing. But when you don't know, you have to start on something else. So there's two options. Uh, one that I was used to using was Vancomycin and Kefurox, um, dropped, which were specially made for this. So that combination covers all organisms. Okay. And then, um, uh, but there is another combination as well was Ofloxacin hourly and something else. So you would use them every half hour. So one drop every hour van come izing on the hour, every hour and keep your oxen the half hour, every hour. Would you continue the treatment through the night for this condition? Yes, we should. Absolutely. Absolutely. Absolutely. For the first few days it has to be through the night. So patient. So this is why one condition we would have admitted patient's in because they wouldn't, would fall asleep. So somebody has to put the drops in for them, make sure they arise. So if you treat them with the right condition, actually, the hypo P in goes completely. So all the hypo P in is secondary the o'neill problem. So if you get rid of the corneal problem, the hypo P in settled and goes away completely. Um One other thing that you didn't say before you uh So you take on your scrapes. What other things would you stand about for Cher's and sensitivity? Do you send for gram stain? Yeah, but that's when you do the scrape, what other things do you have scraped the cornea? What other things do you have to send the lab as well? Or country or culture and sensitivity? Psychology, psychological studies. Anything you can send it for psychology for gram staining? Yeah. Saying what else? Not just the corneal scrape. So you also should send the contact lens the case and the cleaning solution because come from any of those. So you send them all to the lab for culture and sensitivity. So they do separate dates for each of them. Now, it's nearly 11 o'clock, any of another lecture and we've only done six with these. So you want to carry on with red iron next time and then I do another lecture that to do with trauma. Would you look, plan to that? It was good. You enjoyed it today? Okay. That's good. So, we'll carry on because we have quite a lot more after red eyes to go through and there's some important thing. So I'll do red eye again and we'll go from there. We'll do probably another third lecture. Trauma. And I OK, lovely to see you all take care. Don't forget to fill in your feedback forms. I think that's what they're going to say. Thank you. Thank you very much, Doctor. Um Yeah, if anyone, if everyone could um turn the feedback, please, um that would be great. Sure you and I'm going to end this meeting because we do have the next lecture starting. Lovely. Lovely. Ok, see you in two weeks. Bye. Thank you very much. Bye.