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Welcome everyone. Um My name is Serena. I'm one of the F one doctors that just graduated from Imperial. Um And I'm doing the ophthalmology lecture today. Um So just before we start, I've got the mentee at the top and I've also got my um email address. So if there are any questions or any other, anything that you want help with, um I'm working in the Oxford Deanery. So if you need anything, then just feel free to email me. Um I'm happy to answer any questions. Uh Yeah. So in terms of the structure for today, um we'll just be covering the few um common presentations in ophthalmology. So these are red eye, sudden vision loss and gradual vision loss. There are other uh conditions that you will need to go and revise um for your finals. So this isn't comprehensive. Um But these hopefully will cover the most common conditions that will come up in your BS. So we'll start um straight away with case one. So this um is um so you're on fy one and it's your first day of emergency medicine. You've been asked to Clark a new patient, Miss Tracy Adams who is a 54 year old female. All you can see on the system from the Ed Triage Notes is that she has a red eye and that's happened since the morning. Um So in the mentee, can you just um list some possible causes of red eye? Um Yeah, so we'll just start with the most common. Um We'll start with the most common cause of red eye, which is conjunctivitis. So, as you can see here on the bottom, we've got two pictures. So the left is uh bacterial conjunctivitis. And on the right, we have viral or allergic conjunctivitis. So these look um identical on um general examination. Um what uh differentiates the two is the um presence of discharge. So, on the left, uh with bacterial conjunctivitis, you'll get this mucopurulent discharge, which is very, um which is very thick. Um And you'll also get some eye crusting and it's quite significant for bacterial infection. Whereas with viral or allergic um conjunctivitis, you'll get some watery discharge um and the redness but no thick um ent discharges, there's no um bacteria um uh causing the inflammation. So, conjunctivitis, um it's inflammation of the conjunctiva of the eye. Um And we've got three main types. So we've got bacterial viral and allergic, as we mentioned before. Um with bacterial, what's important in the history is it usually starts unilaterally and then um it spreads to become bilateral. Uh So that's because the infection in one eye, then the patient starts rubbing it and then if they touch the other eye, it causes spread. Um The main treatment for bacterial conjunctivitis are uh is these chloramphenicol eye drops, which are some antibiotics that are very specific um to bacterial infection in the eye. And chloramphenicol isn't really used for anything else other than eye infections. Um but we typically give these topical antibiotics as soon as we see. Um the purulent discharge for um from the eye um viral conjunctivitis. Uh as mentioned, we have this watery discharge. Um Commonly a patient will um have an upper respiratory tract infection. Um And because it is viral and systemic, um the conjunctivitis is typically bilateral. So we treat this with supportive care. Um And um we can give artificial tears if the patient is getting quite dry because of the watery discharge. Um But otherwise, as with all viral as with most common viral infections, um we don't really do any specific treatment, allergic conjunctivitis. Um the way to tell it uh tell the difference between that and viral is the history. So, um they'll usually have a history of any kind of allergies like hay fever, eczema, asthma, um or um maybe a new introduction of pets or smoking or um dust mites in the house. Um uh as uh otherwise they're quite similar. So it's got itchy itching and watery discharge and obviously the redness of the eyes, um the main treatments for allergic conjunctivitis are oral or topical antihistamines. Um, so hay fever tablets or eye drops, um, or we can also give ma cell stabilizer, eye drops. So these are commonly, um, sodium chromoglycate and that helps with the allergic symptoms. Um, so moving on to case two, we've got, um, in this scenario, we've got Tracy again with the red eyes, but this time she's saying she's developed sudden severe left eye pain and she complains of blurred vision. She says that the ceiling lights have strange halos around them. So they look like this on the bottom, right? And she vomited once during the consultation on examination, left eye um is very red and you can see that the pupil is quite dilated uh and, and fixed. So when you're shining light into the pupil, it doesn't constrict as it should. You also see some haziness. So some corneal edema on the split lump examination. Um So, moving on to the first SBA um what is the most likely diagnosis? So you've got optic neuritis, central retinal artery occlusion, acute angle closure, glaucoma, anterior uveitis, and retinal detachment. Ok. Amazing. Um I'm not sure if you can see the results on your phones. Um But the most common answer was c acute angle closure, glaucoma, which is correct. So well done, we got a few other um answers, optic neuritis, anterior uveitis and retinal detachment. Um But we'll cover those later on in the session. Um So really well done everyone Um So acute angle closure glaucoma, uh this is when you get an acute blockage within the anterior chamber of the angle of the eye, which is results in elevated intraocular pressure. So you can see in the diagram on the bottom right. Um This on the left hand side, this is what an open normal angle looks like. Um So you can see it some space between the iris and the cornea. Um And in the, on the right, this is what happens in angle closure glaucoma. So the lens pushes up on the iris, um narrowing that angle between the iris and the cornea. Um And then that impairs the outflow of aqueous humor. So normally that aqueous humor follows this blue path and it's drains through the trabecular meshwork on the right in angle closure glaucoma. Um This can't happen. So the you get a build up of the aqueous humor and it doesn't reach the trabecular meshwork to drain down. Um, most commonly, um, it's, it affects people aged 50 age, 50 older. Um And it affects people with long sightedness because of the shape of their eye. Um, again, um, due to the shape of the eye, people with Asian descent, um are more likely to get angle closure, glaucoma and there's also certain medications that can, um, that can affect, uh, that can increase your risk of glaucoma. So, anticholinergic, um, medications such as atropine, which is what we use to dilate the eye, this effect changes the shape of the lens and then um over time, um it causes the angle to become closed. Um adrenergic um medications such as phenylephrine and also tricyclic antidepressants. And um the most common one that is taken is amitriptyline. Uh and TCA is causing angle closure. Glaucoma is quite a common um theme in SB. So just be aware of that one as well. Um The other presentation will be the patient um was in for an eye assessment. They were given atropine eye drops to visualize the eye and then they developed angle closure glaucoma. Um So those are the two most common scenarios that you'll get in terms of the symptoms. So a patient will complain of very severe severe eye pain, um and blurred vision, they'll also often have um quite significant nausea and vomiting. And as mentioned before, they'll have these halos that appear around the lights, these halo that appear. So um you normally you wouldn't have this extra ring around the outside in terms of slit lamp examination. Um the patient has a red eye and the pupil is often quite um dilated and it's fixed like that. So even when you're changing the lighting environment, so you put um so you increase light on the eye, the people won't constrict, uh you also often get corneal edema. And so in SBA S they men, they will mention a hazy cornea. So you can see that here that it's not completely black, there's this haziness over the top and that's because of the fluid, um, that's building up in the glaucoma. And also because of the increased intraocular pressure. If you palpate the eyeball, it is often very hard and tense on palpation. Um So in terms of buzzwords, it's usually a mid fixed midd to fix pupil hazy cornea and severe eye pain with redness. So, in terms of investigations, um, the two main ones that are, that are