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I love how it makes such a big announcing A swell every time does that? Okay, then we kill. Everyone is joining. Hello, guys. Good morning. I hope you're all okay. I think that's pretty much everyone joined. Now, just about a few more moments. Okay, that's lovely on. So good morning, guys. I hope you're all well. We have a doctor. Um, you know, go along with those today who is a consultant ophthalmologist, and she'll be doing elector for us on the back of the eye. Now, just like no, this will be quite an interactive Hopefully. Lecture is well and very case based. So and you can answer questions throughout. Ask questions as well. Every time you want to answer a question or even ask a question, just raise your hand using the function on Zoom, and then I'll have requested review or hop your answers in the chat box on day and we'll read them out. So yeah, if you have any questions as well, just put them in the trap box, and we'll make sure that we try and answer as many as possible. Possible. We'll see you. Thank you. So, um, as you can see today is about the back of the eye on, but, um, we're going to basically go through some common conditions affect the back of the eye. Obviously, it's not exhaustive. It really is just to kind of cover things that are more likely to kind of come up for finally a medical student. Um, sitting exams. Um, and what you would use know is a junior doctor, I guess on so hopefully will be touching specifically on some of the kind of causes of blossom vision that happened because of something to do with the back of the eye. The end of the presentation actually goes through some examination techniques. Such a special feels to confrontation and off. Um, oscopy. I'm not sure if we'll have enough time for that. So let's just play it by ear and see how we go. Hopefully gets released to pick case based discussions. So, um, you hear that? You just see. So it's, uh start with diabetic retinopathy. So diabetic retinopathy is, uh, used to be actually the commonest cause of of, um, register bulb blindness in the United Kingdom until about 2006, when diabetic retinopathy screening was put in place, and so it just makes little bit UK based. But I suspect that across Western Europe similar things would have been happening. And so by about 2009, because of the success of screening people for retinopathy, everyone, that's the type to a type one diabetic. It has meant that some of this reversible blindness has been avoided, and it's no longer the leading cause of of registered will blindness. But it still comes up high in the list of cause. It's so he get Hopefully, some of you. When you have some time, we'll go through the D. C. C T in the UKPDS trials, either. Very, very, you know, more than 20 years ago. But essentially they just showed that people who looked after their risk factors such as, um, you know, that their sugar control, but also things like BP and cholesterol control and so on, and blindness was significantly reduced in those patients. So looking after risk factors, looking at your sugar definitely helps you to not go blind if you're diabetic, right, starting with this one. So we have Mrs Patel. She's 59 years old. She's been referred to the eye clinic, um, from the screening service. And basically she's asymptomatic and she's been diabetic for about 10 years. She takes various times. It's just you conceive for her diabetes, but also a statin on day thing to lower BP. So can I get someone to volunteer? Just describing what you see. Anyone you can feel free to, either raise your hand or arm you yourself. You can even yeah, if you have any. And and so she put in the chart boxes, Well, but preferably someone to amuse themselves and speak would be amazing. It's just it's just just to describe what you see that this simply is that you, you know, need to sort of talk about diagnosed to do anything. But just describe what you see. You picture in front of you. You're finally a medical student, and you're just describe what you see. Okay, I spoke to on the diet. The buck? No. Okay, so I'm gonna help a little bit. So just to kind of get us started. So if you're describing a photograph like this, you would start by saying this is a color funders photo bar on. We would say this is a fun this special of the right eye. So this is, uh we know it's the right time because the optic disc is on this side, and then you have the retinal blood vessels, the thicker blood vessels of the veins and the thinner ones are actually the arteries. This central part of the retina is called the macula area. Just so you'll are familiar with what we're looking at. This is a a color funded photograph of a right eye on. But I had to describe what I see. I would say that I can see some maybe some dot or blocked hemorrhages, and I can see something here, these white dots. And if you knew what the year you might say that they may be exudates and they are out in but near to this central part of off the back of the eye, which we pull the macula area does anyone over the central parts and macula is called phobia bovie A. Exactly. And that's your central point of vision, so encroaching on on the phobia, but not not quite there. But that's what you see. And okay, so what? Based on the history that we just heard What? What? What did he needs? Changes represent. Well, these. So this is obviously diabetic retinopathy. Okay, So is there anything else you want to know about her from her history? Anyone? So you're seeing him in clinic on D? Um, you know, you've just seen this photograph of the back of her eye. Um, you know, she's been diabetic for 10 years. What do you do? Anything you want to know? Anyone, like, what are the medication that she's on? Uh, although she's told us what she's on four medications. Which two? The diabetes, one people pressure and one for cholesterol. Would you want to ask or other complications whether she's had any other complications? Yeah. I mean, so some of the things you might want to know just looking at because you just got a picture in front of people where you probably one knows what's her vision like, um, is this affecting your vision? That's kind of important. And the other thing you might want to know about is what has her diabetic control been