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To do 30 day will be today, we'll be going through today. We'll be going through some ophthalmology high you topics and because ophthalmology is actually quite a broad uh specialty, so we have picked uh some of the relatively high you topics you go through and some of the questions that examines like to ask in the exams, which are relevant for medical finals exams, So first of all just like all medical fields, especially anatomy is very important because it basically helps underline where the structures and then it allows you to link your pathology together with a physical physiology together to allow you to have a better understanding of each disease processes, So this this is just basically a brief picture over the anatomy, which I believe most of you will probably be familiarized with this especially if you're in a clinical years or in the final year after you've done your ophthalmology placement. If not, I've got this picture in the slides, which will be sent out afterwards. Once you fill in the feedback full and you can just have a look at this, get yourself familiarized with the iron anatomy and then moving on to. Uh this is basically just briefly show you what it means the interior margin posterior margin of the eyelids, which will come in very handy in a bit so with no further do, this is uh the first question so I just launched a pool and have a look at the questions and put on, put the appropriate answer. You think it's correct onto the pole, and I'll give you about one minute for each question okay and 10 more seconds ok, amazing, so, I'm just going to end it there so uh in fact the majority of people have chosen be which is warm compress er and indeed how are you doing it. This is the correct answer because um obviously uh this picture. This basically this paints the picture of someone with arthritis and uh the fact that this patient has a history of flushing, intelligence act ASia and this basically showcase uh this patient has a background history of oc asia, which causes meme bomi in gland dysfunction, which is one of the common most common association with bluff rightists, and also the symptoms are very classical picture of blepharitis such as sticky secretions, eyelashes stuck together especially in the morning and some grittiness and I discomfort so well done to the majority of you, guys got this correct and just quickly going through, the fright iss um actually the fright ist into interior posterior, which uh which when I said the eyelids picture will be relevant and as you can see because uh and there are different causes between anterior and posterior arthritis and two of the fright is mainly caused by a staph infection or another risk factors such as psa borick dermatitis will increase the risks of having blood interior blah arthritis, which is the more common cause of blepharitis and in terms of posterior blepharitis such as the patient and our question just then as suffering mainly posterior blepharitis and some of the key symptoms was also shown in the question, so you've got sticky eyelids, grittiness, but also some crusting and some itchy and foreign body sensations. As you, as you feel uh the crusting of the uh secretion being stuck there and as usually bilateral in nature and worse in the morning and gets better as the time goes on an investigation of the fright. It's normally just a very clinical diagnosis and you can do step lamic, and you can see some appearance which I'm going to show you in the next slide and that's most of you have answered correctly. One compressors are in fact the key management for blood fright iss sorry, um can you guys hear me now, brevan, can you can, uh we can hear you sorry about that ok so um and and if one compressors and like hydrin doesn't work and and also if patient's a complaint of having dry eyes and achieve foreign body sensation, you can consider giving some artificial tear drops and if that doesn't work, you can consider a step wise approach of giving topical antibiotics and then proceeding all the way towards topical steroids and then this next slide so these are three pictures of different types of arthritis sorry vincent, just to pause you right there. Uh there's just one question on asking why this couldn't be bacterial conjunctivitis, we're gonna go onto that slater and well because we've got questions regarding content of ITIS, but because I think uh one of the key features of content of itis is the redness of the eye and there isn't any signs of any redness of the eye and the fact because of the questions stem that has showed very clearly that acne rosacea was given. In the questions stem stem as a background and together with uh basically eyelash stickiness, these all these symptoms and this history points more towards bluff rightists rather than conjunctivitis. Picture. As such because normally in content of ITIS, they would point, I think one of the key point is basically redness and they're going to talk more about the eye symptoms itself rather than the islet and the eyelashes surrounding