um conducted in the ophthalmology clinic will be tonometry. So that's this on the uh left here. So this is, this uses a gush of air to measure the intraocular pressure. Um it just feels like a bit of a blow into the eyes. Um And on tonometry, um we'll see that the intraocular pressure is is elevated. We also do gonioscopy. So that's using this special lens under the slit lamp. And this looks at closely at the um at the angle and on gonioscopy, we see that the angle is closed in terms of management, acute glaucoma, acute angle closure, glaucoma is actually an ophthalmology called emergency. Um So straight away, the first line is to emergency refer to ophthalmology. Um Whilst we're waiting for ophthalmology to review, the most important management is to place the patient into a supine. So lying down position without a pillow, um because that will decrease the pressure within the eye, then we often give um carbonic anhydrase inhibitors. So the most common one we usually see in questions will be IV acetaZOLAMIDE. Um A lot of evidence online shows that you can give topical dorzolamide or brinzolamide. So anything that ends in zolamide, um but most commonly in the hospitals, what we have available is IV acetaZOLAMIDE. So that's what we tend to give. Um You can also on top of that give beta blocker eye drops such as timolol to decrease the pressure in the eye. But the definitive management, once we've um given the acetaZOLAMIDE is to then do laser peripheral iridotomy. So this is a procedure that we do um where we use a laser to cut a hole essentially in the iris. Um And you'll see this um on slit lamp examination as well and that will help with the drainage um when the arrow when the angle has been closed. So it creates a new path essentially for aqueous humor to be flowing into the trabecular meshwork. Um So, in summary, for acute angle closure, glaucoma, um you need an urgent ophthalmology referral and to give a carbonic anhydrase inhibitor. So something ending in zolamide and then once that's resolved, then to get to perform laser peripheral iridotomy. OK. On to the third case. So now, um we have a patient, Tracy again. Um she's uh you see her on um to take a history and she has her eyes closed during the entire consultation because she's saying it's extremely painful to move her eyes she says that she's usually really fit and well. And her only medical dental history is that she had a root canal procedure two weeks ago on examination. This is what you see on the, on the bottom. And um you see that she's quite febrile and quite unwell. When you go to, when you go to speak to her, her left eye is very red and there's a lot of swelling um around the outside of the eye and she's also got significant ptosis of the eye. So she's unable to open it at rest. And so in terms of the next question or just advanced slides. So what's the most appropriate initial management on top of an urgent ophthalmology referral? So uh for a lot of ophthalmology conditions, the first line management is to do an urgent referral. So in terms of the F BA S, they probably will ask you for the next management. Um So if you can just answer the mentee, OK. Amazing. So, um again, the majority of people got this correct and the correct answer is b immediate intravenous antibiotics. So, really well done, we've got a couple of answers saying um systemic steroids and eye drop for analgesia and we've got one person saying or antibiotics, but generally, these are, these are really good. Um Answers are all done. So for this presentation, this is most likely orbital cellulitis. What happens in orbital cellulitis is that you have infection within the soft tissues of the eye and you get, um this causes dysfunction of the function of the eye. So this is usually due to an underlying bacterial sinusitis, but there are other causes of causes as well. Most commonly. Um This is, it's seen in young patients. It's quite often seen in Children, but I'm not sure you will have Children in your BS. Um, so young adults, um as I mentioned, um it's commonly, the patient will have a history of sinusitis. Um Males are much more common, more, much more likely to have cellulitis than females. And also a lot of evidence shows that a lack of the hip vaccine in Children leads to an increased risk of cellulitis. So, um yeah. So in terms of the causes, so we get infection that causes inflammation within the eye due to the increased recruitment of white blood cells and um other inflammatory mediators. This then leads to edema and accumulation of pus within the orbit. And then you start getting the symptoms as mentioned before. So the infection can come from a variety of sources. The most common is bacterial infection spreading from the sinuses. So the patient may have ethmoid sinusitis that then spreads directly into the eye um or commonly dental infection. So for our patients, you had a root canal procedure, um this may have been infected and then the uh the bacteria spread to the eye. So this is a very, very common presentation of orbital cellulitis. More rarely, we can also um get orbi orbital cellulitis as a complication of surgery or any injury to the eye because of direct bacteria um that has been introduced into the eye. So this is a common, uh this is a rare complication of all eye surgeries, but something that we always warn patients about. So, if any patient has a history of eye surgery recently, then we have to be very uh very on edge for any orbital cellulitis. There's also a very rare chance that um the patient may have a bacteremia. So blo a bacteria spreads in the blood to the eye and then causes orbital cellulitis. This is much, much less likely. And you would only be suspecting this if a patient is quite septic in terms of the symptoms, um orbital cellulitis, again, it presents with very severe eye pain, but what's very, um unique to it is that it also presents with painful eye movements. Um So that's why the patient in the history had her eyes closed and she said she didn't want to use her eyes again. There'll be very, uh there'll be a lot of redness and swelling around the eye. And due to the swelling, patients will present with blurred vision, the patient is usually quite unwell because they've got an infection. So they'll be, they'll have a fever headache and malaise most commonly. Uh in terms of the signs on examination, the they men may mention that there's proptosis. So the eye is bulging out and that there's painful eye movements or ophthalmoplegia, there's also quite often significant chemosis. So, um fluid leaking from the eye, um and you'll see the eyelid erythema and edema. When you do any visual um acuity testing, the acuity will be much, much more reduced in the affected eye compared to their normal eye or their usual baseline. In terms of investigations. It's really important that we get a CT scan of the orbits and sinuses. So we can see if the um if there is um infection deep within the sinuses and we can also just get an idea of the extent of the infection. Um So we can see here on the right that the um the sinus is very inflamed compared to the other side. Um So here we can see the source of infection. We'll also uh need to do a microbiology, swab and send it for microscopy culture and sensitivities as that will determine our antibiotic treatment. If the patient is systemically unwell, then most likely we'll, we'll also ask for bloods and cultures um to check for any sepsis or any infection within the blood itself. Um like most eye conditions. Um this requires urgent ophthalmology referral because we are risk, we are at risk of losing the vision if this isn't treated fast enough. Um And the main management is to give immediate IV antibiotics. So the most commonly we give either Cefotax Cefotaxime or Clindamycin. But if we are expecting uh suspecting MRSA, then we will give quite a host of um antibiotics and we'll give Vancomycin, Cefotaxim and Clindamycin. Um, obviously these all depend on your local antibiotic guidelines. Um But in terms of um most questions, um it's, it, you'll usually see cefotaxim or Clindamycin or some sort of IV antibiotic to treat the cellulitis. Um And they probably won't mention MRSA. But if there is MRSA, then it would just be a combination of a lot of different antibiotics because it's resistant. So uh quite um a common question is to distinguish between periorbital and orbital cellulitis. So this diagram explains it quite nicely. They do present very, very similarly. So