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Yeah, I think you mean I'll give you an introduction, and then I'm really don't meet myself. Oh, yeah. So we you can see my pulse. Is that correct? Yes. Thank you. Yes, every that. Perfect. And we like so perfect. And we like so So Good evening, everyone. Welcome to our first mind, the bleep and ditto really for the ophthalmologist section. So we're joined here by Dr Pangs. Stem, Who is an STD? Four north, Um, ology. Very distraught at Northwest North Times delivery for thumb ology. And he's currently working in pure college healthcare. Trust on he's off of him. They, uh I did eat. Okay. Thank you so much. Thank you very much. So much. Uh, thanks for giving me the opportunity to do this talk today s so I think the a move based or it's just a really give you a brief overview and also flavor ophthalmology. We don't really expect that much from foundation year. Uh, so so on. We were really friendly people, so we can always come in once it answers any questions. Yeah, So just to give you an outline off the top today, we'll just first go through some basic clinical assessment, off vision and also the external eye. We will then go through some common eyes, symptoms and conditions, and I will be doing this by taking you through a few validated diagnostic algorithms, which you should hopefully find helpful on. I'll try to pitch everything at a level expected off foundation, especially when making a photo ophthalmology and feel free. I think there's a check function, you know, feel free to just pose any questions and also try to make this quite interactive. It's also whenever I passed any questions, just told me to just type in anything in the check box and I'll and I'll check it regularly. Okay? Yep. So the aim again is really? Because I give you a better frame work so that you both leaking equipment, you have more confidence when dealing with my conditions. And by the end of this, I hope most of you so much more comfortable with basic opthalmic history taking on examination and also would just feel bit more confident when you're speaking and referring to off the multi. Okay, so we'll start with clinical assessment. I thought we just got to do a retrospect. I know everything in medicine we should always start history taking. But I think it's just good to start, you know, do a rectal spect it approach and start from clinical assessment first, Uh, so with ophthalmology, Actually, it's pretty simple. We are not looking for much. And every time you speak to us, all we want to know is really, you know, just the fire functions of the optic nerve. So can anyone name a few in the chat? Yeah. No. Okay. Uh, so they are optic nerve function conveniently can be Remember as the pneumonic Afro See eso a is for acuity. Uh, on then next letter f it's for visual fields. Are are a sore people reflex. Oh, is the dreaded off, um oscopy which you know, in real life, we don't really expect it to do and see it's color vision. So we'll go through each of them one by one in more detail. So that answers that you're aware. So acuity. Uh, so we normally do this a decent the eye clinic using a smell in child. So this is a selling chart on the on the left, um, and the way we recorded and the way we conventionally do. It is we normally sit the patient 6 m away from the child and hence the first on number at the top, being six and in ophthalmology. Every test that we do, we always do one eye at the time, I never both eyes together. So if you if there's something to take away from this talk, is that when you test some, you know doesn't matter what you test, the vision people reflects color vision. You always do one night time. And then and then you get the patient to read. Sorry, you get the patient to read from the biggest letter or the way down to the smallest letter, and you record the lowest line that you can read. So in this case on, So if this patient can read this line, I'm not sure you can see my mouse hovering around that that line there So this line would be there's a convenient It's a number there, same toe so this patient can meet this line. You recorded that 6 12 6 being on the numerator, numerator being the testes. And so how far the patient is sitting away from the chart and 12 being that line that the patient can read. Uh, okay. And the thing to bear in mind, so is that if the patient does not achieved 66, which is considered, are you know, normal vision, then you must always repeat of a pin hole. And a good tip is that the larger the denominator on the lower number, the worse the vision can. Any questions at this point? No. Okay, so just take you through some examples here. Uh, so to say, in this case, say, from the patient and I'm testing my own left. Five. If I can read down to this line here our recording this as on 6. 15. Yeah. And the other thing to bear in mind when you test someone's vision, it should always be optimized. If the patient wears glasses of contact lenses, you must always ensure that the patient is, you know, optimize because we want to know what the best are visual potential is for. For the patient, it's always check with the patient whether they were in the any corrective, our glasses or contact lenses. So in this case, as we mentioned already in the previous life, because this patient not achieving six expression or normal vision. We have to repeat it with a pin hole so, so painful. It was what you can see. This patient is holding in front of his left eye. And then we tested vision again on So after using the pin hole, this patient's vision at see here improved to 69. And so we record that as 69, and, uh, the working always refers to it is actually the Latin word war left eye's Oculus sinister. Uh, so that s o with the pin hole, the patient improves. So when this happens when you get improvement of pin hole, then it's a sign that this patient is a reflective era, and it's kind of like a tree out to force and ophthalmology. So if we see improvement of pin hole, we we actually really reassured that this patient doesn't have a serious problem, and actually, just patient just needs this or her glasses are updated. So the diagnosis here is likely to be a effective error. Can eso the next case again? One last example for visual acuity. So this time I'm testing say this is another patient testing using his right eye on because you can see the lowest time that can really 6. 20. So we will record this. And also, I think this patient I'm not mistaken. Also where, uh, glasses or contact lenses? Glasses? Yes, sir. Glasses. So in this case again, you want to make sure that the patient patients vision is optimized the record. This is right Time o d being Oculus, Dexter. Like 10 for right time with classes on 6. 