it, So these are mainly lit pathology. We're going through at the moment okay, so just going back to this, uh the arthritis um slide so there's basically I just showcase three different types of the fright iss because you might be thinking oh interior arthritis with this posterior, What do I mean by that so within interior blepharitis, the two most you can have some boric arthritis so uh which is different from a staph infection. In this case you can see. In this picture. You normally have more oily scale and crusting compared to the other two, and it doesn't seem to as red as the other two because it's not an external infection as such well, on a steady flow staphylococcal blood Rightists due to an infection, you have slightly more redness and oedem of the lit margins and classically you can have some loss and misdirection of eyelashes as well and posterior the arthritis. Due to anatomical location, you can see the lid starring within or inside in the posterior island location rather than the interior eyelid. So as a result that when patient's comes in with the fright Iss, and from a practical point of view is quite important to basically lift up or lift down the eyelids to have a look inside of the posterior eyelids region as well and two other uh common pathology encounter uh regarding let's pathology including style, horse, horse hordeolum, which basically is caused by abscess and lash follicles, also due to staff infection, and these are commonly classically a painful lump and the treatment for this is warm compress, er and then you can consider antibiotics if that doesn't go away or if they're pacing this experience seeing a lot of discomfort and on the other hand, you've got Salesian which is actually a meme bomi in cyst due to block umbo mean glands or duct so classically, uh This presentation is painless and question stems like to say it's firm and actually point inwards and the treatment for this is also very similar to style and Blah. Arthritis is warm compresses, but given the fact that this is assist, and due to a mechanical blockage, one of the methods, if this does not go down, or the patient experiencing uh severe discomfort is actually via surgical drainage where you can actually just remove the block, mm bomi in glands to relieve the patient's uh discomfort. So these are so after these three common lit pathology, I'm going to go to a question too now, so I'm be launching the pole right now so just have a look at this question and let me know what's your thoughts are. This is actually quite a tricky question because since I think most of you've got the first three questions correct, first question correct, so this might be a bit of a tricky one all right, and I'm just going to end up there yes about one minute now, so um so we've got a mixed answers here. Um We've got about 30% of the participants have chosen d, while about 27% chosen, see and if you just have a look at this question. Uh The last line of MRSA test is positive. This is the key uh one of the key clues why it points to questions quite different from what you classically get so in a classical exam question this line is most likely not going to be there and what the others are very classical history of someone with orbital cellulitis with a very uh intense pain in her eyes and exasperates on movements and also it's after some infections as such upper respiration infection, so in this case in a normal exam uh scenario, she is the perfect correct answer, however, by putting MRSA test is positive, you need to consider something to cover for the MRSA infection and in this case vancomycin is indicated. An iV m maximize is indicated and to cover MRSA infection so just something to bear in mind. In case the examiners are feeling a bit nasty but all in all well done to uh most of our participants the 60% have chosen to see Ardie, but just bear in mind. Later on, when you come up to cross cross questions like these and moving on to question three. Before I explain uh the conditions in detail, just gonna relaunch the polls well, let's have a look at the question and I'm going to give you another minute to do this question. Vincent could, shall we give slightly longer um maybe maybe 10 or 20 seconds, yeah uh 10 more seconds, I'm just going to call it there. Then, so uh we've got a mix of different answers as well for this question, with b. D. N. E being the most popular answers and uh being the option being picked the most, and in fact, this is the correct answer, and in this case let me just go through why uh b and e relatively incorrect. In this case, e MRI scan of the orbit isn't technically wrong, but it wasn't it won't be as appropriate ct scan due to the time, the timing of the scan because it's quite a uh emergency procedure because cellulitis uh could cause visual permanent visual damage. As such, so ct scan will be much quicker to organize and to uh to happen than mRI scan while state that examination is uh basically the bread and butter for or ophthalmologist. However, in this case, we have actually already examined everything, but sorry we