with the fever, the eyelid, swelling, the erythema and the eye pain. But what differentiates orbital cellulitis from per preseptal um or periorbital cellulitis is that the painful eye movements only happens in orbital cellulitis. So as soon as you see patient with painful eye movements, you need to refer immediately to um ophthalmology and that also changes the course of the management. So if we have painful eye movements, then we need to give IV antibiotics. So, cefotaxim or Clindamycin, as I mentioned earlier, but if the, if the patient can move the eye without any difficulty, then usually we will just give oral antibiotics because it's just infection of the soft tissue in the orbital septum um around uh around the eye and not the actual deep the deep um tissue. The reason why we get pain with the eye movement is because in orbital cellulitis, the bacteria and the inflammation and infection has spread to the orbital fat and also then down into the extraocular muscles. So, using these muscles um causes pain on the patient. Any visual changes are also usually quite a red flag in ophthalmology. So if they mention any diplopia, um that is also a very strong sign that the patient may have orbital cellulitis. Um Again, because of the extraocular muscle involvement, the muscles being involved also can push the eye out. And that's why we get the proptosis, but this is in quite severe orbital cellulitis. Ok. Amazing. So, um moving on to the fourth case, um we now have a patient um with the red eye again, um on arrival to the side room, you see that the lights are off as Tracy says, it helps with her eye pain, Tracey reports a dull aching pain in her right eye and new blurred vision. She has a past medical history of ankylosing spondylitis and asthma. And she mentions that her mother had quite similar eye symptoms, but she doesn't know too much more about that. On examination. Her right eye is very watery and you see a little bit of redness, the pupil is irregularly shaped. And when you test with a light, it's quite sluggish and quite slow to react. And this is a close up of what you see on examination um using a slit lamp. So just advancing the mentee. So in terms of the next question, which of the following findings are most likely to be observed on slit lamp examination. This is quite a hard question. So, don't worry. Um but we've got anterior chamber cells and flare, dilated pupil and corneal haze, retinal hemorrhage, and macular edema, corneal ulcer and hypopen and conjunctival injection in foreign body. Just give me some time. Ok. Um Good job. We've got quite an even split between anterior chamber cells and flare and corneal ulcer and hypopial. Um Does anybody want to unmute and say what they think the diagnosis is? Is it an Yes, amazing. Who was that? Um II think someone else also answered but I said an uveitis. Yeah. Ok. Amazing. Yeah. Really good job. Um Sorry, I can't actually see anyone's names but um yeah, well done. Yeah, the answer is anterior uveitis. Um And these are the signs you see these are the diagnoses of the other conditions. So, um anterior chamber cells and flare most commonly seen in uveitis, dilated pupil and corneal haze, the angle closure, glaucoma that we mentioned earlier, retinal hemorrhage and macular edema commonly seen in diabetic retinopathy. The corneal ulcer is quite indicative of bacterial keratitis. So that was the other second most common answer. And then we've also got conjunctival injection in foreign body which happens due to trauma or corneal abrasion. Yeah. Amazing job. For everyone. Um Everyone seems quite prepared for the opal questions. Um So this is anterior uveitis. Um So, inflammation of the iris and the CCI your body adjacent to that. Um So you can see here that these are the structures involved in anterior uveitis. So it's essentially everything from the lens and anterior. Um what happens in anterior uveitis is that we get an autoimmune response that then causes inflammation within the eye. This is most commonly associated with HLA B 27. Um ileal being positive um in the genome and so common. Um HLA B 27 associated conditions are ankylosing spondylitis, reactive arthritis or Reiter's syndrome. As I think is the old name, um psoriatic arthritis, um inflammatory bowel diseases and juvenile idiopathic arthritis. So, in any SB if you see kind of inflammation of the eye, red eye and any of these conditions, the HLA B 27 conditions, um it's most likely that the diagnosis is anterior uveitis is there's a very strong association between these and the an uveitis. Um There are also infectious causes because um infection causes inflammation and, and that can affect any part of the eye. Um common infections that cause it are HSV CMV and TB. But um in your exams, it's most likely to be a H HLA B 27 condition. Um in terms of the symptoms. So what uh what happens is that the inflammation causes these adhesions called posterior synechia to form um between the iris here and the lens and that alters the shape of the pupil uh because it pulls the iris. Um and that's why you get the irregular pupil that's quite um quite um significant for uveitis that then also blocks the he flow and can um it further increase the inflammation. So, for anterior uveitis, the patient often exer complains of a very deep aching pain in the eye and they'll get this very characteristic redness which is just around the iris. Um it's quite ring shaped and you can see it's going outwards and the pain patient will also have photophobia or um sensitivity to light. So they would prefer if the lights are off, if when you examine the patient, they have pain when you shine the torch into the eye that would show photophobia. Um The patient as with most conditions will have blurred vision and there'll be that increased tear production because of the altering of the shape of the eye as well and signs in signs on examination. So you'll see this um redness around the cornea as mentioned and the pupil is usually either small or irregular. So you can see here the shape is not um as round as it should be. There's that um dent hair which is caused by the synii formation. Um in very severe cases, you'll get this white deposit at the bottom, um which is called a hypopen. Um So I understand why people put that down as well. Um But this is in very severe cases and that's a build up of the inflammatory cells. Um You'll also be able to visualize the posterior and E TI on slit lamp examination. Um And there will be some anterior chamber cells and flare. This is the most common um thing that uh seen on examination because um you've got all these, uh um you've got all these cells, inflammatory cells and markers within the anterior chamber, which is infected, which is the part that's affected in anterior uveitis. Um So you'll be able to uh see those cells in the examination. Um There also might be um keratin uh precipitates um but this is less likely to be seen. So for anterior uveitis, it's a very clinical diagnosis. Um in your exam questions, most likely it will be that small irregular pupil and a HLA B 27. Um Hi associated history as well. Um In for the investigations, uh is usually to consider investigating HLA B 27 and infective causes if they haven't um been investigated for that previously and management. Um once again is urgent ophthalmology, referral. Uh in terms of the actual symptomatic management. The most commonly we give topical corticosteroid eye drops and these will reduce the inflammation within the eye and then much much improve the symptoms. We can also give atropine or cylate eye drops. These relieve the pain from the ciliary muscle spasm and they can also help break down any posterior sine eye that have formed or help prevent them from forming. Um because these cause uh dilation of the eye. Um We also the most in the most important management is also then to treat the underlying disease to prevent it from happening again. Um So, on top of your ophthalmology referral, um you'll need input from the rheumatology team or also the patient's GP. Um So that's just anterior uveitis. Um It's the main thing to remember, as I mentioned is the irregular pupil redness around the eye um and the constricted pupil as well. Ok. Um Moving on to the fifth case now for red eye. Um So in this scenario, Tracy is presented with a three day history of severe pain redness and reduced vision in her left eye. She says that she wears her contact lenses overnight sometimes, but it