like recently? What's the blood test that we do? Um, that gives us an idea of what sugar control's been like over the previous 2 to 3 months. That is a glycated. Yes, that's right. Like a kid like ated eso the HBA one c basically on. That gives us an idea of of, of whether somebody's sugar control has been good or not so good. Um, and if somebody's sugar control hasn't been so good just based on what I've already told you, you know that poor sugar control will likely lead to problems at the back of the eyes. So what? How would you describe this is obviously some diabetic retinopathy. What do we call it when the retinopathy is near this macular area? What do we say that is? So this is diabetic macular. Um, and does anyone? Maybe this is too much, then placed, um, Got so far. But do you think she requires any treatment to this? This maculopathy. Does anyone have any any thoughts about that? So, basically, as I said, it really depends on what her vision is like. And nowadays, ever more when they're seen in the I, can we'll have something called, um Oh, CT scan, which is a scan that gives you a cross section through the central part of the back of the eye and gives you an idea of whether this thumb swelling there some a Dema. So these are actually these exudates around little micro aneurysm cycle almost excess in its And this is this is basically a form of diabetic macular edema on do if it starts to affect the vision that that the patient might need treatment. But there are some some long standing definitions of what clinically significant macular edema is. Has anyone heard of clinically significant banking or demons? Anyone know anything about that? Okay, I'm gonna move onto the next one, so we've got Ms Blog's. She's 26 years old and she's been a type one diabetic since the age of 12. How HB a one c was 9.3%. Does anyone know a normal HB a one C years? A little. At least. They know my range should be from four point 6 to 6.0. Yeah, it was over 6.5, and you be worried if it's a little diabetic, that's probably going to be over 6.5%. But, you know, you should be aiming to kind of keep it less than I guess. 7% less than 7.27 point 39.3 is clearly high. Um, now she is four months pregnant, and she's presented to our casualty with sudden onset, painless loss of vision in her right eye. Her vision has now gone down to 6/36. Is everyone familiar with checking vision? Does everyone know what sticks over 36 means? What's normal vision? So there's different ways of checking vision, and we do it through the Log March shot or the smell in chart. The sound shot is an old shot that's used, you know, throughout the world and basically, um, in the east and in the West. And what that means is what? It's what you can see. It's 6 m. The six out of six would be normal vision, and six out of 36 is You can see, um um at 6 m. What? Somebody and with normal mission would be understeer 36 m, so that's basically you know. Okay, so, um, the next thing we got is this picture of the funding off Left eye Can Somebody described what they see for me? You need to give a diagnosis. That It's just about getting used to describing. Describing what? You see any any any, uh, any takers Is the stool color fundoscopic Um, here was he, um I'm not entirely sure it's the left eye. So when the optic disc is on the left like this is the left eye, and when it's on the other side, it's the right time. So what do you see? So there's a couple of blotches. Um, Andi Also the color different side, the pale, paler yellow type. Yeah. Yeah. So what we see here, this is the optic disc, and we have rational blood vessels that come out here in here, and we see the kind of a hint of some blood here. Actually, it's not clear cause it seems like it's a bit blood, but there's clearly blood in the funders somewhere. Um, and here we see some powers. You said some pale, which could be cotton wool spots, but it isn't very clear at all. And then there's this white stuff here is actually five breasts scarring. And here we have a feature which is basically typical of what we call proliferative. Restless, rested retinopathy. What we have is new vessels else west. These are new vessels have formed on their four. This patient has proliferative diabetic retinopathy. So why do you think her vision suddenly dropped? Says right eye that she left. So why do you think her vision suddenly dropped? But I actually saw it in her right eye. The pictures of her left eye. But why do you think the vision suddenly dropped based on what you see in the first girl? What happens when you have rest? Not be this And this at this level, when it's proliferative, Retinopathy needs anyone Know what the risk is? What can happen? We have ischemia in the chat. Yeah. Anything else? Anyone have vision? Loss? What does it mean when you got proliferative retinopathy? What is it? What is prolific? What is proliferating? New vessels. We have an attack? Yes, exactly. On These new vessels aren't like normal platelets. Were there a bit like weeds? That kind of grow is anyone know why they wrote? So they grow because there's a scheme yet I think sort of already answered the question. In a way, what happened is when you're diabetic, your sugar is not controlled. And when the sugar in the blood is up and down over time. That causes damage to blood vessels and particularly the small blood vessels. Our smallest blood vessels are at the end of our organs. So eyes are brain kidneys, our peripheries. And that's why diabetic people with, um, vascular damage. It's about microvascular damage. Usually they get neuropathy, they get right in opathy. They get, um, renal disease. They get skimming disease in their brain on on their coronary arteries. They're small end blood vessels that basically can get damaged. Whereas we can't see our blood vessels in our kidneys. Our our brain, The thing about the eyes is we can look into the back and see the rational blood vessels. So that's the big difference here. And if you seeing retinopathy that's advanced, you've always gonna worry about the rest of their body because this is what you can see. God knows what's happening with the bits that you can't see. But essentially here. What happens is that when blood vessels get damaged, initially, they leak. So earlier on that first picture I