20 again Because it's not achieving 66. So you will repeat this pin hole here, pin hole with the right eye, and then repeat the visual acuity again. So in this case with the pin hole, uh, he gets an extract two letters s So this so then you would record this as right i o d with pin hole 6 15 minus two. On the reason we put minus two days. Because on that 6 15 mine, he's not able to read two of the letters there. So you would write a 6 15 minus two. Yeah, So in this scenario, actually, with the pin hole, the vision actually doesn't improve. That much only improves by two letters on. So when this happens, then you are fairly certain that there is an organic pathology on. In this case, it's to do the retinopathy it now. So just some report again. If the vision has improved with pin Hole, then you are. Then you're more it. But there's underlying pathology. If it improves drastically pin hole, then you know it's likely to be just a reflective error. Okay, Eso, I think in real life, obviously, you know, usually selling shots and no way to be found. So a good app, really, that I would recommend on also, actually, it's recommended by quite a lot of my colleagues. It's this at which you can get for free on apple or enjoy, and it's going to be Culp. It's got really cool on easy to use them and shot, which you just hold off 1 m away from the patient and conveniently enough, you know, you just ostentation to read, and then you just select on, you know, the line that the patient read, and then I'll tell you want the patient's vision is on and then yeah, and if you communicate this to us over the phone, you know will be over the moon Yeah, because usually when we also visual acuity, people just say patient can see or patient can you know, really? You know, I just read a book or something, but giving us absolute numbers will be much more useful. Uh, so going on to the second visual function, uh, which is visual feel S o. So in reality again, there's many ways of doing this. There's definitely no best way of doing doing it. I would say Just do whatever feels comfortable for you. Some people like the weakling finger technique on Some people like to ask, uh, how many things you can call in each quadrant. Um, so and then some people like to bring the hands off gradually, vertically, and also horizontally Assume this picture always been mine the imaginary vertical marriage in and also horizontal American. So I did a systematic way of doing it. Always start off with a gross assessment so you can easily pick up any any obvious defect there. Just just ask the patient, you know, just close one eye on, Say, can you see? You know my face Is that any bits that missing? You know, if they're telling you that half the face is missing, then you know, then that's likely that there is potentially a homonymous hemianopia if there is no gross defect than proceed with, you know, examining the peripheral vision in more, more depth again. Always making sure that you test want a time on. Then when you do it, make sure you at the same level of the patient on then the target can be a rep in or your fingers. Make sure that's equal distance between your patient, and I will go through. Okay, so we've just done that. So go through some examples here. Be good if you guys could, you know, chip I/O. Uh, so on on left, you can see some, you know, visual field defects. Imagine these are your own vision. Feels that you're saying scream your left being your left and the right here being your right I can anyone name you know what? What sort of visual field defect there is in the in the first picture? This one here? Anyone? Yeah, has absolutely right. Did you know which sign that it's missing? Left side. Correct. Yeah. So? So let's see. So when so the good thing or visual fields that you can easy localize where the lesion it's so, As you rightly said, this is a left total feel loss on usually when it's and it's monocular, so it's only the left side. So when when you when you're when you're faced with monocular visual field defect, you can be 100% certain that this the problem is anterior to the optic chiasm. So anything in front of the optic eyes, um, so anything in front of, you know, she gets so seeing my, my mouth, any anything in number two here from the cornea at the very front, away, back to the optic nerve. Any problem along this part way, we'll we'll give you a more knock television field defect. So absolutely right. So the first one, uh, it's a left optic nerve problem and the second one, But anyway, I want to volunteer and and tell me what the second visual field defect is. But, oh, perfect answer is a bilateral hemianopia. Angina has a guess as to where the lesion is. The clues here it's in. It's a number two. Okay, So yes, Perfect. Yeah. So it's in the optic eyes. Um, yeah, not not not. Not a lot of allergy will give you a bitemporal hemianopia. So when you see this in real life, um, you know, the first thing you need to do is think about a pituitary lesion. Usually is a pituitary adenoma. And the most sensitive scan to pick up any vision in the Patricia areas that it's an MRI off the off the base of the skull. Uh, so that's good. So we know that's the optic chiasm issue here. And the last one. Number three. Can anyone just just, uh yeah, you're right, John. Joanna. Yeah, Absolutely. Correct. That says that. Patricia. Abnormal pituitary tumor. Uh, so number three visual field defect. Can anyone to see what what that is? Start troops. I'm short with the answer there, but anyone named what the visual field defect is? I was gonna have a look at the check in and see if anyone pollen tea. No. Okay, so this Yeah, uh, a right side. It homonymous hemianopia. So when the right side is affected, then because everything in the ice opposite. So if if the writers affected, then you would expect the lesion to be on the left side. So in this case, it would be the left optic track or the left visual cortex. So so beside him. Okay, Uh, the next will be people reflex. There's not much to say about this, really, But it's important to do this properly. I think a lot people tend to just do this briefly went in examining people. And actually, there's a lot of information to get by examining that someone's people reflex. So key tips and doing this I always tell people, You must make sure that, you know, try that you tried to him on the room, like, you know, to make sure that the pupils are a style it if they can be on get the patient to look far the reason for business because if they look near, they get this knee response where the I saw converge and then