doesn't really cause her any problems. Um But she did wake up this morning quite distressed when you examined her eye, you saw very um red eyes. So, conjunct her, her injection and a central corneal ulcer, which is this um white defect on the eye. He also performed some fluorescent staining which is quite routine in in the ophthalmology clinic and this revealed an epithelial defect over the ulcer. So, um the same, the same pattern of what is glowing. Now, you also noted a bit of mucopurulent discharge again and some crusting around the eye. Um But generally, Tracy says she feels quite well. Um And her observations are all stable. Um So for the next SB um what is the most likely diagnosis? Few more seconds. Ok. Almost everyone got that correct. So, really well done. Uh The answer for this is e bacterial keratitis. So we'll just go into that condition now. So, bacterial keratitis is very, very, very strongly associated with contact lens wear. If you get a question where the patient, it mentions contact lens wear plus the symptoms that we're just talking about. Um almost certainly, the patient will have bacterial keratitis. In this condition. You get um pathogens that invade the cornea, which again causes inflammation and damages the epithelium, the stroma or the endothelium. So, any of the structures within the cornea, um most common bacteria to uh cause bacterial keratitis are pseudomonas, aosa and staphylococcus aureus. With pseudomonas being the most common um pathological bacteria in contact lens wearers. These bacteria adhere to the cornea and then they penetrate the epithelium and go into the stroma. And these, this cause the inflammation. Um neutrophils are recruited to the site and then these um these along with the enzymes cause damage to the corneal tissue. And that's why we get the symptoms as described. Well as contact lens wear. Um another really common risk factor is any kind of trauma, uh trauma that's happened to the cornea or any abrasion or erosion. So, anything that's been rubbing against the eye can cause um cause these ulcers to form. You also get um trichiasis, which is when the uh eyelashes are affecting, are rubbing against the eye, the cornea and that causes um again, more corneal abrasion and erosion. And so that's another really strong risk factor for developing bacterial keratitis. But most commonly it will be contact lens wearing sbs symptoms we get with bacterial keratitis are quite generic. Um So the main thing really are the risk factors that help you tell it apart. So you get redness, pain increased, uh like cremation and watering, you get this watery discharge and uh purulent discharge as well and blurred vision. Um But on examination, that's when you will most likely see this corneal ulcer that forms from the contact lenses or the um the abrasion. And when you apply these fluorescent eye drops, um it really accentuates it on this eye, it's very obvious even without the eye drops, but sometimes it can be quite subtle. So giving the fluorescent eye drops helps it just illuminate under the slit lamp under the special light. Um The patient often will also be quite photophobic. They'll have this redness again, which is bacillary injection and they'll have reduced visual acuity um in the affected eye in terms of management for bacterial keratitis. Um we would do an emergency ophthalmology referral again and the there are quite um strict antibiotics that need to be given. Um So it's usually antibiotics that end in floxacin. Um Most commonly or there's an old one called Ofloxacin, which, um, is usually given a 0.3%. And, um, you'll need very extensive antibiotics. So often they'll actually give the antibiotics every hour, um, until the symptoms start resolving. Um, and so that's a lot more common than antibiotics are usually given. And very importantly during, um, the course of this treatment, you need, need to remind the patient to not use any contact lenses as that can exacerbate or um um prolong the length of the infection. The most specific investigation for this is to do a corneal scrape and we'll send that off for microscopy culture and sensitivities. If that comes back as having quite some strange sensitivities, then we'll need to adjust the antibiotics. But empirically, we usually give ofloxacin um as it's quite a strange diagnosis. If the patient doesn't have um any of the risk factors, then you would consider doing a HIV test for any possible immunodeficiency um to investigate into why the patient has developed infection within the cornea. Um So just to go back, um if you see a, a corneal ulcer, um and contact lens were in the history, um we will be thinking uh bacterial keratitis, which we will treat with ofloxacin for likely pseudomonas infection. Ok? I think this is the final red eye case. Um But in this scenario, um we have Tracy again and she's presenting with a two week history of severe day, deep aching pain in her right eye. She reports redness and swelling around the eye and a gradual decrease in vision. She has a history of rheumatoid arthritis and she has had similar symptoms in the past. Um, but she didn't ever do anything for it on examination. Um You do see quite extensive redness and um you see this bluish tint um alongside the redness as well. When you look at the anterior chamber, there are no cells and no flare. So you're not, you're not thinking there's any keratitis. Uh sorry, you're not thinking um there's any anterior uveitis going on. Um But you do see significant edema and tenderness on palpation. The patient is very um she's in a lot of pain when you're examining her eye. Um But when you do, when you do use the light, um she uh the pupils are very reactive and on tonometry, the intraocular pressure is normal. Um So I'll just leave it up for a few seconds and I know that's quite a long history. You've got deep aching, eye pain, redness, swelling. Um And this is the appearance and just one cement tea. Oh, I'm sorry. Um I'm not sure if anyone saw that. Um So I'd just like you to type your most likely diagnosis in the chat in the ment chat. Give me 10 more seconds. Ok. Amazing. So we've got some answers for scleritis. Someone also mentioned posterior uveitis and iritis. Um But the correct answer is scleritis. And we'll go into that now. So, um I'm aware there's a lot of different um inflammation, um inflammatory conditions causing red eye. I've put a summary table in later. So to summarize them. So that should help with revision. Um scleritis is an inflam in is inflammation in the episcleral and scleral tissues and you get um injection or redness um of the vessels. So the sclera is the white part of the eye. Um and most commonly we get scleritis due to existing autoimmune disease and inflammatory disorders. So, with anterior uveitis, that was the HLA B 27 disorders with scleritis, it's the following disorders. So, most commonly we have rheumatoid arthritis. We also have the vasculitides. So, granulomatosis with polyangiitis, connective tissue disorders like Sle um Sjogren syndrome and IBD again. Um So, because these are quite rheumatological conditions, the risk factors are usually um having being of female sex, being uh between 3050 years old that they're usually the most um prevalent people with uh rheumatological uh diagnoses and having an autoimmune past medical history, but just bear in mind these conditions as um they will really help you in terms of reaching a diagnosis quite quickly in the SBA S. Um So for the symptoms, um as mentioned, you get quite a severe constant eye pain that is worse when moving your eye, um redness, watering, um and often patients will have quite a bit of a headache or ear or jaw pain. So in terms of the history, it's quite generic. Um but the most pertinent signs will be on examination. So what's quite specific for scleritis is that um you'll have that violet bluish hue on top of the redness as well. And that's just because of the area of the eye that's affected. So the sclera is involved, you'll also get decreased visual acuity. And um an important differentiating sign is that when you give these phenylephrine drops, which is like adrenaline, um the redness of the vessels does not go away. Um So the vessels will stay red and they do not blanch. And that's because in scleritis, the it's the deep scleral vessels that are involved. So the phenylephrine will not penetrate. Um Again, the patient will probably complain of pain when you're examining her eye as well. Um