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OK. Do we like? Yes, one second. I think the slide is still loading. Um Oh uh All right, I'm just gonna share my screen. Um Yeah, click. All right, everybody. Uh I believe we're alive right now. Um So yeah, just uh I, I'm down from the BMA. I was gonna say um um just a, just a couple of minutes before um before we start today. Um Yeah, obviously pretty big, uh pretty big another big year um for what's going on in terms of pay um all around um you know, juniors consultants sass now as well. Um So uh mo most of you guys are watching and I'm sure the final years. So yeah, II guess the main message from me is it, it's just pivotal that, that the um that we continue. Um What's, what's, what's been going on and, and the um the great um the great effort everyone's been putting in, it continues into, into your year group. So yeah, big message is if you're not a member, join the BMA, um usually when you go online, you start paying straight away, so it's 3 lbs 75 a month. Um But I'm doing a little bit of a little bit of a deal for those watching. Mind the bleeps that if you join using this QR code on the screen, you get a 10 lb Amazon voucher for joining. Um So cos it's 3 lbs 75 a month. It works out as about getting three months free basically through that Amazon voucher. Um So yeah, so scan that QR code if you're not already a member and then drop me an email when you've done. So, um, and I'll get an Amazon voucher sent out to you. Um, the m the, the more mem members we have the better basically and we just wanna show that the next next year group coming through um, into F one are, are gonna be um strong and, and on it as much as, as much as the, the years, the, the two years now that, that passed as, as F ones. So, yeah, a little bit about uh that a little bit about membership uh in general and sort of benefits that you can be using now as well. Um So, yeah, hopefully everyone knows what the BMA is now. Sometimes we get a little bit of confusion between us, um, and, and companies like MDU and MPS. Um, so they're indemnity companies. So, er, I, if you were to accidentally cut, cut a patient, that's, that would be where you, where you deal with MD mps. Um, we're your union so we're things like your pay your contracts and, and that kind of thing. Um So we actually negotiate contracts for better, for worse, um, in the UK. And that's why a lot of what's going on now is happening. Um BMA, unlike o other unions like unison. Well, on the BMA is purely for, for doctors and med students who are gonna become, um, become doctors. So, yeah, we, our membership at the moment is 100 and 91,000. So that's just doctors and medical students across the UK. Um And that's, that's most, that's most people our members. Um So yeah, so, so do join, become part of. Um, well, it's the biggest membership I've known in my time in the BMA, which is nearly 10 years. Um So yeah, we're, we're going from strength to strength at the moment and, and it just shows the power that we, we can have if we all come together. Um, so, yeah, so a little bit on June doctor pay you, I'm sure you guys know what's, what's going on. Um, um, maybe you've been down to the pickets yourselves. Um, but yeah, it continues basically. Um, we don't know how ii I'm hoping this is the year that things end. I mean, it, I've started to think that, you know, that the current government are, are just waiting for general general election to come along to sort of sort things. Um, and maybe pass the buck. So, I don't know um, II sort of get the news in, in real time as everyone else gets it. So I don't really have anything secret to tell you. II, imagine that the next round of strikes will probably be mid, mid February. Um, you can sort of make a guess based on, um, based on the patterns of the, of the past. It seems to be sort of once, once a month and a couple of days. So I'm imagining the next next strikes might be mid, mid February for juniors. Um, so, yeah, any news we get, um, you'll, you'll, you'll, you'll be first to know, uh, as, as I am. Um, and I asked this question today in terms of final years and, and if, and if, if there was a, if there was a, um, if there was an offer put out would, would final years be able to vote on it. And I think the precedent is that it would include um, final years as obviously you'll be going onto that contract and, and potentially also pre years. So, yeah, only people that will be in membership can vote on that deal. So another reason to sort of, to sort of be involved. Um, so things that you can use right now if this is coming to you, sort of the end of your med school life. I'm, I'm sorry, I wish you'd known this the whole time. Um, but yeah, BMA library, um, we used to have sorry, every, every book you could imagine under the sun in BMA House, um in central London we'd post the books out, but now we've just moved everything online so everyone can get everything instantly. Um You can just go on there, search exactly what you need, any journals, textbooks. Um And, and you'll be able to open it instantly through the website. Um B MJ learning great for exam revision. Um and, and, and, and the like, um, so you may get B MJ learning through the, the med school as is, but this will be, you, you'll have no paywalls of this. You'll have to complete access obviously to P MJ learning and all this is also included in the 3 lbs, 75 month clinical key, great point of care tool. Um If you never used it, it's worth downloading the app and logging into your BMA membership again, you type in any, any condition you can, you can think of. Um, and it'll bring up every single uh journal textbook, um video that could possibly, that could possibly do to do to do with that condition. Um B MJ, um the B MJ itself. Oh, I can hear something. Um the B MJ itself. Um So the, the magazine as your final is, it's a bit of a, this is a bit of an, if you know, you know, sort of thing as your final years, you're actually entitled to get the B MJ through the post every week. So the doctor's version rather than the student version, which is, which is down to once a year. Um So yeah, so four times a month I get them on Fridays. Um, you're entitled to get that B MJ. Um, but you just have to opt in. So if you just give us a phone call on that number at the bottom right of the screen or just, just on our um, general email support at bma.org dot UK. Um We'll, we'll, we'll start sending those to you. Um and just make sure your address is correct. So yeah, that's part of the 3 lbs, 75 month. So even if that's the only thing, um you sort of used on BMA that's less than a pound, a copy um delivered to your door. So definitely worth, definitely worth joining. Um We've got a great um wellbeing support service. Uh This is open to everybody regardless of whether you remember or not and it's open 24 7. Um And the pretty unique thing about this is um it's, it's you have the choice to speaking to a counselor or a peer support doctor. So somebody who's um been through medical school, who's had similar experiences, perhaps um specialty explorer, maybe early to be talking about this. But we got a really good uh specialty explorer tool. Um Basically, it's 20 minutes psychometric test you ask, uh it'll ask you all sorts of work life balance questions and then at the end, it will give you uh a breakdown on what, what specialties would suit you according to the answer you've given. Um really good to do it sort of now and then join F one F two. And, and so by the time it comes to choosing your specialty, um this has sort of guided you a little bit, um gives you lots of breakdowns and, and diagrams and graphs just to show why such specialties would suit you. Um So yeah, really interesting tool worth using. If, if you've not used it before, that's it. Try to be as brief as possible. This is gonna be a pivotal year. Um Obviously you guys starting F one this year is coinciding with, with what's going on with the strikes. Um So yeah, just, just be as involved as, as you can be. Um And definitely be, be a membership. Um Yeah, and, and at least get something for joining as well. Like I said, if you go online, you, you, you don't get anything for joining, but because you're watching this, you can get a, a 10 lb hands, a voucher. So, so make, make the most of it cool. Um I'll let you go on the session. Thanks for listening and then just keep your eyes peeled with everything that's, that's going on or, or not going on. It seems at the moment with the, with the government. Um Yeah, thanks for listening. Thanks Dan Um, so hi, everyone. My name is Nash. Um, I am a and I'm a junior doctor in Birmingham Q Hospital at the moment. And, um, we're gonna be presenting the final series lecture today. Uh, myself and, er, Cameron, um, who's a doctor in Australia? Cameron? Do you want to say? Hi. Hi there guys. I'm, uh, doctor just finished F two now working in Australia. And, yeah, looking forward to the, uh, talk tonight. OK, cool. Um All right. So without further ado, let's get started. So essentially in this lecture, we're kind of gonna go through most of your core conditions, essentially, um which you guys probably have at this point I had a look at in uh from the UK MLA curriculum map. So we'll be firstly going through a quick recap of anatomy, then a quick revision of exam um of, of the exam, the eye examination. So not too much, just not too much depth, but just a quick revision of that. And then we'll be moving on to the sort of red eye conditions um and then visual loss as well as um a few other presentations as well. OK. So next, we'll go on to the recap uh the anatomy recap. First of all. So, um essentially to understand kind of um different conditions, I think it's always good to have a good um basis of your eye anatomy. So essentially, we've got three layers. The first layer is you kind of get fibrous layer on the outside, which consists of the cornea and the sclera and which are both continuous with, with each other. So, the function of the cornea is ma it does the majority of the er refraction actually and kind of focuses the light on the retina. And then you've got the sclera which is a wrist cap which provides some structure to the eye and also allows attachment of your extraocular muscles um allowing for eye movement. Next, uh and all of this is uh avascular. And next, we've got the vascular kind of the vascular layer which kind of provides the nutrients and everything for, for the eye, which is the choroid ciliary body and also the iris. And um collectively that whole thing is called um the iris, ciliary body and choroid are all called the uvea. And what the choroid does in particular, it's, it's full is it's full of uh blood vessels and it kind of supplies the retina um with essentially all the nutrients it needed needs. Then we've got the iris um which controls your pupil and that consists of circular muscle and a radial muscle. And the contractor contraction of that causes um and sorry, the contraction of those calls cause pui constriction fine. And then from there, we move on to the ciliary body, uh which has essentially are the, has essentially consistent muscles which attach to the lens um with processes and these, the, the function of this is essentially to control the thickness of the lens. And um again, that causes, that helps with the refraction of your light of the light onto the retina. And um also, so the body makes the, makes some aqueous humor as well, right. So we've gone through two of the layers and the final layer is your retina, which is the photosensitive layer. And you've kind of got your neural um neural part of the retina, which is, which contains your photoreceptors which go to your bipolar neurons, go to the ganglion cells and then that um sort of signal gets transmitted to the optic nerve and that eventually goes to the thalamus in the brain. And you see, um so that's your kind of your neural layer. But you've also got a pigmented layer within the retina, which um essentially allows for uh absorption of light and prevents light from kind of bouncing around in the in the retina causing a distortion of vision. So, those are the