constrict. Also, that can interfere with your interpretation off that patients people reflex. And then also, uh, again, in order to minimize the knee reflex, I like to shine the light from the pen torch from the bottom, so not straight in front of a patient brought from the bottoms off from the nose area. Uh, And then when you are doing the swinging like test, you have to do it swiftly. It consistently so drinks on a regular rhythm. Uh huh. Okay, So the reason I'm showing you this this complex picture here, you don't have to know any of this. Uh, but the reason I'm showing you this diagram so that you can appreciate that there is a bilateral innovation off the single western nucleus by the sensory pathway which is shown in yellow here because of this bilateral innovation on that is the reason why when you shine a light in one people also, if you shine light here it goes all the way here. But then it innovates both reading the West phone. And then it's sense motor impulses to both pupils to constrict. So that's the reason when you shine light in one eye, both eyes constrict on. This is mediated by the parasympathetic proper way through the state of people, which you can see in the middle here. So remember, that's personal pathway. The clinical relative relevance is that seeing when there is parasympathetic disturbance, so in a third nerve, palsy remember, the people cannot constrict and therefore becomes dilator Okay, so now, bearing in mind So we wish. So it's here. That's imagine this is a patient, so you always people reflects straightforward. So what you do is that you just test the direct reflex in the eye that you are shining the light in. So in this case, it will be with shining the light in the patient's left time so you can see a diet reflects, uh, present in the left eye. And when you're doing this, it's important to look that be our fellow I. So in this case, you can see that the right times also constricting so you. It's also comment that the consensual reflex of the right eye is also present, which is good once you're happy that both are in consensual reflexes, not president. Then you proceed to do the singing. Which test and and that's to test for relative for people, your defense. So on this loss, so just mentioned that already so in the last picture. So you can see that when this when the pentose his swing swing over to the right side instead of that I constricting. What happens is that that I now starting to dilate so when that happens on when the eye paradoxically dial, it's when it's being shown. Then then then Then he would say that there is an R e p t present in that eye. Okay, Uh, any questions so far And things that can give you an RPG just again Some clinical relevance. Hear things that can give our pedia Not that many things, really. One is obviously any soft optic nerve problem. Classically, we we get patients here with optic neuritis in the context of multiple sclerosis I saw. And did you get a dense R e, p T and other pathologist that can give our bodies? So it's either optic nerve or the retina, especially if it's a white spread our original issue like a big restaurant attachment. Oh, a vein occlusion. Yeah, So that's people reflex. If you see one, always think your CRP always think optic nerves or white spread retinal problems. Okay, so next. So there must be I'm not really gonna say much about this because in real life, you know, uh, this many hurdles to doing this. I have come to appreciate off off the doing foundation here myself. Eso the reality for that wants to be. Number one is Can you? You know, it's usually no way to be found. Uh, and even if you need it, And if you really have to do it, you know, just try your best. But be reassured that you know we will. You know, you'd be forgiven if you cannot get you. Because even so, my colleagues, even myself, sometimes we struggle on from a practical point of view in a non off the market setting, I believe the diet, the mosque up off the mosque. It is only really useful for it's blue filter which you can easily find. Uh, you can combine this with florist seeing drops. You can easily find any on, and it can help you identify any any Corneille problems so you can see in the picture here on bottom, right. You can see just with normal illumination on the cornea that looks pretty normal. But once you put a drop of Flores C, which is usually orange, and then you use the blue filter on the moderate, um, a scope and shine it on the and you can see that there's clearly a corneal, Zof peculiar defect there. Also, it's really handy in this case. Um, also, you know, the diagnosis is also really good in detecting whether or not a red reflex is present. And you, you know, you just have to hold the diet on school. And you the patient five from from from quite far away, I can easily checks on the diagram on the white years. Eso the first our picture here on C. It's really annotated saying normal reflex on the bottom to are abnormal. So our red reflexes when you see it abnormal red reflexes tells you that there is some sort of opacity off the popular media, doesn't I? Can be either the cornea from the very fun, the lens in the middle or the retina or bitterest at the back. And so, typically things like cat tried victories, hemorrhage, retina detachment can cause an abnormal right replace. So if you see that, then you know that no, sir like to be a problem, but Mr be dealt dealt by ophthalmology. Uh, so yeah, so don't worry about doing this and in Really? Yeah. I mean, if you have to do it, I hear some key tips. Eso again, like testing for people reflex. Always use a deadline again. The reason for this is you want me I to be, you know, as fully dilated it's possible. And then again get the patient to focus on on on something far because again, if they look at something near, they get that knee response where the people constricts and they're just, you know, and you just struggle to get a view, ensure that you are the same sort of level. It's a patient on day supporting know So, you know, to tell the patient to grief Normally, it's important for you and the patient, because otherwise, if you're holding your breath, you might just pass out when you're doing the doctor. Um, what's could be, uh, always use are the circular white light to begin with. Andreas, lots of numbers on the diet. I almost broke, but I tell people just said it to zero because that just eliminates off any reflective error to begin with. And then any can. I don't die with the number up without the number down to get a clearer view. When when you go into to see the fungus. Yeah. Uh, so basic things. Uh, yeah. So when you're checking someone's right