when you use, when you touch her eye. So in terms of investigations, again, this is a clinical diagnosis, we we usually reach this based on the history and then also seeing that violet blue hue and um the non blanching of the vessels because of the systemic um background. It's important that we do investigate fully with blood. So, doing a full kind of rheumatological work up as well as general assessment of their wellbeing. And we can also consider imaging. So an optical coherence tomography or a CT or MRI scan of the eyes to look at the extent of the inflammatory involvement. Um Again, on top of emergency oal referral. Um The first line management for scleritis is to give oral nsaids. So you just Ibuprofen, um which maybe Tracy took last time, which is why she didn't come in for um treatment. Uh Second line, if nsaids don't work or if the scleritis is deemed to be very severe, we can also give high dose steroids to reduce the inflammation. Um and can also under room's advice, give immunosuppressive agents like methotrexate to um control the disease that's underlying. Um And importantly, we have to do further investigation for underlying disease. So, the main management really is just oral nsaids, there is still an emergency um in ophthalmology. Now, the difference between episcleritis and scleritis is um that episcleritis is a lot more benign. Um and we usually don't really actually need to treat it. So it's just the superficial layer. So the episclera that's involved and not the deep scleral vessels underneath. We don't know why episcleritis happens, but it's usually it's quite common in the female sex. Um And you'll get this redness again with some pain, but usually the area is quite segmented compared to the um diffuse redness we see in scleritis, you also won't have that blue um hue this looks blue in the image, but that's just the photo being taken. Um but the scar will still appear white apart from the, the area of vessels that are affected and significantly um if you give the phenyl ephrine drops, then these vessels will blanch. So this is very, very um common to come up in ba s again. Um If you give the phenyl ephrine drops and they do blanch, that means it's only the superficial vessels that are involved. So it will be the episclera only. And so episcleritis in terms of investigations, once we've done the phenylephrine drops, um and we're quite confident that it's episcleritis, then we don't usually do anything. Um If the patient complains of recurrent episcleritis, then we can do a systemic workup. That's again, the full bloods, um talking to rheumatology or doing some um further investigations to see if there are any other underlying causes. But um as it's very superficial and it's just inflammation of the um top blood vessels. Um Usually we don't actually do anything for episcleritis. We may give them supportive management. So give them some artificial tears that may help with the some of their symptoms. But um generally nothing else. So the difference between episcleritis and scleritis again, um episcleritis will not be, will not have that blue hue and the vessels, the redness will go away. If you give the red, the phenyl ephrine drops in scleritis, it is quite blue. Um The redness is more diffuse and the vessels won't go away even with the drops. Um So this is just summary table for your revision, just comparing the two. Um And yeah, you can just look at this in your own time, it's just the same as we just talked about. So, in terms of uh red flags for red eye, um all of if you see any of these symptoms, um then all of the first line management really will be an urgent referral to ophthalmology. So if that is an option in your S VA S, it's quite an easy way out. Um So any kind of severe eye pain, pain with eye movements, sudden changes to the vision, um pain on light, um bulging of the eye, any changes to the pupil, so mid dilated in acute angle closure, glaucoma, um or um and irregular people in anterior uveitis and any history of trauma or chemical exposure where we're not sure what the damage is behind the eye. Um Then these are all red flags for urgent referral to ophthalmology. Um So hopefully this is an option in USPS. Um And I've just created this table. Um I know it looks quite overwhelming, but I was trying to fit it onto one slide. Um But you can look at this in your own time. It's just a summary of the most common causes of red eye on the left and then the um buzzword symptoms, signs investigations and management. Um for those. So yeah, feel free to look at that on your own time, print it off, turn it into flash cards or like, thank you, whatever you do. Um Yeah, great. So now we're just moving on to the second type of presentation which is sudden, um, vision loss. So I'll just give you this new scenario and then we'll um start the mentee. So you were the f one on your general medical rotation. You've been called by the nurses to review 34 year old Ian Jones who's complaining of sudden onset vision loss that happened this afternoon. You've never met this patient before. So you don't know anything about his background, but as you're approaching him, you need to start thinking of some differentials. So if you can in the mentee, please, um just list as many causes of sudden vision loss as you can. Ok. Really good. We've got a lot of good answers coming in. Um Again, I'm not sure if you can actually see them on your phones. Um So some of the common ones are retinal detachment, stroke, optic neuritis, um different sorts of hemorrhage, uh trauma, I suppose. Um Central retinal vein, occlusion, central retinal artery, uh occlusion. Ok. Really good. So these are really, really good differentials. Um And you've mentioned some of the most um concerning or common ones. Um So good job. Um So we'll start off with the first case. So when you go to review Ian, he says that he suddenly lost his vision this morning and it was like a curtain that came over his eyes from the sides. He mentioned some flashes of light just before he lost his vision. He's usually very fit and well. Um, and he says the only thing he has is um, a bit of hypertension, but he thinks it's quite well controlled. Uh on examination, Ian's really distressed and he's very upset because he's just lost his vision. Um And on assessment of his vision acuity, you can see it's much, it's quite reduced. Um and he has quite reduced vision in the center of his visual fields. So, for Ian, what is the most likely diagnosis? You'll be 30 seconds to answer, go back to the history as well. Oh OK. Um Really good job. So everyone or almost everyone got the answer correct. So the answer is retinal detachment. Um that's amazing. So I always find these conditions quite hard. So um we'll just go into retinal detachment. So this is an acute or progressive condition um where the neuroretina. So the nerve um fiber layer of the retina separates from the retinal pigment, epithelium. And you also then get some fluid that accumulates between in that space where there shouldn't be any fluid and that causes loss of function of the retina. So you can see on the diagram in the bottom, right? Um how this will look. Um So the retina retina has detached from the RP. Yeah. Um this is caused for a number of different reasons. So um the fluid can accumulate under the retina either because of a break in the retina um due to tractional issues. So, when the, there are membranes which pull on the retina and it pulls it away from the R pe and a common cause of that is diabetic disease. So, the neova neovascularization causes this extra pressure on the retina. Um and the third most common cause is exudative. So you'll get this accumulation of subretinal fluid due to infla inflammation. So, any conditions that cause increased inflammation like sarcoidosis, myeloma or choroidal neoplasms. Um Common risk factors for uh retinal detachment will be posterior vitreous detachment as that falls on the retina, increasing age. What do you want me to get previous cataract surgery? Um So common symptoms. So, um the most common uh thing you'll see in ps will be a sudden vision loss and it's, it will be described as a curtain or a veil descending over their vision. They also commonly get these flashes and floaters as the retina is pulling away. Um You get a lot of different light um hitting the retina at different points and you get these flashes. Um on examination, there will be reduced visual acuity and there'll be reduced vision most