have examined the patient and she we already sent home because we thought this patient might have gone home with a preceptor cellulitis. The fact that they didn't improve might have suggested it might be something more sinister and which in this case it's more likely to be an orbital cellulitis given the fact that uh the court, amoxiclav did not helped, so in this case, ct scan would be more appropriate than b and e even though b and e might actually correct so just quickly going through what cellulitis is, so cellulitis may need split into peri orbital cellulitis, an orbital cellulitis, and as as I mentioned before, everything links back to the anatomy of the eye, so for peri orbital cellulitis is basically an infection of soft tissue interior to the orbit of septum excluding the orbit, and in general, 21 month old babies or infants are general, median age of patient's with carrier orbital cellulitis and they normally present with a red swollen, painful eyelids, and on the other hand, you've got orbiter cellulitis, which they need suggest that because it's orbital so orbit is always involved and it's most commonly via paranasal sinuses infection, so it can be after some sort of cold some sort of uh respiratory tract infection, and due to the fact that the orbit is involved, the symptoms are more severe than peri orbital cellulitis, so you tend to have uh more red swollen eyes, but you also tend to have a deeper ocular pain associated with other symptoms due to the inflammation and the pain of the uh fat, fat, and muscle muscles posterior to the orbiter, septum, and the orbit, you likely to have popped osis, diplopia, reduce this, your equity reduce vision in general, and you can also have relative afferent pupillary defect and also symptoms worsens whenever you move your eyes. If you think about it, everything's swollen uh posterior your orbit of septum and the orbit, so it's much harder to move your eyes and whenever you move it, there's a lot of pressure and a lot of pain, and because all those cellulitis is more an invasive infection affects a much larger area and it is more likely than peri orbital cellulitis to have caused some systemic upset, for example fever and invest in this case, and I highlighted this in red um so investigation needed fbc swaps, and most importantly a contrast ct head and orbit because this will allow you to differentiate between orbital and peri orbital cellulitis, so some might actually argue for the question before one of the before sending the patient home, a ct head and orbit might have been a more appropriate investigation to be a like to have a occurred before you send the patient home for the first place and most common organism for cellulitis is staff and threat, and for the management for a peri orbital cellulitis. Oral call amoxiclav while orbiter cellulitis, given the fact that it can just potential to cause permanent visual damage. A mission is quite important and then after that you start straight on iV set and then also flu clocks is still in and then in this question as I've mentioned before because Mrsa was positive to vancomycin is also used in order to cover for the MRSA and then moving on to question four. Now just to relaunch a port now okay, okay, we're giving him the five seconds and just to call it there, so the majority of our participants have vast majority have picked e. S. The answer, and in fact this is the correct answer, and for those who notice this question, I did it on purpose that for d I put topical chloral and finical rather than topical antibiotics, because I wanted to just showcase one point in ophthalmology rather than compared to other specialty like respiratory and uh and other infectious disease, the use of antibiotics is actually quite um interchangeable because most of these topical antibiotics actually brought spectrum antibiotics to start off with, so. In this case, you can give topical chloramphenicol or fluxes in basically any topical antibiotics which are lightens for I use are more or less most likely than not broad spectrum antibiotics anyways, but in this case everyone picked it correctly. E, is the correct answer and the reason being because um the cervical bleeding discharge and the fact that this patient comes in with unilateral I uh symptom, which is quite a suggestive of chlamydia content vitis compared to let's say bacteria, viral, as bacteria, viral conjunctivitis are more infectious, so you tend they tend to appear in bilateral eyes after the initial single eye infection, so e, it in fact it's the correct answer so well done to uh vast majority of you guys um moving onto conjunctivitis, then so so the main thing about conjunctivitis is actually uh. This condition is actually not very serious, as such because most of the majority of the cases were actually resolved without treatment in about 1 to 2 weeks, but the most important thing is to basically uh using contact lens and avoid advice on maintaining good hygiene and their main four main causes to content of ITIS and the subtle differences in in each symptoms allow you to