showed you with the lady with back to diabetes has a milder form of retinopathy where earlier damage to blood vessels causes them to leak, and the leaking causes these exudates and the micro aneurysm since, um, site, sometimes some a demon. But when there's damage that's been recurrent and the I know it tries to heal itself. But those blood vessels become permanently damaged, they start to close off, and if blood vessels start to close off, then you get a skin here because you've got a lack of blood supply to parts of the back of the eye. And if that happens, then there is a stimulus to actually basically grow new vessels. So you get proliferative retinopathy on. The problem with the new vessels is, As I said, they're a bit like weeds or a bit useless. To be completely honest with you on, they start to grow often on a kind of scaffold of fibrous scarring. The problem with it is the fiber scarring is stuck down to the retina on this big, and these blood vessels are very fragile and it starts to pull and you can get what we call a vitreous hemorrhage so we don't have a fund. This photograph of this patient's right I probably because there's no view of the fun this because it's full of blood. I'm just by looking at the back of the left eye, we get an idea that things are probably pretty bad because you've got near vascular activity here, new vessels elsewhere. So you. Sometimes you get new vessels of the optic disc or new vessels elsewhere. And if you see that anywhere on the disk or anywhere else in the in, the rest of them, you've got a proliferative retinopathy on with fibrous scarring. It tells you it's been there for some time, and also you've got a little bit of blood up in the corner here, which suggests that maybe there is some bleeding, fortunately, hasn't completely obscured her vision in the left eye, but you know, it's it's obviously affected the vision in the right eye, and you get in the, you know, acute bitterest hemorrhage. So her vision's drop suddenly in this case, and this patient is pregnant. Does anyone think that that's of any any significance in anyone? Offer what they think Is that significant on not significant anyone anyone that we have an answer in pad glucose metabolism during pregnancy? So it is a significant Yeah, exactly so this is the thing. If you're a type one diabetic and you become pregnant, it's really important that you have your eyes looked at during every trimester. It you know, your chances off developing really, really progressive retinopathy. Especially, for example, if we start off with multiple modern, moderate non for lifting retinopathy. Your chance of becoming severely non proliferative or even proliferative is is high, especially if, for example, your HBA one C at the start of pregnancy was close to 9%. So what do we do when you've got a proliferative diabetic retinopathy with the vitreous hemorrhage? What are our options for her? She's come to casualty. She's lost the vision in one eye. The left eye looks pretty bad, too. Any any ideas of what kind of treatment we do for her advanced level of retinopathy. So in the chart, we have anti V E g F injections from suprep elation because of this year old personal, those coagulation. So she wasn't pregnant than anti progestin? Probably a good idea, but you would want to be very cautious and somebody that's pregnant with drugs like that. But absolutely panretinal photocoagulation. Does anyone understand why you would want a laser, the periphery of the back of the eye. So I explained that we have this thing called ischemia that needs to be. It's actually very jest that's in the eye that's stimulating the production of new vessels. So in order to shut that stimulus down, what we're doing is basically reducing kind of surface area that needs a blood supply to hopefully enable the blood supply that is present to be enough to to supply that. It's almost like sacrificing the proof arrested, uh, in order for us to maintain the bit of the retina that we really need to be able to see on a day to day basis. So it's quite harsh treatment when you think about it. But is the heart situation this is advanced in a proliferative retinopathy? The patient, this patient where the right eye has developed a vitreous hemorrhage? Uh, unfortunately, no view of the back of the eye here, so you probably would want to festival. Do something like an ultrasound scan. Make sure the retina hasn't been pulled off by a lot. Fibrous tissue that's probably their on beckoned, really, to see if if the blood starts to clear if it starts to appear on its own after a few weeks and immediately as soon as you can. You want to get lots and lots of laser on to stop this stimulus to be having active vascular proliferative retinopathy on. But if if if that doesn't happen, if the blood doesn't start to clear, you might be thinking about basically taking the patient to the operating theater to to have the blood removed on Ben have later in theater. But you also want to be thinking about the other eye that hasn't maybe had a Twelvetrees hemorrhage yet to think about doing immediate plan. Rational photo calculation for that, the left eye to rent that hopefully from developing a vitreous hemorrhage in we even worse than Richard Simmons with retinal detachment. So here we have a little bit of a classification. You can develop maculopathy, and you can develop a more powerful retinopathy, which can be non proliferative or pre prefer table proliferative. These days, we tend to sort of describe it as all one are two or three when it becomes proliferative and em note for em. One maculopathy and M one is when there is maculopathy in M zero is when there isn't so Treatment says, as somebody's already alluded to does include antibody Jeff injections and sometimes steroid implants. But laser treatments is still used also. So we just got some examples here of diabetic retinopathy on, um, conscious of time. So here's some example of Mike Mike Rowe aneurysms, which you may know obviously see is as that you see them in this diagram here but on a fun this protocol, they don't like dots basically on. Do you content with a leak? You can get these these these white dots around them and those are your exudates. And when it's in a sort of layer of white dots all the way around a red dot