commonly in the center of the of the eye. But also you can get it peripherally as well and that just depends on where the retina is being pulled, investigation. So, um we'll do a slit lamp examination and commonly do an ocular ultrasound scan. Um But the best investigation to do is an OCT scan. So, ocular coherence tomography. And that will show you the retinal detachment. So you can see that on the top right here. Um This is the retina and it, it's been pulled away from the RPE. Um So you've got this new gap um where there shouldn't be space, it should be um following the same shape as the rest of the eye, this downwards curve in terms of management. Um Again, this is an emergency in terms of ophthalmology. So it needs urgent referral and the common um surgical repair will be to do a vitrectomy. So that is where we get rid of the vitreous um layers. So we kind of take it all out and then we replace it with a new artificial vitreous and that pushes the um retina back into place. So we kind of replace this fluid, push it back into place with the new fluid. And um we also need to look at any underlying causes of why the uh retinal detachment happened. Um If it is sedative, then there will be an underlying cause. So um we'll need to optimize any BP or diabetic control if they have those diseases. Um If there's any infection causing it, then to give the appropriate antibiotics and then inflammatory conditions that we would give any topical or systemic steroids. Um So most importantly, uh investigations will be an oct scan and management will be vitrectomy uh to repair and push the retina back into place. Here, you can just see um how retinal detachment looks. So it should be this red um color. Um But the retina has pulled away um in this top corner, um that is now pushing this. So it's making the bottom half quite hazy and difficult to view. Um And then, um here, it's quite abnormal. Um You can, that's where it's been pulled away. It hasn't got the red here anymore. So, moving on to the next case. So um this time when you see Ian, he reports sudden painless loss of vision in his left eye, he does have some blurred vision and it's quite everything looks a bit distorted. He says again, he's usually quite fit and well. Um he just has some type two diabetes and high BP, but he says all his friends have that and they didn't lose their vision. Um On examination, Ian generally looks quite well. Um His visual acuity is reduced but it's in the left eye, but it's normal in the right eye. When you do fundoscopy, it looks like this on the right. Um And you can see retinal hemorrhages in all four quadrants of the eye. So very, very disperse um hemorrhages. So just moving on to the mentee, I question is what does the fundoscopy image show. So you've got branch retinal vein occlusion, central retinal vein, occlusion, branch retinal artery occlusion, amaurosis, fs and central retinal artery occlusion. No, they all sound very similar. OK. We've got quite a split here. Um Majority of people or just about have gone for the um correct answer, which is central retinal vein occlusion. Um But we've got a few, we've got quite a few people voting for retinal artery occlusion as well. So we'll cover both today and then hopefully you'll know the difference between the two. So central retinal vein occlusion um is interruption to the normal venous drainage from the re retinal tissue due to occlusion of the central vein. This happens in um most commonly people aged over 65 and um people with the typical sort of cardio cardiovascular risk factors. So, cardiovascular disease, type two diabetes, smoking, high cholesterol, anything that causes increased risk of cardiovascular disease, um you're likely to get um the retinal vein affected as well. So the c central retinal vein can be blocked either due to embolus thrombosis or ischemia. Um and it'll be part of the investigations to see um why this, why this has happened. So, um patients will present with a sudden painless vision loss and they'll have reduced visual acuity but minimal other signs. The most common um appearance on fundoscopy is that sort of pizza pie description. So, um a lot of BS will mention it and describe it as a pizza. So it's just very diffuse retinal hemorrhages kind of looks like pepperoni um like a yeah, pretty much just like a pizza. Um And that's just all the retinal hemorrhages that are formed because of the uh blockage of the retinal vein. Um You also commonly see these cotton wall spots and um quite tortuous retinal veins because the central one is blocked the the flow to all the other veins. It's uh from the other veins is all quite blocked. The investigation that we do to investigate any kind of retinal vein or artery occlusion is a fluorescent angiogram and then we can see the flow within the ve vessels and see where um there is a blockage. Um If the, if the patient seems fairly uncomplicated, then usually we can just observe and control the patient's risk factors and um not have to do too much more. This usually does um resolve by itself. It can be quite worrying for the patient. Um And also for you because they've, they've got a sudden vision loss, but it's painless. Um and this does usually resolve, but it does depend on the uh on the diagnosis. Um If there's any macular edema involved, then we would manage that uh as well. Um by giving some intravitreal vegf inhibitors. So these are some injections which um slow down the rate of new uh which will um slow down the rate of new vessels forming and then stop the macular edema as well. And for the neovascularization, we can also um yeah, we can also do this procedure called panretinal photocoagulation, which is where we use lasers that um are blasted at the uh all over the retina and that will stop new vessels forming as well. So generally for crv O, you get this pizza pie, um retinal hemorrhage, uh diffuse retinal hemorrhages. Um And we generally just observe and control the risk factors. And the other common um answer that everyone put was um central retina, central retinal artery occlusion. So this is very similar to um what's happening in vein occlusion. But instead it's the central artery that's now blocked. So again, it can be blocked for embolus, thrombosis or ischemia and has the same risk factors because um the same things cause blockages of arteries. Again, the patient will have sudden pen vision loss. Um But on fundoscopy, you'll get this very, very significant and specific um retinal pallor because you've lost supply um to the majority of the retina and you'll get this um cherry red spot at the fovea because that's where you are getting the blockage. Um So if you see cherry red spot men in retinal pallor, then it's very, very likely to be red, central retinal artery occlusion. If it's the pizza pie on fundoscopy, then um vein occlusion, um investigations are the same. So we'll do a fluorescent angiogram. So we'll see the flow of the blood i in the eye and then we'll see where the blockages are. Um But what's more, what's um significant for c is that we need to urgently evaluate this patient for query of any stroke that may have happened and may have caused this. Um management also includes a firm ocular massage to try and dislodge any embolus or obstruction to the retina. Um As because we've lost supply to the retina, um It is very critical um that we try and unload it as so dislodge it as soon as possible to prevent um vision loss. We also then um we either give um acetaZOLAMIDE to lower the BP to lower the intraocular pressure. And then we'll also give um hyperbaric oxygen which can dilate the arteries cause vasodilation and then um improve the supply to the rest of the retina. And um this is quite critical so that we don't um cause blindness in the patient. But most importantly, we'll also have to just address any underlying causes, find out why the patient got the embolism, thrombosis or ischemia in the first place. So, hopefully, that makes sense. Um And you can see that the fundoscopy images are quite different between the two. Even though the presentation is very similar, they'll have the same risk factors, same symptoms. Um It's just the fundoscopy that helps tell them apart. OK. Moving on to the third case. Um We've got Ian, we're nearly done, by the way. Um We've got Ian now who's reporting sudden loss of vision, but he's not in any pain. He says that he sees some cobwebs and floaters in his vision, which are quite new. He's known to the