eye, use your right hand and on then do the other way around when you examined that. Because otherwise, if you use your right eye exam in, uh, yours are your right hand to examine someone's lifetime. I knew my end up kissing them. Yeah, uh, real, like, I'm just trying this diagram. Yeah, because again, this is one of the many reasons why I want to be It's not really that useful, because the photo on the left is, you know, a classic fun, this photograph that you would get in textbooks, you know, nice white view, including the dis and the macular. Where in are normal school. You just get that really sad, magnified view on the right, but you can't. Can't even barely you can't even see the whole disc. Uh, so so And you still have to build mental picture by piecing off the images as you go along. So, you know, at the end of the day, just try a best on Don't worry, you can get a view. Okay. Okay. So lastly, just touch on television here. Uh, this is not much to be said about this Really A brief screening tool would be the red hep pin, which you know again, if there's any sort color, vision, defect usually that points the problem of the optic now again, extension before classically. You see that with optic nerve pathology of optic neuritis in m s on on the right hand. Just your new issue. Horribly, because this is the formal way we do it in the eye clinic. And actually, if you could, you know, if you're making referrals small, you know, we would really appreciate it if you could tell us what the color vision is in terms of the number of plates that the patient can read. And again the that I was just recommending previously. And the culture It's really good. And it's really, really easy to use on Ishihara test. Uh, so So that brings S So I think that's a brief summary of off clinical assessment. So remember the things to look up. What's easy. So just the five functions off the optic nerve. Remember that on the morning, Afro see a for acuity for feel awful reflex off hormones could be Just forget about that and see for color vision. You know, these are the core information that we are looking for ourselves with the anticipation and also when taking it from. So as long as you mentioned these will, you will make us very, very happy. And we cannot, you know, it's actually can't reject your firms. Okay, well, so any questions so far? No. Okay, so So now I think with the second half off the talk, I'm just gonna take you through, like it's it on some on some common eyes. Symptoms aside, think it's more realistic Patient presented symptoms rather than coming in the label on telling you what the condition is. So, over the next few slides, I'll give you and we share with you some validated diagnostic algorithms that will help you arrive at different I diagnosis, depending on the on the different beaches and science. Uh huh. So, can anyone tell me what the most common symptoms You know, you probably have encountered this yourself. If you've done if you have done any on are doing any at the moment, can anyone just type a few in the check box? Oh, yes. So I can see blow revision, pain. Bloating is conjunctivitis. Visual loss. Red eye. Yes, So this is a very, um that's pretty much it, you know. So you're absolutely right. So, in fact, the most common incontinent ice and arrows are red eyes. That's your right set vision loss, double vision on another couple less uncomfortable once are like watery eyes. And I support where the people size different Unless you don't this many of the symptoms by being given that statistically, these are the most common one. So we will be concentrating on them today in the interest of time. And what could be going through the next year's likes again are the diagnostic algorithms, so you can use them as a systematic framework which will hopefully help to differentiate the common I sentence. You see everyday practice, especially in your GP, so we'll start with red eye. Okay. Uh, so they go, uh, so the with the red eye algorithm on the first question I usually talk myself is you know, is this again in ophthalmology? We are obsessed with this thing where where it's one eye or both eyes. So the first question I ask myself is, you know, is it union natural or bilateral s. So that's the first question so if we concentrate on bilateral to pick to start off with, All right. So the way we the way I break it up is you know, I asked the question. The next question is whether or not the predominant symptom is it or whether it's so grittiness or burning. So it was predominantly itchy. So once or conditions, you've been thinking about some bilateral itchy eyes. What do you think that that might be if anyone could, Could has against on the chat box, you know? Yes. Conjunctivitis. That's correct. Yeah, If I'm being a bit mean here, it has to Can I can I s o? Because they're different types of conjunctivitis. So if it's predominantly itchy, uh, do you know what kind of conjunctivitis that it's more likely to be? Uh, yes. Viral viral content, me, Make the eyes. Really, it's useful. Allegedly allegedly is the correct answer here. So if it's predominant itchy on, so then we we always we always think about allergic conjunctivitis. Often these patients will have a history of atopy asked my Heber on X amount that just, you know, just generally are very allergic on. And in the forties here, you can see that on the left are the eyes obviously very injected. Injected is just another way off. We describe a red eye and also the conjunctiva that is very swollen or Kibo's. So typically you see that in allergic conjunctivitis and on the picture on the right there, this is with the upper limit evertors or turn inside out. You can see this plastics off, cobblestone A pill it where you already you would only see in allergy Conjunctivitis. Yeah, uh, so going back. So if it's bilateral and now the predominant symptom is is pretty or burning. So I think I just look at the chat again. Someone said viral conjunctivitis. Yes. Oh, Dean, you will be right here. It's saying that this is viral conjunctivitis. All right? And then, uh um, the next question to help differentiate because they're also different types or infected conjunctivitis. It can be viral. It can be bacteria. So good ways to ask the, you know, whether that's it, to check whether or not there's any sort of discharge. And if there is this charge on, usually it's, you know, meat nuke mucoid or mucus purely in. Then you would think about on infective type of conjunctivitis. I either viral bacteria. In real life, it's it's hard to tell between the two. So if you see a case like this where both on some sticky and red it is better to always treat