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Condition. Um We'll then talk about taking basic ophthalmological histories uh and thinking about red flags that make us worry about a patient's vision. And we will also be considering differentials for a red eye because red eye is quite a common presenting feature for a myriad of eye conditions. So we'll start with uh going back to medical school. Just talk a bit about eye anatomy and ophthalmology uh is a very beautiful specialty, not because of the drawings like this, but because it's very logical. And if we take a step back and p everything uh back a bit, if you just think up um do a thought exercise and think about what actually makes up an eye and its function. So we have this framework in our mind, it helps us understand how uh where, where things go wrong, how things go wrong and why they present the way they do. So the first question is what actually gives you the form of an eyeball? Think about it, the eye is a closed system, the sclera forms its outer shell. But what gives it the shape is that your ciliary body uh produces fluid called aqueous and the vitreous in the back of the eye as a scaffold for the shape of the eyeball to take its form. And what actually positions the eyeball in its place. Well, you've got muscles holding it in place. You've got ligaments and it's held in a bony orbit. What, uh does an eyeball need, uh, need to live? So, the sustenance of an eyeball, the uh blood supply is delivered by ophthalmic artery by the choroid layer. And the til on the front is actually delivering oxygen to the front structures of the eye. It's very important for an eye to survive. And the eye, uh speaking of survival, the eye loves to be hydrated. It likes to be uh bathed in its tear film and this is produced by your lids and your lacrimal gland and your conjunctiva. And ultimately, what does a uh what does an eye actually do? And how do we see? Well, it bends light to hit a sweet spot on the back of the eye called the macula, which lives in the retina. So the light is reflect uh reflected by your tear film, your cornea and your lens, it passes through your pupil, uh which the size is determined by your iris, which eventually lands on your retina, which then projects it down its optic nerve to your brain to give you sight. So if you just think about what actually uh needs to be there for the eye to have its shape and the eye to do its function. And if you know what each anatomical structure does in the eye, you can narrow down uh what's actually um causing the condition, what's causing the patient's presentation in your clinic. So it is important to be aware of uh the anatomy of the eye. Even if it looks complicated, I think for the purposes of this uh lecture, I'm gonna dial things back and speak, uh sort of simply um and if you just have a basic understanding, you appreciate eye conditions a lot more. Oh, we got one, something important which is the movement of your eyeballs, uh which is controlled by your muscles and your nerve supply. Anyway, the point still stands. We'll move on now, just a quick um slide showing uh some landmarks of your eye. Um This is a frontal photograph of someone's right eye. This is obviously an eyebrow. Uh don't need an eye doctor to tell you that I'm sure all of you knew it, but maybe some things you guys are not that uh aware of the eye has an upper lid and a lower lid. And the space between them when you open your eye is called the palpable fissure or the palpable aperture like the aperture of a camera, it adit uh it meets at two ends, the lateral or temporal end, it is called the lateral canthus and the medial end is called the uh medial cantus. You got your eyelashes and then behind your eyelids are sitting your beautiful eyeball. Uh The white part is called the sclera. The clear part is called your cornea. This brown part is the iris which sits behind the cornea and you've got your pupil there, which that's like in cutting the eye in half and laying on its side. Um The anterior of the eye is the cornea and the posterior of the eye is the optic nerve And light travels this way to land on your retina to go down into your optic nerve. And I'm sure you guys are familiar with a cross section of the eye. So I won't go into too much detail of it and we'll be covering it in a bit later. Anyway, things you might not be so familiar with is sort of keywords that I might end up using inadvertently a limbus is an anatomical landmark. We use to describe the transition area between the cornea and the sclera. So actually the cornea and the sclera are the same collagen structure. It's just that the collagen in the cornea is arranged parallel and that's why it's transparent. But there is this order and the arrangement of the collagen in the sclera which makes it opaque to light. And the transition area between the clear and the opaque is called the limbus. Uh ophthalmologists love to use the landmark uh phrase nasal rather than medial. So if I end up saying nasal, it just means the medial side of the eye. Um we like to say inner and outer and the relationship of inner and outer is basically the vitreous right in the center that's inner. So anything towards the center of the vitreous, we call it inner. So the inner layer of the retina is here and the outer layer is towards the outside of the eyeball. So the outer layer of the retina is on the back surface of it. Ok. So we'll just quickly move through things. Uh We'll start from anterior to posterior talking about the lids. Very busy diagram on the right there. But all you really have to know that it's very important that patients are able to blink properly and are able to close their eyes properly because uh the eye likes to be hydrated and incomplete closure of the lids uh leads to something called exposure. And proper term is exposure kopy and that can be something psych threatening. The proper clinical term for someone who cannot close their lids fully is leg omo and leg oal can either be caused by a neurogenic cause. For example, Bell's palsy um or a mechanical cause like thyroid eye disease, which is the swelling of all the muscles and fat uh surrounding the eyeball and pushes the eye forward, resulting on proptosis. And the lids can no longer stretch over and close the eye properly. And it's uh it's very important to not underestimate if the uh if the patient in front of you is unable to close your eyes because the eye will go red, the eye will go painful, the eye will go dry and left alone. For long enough, the eye will actually go blind. So it is something that's very important. Any insult to the production of tears or the inability to close your eyes can have quite serious consequences. So don't underestimate what the lids do. The eye is looking quite pretty. Um Then we're moving behind the lids. We have the conjunctiva, which is the jelly mucous membrane which envelops the eye from the limbus. And I said that earlier from the limbus which forms the bulbar conjunctiva and it wraps around onto the back surface of the eyelids. And that's called the palpable uh conjunctiva. The corner where it wraps around is called the Fornix and this is where missing contact lenses love to go. So patients will inadvertently somehow forget that they still have a contact lens on, put another one on and they just go all over the place and they end up sitting here in the Fornix. But this is a neat little envelope. It just means that contact lenses can never go behind the eye contact lenses that go missing, never end up in the brain and become a neurosurgical problem. It's always an ophthalmological problem. Uh other ways con um uh the conjunctiva can cause problems if it gets infected or has an allergy results in conjunctivitis, which is inflammation or infection of the conjunctiva. Um It's pretty self limiting most of the time and it's not sight threatening but does need some supportive treatment to help it get better depending on what it is. We might touch on that a bit later. Another thing that uh patient come in with is a very striking appearance of subconjunctival