in the middle of school desserts in it, um, so here we have a next couple of that. So this and little micronization is actually some blocked hemorrhages as well. These are bigger hemorrhages. Micronesian said to be tiny dots, and this is right, actually in the macula area. So this is clinically significant. Macular edema visas, Um, on X two days, and of course, nowadays we really tend to rely a lot on on oh CT scan. So I'm not sure if any of you see no CT scans, but these are, as I said, cross sections of the retinal layers here and focusing in this case on the central part of the back of the eye. And this is fluid in the interesting layers, which indicates macular edema, and you can see you can you can get a lot of fluid there that can significantly increase thickness was the macula. And maculopathy is the commonest cause of visual loss in diabetes. And, uh, proliferative retinopathy is when things have got really bad and we treat it with laser. Actually, we used to usually treat it with a laser, but it really now depends on what the vision is. What's happening with the actual sickness of the retina on, you know, the use of steroids and antibody. Just they're much more common place than they used to be. So there is a sort of a definition off off clinically significant macular edema, which is probably at least 15 years old and still used, And it's when you have retinal, a demon within 500 microns, or you have hard exudates, which are further than 500 might ones from the phobia but actually in their overall size association professional thickening. Or if there's a rational demon that's really big, like the size of a lot of the optic disc on. But it's within five. The edge of it is within 500 lbs of the baby, so treating security significant macular edema is important. And that's why it needs to be recognized, because when it's not treated, you can end up with a scheming maculopathy. And this is a fun dysfluency 100 grand picture where somebody's had diet injected into the arm, and then the dye flows through the rational about vessels and then into the choroid is well, and you start to see uh, where there is no capillaries in the corridor anymore because they've all shut down. And that capillary dropout is so normally you have a tiny area within the phobia where there is a kind of black area. Whether isn't, um, choroid compel Aries on, but when it's not too large. Then you put a skin nick macular, And so, based on those pictures, I just showed you just to do a little bit of recall. What are some of the features of non proliferative diabetic retinopathy. And just repeat some of the things that I just mentioned. Anyone we have. Micro aneurysm, Yes. Cost you more spot here? Yep. Yeah. Yep. So some of these we have here my career since dot hemorrhages blocked hemorrhages, cotton wool spots use, um, cotton wool spots. Colonel Switzer, indication of nerve fiber. A risky me A onda. When you gets really bad, you start to see things like beating and torture. Will sti and Venus changes on gotten spots? You know, a more sort of when things are getting much worse. And there's these things called Irma's, which are basically microvascular of an amount. That's where you get Penis sleeps. Another venous things. Capillary funny. Capillary changes. Not quite proliferative retinopathy for these abnormal. Ask you, uh, connections? I guess. So. Here's some examples of of worsened diabetes. Okay. And then, of course, here we have prolific. So this is new vessels elsewhere. And this is where in fact, the whole optic disc has been engulfed by vessels in this fibrous tissue. Overlying it. So here's an excessive pictorial example of pound rational photocoagulation this one here and this where some of the Russian has been and, uh, lasered. And, you know, it often is done in maybe two or three settings here. We haven't example where And in this photograph of the left, the left eye, you can see that there's some professional hemorrhages. Well, so this patient has been bleeding for me from some new vessels of the disc, then they need that quickly. So if we've got sudden loss of vision, patient comes to you or is speaking to you, let's say your GP and you're, um you know, you get a call from a patient, uh, who you're doing a consultation with. They say that they're lost vision over the last couple of days. What's things in the history might you want to ask to help ascertain what the likely diagnosis might be? What are important questions? Yeah, Just waiting for the moms is to come to bring the baby. So is it bilateral history? Diabetes? Is there a complete loss of vision? Excellent. Yeah. Anything else and I didn't say when. When did it happen? How did it occur? Where they were there any headaches to accompany it? Okay. And he changes division before the vision loss concept duration Any pain involved that does anything make it that family history? Yeah, All these things were important. So here we have some. The things you've already said often the first questions that she You know how much of your vision is gone, but on on what kind of time? Frame. But is it painful or painless? And now they're associated symptoms or associates things in your medical history. Like, are you diabetic or, um, you know, are you very shortsighted? Flashing lights and floaters, Etcetera. Okay, so we haven't example here we have Mr Francis see, 78 years old, he's come, so I can sheltie and he says, his vision suddenly basically going in this right eye. And he is hypertensive. He has hypertensive that stopped taking his tablets because they made him feel sluggish. So this is an older gentleman who saw apologies for the noise. He's hypertensive, and she stopped taking his medications. And that's probably the key. Ah, clue. So can somebody offer, um, a description of this photograph? Anyone we have see, Avdo, you know cysts. But if you had to describe it, what would you say? Cause being able to just describe the picture, always get your points even in an exam you don't know, so we would always stop. I think this is a color funders photograph and being impulsive, it tries to This is the right eye. So you should go to say there's the left or the right time wearable that we have, right? I multiple Restinal hemorrhages. Excellent, yes dot Blot hematuria's hemorrhages. So