the patient with some antibiotics like like chloramphenicol drops because that would just cover be, you know if there is a bacteria element to it. But in most cases in more than 90 a case that 90% of cases it's usually a virus and it would just it would resolve without any treatment Now. And if there is no discharge president here, then usually you know you can. It's usually just thighs being a bit dry, causing a bit of irritation. Yeah, so if we can see him under the bilateral read, I pathway along, the final diagnoses are actually, you know, labor in green. So actually, they're so fairly reassuring. And the thing about to say about an ophthalmologist that if the problem with the problems in both eyes, we usually quite reassure on, but problems usually non urgent. If it's one I, usually we we get quite worked up. So I think, um, I will now go into the unilateral pathway. So the single red eye. So there you go. So the red eye when When one I've read that good tip tip to start is that you should always thought, you know, from the outside and always look at the eyelids. So the question I put here is that to check whether or not the laissus of touching the eyes, because if you know, if there's an obvious off misdirected eyelash, then you know that's obviously the problem. So So some diagnoses are such as entropian on and trick Isis. I'm they're not often seen, but it's good to just be aware that there are no that they exist. So and Trump in here on the left, as you can see and dropping, refers to when the eyelid is interning on where the cousin of it is called Bactroban in DC, when the island is turning outward. So when and dropping, you can see when the islands turning in the eyelashes are obviously scrubbing against the inside of the eye and therefore causing the irritation and readiness and the picture on the right. Here it's a picture off track, Isis, So the difference potentially. Isis and Tropea in is that in Trichiasis, there is no abnormality of the eyelid itself. The abnormality here is just with the eyelashes themselves. So there's just misdirected grove off the island. Usually, this is a result off, you know, badly done. Let's surgery offs from some previous trauma. So if you're happy that there's no lashes touching the eyes, then the next question to ask is, you know whether or not there's normal island closure, can you think of our? Can anyone think of any condition where the islets might not be able to close fully? I'll give you a hint. It's Ah, it affects one of the cranial nerves. Yes, perfect. And so it will be Bell's palsy. Very good being on. So so they go. So if the, you know, always, always ask patients, you know, try to fully close the eyes. And obviously, if they can't if there is, you know what we call leg up films where the eye doesn't fully shut, as you can see on the patient's left eye, then that can be a course or readiness is wrong because the eyes exposed and on due to a port ear from the front of the eye and starts to break down. Uh, and if there is no my lip closure, then you start looking at the eyeball itself. So the golden rule in ophthalmology and Indian GP and any is that anybody ever one side of red eye on you, Natural read. I should always be given a florist and I drops because the reason for this it's because if even if the cornea, I think if you remember from one of my previous life because even if the cornea pierce normal by a plan for it, you might be able to find some issues of the cornea session like a corneal abrasion or cornea ulcer. So then the next thing also here. So once the corneal stains, the next thing is then to just look at how the cornea itself looks. Eso if if it looks, you know, grossly overpaid, then you know that the that multiple layers of the cornea is involved, and that usually indicates a more serious on corneal issue, which which would warrant our urgent a photo ophthalmology. So in this case, you can see the eyes. Obviously you know, white, no pain you can't even see the iris behind the record here on. That's because it's involving multiple years of the off the cornea here involving the strong one, which is the middle of the cornea. So you get this his around the corner. If the cornea looks fine as it's demonstrated in the previous photo, then usually it's just a issue with the FDA in the autumn or surface layer of the cornea. And this diagram here just showed you the different layers of the cornea. Eso from outside in, Uh, actually, it's a billion and then in the middle, and I said, This is the stroma thickness lay of the cornea. It can only respond in one way to any sort of insult on it, and it responds by just turning or paid. So you see an opaque cornea, it zero All right, so next things, So we'll go back to, uh, you know where we applied for us. If there's no corneal staining, then the next thing to look at. Actually, it's the pupils. So then, if you see that the pupil on the effective red eye is larger, is that any sort diagnosis that you might be might be worried about? My Stina my seniors, That is, uh it's the complex condition, Actually, normally doesn't affect the strain. She enough, Even though it affects the your muscle injunction on muscles, it doesn't actually affect the pupils. Are the Irish on themselves? Actually, so, uh, so the condition here is actually. So I'm just showing you things that you shouldn't miss in in any way and GPS that if the pupil is bigger than you must always think off. Acute angle closure, glaucoma, which is on opthalmic emergency. Uh, this is condition where the pressure is extremely high. Uh, and the court and the patient will be in a lot of pain. Usually they'll be unwell to a point where they're, you know, constantly vomiting. And indeed, actually, a lot of the patients get this diagnosed as having appendicitis because they get such a strong, ocular, bigger response. So they often get this tightness. And it's not until someone looks at the eye and say, Oh, actually, that's a That's a red eye where the people bit dilated. So when you see someone with a unilateral red eye where the people is much bigger, I must you must must must must think about a doing good closure. Glaucoma. Um, and you know, if you have to take anything from this algorithm on dust, get one thing right. I'll be happy if you if you get this right, because this is a potentially blinding disease. So then if you get the people smaller or same size, then, uh then the other conditions also think about. So if the people smaller on the patient's having, you know, profound light sensitivity, Uh, does anyone know what's a condition that we might be worried about? Okay. No. Okay, so So we think that would be