hemorrhages because there are superficial of uh uh arteriole, um capillaries that supply it any breakage to this either by something inadvertent like uh like coughing, anything that raises pressure, any valsalva type maneuvers might just cause one of these blood vessels to pop and bleed out. And the blood sits there and it looks very, very dramatic, but it's of no consequence to the vision and it will resolve in 7 to 14 days. Uh The fun fact, why does it's basically a bruise? But why does it appear so red compared to a bruise which uh which looks purple? The fun fact is that it sits uh sits very superficial, there's plenty of oxygen there. So it never really um oxidized. Uh It never really um breaks down into the deep sort of purple you get with uh bruises, uh moving on. Um the sense of your eye is the cornea and it is a very, very important structure. Uh It is the most innervated tissue per square meter in your body. So any insult to it will be very, very, very painful. So patients coming in with pain out of proportion to how your eyes are looking. Think about an insult to the cornea most commonly it's going to be a keratitis, which is an infection of the cornea. Uh As I said earlier, it's made of collagen a range in parallel which makes it transparent and the curvature of the colon is actually very, very important because it does two thirds of the refraction of your light. Practical example, I'm sure plenty of you. Well, good number of you and myself uh in the chat uh were told as kids that they have something like asthma, which is where your cornea is not as perfectly spherical as um the optometrist is wanting it to be and that causes light to reflect strangely and can reduce vision. But thankfully, most of the time can be corrected with spectacles. But anything that affects the topography of the cornea for, let's say, like an ulcer can change, uh how light bends and how light reflects and can severely um impact sight and hopefully it does um resolve with treatment and most of the time it does. So the sclera is continuous with the cornea, but it's opaque because it's a range of orders said that earlier, clinically, what's relevant about the sclera is that it can be prone to um uh can scleritis uh is what you might be thinking of, which is inflammation of the scleral layer. Uh it's not super common, but if a patient comes in with a red eye that is very painful. Um And vision is down, you should uh think about scleritis uh as one of your differentials. Um another tip is typically the stem or the patient might have uh an underlying autoimmune disease. Uh such as rheumatoid arthritis has an association with scleritis and um moving underneath uh or moving inner. We have the uveal tract which is a muscular layer with three components which are all continuous with each other. We have the iris, the ciliary body and the choroid, the functions of this. So the iris is a muscular layer with um sort of circular and uh uh uh uh spoke like muscles which help with dilation and constriction and any insult to the eye, especially inflammation within the eye can cause it to go into spasm. If you have ever had uh you know, like a muscle cramp, you can know how painful that is. So, photophobia is actually a muscle cramp of the iris. So the way we saw photophobia is by relaxing the muscle by just dilating it with a topical eye drop, like cyclopentylate or tropicamide or phenylephrine that will help the muscle relax and take away the photophobia. The patient is uh presenting. But if your patient is presenting with photophobia, you now understand why they have photophobia. It's all because of a muscle cramp in the eye continues with it as the ciliary body which holds, you know, the lens in place of the xus, but also more importantly, it produces the aqueous within the eye, uh which gives it its shape. Uh And then moving on, we have the chloride which wraps around the back of the eye like this. And it's a very rich sort of arterial plexus which supplies two thirds of the outer layer of the retina. So it's very important for the health of the retina for um uh it's what the choroid does basically. Uh So we move on to what the ciliary body is holding on to which is the lens. Uh That's the remaining one third of your refraction. The first two thirds was your cornea and now the remaining one third is by your lens. Um Not much to say here other than it's what uh what develops into a cataract. Usually by the age of uh 65 I would say. Um and the structure of a cataract is you can think of it as like a satsuma where it has a skin on the outside. And so the Juicy fruit on the inside is what we removed during cataract surgery. And we put in a plastic lens which is helped by the skin of the cataract. That's a simplified explanation of it. But really, it really is just as simple as that. There's nothing really complicated in ophthalmology. Um You've got the vitreous which uh to be honest, only really serves a purpose in uh development and embryology where it provides a scaffold for all the other structures of the eye to grow around. Uh Once you are out of the womb and into the real world, it's not really that important anymore because any vitreous can be just replaced by aqueous uh as we grow older, what's clinically relevant is that everybody will have uh vitreous condensation and shrinking and look of uh and it becomes more liquid and the shrinking and detaching of the vitreous is what we call a posterior vitreous detachment. I'm sure many of you have done single best answers with patients coming in with flashes and floaters. Uh And the answer is posterior vicious detachment. If there is no vision um uh deterioration, but if there is, you then think about a retinal detachment, which we'll talk about in a bit. So surrounding uh the back, the inner surface of the eye is the wallpaper of the eye called the retina. If you look at the right, you can see another busy diagram. You guys don't need to worry about that at all. You guys don't need to worry that there are 10 layers of the retina. Um All you need to know is that the retina is the wallpaper. It has photoreceptors called rods and cones and those photoreceptors receive light and project it down uh retinal nerve fiber layer down into your optic nerve into your brain. It's uh an inverted projection map. What I mean by that is that your superior retina is responsible for your inferior visual field. Your inferior retina is responsible for your superior retinal uh for your superior visual field and so on and so forth. So everything's up and down left to right. Um But ultimately, all you really have to concern yourself with is that the retina is the wallpaper of the eye and there is potential space between the retina and the choroid. So when we talk about posterial vitreous detachment, when the vitreous is detaching, it sometimes can cause a bit of that retina to break off. And if there's a crack in the wallpaper, remember that the back of the eye is not just filled with the jelly, but also with fluid. And if that fluid leaks behind and bubbles up the wallpaper and lifts off the retina, we call it a retinal detachment and that is an ophthalmological emergency. And by that, I mean that the earlier you operate on your patient, the better your outcome is that's one type of retinal detachment. And that's the only one I think you really need to know for the purposes of a final medical school exam. So all of the retina then projects down uh ganglion cells into the optic nerve um or you can just call it the optic disc, the and I'm sure this diagram in the bottom, right, might look familiar to some of you. It's how your visual field projects into your brain and, and things we won't go into too much detail about those things um today, but just be aware that this exists and I think we will talk about visual fields and things like that later on. Uh But what I want you guys to just be aware of is the optic nerve clinic, a clinical sign that is very important to see is something called papilloedema. So this is a nice healthy optic nerve uh happy in its place. The margins are