it does not cause a zit. They're all kind of extending from the disc area. And as you say, that sort of in a liquid rinse of the retina, so is it's, you know, Florida hemorrhages everywhere and on. You absolutely got the diagnosis, right? So it was a central retinal vein occlusion on what conditions are associated with having had a central retinal vein occlusion. Someone said low broke BP, high BP, high blood. This patient stopped taking his BP medications is blood. Pressure's probably that high. And what else? So the two communists respected our age and BP, and after that, I would say that you know, things that are making more likely to clot. Um, so the central retinal vein has basically had a strong both cysts. And you, this patient unfortunately developed a central retinal vein occlusion. Um, so any particular medical sort of conditions or situations where you may be more likely to clot any any officer. So obviously, your your propensity to clots is going to be higher. For example, if you have cancer, if you have, um, a prothrombin sick condition, um, you know, some sort of autoimmune condition that makes you more likely to clot. Um, I don't know, like, best. She's disease or SLE or something like that. Somebody that's bed bound that, you know, maybe hasn't been able to move around and isn't, um maybe on heparin like text saying, um uh, if you have diabetes and high BP and high cholesterol, um, you know, you're you're somebody that's that's more likely to have shots especially, you know, on aspirin. Um, so what are the possible consequences of having a central retinal vein occlusion? So these patients come with visual loss. We've already established that, but what can happen there is a result of this situation. Anyone conscious of times, I'm just going to quickly, um se. But basically, somebody who had central retinal vein occlusion will develop potential macular edema that can ski me of the retina and a scheming with the retinas we've already alluded to with the diabetic. But nobody can lead to neovascularization when there's new blood vessels growing at the back of the eye on the retina. That new vessel growth can even extend onto into the you feel tissue, which extends into the iris. And so the iris can also get blood vessels bring in. And if the iris the iris route is, you know, just at the edge between the cornea and the iris you have at the trabecular meshwork, you remember from the last lecture on. So if blood vessels grow into that angle, you can end up getting getting something called peripheral anterior Sign IKI, which is basically where the angle through which fluid normally drains to keep the pressure normal construct to get zipped up by near vascular ization. There's blood vessels and the fibrous scarring that comes along with it all, extending into the angle where the iris inserts into the edge of the trabecular meshwork and so into the you feel at the edge of the salary body. Um, and that could be too near vascular glaucoma, so type of glaucoma which is really, really difficult to treat on to the next case here. So we have Mr Jones. He's not aware of any symptoms previously, but basically what he's noticed is, um, with his optician, has noticed this, um, blood spots on his retina in the right high. So he has been referred to vision that she normal, and this is what the opposition has seen. So can somebody quickly describe this, if possible, fishing on there? There is also a spot of blood that is a him or each eye. Uh huh. Okay, so just know that So I want everyone to try and get into the habit of doing things really systematically. So when you have presented in your exams with a photograph off the back of the night, I start by saying, this is the color funders photograph of its color, and it's a photograph or whichever. I said This is a color funded puff of the right eye of this patient on. Do we see the rational arteries and the retinal veins? And you should be able to say that the showed that the veins is not a very good picture, but the veins are usually bigger than the thicker than the arteries. And basically, what we have here is, as you said correctly, um ah, instead of, uh, whole patch of hemorrhages over the super temporal retinal arcade vessel on this policy just below it, which could be a demon. This is actually a branch retinal vein occlusion. And and so I told you the diagnosis. But can somebody tell me then? Any difference is that you might notice between cases three and four. So one is a central retinal vein occlusion, and the other one's a branch retinal vein occlusion. In the interest of time, I'm just going to ask this question. But basically, whether central retinal vein occlusion, the whole vision might feel like it's got worse with a branch rational banditry shin. You know the divisions affected by the part of the retina that's affected. So here which part of the rest of the well you can see it's a stupid area. Part of the rationale here that's been affected. So which part of the vision may feel like it's become quite blood? Anyone we have, um, losses are loss of vision as one of the differences. And in Syria, yes, exactly. that's what I was looking for is that part of the vision that's lost awareness the central and live in a very inclusion may give you a more global feeding. That divisions gone right down here, you might specifically come to the optician. This patient didn't notice anything. But you might say, Oh, I feel a So when I cover up my other eye, the bottom half of my vision is missing and the point I'm trying to make it. The retina is like a nerve lining that covers the back of the eye, a sheet and everything is inverted like the old style film of a camera. So the top part of the retina corresponds to the bottom half of the vision. The nasal part of the retina corresponds to the same temple aspect of our visual field, and here we know this is the macular area. And so this is your central vision, and this is the bit just above the central vision. So it's the lower half of the rest of the visual field that would have been affected. The unfortunate thing about superior branch retinal vein occlusion is that gravity is against you. And unfortunately, a demon that's here well, very easily sometimes trickle into this area here, affecting the central vision. So