diabetic eye clinic for management of his diabetic retinopathy and on examination, this is what you see under the slit lamp. So, in the S pa um on mentee, so what does the fundoscopy image show? So we've got branch retinal vein occlusion, central retinal artery occlusion, amaurosis, fugs, vitreous hemorrhage or retinal hemorrhage. OK. Um Again, we've got quite an even split. Um but most people have gone for the correct answer. So, vitreous hemorrhage, so all done. So, vitreous hemorrhage um is leakage of blood. So, hemorrhage into and around the vitreous humor of the eye. So the jelly like portion of the eye, um that's the part that we remove in uh retinal detachment. So the same sort of jelly. Um this is mainly seen in people with quite poorly controlled diabetes. Um patients with any trauma that can cause hemorrhage. Um There are increased risk as well of bleeding if um they're on any anticoagulation, antiplatelets or um have any bleeding disorders. So that leads them to increased risk of uh severe significant bleeding within the eye. Um Most common causes will be that uh patients that have proliferative diabetic retinopathy. So, because they're creating a lot of new vessels, these are quite fragile and quite um prone to breaking, um which can lead to um hemorrhage within the eye, also, posterior vitreous detachment and ocular trauma, as we mentioned. So, patients will complain of the sudden painless vision loss. Um because of the hemorrhage within the jelly of the eye, often they'll have quite a red hue to their vision. Everything looks a little bit um tinted like a filter on their vision. Um And they'll have these new floaters shadows or cobwebs because of all the blood that's moving around in the eye that does distort the um vision and the, the rays of light hitting the retina. Um If the hemorrhage is large, then I'll have quite reduced uh visual acuity or visual field defects. But usually this isn't really seen. Um Unless the uh the patient is on these kind of has uh reasons for increased bleeding investigations. We do so on. Uh Again, the mainstay is usually just fundoscopy. Um but we will also do a ultrasound orbit and a fluorescent fluorescent angiography to see again. Um um what's happening with the vessels themselves management. Um If we do know what caused it, then we usually just manage the cause. So if it's proliferative diabetic retinopathy, then we know we need to go down the diabetic treatment um route. So um we'll go into that in a bit. Um But if we don't know the cause, then um the easiest way to replace, uh to treat this is to replace the vitreous humor. So we'll again, get rid of all the vitreous jelly and then we'll replace it with the synthetic artificial version, which is clear and doesn't have the blood in. Um ideally, this isn't um ideally we don't do this and we try and treat the cause. But most often we don't know why the patient has got a vitreous hemorrhage. Yeah. Um I think this is the final case for vision loss. So um we've got Ian now who's reporting a loss of vision in his left eye, which started four days ago and deteriorated. He's not happy in the consultation because his eyes really hurt to move. He's quite a keen painter and he's concerned that his ability to differentiate paint colors has been poor. Recently, on examination, again, he's got reduced visual acuity. Um But you do notice that he's got a relative afferent pupillary defect in the left eye. Um when you were performing your cranial nerve examination. So which nerve is most likely to be affected? Ok. Um Most people went for the correct answer, which was a the optic nerve. Um the other nerves are involved in the movement of the eye. Um But optic nerve um is affected in optic neuritis, which we'll cover now. Yeah. Um So optic neuritis is inflammation of the optic nerve. So this happens either due to demyelination. So, um usually with a background of multiple sclerosis or due to inflammation or immune mediated damage to to the optic nerve directly, patients will present with this sudden vision loss, eye pain worse on movement. But what's quite specific for optic neuritis is this reduced color vision or perception? So, um if you remember the um pneumonic afro that you use for um testing the cra the second cranial nerve, then um you'll know that uh the color vision is um is what's affected. Um So you also get this rapd. So that's when we do the swinging light test, we see that the pupil is quite slow and it looks like it's um dilating when you're shining the light on the eye. Um and that will be in the affected eye where the optic neuritis is, you also have reduced visual acuity and this red desaturate desaturation. So the red, uh so the um uh loss of sensitivity to looking at um between red colors. So the reduced color vision investigations, um the most common one we do is an MRI brain and orbit to look at any demyelination that may be occurring. Um as we're usually suspecting MS when we see optic neuritis. Um and then we uh also do um an investigation called vision and evoked credentials and that just um looks at the nerve conduction of the optic nerve. And then in that, we'll see that it's quite delayed. Um patients that are most likely to get optic neuritis uh are the same risk factors as those for multiple sclerosis. So, age 30 to 50 female sex, white ethnicity. Um and separately, it may, they may have had a recent viral infection which which may be causing inflammation to the optic nerve. Um So, management for optic neuritis. So, um this requires an immediate ophthalmology, referral due to the risk of blindness and um the patient will need urgent IV steroids. So commonly, it's methylprednisolone. Um there'll also be um considered for um treatment of MS. So, with natalizumab, um but that will be under the neuro team. Um So, most importantly, the uh the management will be IV methylprednisolone and an immediate referral. Um So, again, just remembering what's significant for optic neuritis, it's that reduced color vision on top of the vision loss and the uh RA PD, these are very specific for the optic nerve itself being in uh being affected or inflamed. Ok. So, um these are just again, just a bit of a summary of the five conditions you just mentioned for sudden vision loss. Um If you cover these, um then you should be fine for the exams, but there will be a few more as well um that are probably on the curriculum. Um But yeah, just remember these main ones and then um the key fundoscopy findings for each of them. Finally, we've just got one or two cases. Um but um not really many questions on gradual vision loss. Um So you are the F two in the Ophthalmology clinic. Next on your list is a new patient, primary call who's been referred for um gradually worsening vision. Um She has a past medical history um of type two diabetes, hypertension and hypothyroidism. And this is what you see on your slit lamp examination. Just give you a second to look at that. So um for the next SB the last SB, how would you classify this retinal image? Um So I know this is a lot of words, but just which stage of diabetic retinopathy? Um do you think this is based on the fundoscopy on the ment for NP for nonproliferative and D alpha diabetic retinopathy and um PDR for proliferative diabetic retinopathy. Again, this is quite hard. Um And II don't know if this is bigger um but it, it will be easier in real life on your ipad because you can zoom in, you can amazing. So, um majority of you got that correct. So this is proliferative diabetic retinopathy with macular edema and we'll go into the staging of diabetic retinopathy. Now, so, diabetic eye disease um is a macro microvascular retinal damage, which is a complication of either type one or type two diabetes. So, risk factors will be um the length of time the patient has had diabetes for. So the longer the pa, the longer the diagnosis, the more likely they are to have diabetic eye disease. Um patients with a very poor glucose control, um smoking cardiovascular disease and pregnancy um because pregnancy exacerbates um diabetes. So what happens in diabetic eye disease is you get this hyperglycemia which damages the retinal capillaries. It causes microaneurysms, neovascularization and fluid to build up in the eye. Um and this causes the symptoms um mentioned um though the pa patient is usually quite asymptomatic until the late stages when they start noticing this blurred vision, um maybe diprop here um and just small subtle visual changes which