very clear and crisp. You can see two beautiful circles, a cup which is the light of it and this which is the orange, pinkish bit and the vessels coming out beautifully. But if you look on the right, that that's also the optic nerve, but something looks wrong here. The disc, it's a two D image but you can almost see as if there is a, a mountainous region like a volcano and a crater. That's the optic nerve bulging out. And you've got these hemorrhages around the disc, the vessels and as crisp, as clear and as clear as the picture on the left. So what has gone wrong here is this really is a clinical sign of something else that's going wrong in the body. Uh This is called PPL edema and it's typically caused, typically caused by uh raised intra cranial pressure. Now, what can cause that either raised um CSF or something more life threatening like a space occupying lesion. So um any question that says you see a patient with P edema, what's next? Well, it needs to some sort of referral or something. Uh something urgent needs to be done. So take it as an important sign to see. It's not something wrong with the eye, but it's a sign of something behind the eye that has gone wrong. So it's sort of a sentinel sign. So you can look into someone's eye and be worried if they have a tumor or not. Uh moving on uh with uh the optic nerve, we have uh another thing that's important to know about the optic nerve. Uh We describe it uh for the condition called glaucoma. So the definition of glaucoma is not high pressure in the eye. Uh some of you might think, but glaucoma is actually the death of ganglion cells and it's not always due to high pressure, but it often is the uh the case, it's the slow death of ganglion cells and it manifests in an increased cup to this ratio. Sorry, I don't have a picture, but you can imagine the cup to this ratio here is about maybe 0.3 0.4 where you can fit three of these cups into this space. It's closer to 0.4 probably. But in glaucoma, the cup to this ratio then increases to 0.5 0.6 0.7 0.8 0.9 and two, you can't really um differentiate between the cup and the disc anymore. That's, that's how glaucoma progresses. So, uh that's another thing that's beautiful about ophthalmology. You can look at something and see how far gone it is and it often reflects how the patient is seeing. So, uh finally, we just want to quickly talk about the blood supply of the eye, more busy diagrams that I don't want you guys to concern yourself with at all. Uh I don't think this is important for you to know, but all you really have to know is that out of the optic nerve, you have your retinal arteries and your re uh your retinal veins. They come out here over here, we call them central and once they branch out into the superior temporal, superior, nasal, uh sorry, superior, temporal, inferior, nasal, um sorry, superior temporal infer, inferior, temporal, superior, nasal and inferior nasal branches. Um we call them branch arteries and branch veins. And these things can ca uh can become blocked uh resulting in the central retinal artery occlusion or a central retinal vein occlusion or a branch retinal artery or branch retinal vein occlusion. Sorry, there's a typo there that should be a V and uh these are uh things that are site threatening. But the outcome of this prognosis is usually quite poor. Uh the branches aren't too bad, but if you see some of the central um sign the outcome of the prognosis is not good. Um And they do look different. Um I think your SBA s will say someone's coming with a cherry red spot. And that's what a cherry red spot looks like. And why is it that you have a cherry red spot? Well, the the fun explanation is basically this part of your retina is called the fovea. And this is where your retina is the thinnest and has the highest acuity because it's the thinnest, it's closest to the choroid, which is the layer that sits behind the retina. And because that's highly vascularized, it looks very red. So the rest of the retina has gone pale from, uh has gone pale from being blocked and it's become ischemic and pale and white and it doesn't look good. But the one part that still has quite a rich blood supply is actually being supplied by the layer behind it. And that's why that looks red. Um And in the brunch, uh re uh a central retinal vein occlusion, it's not an arterial. Uh it's not the supply that's blocked, but it's the drainage that's being blocked. So you imagine if you step on a hose, it just starts to leak out. Uh The, it starts to leak out the faucet, doesn't it? And it just leaks and leaks and you have all these flame shaped hemorrhages coming out and it's quite a, a striking appearance leads to lots of leaking and fluid that sits in the retina and the eye will not be happy to have this. Um But be aware of what the cherry red spot looks like and how basically a uh, vein occlusion looks like with plenty of hemorrhages, it's quite different. So, uh, before we move on to the next half of uh, the, the session, I just wanted to ask if anybody has any questions, I'll just, uh, swing over to the chat. Oh, you can, I see it for you. There doesn't appear to be anything in the messages. So you're all good. You've been very clear. Ok? If people want me to go over anything before I move on, I'm happy to do that as well. Yeah, guys feel free to drop your questions in the chart. I'm monitoring it. Um And I'll let you know if anything pops up. Thank you. Yeah, just hang on onto this slide for another couple of minutes before we move on you. Oh, we have a new message. Um There's a question from Timothy asking, does a central retinal artery occlusion look the same as an ophthalmic artery stroke on ophthalmoscopy. Uh Let me uh think. Um no, it would not look the same the ophthalmic artery. Uh And II suppose it's a term, maybe it's a terminology thing and ophthalmic, the ophthalmic artery sits, well, maybe I had to go back to this anyway. Uh This is the ophthalmic artery here. It's uh it's sitting here along the optic nerve and it's a lot, sort of more posterior, it's a lot more proximal to where it starts from the circle of Willis. Um So that would affect everything that would just destroy the uh the uh the, the retina would destroy the choroid it with II would say it would look uh it would probably look pale, but I think it looked, it would look different with a central retinal artery occlusion. The classic thing is the, is a cherry red spot and that red spot is contributed by the fact that you can see uh the, the supply of the choroid behind there. But the other thing with uh central retinal artery occlusion is sometimes you can see emboli within the central retinal artery itself like uh a cholesterol emboli or something like that. So, the anatomical uh difference between uh a central retinal artery occlusion and a thalamic artery stroke would be different. Uh presentation, likely the same patient will come in with a dense visual uh uh vi uh visual deterioration probably down to like head movements or perception of light, something like that. They will definitely have very profound vision loss and the prognosis for it will be very poor. Um Interestingly, uh That's interesting that you've asked that. So how I would manage a central, a rest artery occlusion? It's actually basically a stroke. Um It's just that the stroke has happened somewhere where we can see it. Uh So I would um uh it's, it's not really uh an ophthalmological problem. It's more of a systemic issue. A patient is at risk of further strokes. So we need to get their vascular risk factors uh worked up, but that's usually strokes job to, to deal with and not myself. But it's, it's, that's a really good question. Um I would say uh there are two different conditions and I think they would probably look different as well, but pres presenting wise and management wise, probably the same. Does that, uh does that answer the question? OK, Timothy. Um I'll let you know when he responds in the chat. We have another question from Ebony saying I thought that papilloma, papilledema sorry, was only due to raised intracranial pressure