worried about is iritis or we also call it Jerry Uveitis. So this is another is the conditions where placidly the people smaller and the eye itself eyes red. And the redness is unusually. What? Because our Perry limbal or circum Morning. It's just around around the corner here, and the patient is extremely photophobic. Yeah, so you don't get that many conditions that can cause photophobia and ophthalmology. So that's two structures that contribute to for, you know, like sensitivity is only the cornea in the iris. So if you get a patient, you know, true photophobia and where they come in they'll be wearing sunglasses you know on then. Then you always have to think of whether this is iritis or whether this is a corneal issue. But in this case, so this is arthritis. If the patient doesn't have a cold or flu, be on like sensitivity, then you know occupation. You know it's the I really painful, because if it's really painful to the point where the patients waking up at night on they describe it like a tooth pain, then you have to think about something more sinister. Swell like scleritis. Yeah, uh, usually, you see that in the context off connective tissue disease like rheumatoid arthritis. I think it's not painful in the patient's ready to be comfortable on, but pain is unbearable then. Then it's speeds off benign version of scientists episodes and describe it is. Here's the only is or diagnosis that is a non urgent. Okay, so that's the red. I know this is quite a lot of information to take in, but hopefully that will work. Just make a bit more sense. Yeah, And don't worry, I'll send you guys. These are great numbers are nice video version so that you can look at it. If you want eso Lilly has, why does the pupil dilate that? That's a very good question, actually. So the reason the pupil dilates is that because the main driving factor in your any closure glaucoma is that there is a build up off a creek or the fluid in the eye on bears, nowhere for the flu to traded. So what happens is that the pressure are spikes, increases dramatically. And when the pressure's really find the eye, that causes sort of damage to the iron status. So because off that damage, the people then dilates. When you see a dilated pupil, it means that you know, it's pretty fun. Your brief. I don't, uh, pretty far down Welchol at the glaucoma coffee and that in the mortality of the eye, it's usually on that the poor the prognosis now. But that's a good question. So Okay, so the next algorithm here just quickly talking you through. This is the visual loss. See if this is another very, very common presenting complaint by patients. So the key in visual loss is to do a confrontation visual field test when you see them in any of GP on but the first thing you know again, like I said, we're not We're so obsessing. Opera want you to know whether it's one. I have two lines so that the key question is, you know whether or not this morning or what is binocular? It's previously mentioned when it's monocular, you know, you can be a certain that it's in front of the optic chiasm and when it's binocular, it's from the kinds of all the way back to the occipital cortex. Uh, so if it's not below, we then be the next thing to Teo. Ask also to know if the pattern on field loss So here in this example, I think we've really done this already. Can see a homonymous left side. That's right. Homonymous came in know be a so then you know that you can localize division, so it will be so post constant. So in this case, are above the picture here. You can see that on this X else CT scan. There is a hypo dense area in the right occipital cortex. So because the lesions that right side, it gives you a left side of hormone homonymous quadrantanopia eso Then the next one is the bike temporal? We've already are before we going through this. So again, I'm show you on the schedule. MRI scan. I can see a hyper intense lesion in the pituitary adenoma at church area highlighting a Patricia and normal on day, he and the visual field detect it will be a bitemporal hemianopia. Uh huh. So when you see if you you know if you detect anything gross on confrontation visual fill that usually signify indicates quite a significant pathology. So these patients should should always get a scan, you know, at the very minimum the CT scan to rule out any any any acute intracranial pathology. Okay, okay, so that's ophthalmology. Wear more just in the monocular vision field defect because that's more to do with the eye itself. So, uh, when when we're facing a monocle, a visual defects. The first thing we want to know is you know what the visual acuity is. If it's good or it's bad if it's normal, then normally the issue is with the peripheral retina. The reason for normal visual acuity is because the macular, she said, that in the center here is responsible for most of your vision. beauty. So if this area's unaffected, but this area is affected, the perforation a. Then you would get, you know, visual field defects. You shoes off a peripheral visual field defect in. If the vision acuity is reduced, then remember, a Sweet said. If the vision is not 66, you you know you should always repeat that pin hole and and repeat, repeat the visual acuity if the vision security improves a pin hole. Then again, as we've mentioned, you be reassured that this is just a reflective error. If it doesn't improve and it still stays reduced, then the next thing to do would be to test for in our PT and because by doing the RPG by knowing that there's there are any present, then you can localize again exactly where the problem is. That's what also mentioned before. If there is an RPG, there's only two things that can cause the therapy the optic now or the retina. So upset here. If the HPV is president, then you know, try a best. As I said, this is not mandatory, but trial best to find an ophthalmological and to look at the funders. If you recognize you know grossly abnormal is in this case, it's this picture here. You can see that one of the vein is included, causing a bit of us blood to spill into the retina on. So this is a vein occlusion. So if you see a grossly abnormal reaction and that's an IRA PD, then you know that the problem is this with the retina. If the retina is normal, then you know, obviously the problem will be in the optic nerve answer. In this case, you have you shown your picture here showing glaucoma where the nerves are appears to be coming on and you will see this clinically by a large cup. This ratio cut referring to this off central hole yet on this refers to the outer outer circle. So when this ratio is approaching one, that's not a good sign. Yeah, so the, uh if