differentiate between what is the main driving force behind this content of ITIS, So for example in bacteria is usually unilateral and bilateral together with viral and allergic as well. But for bacteria, uh you normally get a pie rule into discharge due to the bacteria infection, one viral. You normally tend to have a watery discharge and in chlamydia conjunctivitis are seen in this pick. In this question, uh the symptoms comes in unilaterally and it's normally an acute nature, so after uh str infections, so basically this patient normally have some history of sexual history or some history of having uh chlamydia infections as such and for patient's of allergic content dividers, they usually uh history we usually contains a topic histories or exposure to allergens as such and the management of these different causes of content of itis is because the majority of them actually resolved about treatment, so some some of the time you can just treat conjunctivitis conservatively, but if that does not work for bacterial conjunctivitis. You can use the topical antibiotics and chloramphenicol is normally the classic topical antibiotics of choice, but obviously as I mentioned before and you can use other brock spectrum antibiotics as well for chlamydia and you can use. Uh As mentioned before some topical antibiotics for that, but also you're a doctor cycles specifically for the chlamydia underlying chlamydia infection and for allergic conjunctivitis. You'll be looking at giving some anti histamines to help calm down the allergic reaction and obviously avoiding the irritant until you get better and you can also consider some allergy testing as such in future. I'm moving on to our next question. We were going to keratitis in a bit, I want an veal, uh but yeah we'll we'll go onto keratitis in a bit. We've got questions regarding that you just stay tuned, but in general, um conjunctivitis is seen as the less severe. It's not very severe but uh conjunctivitis and keratitis. On the other hand, it's made uh it's the symptoms are more acute and you generally have more associations with pain and redness, and you can have kim acis as well. So this is one of the ways to differentiate between the congestive itis of or keratitis, but we're going to go in more depth later on in a few satellites time right, I'm gonna call it there then, and the the majority of uh participants have uh put E as the answer, and in fact this is the correct answer because on the picture, on the, on the left hand side, you can see you can see that there's a small ring there and this is the classical appearance of the rust ring after removal of a metallic foreign object. Um The reason why they've got this uh brownish orange color is because of some metal remnants, which reacts with oxygen in the air to cause this oxidation of the metallic object and as a result of that it causes this color change and when you have a rust ring, what do you need requires a removal of the rust ring and you give prophylactic antibiotics and the next question Also regarding some uh trauma, I could just launched the pools, give it a 10 ticket ok amazing, we just call it there and the majority of participants vast majority I've got this correct and in fact is the correct answer, irrigation with sterile saline solution because this is basically a classic history of someone with having some chemical injuries to the eye, which is also a very common exam question and the last thing you actually want to do is d irrigation with sterile apply an eye drops Because if you remember from your, a level of Gcse, chemistry class is neutralization would create heat, so first of all you're gonna get that uh neutralization reaction, each damage and also if you over sterilize it because alkaline itself cause damage to the eyes, so if you're over sterilize it or in fact if you put alkaline in your eyes again rather than doing neutralization, it can cause further damage to your eyes. So other than saline solution, you can also consider other uh isotonic solutions such as a phosphate buffer solution, which is also quite commonly used and uh next slide so um so basically the slightest uh summarizes, or the traumas or chemical injuries you can get and in the eye, so foreign body basically uh some of symptoms includes the feeding of having a physical foreign body in your eyes and read tall and painful eyes, especially during movement, blinking. Because you've got a foreign body attached in your eye. Whenever you move it, it's gonna irritate your I even more, and as a result that you're going to have increasing a cremation as your I try to get it out and you can also have blurry vision and photophobia such and as seen from the question, we have a question of rust rings, which basically symbolizes oxidized metallic objects and requires removal as soon as possible some investigations. You can use this x ray of it's metallic to basically see where exactly the uh metallic object is, but you can also consider eh my scan as well and monitoring is pretty straightforward if it's not supposed to be there, then just remove it and