without other causes. I was told this on placement by consultant yesterday and I'm confused. Yeah, that's a uh that, that's a really good question. Um The answer to that is uh may maybe the consultant didn't explain uh what he meant fully any raised pressure in the brain. Uh can either be caused by something like idiopathic intracranial hypertension. Uh It's like there's too much CSF and that's compressing the brain and that usually results in the bilateral papilledema. But if you imagine if you have a huge mass sitting in the brain that would just increase the intracranial pressure as well. There's something that, that is there in a tight close space that shouldn't be there that's been growing and slowly increasing the pressure in the brain and that would cause papilledema. Uh I didn't talk about it but papilledema has grades as well. Um If you ever see papilledema like this. It's definitely something pathological going on. Um whether it still can be really high intracranial uh hypertension, but it's definitely something that will need to be treated. But PPI edema can be very subtle as well. It can just be a small section of the disc that's slightly raised compared to the others. And usually it's like ac shape, that's what we call a grade one, PPL edema. And grade two would be the whole ring being raised, but the vessels are not obscured and grade three would be, the vessels are obscured so on and so forth. But um no, uh Papilledema is basically a sign of raised intracranial pressure. But what causes raised, intracranial pressure can be a myriad of things. It can be something malignant or benign. Um And uh it's just a marker of something isn't uh isn't something behind the eyes isn't uh quite right. I hope that's uh that's an OK. Uh answer. Yeah, he said that makes sense. Thank you. Um Timothy has responded and said, thank you. That was very helpful. He said, what are, what are the pale spots present on the crv of the pale spots here? Uh Are you talking about these things? Uh I would, yeah, I would say, yeah, probably like cotton wool and things. It could be cotton wool spots. Uh Generally you see them in like diabetic retinopathy and the area of like fluffy exudates and sort of waste products that go in. It could be that this picture here, I just lifted off the internet could be someone with a CRV O maybe a couple of months down the line rather than right soon after. But I wouldn't expect cotton wo spots to develop that quickly if it was completely acute. I think if the, if you have a picture where it's very dramatic where you have all these flame shaped hemorrhages um spreading out like this uh in all quadrants. Uh The main thing to think of is a CRV O I can't remember, I think people call it a stormy sunset. Um uh is, is how they describe it in an SBA, something that might look uh uh similar is a pi uh pizza pie Fundus. I didn't have a picture here but it looks like this, but there's a lot of sort of creamy lesions going around and that tends to be uh CMV. So cytomegalovirus. So, uh if you want to just Google, uh CMV Fundus pizza pie, uh you see plenty of examples of that and, and make sure you see if you can appreciate the difference between a CRV O and A CMV Fundus. Although I don't think you, you likely ask about CMV Fundus though anyway. Uh Yeah, sorry. It's uh got a bit more discussion uh there. So talking about something else as well. But uh I think we'll just, uh if there are no more questions just now, uh, there's just one last one and then we can keep going later. Um Emily's asking, she says she's confused about the white disc and pink cup. What when you say Raio, is it the loss of white to pink? Uh Yes. Ok. Sorry I should have uh this is my fault. I should have included a camera. Uh sorry, a picture of, of a cut uh of a an increased cup to this ratio. So it's so imagine that this cup here just gets bigger and bigger and the rim gets smaller and smaller. So if you uh just Google uh increased cup to this ratio, uh that should show you some pictures of how a glucometer disc should look like and how that looks and you can compare it to this picture. This is a pretty healthy looking nerve, in my opinion. Cool. Um I hope that uh it's, it's best if you just look at the pictures and, and, and see it. It's uh rather than listen to me talk, I'm probably not the best explainer. Um And uh we'll move on to the next part if there are no more questions about anatomy, nothing else. Yep. I think that's OK. I think we'll move on to the next bit. And if you have any questions about anatomy, we can always ask at the end. So we'll move on to the second part of our lecture which is, you know, red flags, red eye and history taking in ophthalmology. Um, so we've gone back to sort of the, uh, sort of the thought exercise. I thought it would be good to reread it. But if we think about these things again, what gives the eye, whats form position, sustenance, basically, what makes an eye and eye, uh, and if there's any insult to any part of that anatomy, you will have problems. So what can cause an eye to go wrong? And, um, you can think about sort of surgical sieve or etiology of things. Most commonly in eye, you have infective causes such as conjunctivitis or keratitis. You have autoimmune causes like allergy, uh or uveitis or scleritis. Vascular causes like ACR O or CRV O and traumatic causes like a retro hemorrhage, uh blowout fracture, globe rupture or, you know, malignancy. So, you know, a space occupying lesions resulting in the sign of papilledema, you know, nerve palsies or, you know, like a ho syndrome. So these are things that uh um uh Horners syndrome is a sign, by the way, it's not really a thing. It's, it's a, you need to find out what is causing the Horners Syndrome and it could be a neoplastic cause. It could be a traumatic cause, it could be a vascular cause. Um So I was just going through uh red flags. Uh and the nice guidelines do have uh things that you would need to do same day referral to ophthalmology. Um I think most of this might just advi uh might end up in advice to you over the phone. Patients may or may not be seen same day just because you see these things. But these are markers of potentially dangerous things that your patient has uh for their eyes. So uh the first one is reduced vision or visual acuity. Oh oh, did my screen uh is everything OK. My screen just went black for a moment. We can see your screen again now. Yes. Oh Must be. It must have been my laptop. Sorry about that guys. Let me just skip to that part again. Also, if you guys have any questions at any point, just feel free to start dropping them in the chat and we'll answer them in the next post for questions. Cool. Yeah. So if you refer to, you know, respiratory or refer to uh let's say you refer to cardiology, the, the thing that they want most is y you know, the heart rate, the, the um the rhythm of the heart and or the E CG or something like those are things you always have ready before you refer to ophthalmology. I think any time you want to refer to ophthalmology or worried about your patient's uh vision, it there must be some measure of visual acuity uh before you refer on to ophthalmology because that's basically the lifeline and the most important uh marker for the health of the eye for us. Uh And we talk about visual acuity a bit later on and uh how we can do it in a clinical setting. But just keep in mind that visual acuity is as important as breathing uh is uh for everybody else. Um deep pain in the eye or tenderness on palpation of the globe, right? It could be like scleritis, it could be high pressure in the eye. So yeah, it is a potentially dangerous sign, photophobia. Lots of things can cause photophobia as uh I said earlier. But if you think about what's causing photophobia, it's a muscle cramp in the eye, but we need to find out why that muscle cramp is happening. This is quite important, unequal pupil or abnormal pupil reactions, unequal pupils are called anisochoria. That's the medical term for it. And it can be for many different reasons and sometimes it can be something uh