there's no RPG, Then again, you should try to look at the fun This, uh, if the, uh, rectum this so you get a good view of the retina. But then there is an obvious problem problem in the macular. Then you can be certain that that issue is from from the Macular here on in this case, I'm just showing the picture that this is a, uh, HD later medical ID generation. When you get so drusen like deposits are in the macular causing situation in vision, you classically see this in in three older population where it went, about 10% of people have, uh, if there is no good view off the record, and then you have to think about, uh, opacity of the media eso this usually can either be in the vitreous. So in this case, the ocean your picture, whether it's bitches hemorrhage, where usually patient will tell you that the vision, it's just suddenly disappeared. So if the patient comes in some loss of vision, think about bitterest hemorrhage and the other condition that can cause this this retina detachment. If it's a more gradual loss of vision on, then I always think of off cataracts. Okay, so how is everyone doing the last thing here? I think I've got one more good than just double vision. Is everyone still okay to for me to go ahead? Yeah. Okay. Okay. S Oh, I promise that this will be the last one. Amy, answer questions. What about loss of vision totally due to central retinal artery question. That's a good question. So I'll just quickly just go back to the algorithm. Amy. So you've asked about central retinal artery occlusion, so central retinal artery occlusion would fall on under this pathway because when you do the endoscopy, the retina itself will definitely look at normal on Because because the central retinal arteries affected the majority of the retina will be affected. Hence it will give you an RPG. So remember, a So I think that the only two structures in the I went effect that will give you an RPG. It number one is the optic nerve. And number two is the retina. Only when it's widespread rectum or when it's a widespread rectum issue. So, yes, a central retinal artery occlusion would for me this year in this part? Uh huh. The Okay. So the last one is double vision diplopia. Since this one is actually quite important because it has, you know, uh huh. Life or death sort implications. Sometimes, if especially now it's all started the context of a nerve palsy. So to start off again, we you know, the thing we we like to answer this. Actually, we like to clarify the patient whether or not what the experiencing is truly double vision, whether they're saying two separate images or whether it's just really blood vision. Uh, so if it's just blurred vision, you know patients saying that things are actually just saw a bit hazy and not really splitting into two. Then you know, I you can just revert back to the visual loss of a rhythm because it could just be a cataract. So But if the patients actually telling you that you know, it's, you know, it's really two images, I decide by side or 100 off the under, then you know, then that is diplopia. So then the next thing to do is well, you should ask the patient to cover one eye and ask them if the double vision is still there. It's still then, uh, despite them, you know, covering one night. Then we would say that you know, that's monocular diplopia. And when we when we see that when we when we know that patients monocular diplopia way, we can instantly take a SCIRI leaf, and we know that this is nothing serious because usually It's just, um, you know, due to some sort of media, pass it easy in this case, a cataract. So if if the patient tells you that you can see double vision even with one eye close, you know that is almost certainly nothing serious. But if the patient until it tells you that no, actually with one eye shut but they don't see double vision. So you know then that it's binocular diplopia where they get double vision only with both eyes are open. Eso then you wanted to know how the two images a separate that so the patient can I tell you that it's purely horizontal So the image are classically would be cited by sight on in this case, usually the only two conditions that can give you this off presentation. So a good way to differentiate this is to get the patient to look to the site that makes the double vision waas I And if they look in the so so just before show the two conditions Can anyone So I guess, uh sorry in the chapter in on that what conditions can give you a horizontal? The flow there? No. Okay, so the first one, which is important to pick up is, uh, six North palsy. So when you get the patient to look to the site, that is worse. Um, what happens is that the the I will appear to be converging. Uh, and the reason is because so in this case, the problem is with the right time. So there is a right six palsy here. So because of that, the the six enough innovates and lateral raptors. So if the lateral rectum doesn't work, this I it's not a it's not able to a be done, So I'm not able to bring the eye out. So this patient is actually trying to look to his right. So the right time here, it's not, you know, maybe Dr going out, but the left. It's so so when when this patient looks to the right on, the eyes were appear to be appears to be converging and and that's where the double vision is worse. But if the this patient tries to look to his left on this way, both eyes will be able to do do so because there's no weakness off the lateral rector's on the left side. Uh, so six left is very important because, you know, this could be a sign off base intracranial pressure causing what? What we typically associate. It's a false localizing side. So if you see a six palsy on, the important thing to do is to get a scan and just to make sure that there is no no intracranial pathology, so the so. The other thing is that if the eyes diverge when you get to look at where the double vision's worse, then on the other condition to think about is into nuclear ophthalmoplegia. This is much. This is much rare rare, uh, and usually you see this in the context off multiple sclerosis. So the problem here lies in a specific pathway away. The the A deduction off the affected eye doesn't doesn't function properly. So this patient, in this case, the patient's here is instructed to look to her left. So the right this area, the left eye is functioning properly, but in the right time, on the eyes, unable to $80 unable to look inwards on, Do you know so? And this is where the double vision is is worse. So this patient here appears to be so diverging the eyes. So when this happens, then you can solve our confidently localized and name this internuclear ophthalmoplegia. And