they may put down to old age. Um So the main way we check this is with fundoscopy. So we would usually do fundoscopy screening for patients with diabetes. Um and you see microaneurysms, hard exudates, cotton wool spots, intraretinal hemorrhages and macular edema. And I'll go more into that in the next slide. So in terms of the investigations, um we just do fundoscopy for monitoring and if we are suspecting any macular edema, then the best investigation to do is an oct scan so that there you can see any fluid build up under the retina um management. Um If we are querying vision loss, then you would urgently refer to ophthalmology as it may be quite late stage. Um But otherwise, um this is usually managed in clinic. So um the two main stay of treatment. Um so for proliferative diabetic retinopathies are when we see new vessels forming the neovascularization, the main treatment is the panretinal photocoagulation as I mentioned before. So that's the shooting with the laser to stop new vessels forming um with the diabetic macular edema. So we see fluid build up um at the optic disc. Um then we'll give these anti vegf injections. So commonly it would be run in biz or Bevacizumab. Um But you can also give um any um injections and accept and these are the anti VF injections. Um You only give these if we're suspecting macular edema. So the staging of diabetic eye disease. So, we've got mild, moderate, severe proliferative and then finally, this leads to vision loss. Um And until it's quite severe, we don't actually have any clinical symptoms. Um So in terms of what you're likely to see on your, in your exams, um are these kind of buzzwords which are very common in diabetes. So, um first you start off with these small microaneurysms that start forming and then you get these specific hard exudates, which are these um solid white um deposits in the eye. Um You also get these cotton wool spots which are um a lot more fuzzy and they do just look like yellow cotton wool and in severe diabetic retinopathy, then you'll start seeing these hemorrhages form, they won't be complete, they won't be as dispersed as we saw before. Um But in um diabetic retinopathy, you'll start seeing these spread slowly around the eye. And then finally, in proliferative diabetic retinopathy, you'll be looking um around the optic disc. And also you'll just be looking for any kind of new, small short blood vessels that start branching off any existing blood vessels. And that's because of the ischemia. You're getting um in diabetic retinopathy due to the damage. And so the body responds by producing new vessels. Uh these then can worsen the hemorrhages as the new vessels are quite fragile. Um And then over time, this um proliferation causes vision loss. Yeah. Um The only other thing to mention is that we also look for diabetic macular edema. So if we see swelling around the optic disc, so the margins are quite blurred. Um then we know we've got macular edema and that uh straight away puts it into quite a significant um worrying um stage even if um it's only moderate deal com when you look at the components that are involved. Um So here you can see that the disc margins were quite blurred. So that's why um we said that it was um it was macular edema and you can see all the features here. So the heart exudates, the coal spots, the um retinal hemorrhages, um new vessels forming. Um these are quite hard to see, but you can just see small branches coming off the main vessels um and the edema. And finally, we've just got hypertensive retinopathy. Um So this is the other form of microvascular retinal damage, but instead of diabetes causing the damage, it's um the hypertension. So the hypertension causes damage to the retinal vessels. And, and again, it's very asymptomatic until the late stages where it's blurry. So this is usually picked up on screening for patients with hypertension. Um The current guidelines I think are to screen every five years. Um But um if the patient has already been uh picked up for hypertensive retinopathy, then they may have more regular screening. Um risk factors are the same. So just anything that causes kind of cardiovascular um disease or hypertension will um they'll also be at risk for hypertensive retinopathy on fundoscopy. There's significant um signs you'll see of the arterio arteriolar narrowing, copper, wiring, um av nicking and again, you'll get these cotton wall spots and disc swelling and the hemorrhages as well. Management is this uh investigation sorry are the same. So we would look at fundoscopy to keep monitoring the stage and also do an CT for suspecting edema and fluorescent angiography uh to look at um more detail at the vessels management though is very simple. So um first line will just be to improve the BP control. Um So um following your usual hypertension um management guidelines um and increasing the management, we'll also monitor and treat any underlying cardio risk factors and um send the patient for ophthalmology review regularly to monitor the progression. So, um I've just put this summary slide in um to for your revision. Um And this just explains what each of the um signs you see on hypertensive retinopathy and why they are um why they are happening first stage. Um Grade one is you'll get this arteriolar thickening and these increased reflectiveness, which is the silver wiring. So um that will be the kind of bright looking vessels um on fundoscopy because the they have become thick and they reflect more light. Grade two is um on top of that, we start getting this nipping. So at the, where the vessels cross, you'll start seeing that they come in a little bit. Um And that's because of compression of the veins and um atherosclerosis. Grade three, you'll start seeing some um signs of retinal ischemia. So that will be the hemorrhages. Um and the cotton will exudate and then in grade four, you see papilledema. So if you are suspecting grade four, the first thing to look for is papilledema, it's the easiest thing to spot. Um It means you don't have to find the other um signs. Um And again, this is just a de this is just taken from zero to finals. So it's just a better diagram of what's uh of what each of the signs are. Um And it shows you the A V nipping here. Um the silver wiring which are the bright, the brighter vessels, the hard exudates and the papilledema. Um So, yeah, I think that's everything. Hopefully this QR code works. Um This is just for the feedback form um which I would really appreciate if you um filled out. Um But otherwise I'm happy to answer any questions. Amazing. Thank you so much, Serena. I, I'm gonna add the link to the feedback form in the chat as well. OK. Hey, um thank you so much. Uh This has been really helpful. I was wondering if you could just go over the um what the hypopyon and the posterior synechia bits are again. Yeah, sorry, I just muted. Um Yeah, let me just go back to those slides. OK. Um So the hyperion and the posterior si that's uh that you mentioned. Um they're quite, they're in, they're seen in anterior uveitis. So, posterior ane specifically are, are specific to uveitis. So if you do see those forming, um then you can straight away say that this is uveitis, they happen because um of adhesions um due to inflammation, um the we get this um autoimmune inflammation that causes inflammation of the um at the iris. And then you get um these um adhesions that start forming between the iris and the lens here that um these are responsible for that change in eye shape that you can see here. Um And you can actually see the posterior Sunni eye here that's kind of pulling on the um iris and then causing the people to have this irregular shape. Um in severe um anterior uveitis, we may also get this thing at the bottom um called a hypopyon, which is this white um deposit and that's just all the inflammatory cells um in the anterior chamber. Um When it's quite significant inflammation, you've got white blood cells, you've got cytokines, you've got enzymes, all these inflammatory cells um as they clump together, um you will see this um them forming this deposit called a hypopyon. Um This is usually just seen in severe anterior uveitis only. Um I hope that answers your question. Yeah, it does. Thank you so much. No worries. Uh You can feel free to message me. Um II put my email at the start of the slide, so they'll be on the slides as well if you have any other questions and I can also send some resources um if you're interested.