sinister like a space occupying lesion or something like that. So it is quite an important sign to pick up and if you do pick it up, um that's, that's good abnormal pupil reactions. So I'm sure you guys know about your direct and consensual reactions and also your R APD. These are things that also give us a marker of telling us if something behind the eye is not entirely right, any high velocity injury uh or any chemical injury is also important. I would say if patient has been uh if the patient has been sort of doing any hammering and something's flew into the eye that's potentially sort of uh something that's dangerous. It probably will just be a metallic foreign body sitting on the front of the eye. But very occasionally if they've been hammering something sharp or something sharps slown off, it can just go into the eye and cause uh what we call an open globe and that's uh not good for the eye, um, chemical injuries. Um So, uh for your knowledge, alkalis are more damaging to the eyes than acids and most chemical injuries. The immediate treatment is just lots and lots of washout with saline that to try and get that chemical out of the eye. Um I work in Scotland and at the moment, the uh uh the main uh uh emollient for eczema on sort of dry skin is, uh, is, is a moisturizer called Epix. And Epix is actually very, very, very toxic to the front of the eye and can cause a chemical injury in the eye. So, if any of your patients, if you ever see that they end up with Epix and they've been putting it around their faces and their eyes are burning, you know why. And uh, or if you see any patients with Pima, please tell them, don't use it around their eyelids because it happens more often than you expect. And it can be quite dangerous long term for the patient's uh prognosis as well. If it doesn't heal up entirely correct most of the time it does though, but it's very painful and very unpleasant for the patient. Um, contact lens use is something that's very important. Um, uh, to give us a history of, uh, contact lenses are just, um, uh, they give us a lot of business. We can put it that way where it causes a lot of infection. Um, and it just raises the risk of infection and patients, uh, knowledge on proper contact lens use and proper contact lens care. Typically, it tends not to be the best. Uh And that just puts the risk of infection through the roof, uh and can lead to quite bad uh circumstances if it's not picked up early. So, fluorescein staining, I don't know. Uh it's ok if you don't know what that means, essentially, if you work in A&E uh you might have a slit lamp and you might put a orange, chemical, uh orange, uh eye drop into the eye called fluorescein and that stains up bright yellow if there's any epithelial defect. So, if there's any epithelial defect on the eye, um might be worth just chatting to an ophthalmologist to get some reassurance that is it an infection or is it just an abrasion? The latter is not dangerous, it just pain, it's just painful that woke you up. Um And lastly, uh it's pediatric sort of things you might encounter if you do GP neonat or work in the hospital impedes neonatal conjunctivitis in the 1st 28 days of life. Um, there are some, uh, there, there are 44 suspect, uh, bugs. I think it's gonorrhea. Uh I can't remember the other three, but these things are dangerous bugs which can perforate the front of the eye and cause permanent blindness. So this needs to be seen by ophthalmology and treatment needs to be started. May not need to be seen by ophthalmology, but treatment needs to be started and we need to be aware if you ever come across this. So these are the red flags according to nice and I agree with all of them. Um We move on to more of a uh interactive part of the uh lecture. I've left a QR code for an article I found for a flow chart for red eye, which I thought was quite useful. Uh You guys can scan that uh over there. I think whoever completes the form will get a copy of this anyway, and we'll get the link down here all the QR code. But I think it's worth just reading the whole article and uh looking at that flow chart to help you build your differential diag for uh red eye if it happens to you in an SBA or if it happens to you in real life. But basically you can go down take the history and just follow it and then your most likely differential diagnosis will pop out and it's pretty accurate, I would say. Um because yeah, as I said, let that red eye can be a presenting fea feature for a myriad of diseases. So we'll start with a few uh single best answers. So let's go through some painful red eye, single best answers. So these are all patients coming in with a red eye into your clinic and they it's all painful, right? The first one I've included pictures as well because ophthalmology is a very uh visual specialty, Most of your diagnosis or you confirm most of your diagnosis on split lamb examination. Uh So in most what medical specialties history, there was, about 80% of your diagnosis depends on your hi history. I would say in ophthalmology, 80% of your diagnoses will depend on your examination. So if you like looking at things, ophthalmology is uh a pretty good career for you. Anyway, uh let's start with this one. A 36 year old female contact lens wearer has come in today with a very painful photophobic and red left eye. The vision is down to 612 and on slit lamp, you notice conjunctival injection. So, conjunctival injection is a way to say a red eye essentially and a circular epithelial defect staining with fluorescein measuring about two millimeters. Um What is your most likely diagnosis? So, um II don't know how I wanna play this, but uh if people just type in the chat, what they think is the most likely diagnosis and then I'll answer it and then we'll go through how I would tackle this question. I think that's how we do it. So people type in the chat what they think it is while we wait for that. And I'd like to point out over here you can see that there's a bit of conch coming in nasally onto the cornea. Uh, if anyone can name what that is in the chat, that's like 100 points to you. Uh, I would, I would give that answer out uh soon as well, I just noticed that this was here. Actually, I didn't, I didn't see this when I was making the slides. Uh People are saying d everyone's putting D and very good you guys uh single best answer masters as we have all trained to be uh in UK medical schools. Um it is microbial keratitis and uh the main thing. So risk factors, contact lens, wear a huge red flag uh for keratitis, it's very painful. Uh So it's going to be some sort of insight on the cornea. You can actually see it there. Uh photophobic. Um Yeah, totally expected. There's gonna be inflammation in the eye because of this and inflammation leads to the, the muscle cramping in, in the iris and the redness is just because the eye is so irritated, vision is down to 612, which is not a huge decrease. So if people understand what sins mean. 6/6 is uh what we call 2020 vision. It's the same thing we just measured in meters. 