kind of two layers in the retina. And within the retina, there's certain areas that we need to be aware of. So we've got the macula, which is the central portion of the retina. And it's where you, you have a high resolution of um color vision. And within the macular, you've got the little um piter, which is called the fovea. And that's where you have the high, the highest concentration of cone cells in particular, which provide your sharp the sharpest visual acuity. And finally, we've got the blind spot, which is where the optic disc is. And that's kind of where um all the vessels can merge and your optic nerve is and um goes off from there basically. And um just in terms of your uh chambers, the anterior chamber, which is kind of between the cornea and the iris. And that contains your, the aqueous humor. And then you've got the um posterior chamber which has the vitreous humor and you have, you might have a sort of uh remnant uh embryological remnant, which is the um hyaloid canal, which is there as well. All right. So that's a brief recap. And um 01 more thing I forgot to mention actually is the, you have a layer on top of the sclera which is conn conjunctiva, um which is kind of like a see through layer on top as well. All right. So from there, let's go through briefly through the eye examination. So I kind of like to think of it as having a general inspection of the eye and then you kind of move on to your sort of tasks. So uh in terms of your general inspection, we've got the um you're going to expect, II like to think of it as you, you inspect the periorbital regions, then you move on to the eyelids and then the eyes itself. So including the pupils when you move on to the eyes. So certain abnormalities that you might want to mention and pick up on um or pay attention to when you're having, when you're doing a general inspection are things like swelling, redness, discharge, um any prominence of the eyes so that if one eye is particularly popping out or the other um also um abnormal eyelid position, so any drooping sepsis, um and we'll talk a little bit more about all these and the relevance of all these um signs a little bit later. And also you want to know the um the shape size and um any and asymmetry um of the pupils as well when you're doing a general inspection. So general pupil inspection is involved in this. So in terms of the the kind of your special test or the sort of structure of your examination, you can remember it as um Afro C um which is kind of how I remembered it. Um So you've got your visual acuity that you want to test first and then you got your visual fields, then you move on to your reflexes. So your direct consensual and accommodation reflexes, then you get the ophthalmoscopy or fundoscopy and finally, don't forget to test with blind spot. So some people kind of miss this, but you can kind of mention it, you can mention it within your examination. So, and finally, you've got DC, which is your color vision and you use the Ishihara plates here. So, so we'll briefly talk about um vision, the visual acuity assessment. So when you're assessing visual acuity, you can use either a Snellen chart or a logar um chart. And you ask the patient to essentially stand 6 m away. You want to test each eye separately and you want the best vision that best corrected their best corrected vision essentially. So you want their glasses on and you ask them to read as far down as possible uh starting from the top, making their way down and record the essentially the lowest readable line. And if the vision I and then if they, if they have um decreased, decreased visual acuity in terms of in comparison to previous tests, then you can use a pinhole which um can identify whether they have a refractive error or not. And the reason why the pinhole works is because if they have a refractive error, your and you use the pinhole, you're kind of directing the light directly through the center of the lens, uh which has the area of like least refraction and it goes straight onto the back of the eye, onto the macular phobia. So the place of highest um visual acuity and that will hopefully if there, if there's, if it's just a refractive error that can be corrected with glasses, that will kind of correct um whatever error that they might have. And um so as it says, her normal eyesight is essentially 66 or 2020 vision and just in terms of the numbers and the presentation of it or of the visual acuity, you can present it as the numerator, which is the distance that the patient is actually standing away from the um chart. So six at the top and then you've got the denominator, which is the er distance at which uh normal I would be able to read. Um the last line that the patient has read up to. So it's a bit confusing unless we, we take an example. So for example, if a patient has a vision of 69 and minus two, it would mean that the patient can essentially read up to the letter O on the chart. So that would be the, they would essentially be able to read, they would actually be standing 6 m away, but um are only able to read up to the le the line, which a normal eye should be able to read at 9 m away if that makes sense. And the minus two is um just means that there, it essentially tells you how far along the line they're able to read. So they're able to read up to the ninth line minus two letters. So that'll be the o OK. So that's pretty much what you kind of need to know um from here. So next, we'll move on to um visual fields testing. So I'm pretty sure all of you guys will, will have gone through this uh during your cranial nerves examination, but just a quick recap, a few, a few uh points to note when you're examining each eye, make sure you're mirroring the patient. When you're asking them to cover one eye, you mirror them and then you kind of use either wiggling fingers or a um a um I think it's a happen to kind of um measure the vis visual fields there and you kinda work your way inwards. Um And generally, when doing visual fields assessment, I tried to ask the patient with, I try to do a gross assessment. So ask if there's any uh parts of my parts of my face missing. First of all that you that you would um ask to tell any gross or abnormalities and then you would move on to the um kind of fine um fine adjustment. So using the wiggling fingers and moving your standing equidistant, um sitting equidistant away from the patient and kind of moving your fingers inwards. And um comparing when they see the finger or happen compared to when you kind of see the fingers all happen. OK. Um And also there's also auto automated perimeter perimetry, which you can um also mention um which essentially gives you a better assessment of the patient's visual field. So next, we've got the assessment of uh pupils. So when you're assessing the pupils, as I mentioned, talk about size, symmetry, color and shape, we'll talk a bit more about the relevance there later and you also want to assess for er, the reflexes here with the pupils. So you want to assess the direct light reflex, the direct reflex and also the consensual light reflex. So, the direct, right li light reflex is essentially when you um shine light into someone's eye, that pupil will constrict, consensual light reflex, the other pupil will constrict uh as well. And that is essentially because whatever sort of afferent, what whatever sort of signals that one eye gets the afferent pathway kind of takes it all the way back into the um kind of back of the uh into the brain west, into the west nucleus. And there's a crossover of the um pathways here. So whatever you perceive in one eye, the effect that that causes and the signals that are sent out from whatever um signals that you receive are sent out to both eyes. So both eyes will either constrict or both eyes will dilate because of the crossover in signals. Don't worry too much about this diagram. Um It's just to show you that there's a crossover signal. So both sides of the brain receive the signals from each eye and that kind of affects um both eyes equally. So having said that um we'll talk about R APD very briefly. So because of the bila bilateral century innovation of the N OSR nucleus, we've got, we've got um we, it should, if you, if you shine a light in one eye, both eyes should constrict in R APD, there's a unilateral defect in the afferent pathway. So the signals coming from one of the eyes. And because of that the other eye, I the other eye might be um the other eye is essentially normal or lesser affected. And this remember it's a relative effect. So if one eye is seen to have um a defect, it's relative to the other eye doesn't mean the other eye is completely normal, it just might have a lesser defect. And um essentially the efferent pathway is intact, but um it's the afferent pathway that you're ki that's kind of affected here. And so what happens when you have an R APD is that if you shine a light in the uh in the affected eye, if, if you shine a light in the um not unaffected eye, the affected eye will be able to constrict because there is a um because the eer pathway um is intact. Whereas if you shine, shine the light, swing it to the other side and you shine it in the um affected eye, then the um but then you won't, then you'll see the um affected eye will be dilated or er, it won't really react to the light and the um and you won't see a reaction um in the um unaffected eye as well. Ok. All right. So, move on to the fundoscopy or ophthalmoscopy. So, here one second. Yeah. So we'll move on to fundoscopy. So essentially what you want to do with fundoscopy, assess. Uh you generally, when you're doing fundoscopy, you want to be in a dim or dark room um to try and get the patient's um eyes as dilated as possible. So you've got a good view then um you find the red, red light reflex, so stand up approximately 45 degrees to them, maybe a little less. Um and then follow the red light reflex in or red red reflex in. And um you should be able to see the back of the eye. And then from there, you will be able to identify the um the vessels of the eye and then you kind of work your way from the, from the vessels towards the optic disc. And in terms of what you're commenting on, um or what you're trying to observe with the optic disc, in particular, you're trying to observe the C color and all. So with the borders of the o the ob borders of the disc should be quite clear and well defined and it should look kind of orangey pink like a donut sort of donut sort of thing. And um you want to cut, you want to comment on the um cup to disc ratio as well. So this is shown quite nicely in the diagram there. So you've got the CP on the inside and you've got the disc on the outside and that ratio should be 0.3 and we'll talk about the significance of uh the ratio being um higher or around approximately one a little bit later on. And finally, when you're assessing the retina, uh you want to kind of, you want to assess it in quadrants, you want to divide the retina up into superior temporal, superior, nasal, inferior, nasal and inferior temporal quad quadrants and um kind of comment on the abnormalities in each. OK. So that was a brief recap. And finally, we've got color. So you've got the Ishihara plates and you, yeah, and then you kind of um have a look, you ask the patient to read through, read through the numbers. First plate is always a test plate and you comment on how many of these plates the patient has got right? OK. So now we'll move on to um the red eye sort of presentations and I kind of work kind of from the front of the eye presentations, from the front of the eye to the back. So we'll work through some SBA S for this. So first SBA is a seven year old child presents to the ed with erythema and swelling of the of the of right eyelid and periorbital regions. On examination, the area around the eye also feels warm and appears edematous. The patient is noted to have uh reduced visual acuity in the right eye. What investigations would confirm your suspected diagnosis? Uh Yes, I believe the recording will be made available uh Bianca that is the screen moving. Um Let me just see. Is that, can everyone see that now? Ok, perfect. All