in terms of visual loss, it may feel like you got This is a blob of blurring below your central vision and then maybe gradually extends into the central vision if you develop macular edema with it. So central retinal vein occlusion tends to occur later in life. And, um, is a set of thrombosis of the central retinal vein. And this sort of a skinny, as I said before, can lead to, um, more severe ischemia. And often, if it's affecting the whole off the vision, you'll see that the patient has a relative afferent pupillary defect. Um, we mentioned relevant relative afferent pupillary defect in the last lecture. Um, and if it's a skin that you can end up getting proliferative and changes and near vascular ization on a sneer, vascular, it look a much I've also already mentioned, and so you would want to he think it's a schematic. Think about doing a panretinal frotek regulation like you did with the diabetic patients. If you know to prevent worsening ischemia or ischemia that's already prolific of that hasn't quite lead to neovascular glaucoma to prevent that vascular will come from occurring and a branch retinal vein occlusion. You know, it's It's a branch that, ah, retinal vein that that that becomes thrombosed on. But if they're younger is often they are, you may need to look for other causes. As I said before, you know they may have another autoimmune condition or a situation that means they're more likely to clot like maybe they have some cancer or something else going on. And sometimes it's It's, um, symptomatic when sometimes it could be a symptomatic if the macular isn't involved. Um, again, these patients can also develop a bit of a ski. Me of that part of the retina is really severely affected. So we do need to watch these patients for development of neovascularization returned to watch. Patients have had a branch vein occlusion or a central retinal vein occlusion for 1 to 2 years, at least because things can happen later on. We talked about some of this already. I'm surviving on two number five. We have this young man, 35 year old, and he's noticed difficulty seeing in the dark for the for the last few years, and it's it's started. Effect is driving in his general health is well, but he did mention that his uncle also went blind in his fifties, so he is worried that this could be related. So I'm going to show you a picture. Now, this is a zoomed in picture, um, off off the eye. And you're seeing part of the peripheral retina here. So this is a color fun, this photograph? Um all right, I and you're seeing the purple rest in here. Let me just describe what they see. Just that was the salient feature. Here. You have t say one thing. What do you see? Just describe it. You don't need to have the diagnosis. Necessarily. What's this feature described as anyone? They have pigmented deposits. Yes, there is some pigmentation, but he wanted it with the visited and descriptive term has given to this. Um, someone said spider like this Vital like, Yeah, I like that. Okay, so it is known if bone speculating So this bone speak Your pigmentation is by the like, Oh, degree. And it's in the peripheral retina. So any idea what the diagnosis might be? Where where do you see bone spicule rational pigmentation in the periphery of the retina. But we have retinitis pigmentosa. Yeah. Is the family history relevant? Yes, yes. So exactly because it's hereditary usually, um on did anyone? No. Which part of the retina it tends to affect to start with? And the rods were health exactly. Very good. Excellent. So it can be or some dominant recessive Well, except there's many different types of retinitis pigmentosa, and you get progressive loss of your photoreceptors and rods are damaged first. And this is a typical thing that we talk about is night blindness as an early feature? Because, um, you know, they really, really struggle a soon as it gets dark, they're leading their peripheral mission. And there are various syndromic associations, like restaurants, where you get cerebellar ataxia or rashes syndrome, where you get ah, hearing loss and recognized pigmentosa and Kern stairs where you get sometimes get recognized. Treatment is a little always, but you get kind of what found the please. Um, and so there's various things these released syndromes that you may or may not have heard of. But I think the key is to be able to know Call it bone spicule pigmentation and to know that it's the rods that damage first and that night plane. This is a thing, and it's course hereditary, usually so living on we have Mrs McKay. She's 77. She's noticed distorted vision in her left eye for about a month and was referred to the eye clinic. And she's got a history off breast cancer with brain metastases for what she's been told is in mission that she basically lost the year before, had chemotherapy, and she had radiotherapy for her brain metastases. So we have picture here, Onda, can somebody offer? You don't need to talk about the diagnosis necessarily. But if somebody can just this is the the first craft that you're being shown. Just describe what you see. The one offer a description, please. We have optic disc swelling and those, uh, months after Afghanistan oscopy off the left eye. Yes. Yeah. So this is more just to correct. There is no optic this swelling, but yes, it isn't on this photograph off the letter absolutely up anymore. We have, um, edema, grade block pictures here. Uh, last IQ masses. Yeah, right. So you know, these are all the things you would be thinking about. You be thinking about mass you be thinking about with. This is a demon. There's this great touch, basically in the center. And this part here is, of course, the macular area. So no wonder it's causing distortion. Her vision, because it's affecting her central vision and you can see some block hemorrhages a swell. So there's some sort of a ah vascular vascular problem going on here on in the history. We know that she's had Brain Mets from her previous breast cancer and has had radiotherapy. So if you're gonna do you radiotherapy to brain mets on depending on what kind of radiotherapy you have, as you know, it's sometimes gonna affect the back of the eye. So this could be radiation retinopathy, which tends to present with hemorrhages and sometimes oh, deem a macular edema. And you