66 means that at 6 m, you see what other people see at 6 m. 6, 12 means at 6 m, you are seeing what other people see at 12 m. Other people being people with normal healthy eyes, so it's just reduced, not humongously, it's still pretty decent uh vision and that's because the ulcer is sitting out of the visual axis. If the ulcer is right smack bab in the middle of the pupil vision will probably be like 648 or 660 or something like that. Um Yeah, but if it was a huge ulcer, it would change the topography of the cornea and vision would be lower as well. Um So yeah, vision's not humongously down. It's contact lens where uh you've got an ulcer that's staining. It's definitely uh not, it definitely sounds something infective. Could it be anterior uveitis? You wouldn't have the ulcer? Could it be scleritis? You wouldn't have the ulcer conjunctivitis? You wouldn't have the ulcer. So, yeah, this was a pretty simple one. Micro keratitis. And did anybody type in the chat, what do you think this could be? If not, I'll just say what it is. This little thing popping out nasally so far, there's nothing in the chart unless anyone wants to. Yeah, it's, it's all right. Uh It's a, it's, it's a pterygium uh PTE uh YG II was gonna guess that, you know, very good. Very good. You get the points then actually, um, it's unlikely to come on your exams but you can google it out of your own interest and see what that's all about. But it's pretty benign most of the time. All right, let's move on. The second patients come to your clinic with a painful red eye again. Um, a 25 year old male who has a chronic history of back pain has presented with a very painful injector and photophobic. I spelled that wrong right eye. He describes the pain as a dull throb on an examination position is down to 636 and the view on the slip is hazy. But you see grade two cells in the anterior chamber. K precipitates and posterior siae. What is the most likely diagnosis? Is it a anterior uveitis? B scleritis c conjunctivitis or d microbial keratitis? So, I'll let you guys uh put the answer in the chat and we'll move on. Um We have a question from the previous question. Sorry, I don't know if you want to address it. Now, I'll finish this case first. Uh Let's, let's address it now. I'll, I'll forget. Yeah. So, uh there's a question asking, what's the difference between a corneal infiltrate and a corneal defect? Sure. Um an infiltrate tends to have the connotation that there is an infection, an infected process. A defect just means that uh that's been uh the epithelium of the, it's like basically, there's been an abrasion or an upset to the epithelium of the, of the cornea. I said earlier, the cornea has made a few layers and the front layer is called the epithelium. Uh So a defect uh I would use the, the terms epi defect for any of abrasion or infection. But an infiltrate usually speci uh specifically refers to an infection. There is another term that gets thrown around a lot and that's a corneal ulcer. It's not a very helpful term. It's just sort of an old fashioned term usually refers to infection as well. But it, when you see something manky on the eye, people just say, oh, there's a corneal ulcer. It's actually not really proper terminology. It infiltrates much more helpful. So all these white fluffy bits around it. I would say that that's looking pretty infiltrative anyway. So let's move on. They used to infiltrate that or something. No, II defects. Yeah. Anyway. Uh So have you put in answers for this one yet? If not, I'll just give it, but I'm sure most of you will say anterior uveitis, a young guy with chronic history of back pain makes you think of uh some sort of systemic thing going on. Most commonly, it's gonna be something like Angon, which is HLA B 27 and um uh positive, which is associated with anterior uveitis. If anyone ever comes in with, you know, just think it's probably gonna be anterior uveitis. It's very painful, injected, injected and photophobic. Uh Yeah, it always says photophobic in anterior uveitis. Uh and it's a dull pain like a tooth ache. Uh That's what it usually feels like. Vision is down to 636. These are all classical signs on split land. For anterior uveitis. You don't need all of them to give you a diagnosis. If I just seen cells, I would still say that's uveitis. But these are sort of the group of things that come together cells basically is uh immune cells that are floating around the anterior chamber. K precipitates are all these of things that are deposited on the endothelium of the cornea. It's just basically the immune cells that have floated down, landed and stuck themselves on the endothelium and posterior SIA is when the iris sticks down to the lens. So if you remember the anatomy, the iris is uh anterior to the lens. Um and when it's irritated, it can become inflamed and sticky. And when it sticks down, that's we, uh that's why we call it a posterior sych. And we answer here is anterior uveitis. Moving on. Got a picture here of a 72 year old female who has presented to A&E with blurring of vision, a severe throbbing headache and three episodes of vomiting since 5 p.m. She is known to have migraines and visual symptoms but says this feels very different. On examination, vision is counting fingers. There is a mid dilated and fixed pupil and the eye is red. That's what the eye looks like. Can you see that there is an isochor different sizes in pupils and this is mid dilated and it's stuck. So what do people think this is, is it migraines, angle closure, glaucoma, a cluster headache or a potential subarachnoid hemorrhage? What do people think it's fine in the interest of time? We'll just move on. You are at an ophthalmology lecture. So it's going to be the ophthalmological. Um People are saying B yep, excellent uh the ophthalmological condition. So this is angle closure, glaucoma. It can present like a headache. Patients can be systemically unwell with vomiting, they'll be absolutely miserable and this is a site threatening condition and needs prompt uh treatment uh and action to, to make sure that we try and reduce the pressure in the eye and get that eye. See again, the earlier you act on it, the better outcome there is for your patient. Um Anyway, this uh these are the uh things that absolutely uh help you um be confident in your answer. It's the mit dilated and fixed people. So anterior uveitis usually would be a constricted pupil, but with glaucoma, it's usually going to be a dilated and fixed pupil. So that's, that's how you differentiate between one way to differentiate between the two. Ok. Oh right. Uh Another contact lens wearer has come to your clinic with a very painful photophobic and red left eye vision has come down to 660 on split lam, you notice conjunctival injection, a large central epithelial defect staining fluorescein and it's a lot bigger four by five millimeters and there is a hypopyon. So hypopyon is a collection of basically pus immune cells gunky stuff in the anterior chamber. You can see that it's aha horizontal line because it's a fluid level. What should be your next step in your management should use that? Oral antibiotics, direct the patient back to the opticians. Start chloramphenicol ointment. Or do you want to refer to ophthalmology today? So I'll just go ahead and answer this. I I'm sure most of you would do the wise thing and immediately refer to ophthalmology. I think most of you will know that uh the underlying condition here is the same as the first case. It's microbial keratitis. It's contact lens use again. But this is when it's really far uh far gone, you can see the size of that ulcer. It's starting to just, yeah, as someone pointed out earlier, infiltrate just infiltrating everywhere. Looks super gunky. That's, that's pus in the anterior chamber. Uh the eye is so red and inflamed. It's just um I don't even if you didn't know what it was, I'm sure you would call ophthalmology. Um because look how horrible that looks. Anyway, let's move on to less painful red eye SBA S. So patients are presenting with either no pain at all or different symptoms or um yeah, uh or just some discomfort in the eye. So a 13 year old boy has come in uh history of atopy, you know, asthma eczema, uh with uh several month history of bilateral itchy red eyes, vision is at 69 in both eyes. So slightly reduced and on examination, you see that both lids are a bit puffy, the eyes are red and there's chemosis. What is the most appropriate next step for this patient, which you give the patient chlorphenol ointment, lubricating an anti antihistamine eye drops same day referral to ophthalmology, uh which you give him some hydrocortisone ointment around the eyes. So chemosis is basically this. Can you see that the conjunctiva is a bit puffy oh and has come out. But um, it's a bit, it's a bit swollen, isn't it? So it's fluid that's gone underneath the uh conjunctiva just from sort of an allergic reaction usually and it's caused it to become very puffy and edematous looking. It's not dangerous to the eye, but it can be uncomfortable and the itchiness of the eye can be very, very uncomfortable as well. Uh It's not