right. Let's have a look at the pulse. All right. Um There's a slide on the um F ba now at the moment it's on the SBA but there's no answer yet. Oh, ok. That's fine. Um So let's have a look at the poll. Uh One second. And so have you opened the pole to the All right, SBA one just opened the poll for that? All right. So some people have said slit lamp examination, some people have said um swabbing culture for sensitivities. Um Quite a few of you have said CT orbit and few gone for MRI orbit. So the correct answer for this question to confirm the diagnosis is act orbit. And so what we're considering here is child, he's kind of come in with redness, swelling of the eye also some. So you're considering essentially per periorbital cellulitis or orbital cellulitis and particularly the thing that you that should be ringing alarm bells here is the reduced visual acuity, which should uh which is one of the things that you kind of look out for um in orbital cellulitis that you won't see in periorbital. And the sort of imaging that would confirm the diag suspected diagnosis um is a CT orbit. The others are, are um valid options. So, the swab and culture for sensitivities, you could do slit lamp examination, you definitely will. But the thing that will confirm the diagnosis is a CT orbit and um on the CT orbit generally, what you would see um, is sort of uh inflammation of the actual ocular muscles. You can see some proptosis there, um and there might be some fat stranding as well. Um I think you can see some there. Yeah. All right. In terms of, so, in terms of the difference between pres er sorry, er preseptal cellulitis and orbital cellulitis. Uh we've got are the slides moving. Yeah, they're moving. Ok, good, perfect. So, in terms of preseptal cellulitis or pre periorbital cellulitis and orbital cellulitis, um you, you have something called the orbital septum and um essentially preseptal is before the septum. It's inflamma inflammation and infection of the soft tissues um anterior to the orbital septum. And this includes things like your eyelid, skin, subcutaneous tissue of the face. Uh but not the actual contest of the orbit. Orbital cellulitis is infection of the um fat and muscle posterior to the um orbital septum uh with the orbit but not actually in er but not involving the actual globe. So the main differentiating things that you should look out for here are the five P. So pain um particularly on movement on eye movement or in in orbital cellulitis that should be ringing alarm bells, periocular swelling, which you can get in sort of both pupillary um involvement and visual changes. So, if there's inflammation of the um extraocular muscles, you can get some compression of the optic nerve which can cause visual changes. Um and also proptosis. So, again, swelling of the extraocular muscles, pushing the eye forward and you might get um a palsy as well in um auto cellulitis. All right. And one of the other things to look out for was also diplopia. So you might get double vision because there's restricted eye movements in orbital cellulitis. Whereas that's not the case in periorbital or preseptal. So we've kind of gone through this sort of diff the differences um in each there very briefly. But the main things that you should look out for again in orbital are proptosis, pain with eye movement and or restriction of eye movements, blurred vision or reduced visual acuity and diplopia. So if you remember those, those are kind of the main differentiating um factors and they should ring alarm bells and have you sending this person to um get um assessed by uh an ophthalmologist that same day. And um don't forget in your history to ask about uh the systemic symptoms. So even with preseptal cellulitis, you can get a patient who's um septic. So don't forget things like your fever, malaise, um et cetera, um just general uh symptoms of um infection and sometimes you can also get headache with these uh with these sorts of presentations, particularly orbital cellulitis. So in terms of investigations, um you can, as I said, CT orbit, CT sinus in orbit plus or minus the brain for orbital cellulitis is key in um confirming your diagnosis there in terms of um preseptal cellulitis, um antibiotics, the coamoxiclav is generally uh what's given. Um And if you are worried and you can't really tell the difference between um both and you're unsure about the diagnosis. It's always safe to refer to secondary care for further assessment. Um better safe than sorry. Essentially, I'm, if you're not um confirmed that it's um just precept and not audible, uh whereas if it's orbital, you definitely want to send them for urgent same day assessment by ophthalmology. And that's a key key point there for your exams and um IV antibiotics is generally what's given but I think generally what's used particularly I II know in Birmingham trust it. Um Third gen and er third gen cephalosporin plus or minus um metroNIDAZOLE. But again, local guidelines might differ. I think they're starting to use er Metro metroNIDAZOLE alongside cephalosporins right now. Ok. So moving on just a few key things that you might help you particularly with your exams is that knowing when to refer. So generally with these, again, if you're unsure of the diagnosis, if they're systemically unwell and they have pre and you suspect preseptal still refer immediately emergency for the same emergency for a for a same day ophthalmology um assessment, then you got um anyone with suspected orbital cellulitis Children. Um I think with any, you want to be very careful when you're treating Children. So you want to send them for a secondary care for um some assessment. And if they, if you think they require drainage or they have, they might have a lid lid access which requires draining again, refer. So that's preseptal and orbital cellulitis. Um Let's move on to the next SBA. Thank you. So, a 30 year old male presents to the GP with a two week history of ongoing irritation in both eyes. He mentions that um his eyes feel gritty which is worse in the mornings and on examination, there is some mild erythema and swelling of the eyes bilaterally. What is the answer here? We've got a couple of responses. We'll just wait a few seconds more. Yeah. All right. Um OK, that's all the answers in and yes, it is warm, uh warm converse and lid hygiene. And does anyone want to pop in the chat or why that is or what they think the diagnosis is here? Ok. Someone's got a viral, is that viral conjunctivitis? You're, you're saying? Ok. Um Well, actually what I was getting at more with this SBA is um blepharitis particularly. Yeah, blepharitis um can present again, can present similar to conjunctivitis. So fair enough that is um possible differential. But in this f ba what I was getting at particularly with um the wording was that it's bilateral, it's gritty and it's worse in the mornings generally ble blepharitis can present with gritty eyes rather than any um, discharge or watery or um, either watery or sticky discharge, particularly worse in the morning. So they can sometimes wake up and they feel it's quite gritty, sticky, hard to open their eyes. Um, and it's irritation as well. And also the fact that this is bilateral, generally, blepharitis presents as bilateral and that's why I was kind of trying to get out in this um S va. And uh but yeah, and the warm compress and lid hygiene is essentially the um general management for it. So what actually happens um in blepharitis is that the ology is actually unclear, but there are certain causes for it. So there might be my gland dysfunction, which you don't actually, which causes lack of secretion of the oil um film on top of your tear film. So your tear film kind of evaporates which causes irritation of the eye and the um and that causes your sort of grittiness. And um uh yeah, your sort of grittiness, your um stickiness, particularly in the um in the mornings and also the redness and you might have a little bit of swelling around the eye. Um in real life, it's quite difficult to differentiate um conjunctivitis or blepharitis, but you can certain things might point to one or the other. Um But in this case, blepharitis because it was more bilateral um grittiness rather than stickiness and it was in the morning and with these patients um in terms of treating the actual infection in uh sorry, in terms of treating the uh blepharitis is more hot compress eye hygiene is very key. Um and some people who might have a the cause as being dry eyes, uh you can give them kind of artificial tears as well, but generally it's hot compress eye hygiene and kind of hoping for the best. Basically. Um if it does prolong and you do and it's really affecting the patient, then you can consider ophthalmology referral for um further guidance there. OK. So I've kind of er, I kind of saw this SBA somewhere else actually, but I thought it illustrates a very good point. Um So a 22 year old female who's um presented to the GP with a um painful swelling of the eyelid as shown in the picture below. What is the likely etiology of this presentation? Ok. Get it just a little bit longer. Oh OK. This is um split the pole quite a bit. Um So there's quite a few of you either going for C or D. We've got some people, OK? See kind of it further ahead. OK. Wait a couple more seconds and then we'll go to the answer. OK. So we'll go to the answer. Now, the answer is actually d so what are for those of you that got that? Um So it's an oil done abscess that caused, that caused it is caused by Staph Aureus and the kind of two differentials that I was getting at with this, er, question was either, is it either a, um, a sty or is it a Chla? And the main difference is, uh, and the fact that the one, the thing that was kind of pointing towards a sty rather than a Chalon here is the fact that it's painful, swelling. So, a sty is um, essentially a kind of walled off collective um pus essentially because, and that is why it's an abscess rather than um a cyst. And it's kind of a pain, uh painful, infectious abscess of the um oil glands. So it can either be inside um which is in the mi glands or it can be external, which is the glands of um xy or mole, which is kind of represented in the diagram there. So that's either Hordeolum externum, which is the external glands of Xy and Mol. Then you got Hordeolum internum, which is the inside uh which are the infections of my glands. And whereas a Calion differs because it's a um uh it's, it's not really um infectious in origin. It can appear after an infection because of lipogranulomatous inflammation causing a, the appearance of a cyst. And um that residual cyst is essentially that residual cyst after sort of infection is not really pain, uh painful. And it's generally um it can be a small lump, it can be quite large and some people, I should have mentioned. Uh But um it's painless, which is the main, um main thing that you've got to note there. And I thought that question kind of illustrated uh um a this point quite well. So, um moving on from here, what the management for these uh for both of these is actually quite similar. So, don't need to worry too much, um, too much about the management. It's generally quite similar self limiting. So, um the patient should generally get better by themselves. Again, warm compress eye hygiene, kind of open up the glands, let the, let the um open up the, yeah, open up the glands, er, let it drain itself off and um make sure the patient doesn't actually puncture the sty um because that can cause uh cause the pus to spread, cause further infection, um further sts, et cetera. And there's also some consideration of antibiotics if there is a concurrent conjunctivitis. So, because of infection of the conjunctiva that can spread to um the lid margins causing infection of the um of the oil glands. And if it's not resolving, then a referral to ophthalmology with incision and drainage can be considered. But generally for your exams, most likely they're gonna ask uh what's, what's the first line management? Warm compress eye hygiene is very key. Um So you just kind of remember the difference, painless calas, painful sty and um um so not entirely sure for how