usually, like I said, we see this in the context of multiple sclerosis, so the management is pretty much the same. So if you see an eye that's diverging or converging, then uh uh, boredom thing to consider is a new imaging. Because in the context of M s, if it would be important to look for in this or peri and trickle a white matter lesions assault, the other signs off systemic signs of multiple sclerosis uh, so come back to holiday. Image is a separate were nearly done. So if we images on separate are, you know, separate, separated vertically or obliquely, then we have to think of other premium nerves. So anyone want to name me to Why the craziness? We We've not We've not mentioned Sorry so much to see in your you're on today. Absolutely correct. Yeah. Four. Yes. Correct a. Me. Anything else? What other craziness would not mention you had mentioned six forth with. Now you've mentioned that as far what's the other one was the most important one that you need to to know ever miss are in any Yes, I certainly that's right. I think so. Uh, So So, uh so when When patients tell you that there is a vertical diplopia, the next thing that you have to assess is the patient's pupil and also the patient's island. Because by looking in the people that gives you a lot of information is if the pupil and the islands involved, then we get really tricky because then that points are towards a a problem with the burner. So in in this picture a fee, Um, I've written and I say Korean so unequal people size or toast is person. So if you see that so in this case, the patient's right time, there is a full Tosis. So, you know, we don't manually lifting the on it. The patient has a full Tosis. Um, and if you lift the island, it is very likely that the pupil will be dilated competitive. This left by here on and also classically in the text books, they say that the eye is off, down and out in a certain palsy, so but in real life, the spaces are typically don't present in this manner. Usually they get a combination of off people on let's signs or they can get in complete 30 and 40. But the important thing to say is that I know in medical school we have fought, so try to differentiate it on the basis of whether this is medical or surgical 30. Now where, where, where? Whether or not the pupils involved. But the guideline now is that in any formal spurt, the patients should get a scan because you cannot rule out, you know, involvement of the posterior communicating artery aneurysm on the basis of whether or not the pupils involved. So if you see a so slight doses but the I sort of patients complaining of vertical double, double vision and the I slightly don't an hour. But the people is not dilated, you should still scan of these patients. So that's the take home message here. Uh, and then I just wanted to see Amy. So yeah, so and they could see upon manual lifting of the eye. I can see that that people can just barely make out that people's down and now actually, and also dilated. They're so so In this case, this patient needs an urgent Are CT angiogram now to check for any any, any people mannerism? Uh huh. So then if the, uh, the pupil and the lipids are not involved, then we are usually a bit more relaxed than you can. So then, you know, you sort of know, actually, so this is not not really if they're in there. Uh, so with the seven conditions that can give you better with the observation So the first one here put this fire disease because just remember, in ophthalmology, the the great Minutka start are graves' disease because it can give you any any sort of pattern or double vision. So if this patient and if this patient comes to you with the classic signs off graves where the I saw Cocteau's The eyelid is retractor, patients got sort steri appearance, onda patients complaining of double vision. Then it is likely to be our disease. And and you should investigate any sold on systemic, uh, complications. And then So I was doing a force off function test on and then I think so. In this case, here s so let me just have a look at the picture. So So the picture of the top eyes showing patient looking in primary gaze. You're looking straight ahead and in the bottom picture here is showing that the patient's attempting to look upwards. So actually, on the right side, the eyes not able to elevate. And the reason for this is because the inferior rectus here, which is responsible for depressing or pulling the idea, is restricted. This is tight because of fire and I disease. Uh, so the last condition here is a means mentioned. This is create create for palsy on this is usually a diagnosis of exclusion on. So if you exclude everything in the patient still complaining of arts or double vision, vertical double vision, then I think about it. Enough for policy. Yeah, so I think that's it. So hopefully by the end of all of this, I'm hoping that we have addressed them over the last couple of nights and hope that you've learned something useful on so thank you for listening. This is the QR code. If you want the algorithms feel free to just scandalous and you can get the, uh, Grams And the other teams are also include the other common eyes, symptoms that that I'm not not describe it. Lovely. Thank you. Paying That was a very formative lecture. And it's very comprehensive as well. And I'm sure we will gain a much better idea of this kind of things to include one where making Pharaoh's or when we suspect. And then I pathology happening on. And I'm just going to copy the feedback link into the chapped face. If you could all just fill in this feedback would be very valuable for both Mind Sleep team and for Dr Pain as well. Um, on thank you very much. I hope you guys all found that on a lecture to be very helpful on dot Thank you again paying. Don't think it's been a precious half year. Thank you. Thank you very much for the end. If anyone has any questions is well, now if they around for a few minutes Okay. To chat ulcer. Seen some questions, ICP be a differential. Yes, Alexander. So I see P is definitely a differential that you should always consider. I think I think you're doing this to the presence of a six month policy. Yes. So always always think of CP does. That is potentially life threatening. So you you should always always think about Grace, my CP in a six. Now on always scan these patients. Uh, definitely. Yeah. So, yeah, I feel free to, uh, just just take a screenshot. Anything if you If you if you need the algorithms. Yeah, well, thank you, Im and you'll also and I'll take a screen. Shortest. We'll set out with the emails. The attendees is Well, thank you again. Wonderful Evening, everyone. Take my My okay?