site threatening but it needs to be treated with very al allergy supportive treatment. So, lubrication, antihistamine eye drops and I would probably see them back and if there's no improvement, then I would then refer on to ophthalmology uh for the advice. But I think in the first instance, um this is something that you should be confident in managing yourself if you're working in like a GP setting on a pediatric setting. Ok. A 20 year old male uh presents with a bright red eye with copious amount of mucopurulent discharge. The eyelids are also very swollen and he reports that the eye is slightly uncomfortable. And his main complaint is the amount of discharge vision is initially 660 but then you clea uh clean the eye and he blinks a lot and improves in 612. What is the most important differential to rule out here? Viral conjunctivitis, staphylococcal conjunctivitis, gonococcal conjunctivitis or vernal conjunctivitis. So I'll give people II put different terminologies for conjunctivitis here. Um which uh I may need to explain, I just trying to trick people out, but I'm sure people are smart enough to know that the rails of 01 out or the rails of uh suspicious. One is gonococcal conjunctivitis, which is the sign. Everyone's almost. Oh, so you guys are actually don't, don't need me today, but these are just, these are just different names. Viral conjunctivitis usually bilateral, usually watery the sh rather than mucopurulent. Like in this picture. Uh I can be very sore, very uncomfortable. It's very, very contagious. Uh Staphylococcal conjunctivitis is just another way to say bacterial conjunctivitis because most bacterial conjunctivitis will be caused by uh staph aureus which is a commensal of your lids and lashes. Um Gonococcal is yeah, sexual, sexually transmitted and this is a classic case. Uh, lots and lots of gunky discharge. It's horrible. It's important to take a sexual history of patient comes with the eye that looks like this. Um, Verno conjunctivitis. Do people know what that means? Verno, I think means spring or summer or autumn. I'm not sure. It's one of the seasons. I think it means spring. But essentially it's, it's hay fever type of uh, conjunctivitis. It's allergic, so viral, bacterial and allergic and gonococcal is the odd one out here. Ok. A 32 year old female has presented with focal injection in the left eye starting in the last 24 hours. The eye is very slightly gritty and there is no discharge vision is 66 and the rest of your examination is normal, which option would help you a your diagnosis. A So 1 1% cyclopentolate b 10% phenylephrine c 4% pilocarpine and D 1% tropicamide. So this is a bit more of an advanced question. I think everybody can appreciate that. We are suspecting episcleritis here because it's a focal injection. It looks pretty superficial. Uh and the eye is not very painful at all. Vision's not affected. Um But there is a diagnostic test that we use uh in ophthalmology to help us differentiate between something that is not dangerous, which is episcleritis and something that is dangerous, which is scleritis. And the answer here. So let's say you didn't know what any of these things do 1% cyclopentylate. Um, I guess you might know that this dilates the pupil 10% phenylephrine. That sounds like a big concentration, uh, of adrenaline there. You probably know that might dilate the pupil pilocarpine. Hopefully, you know that this constricted pupil and 1% tropicamide, um, uh, dilates the pupil as well. So you've got three dilating drops here, but only one of them is sitting at 10%. So, if you had no idea, I don't know if this is a true, a good strategy or not, but just be brave and bold and just pick the, the real odd one out. And the answer is b 10% phenyl efferent. The explanation is because 10% phenyl efferent will blunt the, uh, superficial vessels, which is what's affected in episcleritis. But it would not, uh, b blanch the deer, the deep vessels which is affected in scleritis. So if you instill 10% phenylephrine and the eye goes white, you can be pretty confident. It's just episcleritis. If you instill 10% phenylephrine and the eye is still red, you might have to think about if this is scleritis instead, which it can be site threatening and is an important differential. Ok. Uh, we're running pretty short on time, I think. Yeah. Do you want to take it or leave that for later? Uh, yeah, I'll just take it now. Yeah. Uh, where do you get a mid, mid dilated pupil in glaucoma? Oh, excellent. Uh, I should have had a slight on this. Um, it's to do with sort of fluid production in the eye and how the pupil reacts. Uh I think in, um, if, if I'm giving another lecture, I would be happy to talk about it. But I think, let me think. Um, basically it's to do with, uh, it's to do with how the, um, the, the, the f fluid is being produced and how the iris bunches up and blocks the angles and when it bunches up and blocks the angles, it, it's, it's stuck there and the iris just can't move anymore. And that's how you, you result on the mid dilated pupil. But uh that's, that's as brief as I can, I can make it, I'm afraid um probably best to, to look it up and, and see if that's an explanation or video on youtube about that. Um If we do do more lectures in this series, if I do end up doing more, I'll definitely add that on so we can talk about it. Um Cool. Uh So we move on to history taking portion. So I'm not really sure uh how we're gonna go over this, I assume going over history taking is more for the purpose of the, what do you call it? The CPS A which is the A component of your UK MLA uh in real life. Ophthalmology. Histories are so short. I spend 2 to 3 minutes talking to a patient and get them on the slit lamp, really just focus on your presenting and history of presenting complaint. And we only ask the other domains if we suspect that it's relevant. Uh The main things I'm sure you've been taught, taught in your medical school, but it actually really pays to just start with an open question just asking. So when you come in and they usually tell you everything you need to know in the first few sentences. And then by and large, we confirm our differentials on exam and get our own scans of the CT machine or whatever we need and we do it, do most things ourselves. That's a real world version of things for the purposes of your exam. I think just take your history as you would as if you're taking a respiratory history or cardiology history, you know, do every domain presenting complaint, history, presenting complaint, past medical history, blah, blah, blah, blah, the other things. But you know, be logical in how your conversation flows your questions and your differentials go back to your surgical. See if do you think this is infective, do you think this is a vascular problem? And do patients, are they coming in with systemic symptoms? I think this is something that's actually very important in in uh if a patient, if you actually have an ophthalmological uh patient uh coming into your os. So if patient is has been unwell with lots of fevers, you need to think about orbital cellulitis. If you've been vomiting a lot with a headache, you might, you might think of ankle closure, uh, or you might think of, you know, idiopathic intra cranial hypertension. Uh, that's how people can be affected and don't forget that patients have two eyes most of the time. So after you see your left eye or your right eye or both of your eyes and in terms of a clinical skills uh station that could come up in your CPS A, I assume it'd be the same as uh what it's been in acies around different medical schools, but be aware of how to use an ophthalmoscope, make sure you know what a normal fundus looks like. Uh make sure you know what uh nonhealthy funds look like, like the ones I've listed here, um and uh be slicing your cranial nerve exams. Uh So, you know, 1 to 12, uh the ones that ophthalmology are interested in, uh two, which is your optic nerve. Um One is your nose apparently, but two is your, your eyes. So acuity feels itchy hras reflexes in your direct ophthalmoscope and you have uh Crans 