long. But um I think few weeks and if the, er, yeah, I'd say a few weeks of, um, eye hygiene and, er, warm compress if it's still not resolving, um, and it's causing a significant and if there's, if there's no, um, evidence of resolution it's still getting bigger. And you think that, um, it's your, it's your kind of decision. If you think that it's causing a lot of pain to the patient or a lot of discomfort, then you can consider ophthalmology referral. Um, in that case. So I'd give it a few weeks and see whether there's actually any improvement with the warm compress and eye hygiene. If it does, if it, if there is improvement, then I think, can tell them to stick with it, keep going. Um, and it should resolve itself in most cases. It actually does. It's um I don't think, I don't know if Cameron um has any input in that, but I don't think there's um uh too many that kind of go into ophthalmology for a referral. Ok. So we'll hope that answers your question, Liam. Um So the next question, it's a bit of a long one. Uh but a 30 year old male presents with bilateral, er, red eyes with sticky discharge, er, for four days, the patient last wore contact lenses one year ago and his uh seven year older son recently had the same problem, but it only lasted three days. What would you advise in this case? What would be the management or the point, the protocol here. OK. All right. OK. All right. We got some people going for the, the Acyclovir, er, we got some people going, most people were actually quite er, going for the chloramphenicol eye drops. So, c we've got some people going for sodium chromoglycate eye drops and finally we've got a few saying, take conjunctival swabs. OK. So for this, um the answer is actually prescribe chlorophenol eye drops out of all of these um sort of options. This is the uh most sensible option um that you'd go for and advise the patient to reattend if there's worsening symptoms, a kind of safety net. Um So does anyone know what we're kind of working with here? What we're considering if that's the answer? And for in, in terms of the questions ST anyone one o'clock. Um Yeah. So um that's fine. So we're kind of looking because there's um bilateral red eyes, sticky discharge um for four days. And also this patient has a seven year old son. I think that's who's had a similar sort of problem, but it only lasted a few days. Yep. Yep. That's it. Infectious conjunctivitis, um bacterial conjunctivitis in particular is what we're considering here. Exactly. Hold on. So, and that's mainly because of the sticky discharge, the um and the contact that this uh patient has had with us on. So some of the sort of um so with infectious conjunctivitis, some of those sort of general signs that you can have are this are conjunctival injection. You can have uh typically unilateral, but also you can, it's typically unilateral, but you can also have uh bilateral. So don't, don't solely base the diagnosis on um unilateral. Bilateral, consider some other options as well. Um And then you've got lid lid swelling and erythema and you've got um grittiness as well. Um Clear discharge is particular to um either viral or allergic conjunctivitis. Um Whereas bacteria generally, particularly with your um yeah, generally, bacteria will have sticky like pussy dis discharge, which you can see in the next slide. So here you, we've got viral and bacterial conjunctivitis. So generally, the difference with viral conjunctivitis, what you're looking for in the history is um possibly contacts with people who might have, er, who might have had this sort of thing, you're looking for clear discharge and uh they might have a history of an upper respiratory tract infection and um in your, on your examination, uh try to feel the lymph nodes, they might have periauricular um lymph node swelling and um sometimes there's some photophobia with viral discharge. Oh, sorry, viral conjunctivitis in particular. Um Not really sure why. Um But I've read it, read it in a few, few, few places where there's, that's more specific to viral conjunctivitis, I believe. And um the causes are commonly um adenovirus here. Um So that's, that might be again, one of the sort of things that you're asking your S PA S with bacterial conjunctivitis, you've got per uh perent discharge, sticky eyes, um, and that should kind of pop out of you as bacterial conjunctivitis there um with uh red eye and also ill contacts again. And the causes are strep pneumo and um staph aureus and h influenza. Um in that order. And generally both, both are actually, er, self limiting most of the time. So nice, actually advise um, not prescribe or, or to avoid, er, prescribing antibiotics as much as possible. Um So generally they should resolve within a week or 10 days. Yeah. Or would first of all change your original plan? No, not really unless it's, unless it's severe photophobia and you're, and, yeah, unless it's quite severe photophobia. In which case you might be considering um, another sort of diagnosis, but not really because um all the other, all the other parts of your examination and history would lead you to think of viral conjunctivitis here. Does that answer your question? Cos photophobia quite, um, can actually quite, er, can actually present quite a few um, benign, benign conditions as well. Um, but if it's severe photophobia, then you might consider um uh other sorts of diagnoses differential diagnoses. Ok. Perfect. So management. Um again, nice kind of advice to avoid antibiotics. Chloramphenicol drops, uh 2 to 3 hourly can be considered as antibiotics. Um If you do want to prescribe antibiotics and we'll come on to why in a second. Um, and if you kind of want to avoid antibiotic prescription, then one thing you could do is a delayed prescription. So, I guess this is more in an ay sort of setting. Or if they give you the option in a, you'd select kind of a delayed prescription rather than immediate, um, antibiotics. And general advice is very important for these patients. So, no con try to avoid contact lenses, don't share towels. Um And also, uh there's no need for school exclusions, which is quite a common exam question. I think. So, what was the origin of the bacterial conjunctivitis in the case cases? The contact lens, even if in the last year. So, I mean, it was uh fly a colitis and the case is so if it was, if it was a year ago, um it's less likely to be um, some, it's, it's less likely to be a sort of um, um, some like fluid infection. Essentially, it's less likely to be something like pseudomonas or something like that. It's more likely to be um, the strep pneumo or staph aureus or h influenza, something more common, especially because the patient wore his contact last year than one year ago. And recently he's had contact with um his son as well who's had a similar sort of infection. So it's more likely that this is going to be um one of the more common common options rather than a um, like pseudomonas, for example, even though he is a contact lens wearer. Ok. So, um moving on to the uh consideration for antibiotics. Um if they have purulent, painful and red eye, then it's always worth considering just giving them antibiotics if they're a kid as well. Um If a child comes in, no worries at all, um, if a child comes in and you can prescribe antibiotics, I think it's always worth it. Um You don't kind of uh it might aid there um the recovery. Um And then you also want to consider people who are in contact with um other vulnerable people. So people who work in work with, who are carers, um ICU workers, nursery workers who are in contact with um vulnerable um people of the public in general and also contact lens users. Although in that case, I think I would consider an ophthalmology referral um if they recently wore contacts and it's quite a florid infection and then you'd kind of consider an ophthalmology referral and that brings me on to the urgent ophthalmology um review, particularly if you're considering an S ti sort of course for um conjunctivitis for the conjunctivitis. If it's a neonate that comes, comes in with conjunctivitis. And yeah, again, s ti risks you want to ask in your history and also if they fail treatment, if they're not improving with antibiotics, then you can consider then, and you, and you're pretty sure that you, you, you what you're thinking conjunctivitis, then you want to send them off to, um, ophthalmology for a review. Ok. And the final type of conjunctivitis that we got is allergic. And what's going to differentiate this generally in your exams is the atopic history. So, um, yeah, generally allergic history and also it will, it will be sort of cyclical. Um, it'll appear seasonally or, um, monthly, uh, or to particular expo expo uh, exposures. W will we get the slides and recording? I think the, I think um said that they'll be, they'll be recording. Yeah. So um you can get itching, watering um and you can get uh and this can generally be bilateral as well. And what you can have is these swollen lids and swollen conjunctivi conjunctiva um as well as a little bit of photophobia here as well. Um Generally any sort of inflammation around the area and um particularly if it's affecting the cornea, you can get um some photophobia. Um and what you would do in this case or what do you want to also consider having a look at the conjunctiva? You might see. Uh oh, is there a feedback link for today? Yes, there is, there is, it will come through. So uh there's also chemosis which is swelling um of the surface membranes of the eye which cau which is caused by accumulation of fluid there. And um again here, basic eye care, cool compression this time, er cool compress um and kind of avoid rubbing the eye in terms of medications that you might consider. So, mailer stabilizers, um, things like so, uh sodium chromoglycate. Um, and in severe cases, the steroid consideration. But I think at that point, you would want to, um, kind of get input from ophthalmology as well. Ok. So next question. So we have a 50 year old, uh, woman who presents the ed with left eye pain over the last 48 hours, which is worse at night. And um she has a past medical history of acid and chloroquine. She's myopic and wears glasses and on examination, the left eye is deep red and injected throughout. Um, the pain is exacerbated by eye movements. What drop would be most useful to support the suspected diagnosis? Uh And have you opened the pole for this one? Oh, yeah, perfect. Thanks. This is to support the suspected diagnosis. All right. So, uh we'll move on just in the interest of time. We've got quite a bit to go through. Um It's phenylephrine drops in this case. So, d and um, so what are those that got that? And this is because what we're considering here is either episcleritis or scleritis. And um essentially that's because the, the things that are key in this question are the history of se so a rheumatological sort of condition there. Um We've got the, the fact that it's worse at night. So, and also because of the fact that it's pain that's exacerbated by eye movements. Um I believe the reason why um and what we're considering here is scleritis in particular to, to kind of differentiate from epis and scleritis. You want to put in phenol efferent drops which blanches the blood vessels in, in um in episcleritis. So, in this case, if you put the phenylephrine drops on, you wouldn't see um the blanching of blood vessels kind of uh and you would be thinking more of scleritis. So, topical nsaids is good for pain management. Um prednisoLONE drops you might need for treatment. Um Chlorophenol drops not really indicated here. And um with fluorescein eye drops, you wouldn't, it wouldn't really differentiate. Um or yeah, it wouldn't really differentiate um or provide much um youth in kind of supporting your diagnosis or suspected diagnosis. So, episcleritis versus scleritis. Um epi scleritis is uh just is essentially um inflammation of the episclera which is more superficial. Um and this can cause kind of mild pain discomfort. Um not really some in some patients, it doesn't cause pain at all, actually mild pain. Possibly you can have some watering, some redness of the eye, uh generally discomfort