know this Does anyone else anything we could do for her? So do these days, you know, it's a bit like your treatment for any sort of, um, retinopathy. Um, we may give antibody Jeffs. It has been used steroids a little with less effect, Um, and sometimes rational laser as well. If there's an each sign that it's becoming in the skin. It's situation sometimes, um, macular laser. But you have to be very careful about being very gentle with the laser treatment over the macular. Because you wanna call scarring. It's about, um, that type of macular is not the kind of burn, but it's just kind of stimulate the macular to kind of re absorb that fluid. Um, so age related macular degeneration is, is what we're moving on to now. There's a leading course of visual loss on Dove courses. We have an aging population. It's becoming only an increasing problem. Um, and very broadly speaking, it's wet or dry. My going to spend too much time Anderson time, Um, so I'm just going to show you a couple of pictures. So we have dry and wet macular degeneration, and you can see that dry macular degeneration and in this color from this photograph off the right eye shows some atrophic patches. I apologize. Not very clear picture, but essentially you can get these we sort of spots that look a bit like exudates, actually. But so there's a bit more grainy and bit more granular, and they're called Drusen on. You can get pigmentary changes, so you get lost pigment and then pigment clumps. Um, so you get a traffic patches and then pigment. And this is your typical features of dry age related macular degeneration, which is essentially wearing down off the retinal nerve layers affecting the center part of the back of the eye or the macula area, which cause corresponds of central vision. If you're looking at a CT scan, you may see that these in a laser the Retin of kind of lost there, you know, they're normal architecture, and nor did it healthy dips that, you see, is the phone via on a no CT scan that becomes no longer, uh, here we have an example of wet macular degeneration or color funders. Which problem again? A right eye. And you see a bit of a sub little hemorrhage here. So what's happening in wet macular degeneration is that wear and tear change in the layers off the retina have lead to leaking off. Um uh, fluid, sometimes through the growth of blood vessels. So it always like a crack in the r p e layers. So if you think about the retina, you have the retinal A is that you see on this CT scan and then you have the r p E layer, which is supposed to be watertight. And underneath is the choroid and the Korea capillaries. All kind of quite Niki. But this retinal pigmented all prevented a silly a layer is is watertight. But if you get some sort of ah, a breach in that through blood vessels going through into this the retinal age, you'll get fluid. And that fluid accumulation, or sometimes even bleeding, can lead to retinal hemorrhages. Ondo Dema on Dwight Macular degeneration Essentially. So, if you see somebody with dry macular degeneration is anyone know what, um, advice? You might give them anyone. So we have anyone heard of it. And if any of you kind of the Amsler grid, So when somebody is not drying macular degeneration cause we have to wise often we don't realize that the vision might be going down in one eye or the other eye. So it's important to isolate one I a time and maybe once a week. What we ask patients to do is we'll ask him to look at the Amsler grid. It's just like a grid basically on a sheet of paper that you might just put in front of your eye. So you cover one eye up. You look at you and the grid, and maybe you can all google Amsler grid later. But essentially the grid has a dot in the middle, and you want the patient to look at the dot and or at the grid, at least if they can't see the dot and just get a sense of whether the vision in that eye is changing and maybe do it for the other eye. And if they do it once a week or something like that and they've got a bit of dry macular degeneration and hopefully, if they did develop worsening of the dry macular degeneration or, worse still wet macular degeneration, which may give them more acute central visual loss, then they will present quickly because it's important if you have a wet macular degeneration that you get treatment, which is usually in the form of intravitreal injections, injections into the back of the eye off anti veg F treatment. That helps to basically, um, dry out that fluid that's leaking through and hopefully shot off those vessels. And that really is, you know, treatment. Over the last 15 years or so that has made the huge difference to treatment of wet macular degeneration. Dry macular degeneration. Unfortunate doesn't have kind of treatment to reverse it or to definitely, absolutely stop it. But we do know from ah, longstanding study called the Blue Mountains. Studies on Australia that showed that taking vitamin supplements are not smoking are are really helpful. Risk factors are and our age and smoking on, but they're not smoking is important. And, uh, taking these vitamin supplements that contain lutein on Zanthi in vitamin A C E. And you get these capsule Excuse me for most chemist these days, where something like it's good that you know that they have brand names such a smack you shield or preservation or Ocuvite the semi different ones on the market that we use septated patient. So don't smoke, take the vitamin supplements and wanted to your vision. Basically, they're going on to this next case. How many minutes I got left, like a six minute. So we have Mr Spencer here, who's 20 three's got no past medical history. So young guy on, he's basically had a routine. Um um, check up before his new job starts on. This is what they see. Somebody. Can somebody just describe the verge bath very quickly? Okay, so this is and the lower half off color from this photograph or a right eye on what you see is actually Korea rational scar. So you could see it kind of pale bit and then the pigmented bit. And this is like it basically is just a very well established Korea retinal scar. And so what? As I said, it's a chorioretinal scar. Does it require treatment? No, it doesn't. Because actually, well, away from the macular, and it looks hold. Uh, does anyone can you