34 and six, which deal with your eye movements. So make sure you know what to do for, for those things and how to do those things for your uh clinical skills um uh stations. OK. And you know, I'm, I'm sure all of you will pass your medical, uh exams and you guys will all do fine. You guys uh absolutely aced the uh single best answer there. So you guys, you guys, you know, have been through so many years of medical school and you guys are capable people and you will graduate and you will start working in the NHS. Uh and you will come across patients with eye problems in various different settings for the purposes of, you know, being a good colleague to ophthalmology, whether or not you end up working as an ophthalmologist or not. Um the real important uh l biomarker of how an eye is doing is honestly the visual acuity. I so many times, II don't even care about the history or what the patients. And if you tell me that the patient's vision is down to 660 that my attention is immediately, you know, my ears immediately perk up and we, we're all here today on a computer and we all have the internet and things, we all have technology in some forms. So II don't think it's unreasonable. Uh for me to say that there are things that are available on your phone. So if you use an android, there is a really helpful app called Peak Acuity and I suggest you just download that it's uh and, and go through it. It's such an easy way to examine the patients visual acuity from the bed site. Um If you use an iphone or if you don't use an Android, you can use MD CP and that has a uh Snellen chart on it. And even if you can't just Google Snellen chart, you know, any informal visual acuity, sometimes I even ask the Referrer, can the patient read the posters on the wall? And if they say yes, I'm, I'm a lot more relieved um uh from, from hearing that um of, of this can, can the patient see your face and they say no. And it's like, yeah, that's, that's something going wrong there. Be confident and be uh competent in assessing pupils of your patients. If the pupils look unequal, uh you will notice it. It's usually quite obvious if there's an absence of a direct or consentual, you will notice it. R APD is an interesting thing uh because they've done studies and ophthalmologists themselves can't actually agree between each other, whether there's an R APD or not when it's very subtle. But if there's an very obvious, you know, R APD, we want to know about that as well. The last thing is a resource thing. Some A&E sensors might have um uh devices to measure intraocular pressure and most places don't. So I don't expect you to do a pressure for your, for your patient. But if patients coming in and you're suspecting angle closure, what you can actually do is just put your finger on the eye and compare both sides. If it's an angle closure, normal pressure of the eye is 20 in angle closure. It's usually up at 40 or 50 60 70 there will be a mark difference. The eye will feel quite hot. So, uh your fingers actually are quite a useful tool uh that, that you have uh so many people refer to me and say on fundoscope. I see. So and so I don't need you guys. I think most of my colleagues don't expect you guys to actually report what you see on the fundoscope because we don't use a fundoscope ourselves. It's a really difficult uh apparatus to use. It's not easy. Uh It's cumbersome and it's not very good. Uh an examination of slit um is much better to look at the fundus. So don't stress yourself out about having to use a fundus, cope in real life. But if you can, you might as well try. Um and just some practical advice. These are a list of true eye emergencies that need uh need immediate sort of treatment because time is sight in ves, you have like uh like time is limb or something like that. And, and uh in stroke, you have time is brain, but these are the only true uh ophthalmological conditions where time is sight and you might run into this uh in your A&E or in your GP you know, angle closure we've touched upon ocular GCA orbito cellulitis, retro bubble, hemorrhage and globe rupture. The last two will be traumatic in origin 99% of the time and you will miss it. So don't worry about missing these things but be aware of these things. Um And that will help you prepare for uh the start of uh your medical career. Oh And this is the same as the previous, but that's the end of uh the slide show. So uh we'll take some questions now. So if anyone has questions, feel free to drop them in, um The slides get automatically sent to you guys when you fill in the feedback form, which I'll put the link to here. Um Dr Jen, if you don't mind, um I'm just gonna share my screen to show the poster of our next session so that people can um also sign up to that if they want chair tires, screen drink. Can you see my poster? Yep. Thank you so much. Um I think you would have access to the chat now, so I'm not sure if people are dropping questions, please make sure you guys do the feedback. Thank you so much for coming and this is um the sign up for our session tomorrow. All right, I think you guys should be able to access all the events as well from our metal page. Um Feedback form is not working. Oh, um You guys should have gotten emails to be fair about the feedback form. Um Oh, I see it's not working for a couple of people. Fine. Um I'll try and sort the feedback form now. But you guys should have received an email from me asking you to complete feedback for the session if you signed up to begin with. I'll also try and look if I can share it. All right, I've, I've just seen this question uh in practice, do you tend to give Prostaglandin analogs for acute angle closure glaucoma? In practice, we throw everything at the eye to uh bring down the uh the depression in the eye. So yes, I would give uh give that I would give every class of uh antiglaucoma uh medication in addition to uh IV acetaZOLAMIDE. And if it's still not responding to that, we give IV Mannitol. So that's, that's how you would do it. Um Mo to be honest, the eye drops are uh homeopathic and it just helps the ophthalmologist feel better. I don't think it actually helps with the pressure acutely. The main thing that brings down the pressure is going to be your IV acetaZOLAMIDE or your IV Mannitol. But yeah, we just, we just threw everything at the eye when, when that happened. Um The ultimate, if you get a question, what is the ultimate um um so sort of treatment for angle closure, glaucoma? It's something called a peripheral iridotomy. And um uh yeah, basically just Google uh angle closure glaucoma just to see how it actually happens. Um The peripheral iridotomy is making a small, tiny extra pupil, uh usually superiorly uh in uh near the limbus. Uh So towards the periphery of the iris and that gives an alternative way for aqueous to drain and not be blocked up and not cause uh a BP in the eye. Um This is another feedback form link for people who are still on who wanna fill it if they wanna get access to the slide. OK. Yeah. So you're amazing. Doctor Jane. You don't have to wait back. I think there's, there's no more questions for you. There's just loads of things. Excellent. That's great. But you already have the light so you can disseminate that. You have the PDF that um it automatically gets disseminated by metal. Ok? Cool. Yeah, but you have, you need to do you have, you have the copy of the PDF, don't you? Yes, I do. I do. So I'll, I'll write the article based on that. But yeah, thank you so, so much on behalf of the entire, I hope the rest of your lecture series goes well, thank you. If you are interested in giving any more, obviously, feel free to contact. Yeah, I think it gets a bit more. The remaining topics look a bit more complicated. So I'll let we handle that more than capable. So, yeah. Right. Take care. Bye bye. Thank you so much. Bye. Right guys. I'm gonna end the webinar there. So if anyone wants to copy the link, it's right there. You should have also received it on your email if you sign up for the session. Otherwise everybody have a good evening. Thank you for joining.