and, but the us the the visual acuity will be completely normal. And also if you on examination, if you push it, push the blood vessels with a cotton bud, they're actually quite mobile. And this is because it's quite superficial rather than the deep um er scleral layer that's collected. Whereas in scleritis, you've got deep boring pain for these patients. Like these, these patients will generally be um yeah, in quite a lot of pain and it's um quite, it could be localized or diffuse uh red eye. Um and you might get some blue discoloration because of um because there might be some because you might be able to see the uveal um layer um underneath essentially, I believe. Yeah. And there you can also, it will also have a sort of subacute or grad or gradual um onset to this, right? So those are the kind of differentiating factors. And when you, when you want to differentiate between episclera and scleritis, you um put on phenol, ephrine drops, which kind of blanches in scleritis. And um here you've got kind of a um a visual representation of the superficial layers of, of the conjunctiva. Um So you've got and the, and the episclera. So, and whereas in the sclera, you've got more fixed um deep vessels, which is why they're, they're not mobile and because the inflammation is deeper, it causes more pain, essentially the, all right. So, moving on a few associations, you need to know with scleritis, um you want to think of your room um sort of background. So you want to think of lupus, rheumatoid arthritis and IBD. So things like if you remember for IBD, in particular, the the patients might have extra gastrointestinal um manifestations of anti uit and scleritis. So this is something that you should remember. Whereas, er, with epi epi scleritis there, it can actually be recurrent episodes that you've got to remember to ask about in the history management. Whereas one you're kind of less worried self limiting. So you want to reassure with episcleritis, provide some NSAID drops for pain, but mental safety net. But other than that, other than that, you're not too worried with scleritis. You want to refer for urgent ophthalmological review um in a clinic uh in the local clinic in within 24 hours. And uh you can provide some nsaids for pain relief and steroid drugs are usually what you're going to give the or what's going to be prescribed to the patient and you might consider immunosuppressive patients, uh immunosuppressive agents as well um or oral steroids or immunosuppressive agents because you want to control what's actually causing the scleritis. Um OK. So the systemic cause of the scleritis. Ok. So does anyone want to pop in the chat? What I'm trying to get at? What sort of what diagnosis I'm trying to get at with these pictures? So the one on the right is particular to one type of um diagnosis but the one on the left is more generic. Yeah, that's, that's the one on the right. Yeah, absolutely. That's a standard dual stop photo. Uh So yeah, so herpes simplex keratitis is what I was trying to get at with the right picture. Um the, the general gist of what I was trying to get at with the whole thing was keratitis in general. So, keratitis is the next um condition. So it's generally inflammation of the cornea and what the the causes can be either infective. So you want to think of bacterial amebic and parasitic um sort of causes generally. Um Yeah, and um particular sort of your standard exam, you your sort of um exam type um scenario that they might give is a person who's been swimming in contaminated or fresh water. Um And then has come in with um this sort of hazy cornea, um reduced visual acuity, a lot of pain and that might be amoebic um keratitis in particular. Um but general keratitis is inflammation of the cornea and what you want to do when you see these sort of patients is you want to identify how bad the infection is. Um if you see a hazy cornea and you're quite worried because you're thinking that the er infection is quite deep the and that's because it's affecting the stromal layer and there's some stromal um keratitis or stromal edema there, which is causing that um haziness. If it's not hazy, you're a little less worried, but you still want to kind of refer to ophthalmology for assessment for keratitis and the it's more epithelial there. So on the surface layer, be aware of contact lens wearers, make sure they don't put on their contacts again and if they are contact lens wearers, you definitely want to refer for same day ophthalmology um assessment. And the other thing that can kind of cause keratitis is a foreign body or corneal injury. Um And a few of the other things that you might be present in, apart from just the hazy corneal or corneal injury is uh kind of purulent discharge and they might have some photophobia again. Ok. Um And then obviously you treat depending on the course of antivirals antibiotics. Um OK. So here's a brief diagram of the corneas, which kind of gives you an idea of how deep the infection goes. So you've kind of got the epithelium. So that's less worried about. But if it extends to the stroma there, you get some stromal edema and that causes the haziness that you see. OK. So next question is, so we've got a 22 year old uh male presents the ed with painless red eye as seen in the image below. And I guarantee this will like this. Will this will most if you see an ophthalmology question, this will most likely come up. Um He mentions that um this has come on after vomiting yesterday morning following a night of considerable alcohol consumption and the patient is completely well, otherwise, what do you think the diagnosis or what's the appropriate management um for this patient? Sorry. OK. And if anyone has any idea of the diagnosis, just pop it in chat. Yeah. Yeah. Subconjunctival hemorrhage. That's the one and most of you got the right answer. It's sent home with reassurance. Um So this is one of the big learning points. So if you do see this sort of thing come up, subconjunctival hemorrhage, just send them home with reassurance. And that is um because it is a completely benign condition um in the history, you might, yeah. Yeah. Subconjunctival hemorrhage. Yeah. Well done. Um you might have coughing sneezing or vomiting in the history and after that, they might develop, develop a burst kind of blood vessel there in the subconjunctiva and that's causing a, a sort of bleed, but that resolves by itself within 2 to 3 weeks time. Things that you would consider asking is also things like, do they have a history of hypertension? Are they on blood thinners and you might send off blood for like clotting or something like that? So, um, just be aware of those sorts of investigations. But if there is no cause, um, or if there is a clear like trigger that you've, that you can see, then you can uh discharge them safely with safety netting patients who've had surgery actually. Um, so, so things like cataract surgery can also present with these sorts of red eyes and they might be quite um anxious. Um, so reassurance and send home with safety netting. So next one, we'll move a little bit faster. So a uh 65 year old male presents to the ed with a red painful eye. The patient is also hyper hypermetropic has a past medical history of rheumatoid arthritis. On examination, there's conjunctival injection and a fixed mid dilated pupil that's non reactive. What investigation would confirm your diagnosis? So we'll give 1520 seconds or so, if anyone, um you can also pop the answer in the chat, I think. And have you opened the poll? Yes. Ok. So we've got a bit of a split, get a couple more responses in and then I'll OK. Real be on. Yeah. OK. So um what kind of diagnosis that I'm getting at with this? Ba was um acute angle closure, glaucoma. And that's the kind of presentation there um on the, the left eye there. And the answer to this is actually not tonometry. Um It's actually uh gonioscopy. I can't really say this word usually um surprised I've got it right. It's uh and it's because it kind of gives you a direct view of the iridocorneal angle, which is what you want to confirm is closed to um diagnose, to confirm your suspected diagnosis of acute closure glaucoma to tonometry you would do as well to and it will show you and it will most likely show you an increased um um intraocular pressure. Um But it's not diagnostic, diagnostic would be doing a gonioscopy, which would be essentially placing this sort of special lens which allows you to view the, the angle between the um iris and the cornea, OK. And the particular factors in the history, the or the, the stem that points towards this is the fact that the patient is hypermetropic. So they're more um sus susceptible to um acute closure glaucoma. And also there's a fixed mid dilated pupil. OK. So glaucoma um is, I think there's a, there's a common misconception that it's linked to or it's caused by um raised intraocular pressure. It's actually a group of diseases that c um that causes uh progressive optic neuropathy and it can be associated with um intraocular pressure. Um and it's a key modifiable risk factor. And what actually happens in acute angle closure, glaucoma is if you look at the image on the top, right, essentially, the iris comes down and um the media iris comes comes down and the, the distance between the lens and the iris kind of gets smaller, there's a pupillary block. And because of that, there is a build up of fluid in the um firstly in the posterior chamber which pushes the um the peripheral iris towards the cornea. And that kind of closes the iridocorneal angle there. And that prevents the drainage of the um uh the fluid in the anterior chamber from the anterior chamber through the trabecular meshwork. So there's um because of that um closure of the iridocorneal angle, which you, which is the main thing that you need to know there's a build up of pressure and that can cause um all sorts of uh that can cause uh essentially all the things that you're um experiencing in acute angle glaucoma. What a patient will present like is with severe pain, might be ocular or they might be, they might actually have quite severe headache as well, reduced visual acuity. And this might be due to the um stromal edema that they might have. So, again, the hazy cornea and um particular, it's, it's particularly worse when um, people, uh, kind of people might come in presenting with, um, this onset after they've been watching TV, in a dark room because the pupils dilated and because it's dilated, there might be high risk for a pupillary block there. The on you, you should also palpate the eye here. Um, and you'll feel that it's quite hard in comparison to a normal eye and it'll be quite red and, uh, it'll be quite red, er, significantly red as well. Other things that, that people might experience is a halos around the, uh, around the, um, around lights. And that's again due to a stro a stromal edema and sorry, the reduced V QT is also, it could also be because, um, of the nerve damage, um, and finally, don't forget the other symptoms that the patient might be experiencing. So, nausea and vomiting and abdominal and, uh, sometimes even abdominal pain. Um, ok, so management of this, uh, I kind of break it down in my head into the goals of management. So, either reducing production of the um intraocular fluid or it's um increasing outflow. So we got the drugs that um we got and then we got the topical drugs. So the drops and then we got the systemic drugs that we kind of give IV. So the main ones um that uh kind of reduce production are beta blockers. So, Timolol and um carbonic anhydrase inhibitors. And then you've also got the ones that increase outflow, which are the Prostaglandin analogs, Alanap Prost and Pilocarpine, which is the direct parasympathomimetic. So, um after you've uh so after now, now we consider the topical drops, we are going to consider the um systemic um treatments. So that's the IV Mannitol you can give and also, but that's I think with senior senior input, you'd consider getting that. But the thing that you would want to start is IV um ace or oral acetaZOLAMIDE. I think it's generally IV in most um kind of example, sort of questions. OK. Um