think of any conditions where you can get chorioretinal scars? And I looked like that. Any guesses so well, a tickly common would be something like toxoplasma retina cordite. It may have heard of it or not. Um, an infection that often is, um, passed on to the fetus if a mother gets it during pregnancy. Um, but basically often passed through cats. Actually s o. So, Yeah, you can get these retinal scars. And here's some more examples of Korea retinal scars. Now Obviously, if the Chorioretinal scar is affecting the macular, then that's going to affect the vision on sometimes these old scars and then develop new scars nearby. And they look more like creamy, you know, almost like a cotton ball sort of spots, but could be two swelling, and they need a prompt treatment, especially if they're near the macular. So moving on how time that we're about four minutes and Mr Chinese 33 you've been asked looking is funders, you haven't been given any history, but you notice he's wearing sick glasses. So this is what we see. Um, a friend. A photograph of his on This is a first graph of is right high. Then you don't want to describe what they see. So you conceive basically that there's this thing called peri papillary atrophy, basically a trophy around the optic. This this is the optic disc of the right idea of the breath and blood test was a little just really paying all the way around. And it is very typical of somebody who's, um who's what, actually, So he's got stick glasses. What's he likely to be? Anyone big glasses and a retinal looks like this, he's likely to be very shortsighted on. Basically, they get this more short sighted. You are the bigger your eyeball, the center you're rushing around the back on. So you get this sort of retinal thinning around the optic disc, and some of you can even get, um, myopic maculopathy, which can be dry and can even lead to wet changes, a bit like macular degeneration. So this is just a mile pick optic disc. That's what you see. Um, moving on to Mrs Jones. She had cataract surgery the year before, was really happy she was short sighted. A Z well, so Cinryze dinner. Now, this week, she's noticed flashing lights and floaters in her right eye on the vision's become blurry. Onda. This is what you see. What is the diagnosis? Anyone? What do you see? Retinal dispatch one breast. Exactly. So this is a color from this photograph off the left eye, and basically you see this big balloon or resting coming off superior. So based on what you've already been told, which part of the retina that which part of the vision has started to kind of have a shadow or over it? The top or the bottom. It'll be the bottom. Yes. What exactly? Yeah, so you've got the inferior visual field that is lost. And once it's basically as you can see here, hit this central vision, it's going to mean that the central mission goes, uh, so what's the treatment here that we have? Laser? Yes, it was just a retinal tell you would laser around it. So just that I'm very conscious about Bob a minute, but we get flashing lights and floaters because basically we'll have the sink or vitreous gel in the back of the eye. It's like a form jelly. It stuck to the rectum when we're born and and all of us as we go through life, the jelly liquefies, it comes off the retina. And most people, you know, just love saying some people notice floaters, and that's a bit of jelly floating around. It's of no real consequence for the vast majority of people. But I guess one in 10,000 people in particularly if you have trauma or surgery or you've had you're really myopic. We've got condition like stick list, and, um, you're more likely to get a terror is the jelly pulls off the retina usually just peels off. But if there's a tear of the retina fluid contract underneath the tear but like wet wallpaper the ref neck and then start to actually balloon off. And that's what retinal detachment it's. It's just a tear there, and there's no detachment. Then you can laser on the two almost like soldering to kind of secure. It's a fluid can get underneath the rectum, it come up. But once the retina starts to come off, you've got a retinal detachment, and you've got shadow covering your vision, loss of vision, possibly complete loss of vision. On the longer the retina is awful, the more chance there is that you won't be able to recover your vision, even if you have a retinal detachment operation. So surgery is urgent on surgery is done either from the outside to kind of apply a buffalo and laser to the outside to get the retina, whether it's a terroristic, that once the fluid can kind of get reabsorbed well, removing all the job from the inside of the ice air going into the I doing something called of the tractor me on, then lasering around the tears and flattening it sometimes with ah ah ah, Gas or air, or sometimes even with, um Well, the condition have that. Things are so very, very quick. Summary, Um, conscious. This is our last minute, actually. So I'm just going to say, Can anyone call out any causes or painless loss of vision? Based on what you've seen today? Just was. The pain is also vision. So vascular things tend to be painless, like retinal arteries or veins occlusions or retinal detachment. What about, um, painful loss of vision? Anyone so front of the eye things can cause loss division to We cover some of those last week like uveitis angle closure. Glaucoma end up sunlight, especially talked about to here. We got some painless causes. We didn't talk about central serous retinopathy, but it's fluid. It affects the central part of the back of the eye, which hopefully you can look up in your own time. So that's I think, where we're gonna have to stop. We don't have time to examination techniques, but I hope that was helpful. Any We're gonna go any minutes for questions. Your attention. Thank you so much, Doctor. I also use that before. I know they say it really tight to fit everything in plus questions in one hours. And thank you so much for your time. I'm Yeah, we are gonna have to be the Hey, guys, I'm so thankful, really making you know. And so yeah. Thank you so much of you. That link is in the chat guys, so make sure you get that on. Do? Yeah, We're gonna end the lecture here. Thank you so much. Miss On there again. Thank you. Yeah, Thank you so much.