So, II think the mission is just trying to sort his um Mike just now. So give him a minute or so. Hello. Can you guys hear me now? OK. Uh Sorry about that. All right, let's get to the slide. Yeah, apologies. There's quite a few. OK. OK. Lovely. Thanks guys. Uh One moment. OK. So acute closure, glaucoma glauco er glaucoma. Um So we talked about management. Uh So we'll move on to the last part of the red eye um I think we'll, I'll give you the answer to this one in the interest of time. It's the um light. So this patient has come in presenting with um history of an bond, they have a left side, left sided um eye pain redness blurring. And this has come over um several hours reduced visual acuity with small pupil and the fluid level is visible. And what you're considering here is anterior uveitis. And because it's an inflammation or iritis, um as it's also known and because light and accommodation reflexes kind of causes constriction um of the pupils and dilation of the pupils. Um that causes er, the patient more pain because that's er, the iris is what's affected here and generally people with anterior uveitis um kind of, they, they'll again be in quite a bit of pain. Um and this will call and what you're looking out for in exam questions is the fact that it's unilateral, they will have um significant photophobia. Um They will have a quite a red um eye with uh injection or redness around the er limbus and also commonly a headache as well. Um But you also want, you want to particularly look at a history which will kind of give it away, which are your sort of, um which I kind of break down as your room factors, your um gastro factors and also um infection related factors. So you've got your HLA B 27 or sero negative uh, spondylar arthropathies. Then you've got your SL E and sarcoid and you've got IBD as your gastro and then you've got the sort of, um, other, um, infectious causes, which I didn't realize either actually until I kind of read into it a little bit more. So TB HIV, syphilis, um, and hepatic keratitis can also cause like inflammation of the, um, iris. So, investigations, um, you want to look at, look for a slit lamp and what you might see in exam er in ba s are things like flare are cells in flare. So a smoky um appearance of the anterior chamber is a flare and the cells are the little dots you might see um you might see Katic er precipitates which might I which again is a sort of buzzword that you might see in um SBA S but they can look similar to cells on the anterior chamber. And then you can also see an irregularly shaped pupil which is key again. And uh can anyone tell me what the er middle f fluid line there is or what that's called a little collection at the bottom of the eye, I image of the eye there? No. Yeah, exactly hypopyon. Perfect. Um So that's a once the cells kind of settle down, um they kind of form that fluid level, the hypopyon again, urgent ophthalmology referral, you need to refer this urgently and they, they need to be seen within the next 24 hours. Um And the goal of treatment from ophthalmology is um essentially to reduce inflammation. So, steroids um are are useful here and also cycloplegic agents such as atropine which um could kind of um dilate the pupil and help it, help it relax essentially and cause. Um and that essentially helps the um uh yeah, and that kind of helps the situation there by dilating the people rather than keeping it constricted and kind of irregular and also um systemic steroids as well to kind of control what's causing the um the um anterior uveitis. Um oh Someone said high femur. Um So high femur is actually a collection of blood um which might be seen there. So that would be completely red, looks similar to that as a fluid level, but it'll be red and that might occur with ocular trauma. Ok. So um just a quick thing for you guys if you want to know. Uh Can anyone hear anything? Um OK. All right. Um It's a quick thing for you guys. Good place to have a look at all of this is the nice C KS guidelines for red eye um for the red eye. Um They give you guidance about what to refer, what not to refer or what. Yeah, what particular do you refer? Um So that's all there if you want to have a look. So here's the feedback um before we move on to the next section. Um and I try to move a little bit faster. Um OK. Just a few seconds and then I'll need one. OK. So moving on, um it will be at the end as well. So don't worry, um visual loss is what we're gonna cover next. Um This will be I'm, I'm going to just try and give you sort of structure to triage someone that's coming with visual loss rather than go through um every single sort of presentation, we'll try and briefly color certain things, but to give you sort of triage method for visual loss. So what do you want to identify? First of all, when someone comes in with visual loss is ever whether their, whether their visual loss is monocular or binocular, and this will kind of give you a pathway to go from and you want to identify if it's monocular, which eye in the history um always ay marks there. So, uh when you have, we first go through binocular visual loss, if you have binocular um visual loss, then you're considering something in the posterior visual pathways. So something behind with the involving the optic chiasm or um behind and you either have generally, most presentations will be either a homo homonymous defect or you'll have a bitemporal defect. So we'll cover the, the, we'll cover the uh the sort of homonymous um defects that you might have. So generally, these will be behind the optic chiasm with the optic tract. Um And if you have a lesion in the, and if you have a lesion in the um in the optic tracts, you will have a sort of homonymous hemianopia or if you have a lesion in the optic radiations um or the optic radiations, then you will kind of all which covers Myers and bas loop, then you will have um a, a hormonal hem. The other thing that you can, you can have is a quadranopia as well, A homonymous quadrant inopia. And this can be because you have a lesion in either um Myers or sle or either parietal or temporal um lesion. And the way I I'm pretty sure quite for you if you, you know this, but there's an acronym to kind of remember which quadranopia goes with which lesion. So if you have a parietal quad sorry, a parietal lesion, then you have an inferior quadra. If you have a temporal lesion, then you have a superior quadrat. OK. So just a brief one, I think you'll kind of uh touch base on this maybe a little bit more in neuro neuro as well when kind of kind of kind of strokes. OK. So next, we'll move on to bitemporal, bitemporal um hemianopias, you will generally have a compression of the optic chiasm. Um And this can either be from below or above and generally what you would kind of find is either a generally with exam questions, it could be pituitary adenoma and that's kind of compressing from below or a craniopharyngioma compressing from above. These are the most, these are the kind of common exam sort of things. But um yeah, um these are the, these are the two sorts of things that you would um kind of consider when it comes to exams, there are other causes. But um these are the two that um I kind of picked up on. So the that's binocular visual loss, if you have monocular visual loss, what you want to um do next is identify which eye and then test the visual acuity. So, as we mentioned before, we talked about testing visual acuity, we if it's reduced or you, you want to see whether it's reduced or normal. If the visual acuity is normal and someone has some visual loss, uh monocular visual loss, then you'll consider that the error is most likely due to the peripheral retina. And this could be um things like uh retinitis pigmentosa, which is one of the kind of conditions there. But it also could be something that's shown in the picture on the right. Does anyone know what that is? That kind of covers the peripheral retina? That's fine. If um if no one does, that's fine. Um So it's a um it's pan retinal photocoagulation which um people, some people can have if they have um extensive hemorrhages in the er retina or laser therapy in the retina. OK, to kind of stop the bleeding exactly around there. So, that's what you can see next. Um So that's kind of normal. Uh If you have normal visual acuity, you consider peripheral retinal problems. If you have reduced visual acuity after monocular visual loss, then you would kind of do your pinhole assessment uh to see whether this is due to a refractive error or not. I think we've gone through that already if it's not due to a refractive error, um then what you want to do is you want to assess for um if the, if the sorry, if the visual acuity still remains reduced, then you want to check for R APD. And again, we've kind of gone through R APD. So once you've tested for that, if there is um a relative afferent pupilary defect, then you want to do a fundoscopy to see what's what in particular is causing the R APD and hence the visual loss. And generally, there's two things that will cause. This one is an abnormal retinal appearance that you'll see on fundoscopy and we'll kind of go through two particular presentations here and that will cause this. So does anyone know what the one on the left hand side is? Just pop your answers in the chat? Yeah, exactly. Retinal artery occlusion. So you've got a pale retina there, you've got the cherry red spot. Um Yeah, exactly. So you've got the PA you've got the pa retina there, the cherry red spot, you got your kind of attenuated blood vessels that you can see on the top left there. And you've also got, and uh yeah, and you've also got the cherry red spot essentially occurs because when you have um the um cr O, then you've got um kind of retinal edema. And because of that, you can see the underlying um fovea and the fovea actually has its um blood supply from the, from the um kind of choroid plexus. Um So it has it has its own kind of blood supply. So, if the central retinal arteries are occluded, then that's not affected. And you can see that red um bit of the foia there. And finally, um what's the um what's the presentation on the? Right? Z we've gone for 11 of the obvious ones. So the next one. No, not hypertensive retinopathy. Um It's actually, yeah. C ob Yeah, that's it all done. Um We've got um central retinal vein occlusion, essentially, you can see your kind of flame, er sort of flame hemorrhages, you can see your um cotton ball spots um and that's all related to uh CRV there. So, um and you also, you can also see some of the disc margins there and sort of stormy sunset um appearance. Yeah. Uh Also one thing to know is that there's quite nicely dilated um tortuous retinal veins that you can see in that picture in particular, which is linked to CVI. OK. So just in terms of quickly, in terms of management for, um, uh, central retinal artery occlusions. It's basically managed, um, as a, as a sort of stroke. Um, so you're kind of ruling out hemorrhages. Um, and you're going, you're gonna give them aspirin, um, find the source of, um, thrombus that's kind of causing the occlusion. And, um, you do all your investigations kind of directed with that. So, um, ultrasound carotid echo kind of hunting for the, um, source of the clot. Ok. And again, these will require ophthalmology referral. So these are just a quick presentation of something that you might see in, um, exam questions. One, the one on the left is a central, uh, sorry, a branch retinal artery occlusion. So only one part of the, um, retina is kind of pale and the other one is a, um, branched retinal vein occlusion. So you can see the sort of, um, uh hemorrhages and you can see the, um, kind of, yeah, you can basically see the hemorrhages. You can see the, um, dilated to tortuous veins, um, in the, on one side and not the other. So those are the general two, that we've got with the abnormal retinal appearance. Next, we've got the normal retinal appearance, which is the, uh, which we consider the optic optic nerve pathology there if you got kind of normal retinal periods. Yeah, we've got optic neuritis. Um, so if someone's come in presented with, um, poorer like poorer discrimination of colors or red desaturation in particular. And you've got, and it's worse on eye, there's worsening pain on eye movement. Um then you're thinking of optic neuritis, something that is specific to this is uh central scotoma. Um So it's commonly in um demyelinating lesions, um such as uh which can occur in things like MS. And for these sorts of patients, you want to, essentially the management is starting them on high dose steroids to, to stop you or prevent the in or prevent the inflammation from getting worse and kind of settle it down, preventing further optic nerve damage. So it's important to refer these uh these guys immediately for ophthalmology assessment. Um And yeah, so the other thing that you want to consider in terms of optic optic nerve pathology is uh raised intraocular pressure, which um you will see in primary open angle glaucoma. So, so the findings that you might find in primary open angle glaucoma is optic disc cutting. Um So as you mentioned, the ratio should be naught 0.3 before. If this is greater than naught 0.3 as shown in the image, then you're kind of considering um the increased pressure causing the cup to get deeper and wider. And then you also might see things like bayoneting of vessels, which is kind of when the best vessels come to the um optic disc. And because it's quite deep and uh the cup, the cup size is actually quite deep, um it will go straight down into the um into the cup and kind of come out at a different place. So it won't look continuous and that kind of looks like a bayonet and that's why they call it bayoneting vessels there. And again, um for these sorts of things, you want to refer formally for an ophthalmology diagnosis. So when you refer to ophthalmology, for primary open angle glaucoma, they'll do kind of a full assessment involving fundoscopy, um a visual field assessment. So, automated perimetry um mainly. So not just the fingers and the um the um habit, you, you have an automated perimetry, more specific. Um you get, you will measure the central corneal thickness as well. Tonometry, measure the pressure of the eye and um gonioscopy because you want to see whether the iridocorneal angle is open or closed. Ok. So Cameron, if you just wanna go through the um management, so uh the management. So treatment is usually started an intraocular pressure of 24 millimeters marker or above. Um 360 degree selective laser trabeculoplasty is recommended in nice guidelines and for all patients needing treatment. Um And that is using laser directly to the trabecular meshwork and that, that improves drainage. Um And then a second procedure may be at a later date. Prostaglandin Prostaglandin analog eyedrops. Um An example that would be with toops um are the first time medical treatment they increase uveoscleral outflow. Um and then trabeculotomy trabeculectomy surgery may be required where other treatments are ineffective. Um essentially creating a new channel from the anterior chamber through the sclera um to a location under the conjunctiva, um causing a bleb to be created on the conjuncta. And then from here, it's reabsorbed into general circulation. Ok. Cool. So, um that's kind of primary and called glaucoma in a nutshell. Um in terms of the, in terms of er moving on from there, in terms of visual loss, we've got. Um so we've considered the um kind of differential diagnosis or the approach that you take when R APD is present, when it's not present, do you again want to do fundoscopy and you will have a look and see what you can see in the retina. If the retina, if you have a clear view of the retina, then you most likely you're gonna have a sort of macular pathology and Cameron will uh kind of tell us a little bit more about some of the things that can happen there. Yeah. So age rated macugen generation is a progressive condition affecting the macular most common called the blindness in the UK. And it can be unilateral but also bilateral. There are two types, wet and dry, wet, is neovascular and dry, is non neovascular. Um So, bruising are an important finding with um age related marogen generation. Um So dr are yellowish deposits of protein um which, which are proteins and lipids between the retinal pigment and Bruce's membrane Um And sorry. So, um so in, in wet age related new vessels developed um from the choroid layer and grow into the retina. So that's what they call neovascularization. Um These vessels can sometimes leak, causing edema and faster vision loss. Um And then a key chemical that stimulates the development of these new vessels is vegf or vascularity growth factor. And this is the target of medications to treat wet age rated ma. So the risk factors in this are old age smoking, family history of cardiovascular disease. Um and the visual changes associated with AMD tend to be unilateral. So, gradual loss of central vision, reduced visual acuity and wavy appearance to straight lines. Um wet presents more acutely often than dry vision can develop visual loss, can develop within a few days and progress to complete vision loss within a couple of years. Um Then just when you're examining someone for this, you wanna do check your visual acuity which will be reduced. Um They might have a squamata or scotoma, sorry, an enlarged central area of vision loss. Um and dris and may be found in fundoscopy, you want to do a slit lamp examination to get a detailed view. Um and sometimes use fluorescent angiography and to give a fluorescent contrast to assess the blood supply. And patients with a MD require specialist ophthalmology assessment. Um And there's no specific management or treatment for dry MD. Um it just involves monitoring and reducing the risk by stopping smoking, controlling BP. Um and then anti vegf meds are used to treat wet. Um So, anti vegf may will block the veg F and slow development of new vessels. Ok. S so the next one is diabetic retinopathy. Yeah. So, diabetic retinopathy and would be under kind of diabetic eye disease. And it's characterized by damage to the microvasculature, supplying the eye due to high chronically high blood glucose levels and leading kind of to insult to the retinal cells and deterioration in vision leading to blindness, um cataracts, cranial nerve palsies are also other complications and opal modulates diabetes. So, is not the most common called blindness in the working age and demographic of the UK and almost all patients with type one diabetes of some degree op within 20 years of their diagnosis. So, risk factors. So exposure to hypoglycemia duration since diabetes diagnosis, high BP, um so rapid improvement in blood sugar levels. So, if you rapidly lower your blood sugar level um and increase the progression of diabetic retinopathy. So, a lot of patients, clinical features of it will be asymptomatic. Um A lot of these patients only present after developing clinically significant ma edema or having a large vitreous hemorrhage, but it can be picked up on regular eye testing using visual q fundoscopy. Um It can be classed into different types. Three classes, proliferative, nonproliferative and diabetic macular edema. Um nonproliferative can be further subdivided to background retinopathy and prep prolift retinopathy. Um And there are different kind of things you should be looking at and these people sub blot hemorrhages on fundoscopy, venous beating, um microaneurysms um and hard exudates, cotton wool spots are all things that you'll see can be questioned in in final exams. And proliferative diuretic retinopathy is characterized by new vessels on the disc. Um And yeah, and then diabetic edema is characterized by derma changes, Orem changes in and around the macular. Um So, yeah. So investigations you wanna do you wanna do HBA1C to see how poorly or well controlled the patient's diabetes is um fluorescent angiography as well to look at the vasculature of the retina. Um An optical coherence tomography provides a cross sectional view of the retina. It's an imaging technique. Um So my managing it blood good BP control, good glycemic control diet, exercise. Um an imperative um photocoagulation is the primary intervention um used. Yes. OK. All right. Um So, yeah. So um after, so after those sort of presentations, that kind of um can you can see that would cause problems with the ma or have some macular uh pathology when you're looking at, you're looking through a fundoscopy if you have a hazy sort of retinal view um in when you're kind of triaging a patient and you have a look through a fundoscopy, you're considering. So considering something that's um occluding your view. So the one of the things that it could be, is cataracts, cataracts leading cause of curable blindness in the world. So, very important to um identify them. Essentially, it's cloudiness, cloudiness of the lens, um, gradual pacification as you, uh as you grow older, it has its um certain risk factors that you should know. I think the main ones that you should pay attention to are things like smoking, diabetes and um systemic corticosteroids. Uh One of these sort of exam things that might come up is that systemic corticosteroids um could produce a certain type of cataract and that's a posterior subcapsular cataract. Um So that's, oh, I don't think you see my pointer but um you can see it in certain diagrams if you type that in, it will kind of give you a good view of where these sorts of cataracts form. And there are other sort of uh other other risk factors as well like alcohol trauma and um UV exposure. So what you do, um you can, you can consider again as, as with everything conservative, medical surgical, I think here, this is mainly conservative and surgical, conservative. Um So increase the glasses prescription and encourage um bright light when they like when they're reading, um er, or focusing on focusing on certain things particularly with reading. Um and also a referral for um to, it doesn't need to be urgent but just a referral to ophthalmology to kind of um start the process of um getting um the cataract surgically removed So the surgery that's kind of done for cataract, cataract surgery is for PCO emulsification. So they kind of just put in an ultrasound probe, um into the eye, uh, which kind of breaks up the lens and then they kind of suck out those bits, um, inside, uh, they kind of suck out the bits of the lens, um, and put in a sort of new lens, um, or an artificial lens that, um, doesn't have a cataract essentially. So that helps the patient see you afterwards. Um And the sort of complications that can occur in particular that you might be aware of are things like um infection. So, endophthalmitis because it is an invasive procedure, posterior capsule, um P or um or uh per during surgery as well. So they can go through the post cap cap, which is kind of show sort of show in the images that are there. Um So the the probes can go through there and that can cause some complications. And then uh some of the other sort of complications that to be aware of are things like retinal detachment and posterior capsule. Uh As we mentioned, posterior capsule rupture already. OK. So one of the other things that kind of occludes your um vision of the retina apart from cataracts is a vitreous hemorrhage. So this is kind of sudden painless visual loss presentation and when you have a look in the or or or something that patients might complain of is uh quite a few floaters in particular. Um I think, yeah, generally quite a few floaters in particular and they might have a red sort of hue because of the blood that's in the vitreous. And um what um what you've got to kind of be aware of in terms of history is that you've got to take into account whether they have proliferative diabetic retinopathy, causing hemorrhages and bleeding into the vitreous and also things like posterior vitreous detachment. So as you get older, the vitreous is kind of a um of the vitreous essentially kind of detaches from the retina. Um because it kind of shrivels up essentially and that detachment can pull on the retina and cause some tears and that can sometimes cause bleeding and that cause that causes bleeding into the vitreous tumor. Ok. And um as of anything, if something bleeds, think of trauma. So, ocular trauma ask for that um in terms of management of this, um it's uh an ophthalmology referral is warranted here to kind of get it fully assessed and see what the cause is for this. And um if you're seeing them in Ed, you can always get a slit lamp out and kind of have a look um at the um at the patients, see, see what you can see with the slit lamp and you might see some uh red blood cells in the anterior vitreous. Um Also an O CT can be done uh So um coherence to uh tomography er which can er kind of give you a better um image of retina retina as well to look for any tears. OK. Next, uh we're nearing the end guys, I promise. Um we, we got the, we got retinal detachment which is um again, kind of painless er visual loss. Generally the people, the classic presentation is a curtain like visual loss uh from the peripheral er retina to the central retina. And um what you got to be aware of in history is to try and pick out these sort of patients is flashes and floaters, they, they'll come in presenting with. Um and then you got to that should ring alarm bells to kind of think of um retinal detachment. And if, especially if they're high myops so high myopic prescriptions, you've got to be aware that these, these, these kind of patients can have a, a sort of a retinal detachment. And in terms of management, what determines the management here is that is whether the retinal detachment involves the macular or whether it doesn't involve the macular. If it doesn't involve the macular, then it is more urgent that you send this patient to or it's more urgent that they have an ophthalmology referral or assessment and that they have the surgery that's required to kind of correct this because um the outcomes are a lot better and without um the macular coming off their visual acuity. Um um will be preserved. Um More than if a patient has um their, their, their macular um already um off during the retro detachment. So if their macular is still on there, then um it is more urgent and you want to send them off and get assessed by ophthalmology, um urgently macular is off, then um a few days they can, they can wait a few days um for their surgery macular on, they need their surgery urgently. OK? I think that's the main kind of take away from the management. Um and certain things that you might see in terms of um the in terms of the exam questions in um the slit lamp of pigmented cells or Shafer cells. So retinal pigment can be thrown up when it kind of detaches and um again, vitreous hemorrhage as we mentioned um has a link as well. OK. Yeah, same day ophthalmology referral. So this is kind of like the triage um sort of tree as a whole. So you guys can um once the recordings out, you can kind of have a look um at this and this will kind of give you an idea to how to triage the um the a um acute or visual loss essentially. OK. So um I'll leave it to Cameron to just talk a little bit about diplopia. Yeah. Sure. So um diplopia double vision kind of happens when there's a mismatch in image produced by the eyes um by not cure vision develops because the brain can fuse separate images from each eye to a single image, aided by extra cure muscles and ensuring that both eyes look directly the same object. Um If this mechanism fails due to problem with failure muscles or nerves, the occurs um in young Children, it can will result in suppression of the image. And if untreated, it can reduce vision and the affected eye. Um so it can be very in different causes, might not mono cure by not cure. Um So, mono di is due to a cure cause while bilateral the is more commonly caused by neurological systemic conditions. Um Mono opia can be caused by corneal irregularities, tears, cataracts. Um whereas by not cured, appropri of both eyes can be caused by neurological conditions. MS myia gravis, thyroid diseases, vascular causes strokes. Um So for the kind of the main part of it, the red flags, you just want to know if it was a rapid onset of the can, it can be with CNS symptoms and M or A V cause and if it's persistent and elderly people presenting with the head or sudden onset headache with the pia. And so you want to check on clinical exam, visual acuity, color vision and inspect do a proper ophthalmic examination. You might wanna do some CT or MRI of the brain and you wanna check blood blood pressure and blood glucose. Um If you have new onset, you should stop driving Um Yeah. And it's just, it, it's important to be aware of the poo because it can be cause of many different things. You having a kind of awareness that that needs to be investigated is pretty important. Ok. All right. So, uh we're just gonna go through one final thing. Um, and that's anisocoria. So this is, er, Ane Aoria, which is a, a difference in the pupil size essentially. And that's due to either the affected pupil being dilated or it'll appear as constricted. And when a pupil is either dilated, when the affected pupil is either dilated or constricted, that's either due to one parasympathetic innervation disruption or the second one is sympathetic innervation disruption. So you're parasympathetic. So kind of keep you simple. The parasympathetic um innervation causes your um uh oh, sorry. Yeah, parasympathetic um innervation kind of causes your pupil constriction. So if it's affected or if it's uh if it's, yeah, if it's not being innervated, then you get a dilation of that pupil. If you have sympathetic uh your sympathetic innervation here, so your flight or fri uh flight or fight a response, um You have a dilation of your um people usually with sympathetic innervation. If that's disrupted, your people will be constricted. So, working your way down there down this sort of tree, if you have paras a disruption of parasympathetic innervation and your pupils dilated, you're thinking of either a surgical third nerve palsy um or a DD tonic pupil, which is kind of a um benign phenomenon, uh a DS tonic pupil, whereas surgical third nerve palsy, um you're thinking uh the most, the classic kind of um ba um answer to this or the cause of this is kind of a posterior communicating artery aneurysm which is compressing the um the um fibers on the, yeah, uh which is kind of uh compressing the fi uh fibers externally and um uh the parasympathetic fibers externally and causing that, um, surgical third nerve palsy. And, uh, you'll see a down and out pupil here which, um, I'm sure is covered in your, uh, kind of neuro lectures as well. And, um, so again, we'll see a dilated people as well, you know, whereas eighties tonic people, um, it's benign phenomenon and you see a dilated people that contracts in segments. So you'll see like sort of wor er a worm sort of contraction. So, different segments of the people will contract, differ, contract, um, not in sync and to kind of differentiate that and to, to identify this diagnosis, um, you could use Pilocarpine drops which causes an over constriction due to, um, deer denervation hypersensitivity. So, because there is a lack of process and sympathetic innervation here, put some, um, um, Pilocarpine drops there that will cause, um, ra uh, rapid or, um, exacerbated er, constriction in, in comparison to the other people, then we move on to the constricted or sympathetic er, innovation disruption. So you've got your constricted people. So you've got your Horner syndrome. So, uh ptosis meiosis and anhydrosis. Uh you, you different, different causes of that. Um But it's just worth to know about Horner Syndrome. Um And you've also got the Argyle Robertson pupil there and in particular to kind of identify um uh one second. Yeah, and to kind of identify um Horners syndrome, you've, aside from the triad uh to try and identify what's happening you can use. Um II believe it's aperidine that you use to kind of identify Horners because so a aprodine kind of works because if, if there's a lack of sympathetic um innervation or denervation, lack of sympathetic innervation to the eye, then there is a lot of uh noradrenaline um receptors that kind of up regulated on the post synaptic membrane and apo cloNIDine kind of goes there and um binds to these uh receptors and that causes a um dramatic pupillary dilation. Usually usually, um, noradrenaline, um er receptors are kind of um presented on the presynaptic membrane and cause some mild constriction, which is why if there's no um denervation or there's no um, symp er, sympathetic er innervation, the lack of sympathetic innervation, um then you will see a mild constriction on application of um aperidine usually. So simply application of aperidine causing massive or traumatic pupillary dilation thingy corners, application of a carnitine with mild constriction, normal people. And then you've got your causes of Horner Syndrome. I think Um So you got essential preganglionic and postganglionic causes don't need to know too much about this. But it's just to be aware that this um lesions in different areas can um cause um Horner Syndrome. OK. Just a final point. Uh Does anyone know what this is or what I'm trying to illustrate with this picture? Final slide, I promise. OK. So this is papilledema. Um So, um due to increased intracranial pressure, you can see that there's um bilateral, it's bilateral um kind of blurring of the disc margins uh that you can see and it's, it's only if it, if this is Yeah, exactly. Well done papilledema. It's if it's bilateral. Um and there's a blurring of the optic disc margins there that um you'd say that this is papilledema. If it's unilateral, it's not, it's not called papilledema just a minor point that um that's um generally um missed essentially. So that's uh important to know particularly with increased intracranial pressure. OK. So that's the end, sorry that it took uh quite a while and we had a few disruptions. Um But I hope that was useful for you guys. Some of the spot diagnoses that you might wanna look at are these sort of um things that you can get in BS. So you can have a look at those times and kind of look at these sort of things and kind of Google them in your own time. Um But yeah, these sort of things that can come up with uh in certain exam questions. So in summary, um I think just learn to identify your ophthalmic emergencies. These are the sort of things that are gonna come up in your finals and um have a method to kind of triage your presentation. So I've kind of given you um a way to work for red eye trying to work through your diagnoses from front to from the, using the anatomy of the eye from front to back. And then you've got your differentiating factors there and then you've got the pathway to that. I kind of said um to kind of work through visual loss um to identify the sort of differential diagnoses that you're thinking of and that, and I'm sure you guys will be absolutely fine in your finals. Um So good luck. Um This should be a recording that kind of goes up. But um here are some references and resources that you guys can use. So hum headaches, obviously. Nice C Ks and um B MJ article which gives you ophthalmic emergencies. Um gives you an overview of ophthalmic emergencies. Cool. So, um thank you guys for listening and to uh for uh staying awake for all the time, but um here's the QR code um for the feedback for the session. Um And I believe the next session is ent if I'm right. Um And if you guys have any questions um floors open now or you can uh kind of email final year. Um Mind the beep um If you have any questions, thank you so much. Nah, no worries and come in for that excellent and comprehensive talk on ophthalmology. Um Yeah, the recording will be up so you can go back and watch any pieces that you wanna review. But I think, yeah, it was a really comprehensive um, comprehensive session on the, on the topic. What I'll do is uh, the feedback forms in the chat, uh, and also up on the screen ahead of you. Um, but yeah, if you're all right, let me call down below. Yeah, sure. Um, I know it was a, it was a, it was a lot of information to take in but if you guys have any questions do, um, do email the final year. Um, mind bleep. Um, we'll, we'll try, uh, we'll try and answer as many questions as we can. Ok. All right. Thank you. Thank you.