also to give some topical antibiotics as prophylaxis and corneal abrasion is when the epithelium covering the corner is damaged and breach, and because the cornea is one of the most innovative structures out there, so it's normally extremely painful and the symptoms very similar to foreign body because it's also just scratching the service and damaging it and investigation. Wise, uh you can use a fluorescent and cobalt blue light to visualize the damage and then management wise, you also uh symptomatic relief of paracetamol, ibuprofen, and then you can give cycloplegic and also topical chloramphenicol other broad spectrum antibiotics as you wish and moving on to chemical injuries and in our question it was a bleach and which I'm not sure if anyone called. A quick glimpse of my my explanation of the answer, but what is the most common acid found in bleach if you could just put it in the chat oh so, Matthew um so, okay, yep, so and in fact that is correct and then hydrogen peroxide I'm afraid is not the answer, but to check for the ph for chemical injuries, you can use uh ph paper as you irrigate uh d. I, and ideally you would uh written in the management here, So you ideally you keep irrigating and then you keep checking with the paper until it's about 7.4 it's where you basically stopped irrigating the eye and then uh just uh the key point key takeaway message for this is once you've got a chemical injury rather than doing anything else you just keep irrigating the injured, I, until the ph is about 7.54 and then recheck every 20 minutes and another key point is the alkaline causes more severe damage than uh acidic chemical injuries. Because alkaline doesn't uh it's going to cause a liquid liquid, factive necrosis. As a result, it's just what happens is. It's just going to keep penetrating your eye deeper and deeper while on the other side, if you got an acidic injury, the moment it penetrates one layer. Um The body is going to have a response to it and then it's gonna seal up the layer, even though the layer is damaged. It won't be as uh penetrative it is than alkaline uh chemical injuries and moving on to our next question, This is quite a tricky question. I would say this is quite a tricky question, give you 10 more seconds cool, amazing, so, the the majority of people got to see as the answer, which is actually very impressive, is correct, is the correct answer and what's even more impressive it's uh there's only a few people who pick deep, which I thought would be one of the uh most popular answers because what I did here I I try and trick you guys by saying he's been doing a lot of swimming in rivers in Candida, but for those, obviously the majority of you guys in this case, you've got a very good knowledge regarding this. Um uncle chera is basically uncle, sarah is basically endemic in Africa rivers, so Candida would uh you you're very less likely to find it. In fact it's going to be impossible to find it in Canada's to and in fact see is the correct answer and one of the key to give aways, as well as the parents. You can see a trauma, ring shaped infiltrate, which is basically highly suggestive of acanthamoeba infection, which differentiates itself from the other causes. Uh I see uh the second most popular answers be pseudomonas, which is also one of the most common cause, but in this sense uh see is the correct answer very well done too, the majority of you guys so so moving on to care otitis. There's the mainly about five causes of care otitis and what you get from keratitis is in general is a wet, red, swollen, painful eyes and you're gonna tend to have more visual symptoms as well, so you have photophobia and reduce visual acuity and can also get some tea, tearing and discharge and foreign body sensation and the majority of keratitis. The first form of management is to remove the contact lens as soon as possible. If you have a do you wear contact lens and there's there's a possibility of a corneal ulcer from from performing and in that case you need a cornea scrape as soon as possible, so we're just going to move on to more details about each causes of care otitis as uh think Matthew have asked previously uh. Sorry show, P has asked so for bacteria, courses of keratitis. The main cause is basically pseudomonas of staff and pseudomonas more normally more common than staff and risk factors of all keratitis, especially in bacteria, is contact lens use, so in a questions them before even reading the question if it says like contact lens, it's your alarm bells should start ringing whether or not this can be keratitis or not. And this is also one of the questions like one of the clues, examines like to give you to differentiate between parotitis and conjunctivitis, is the fact that the patient in the question stem uses contact lens, so because contact lenses is a risk factor, what do we do we remove it so for bacterial keratitis for management wise. In fact, the management for all keratitis is to stop the use of contact lens and we can give topical antibiotics, so anything you would like basically all the broad spectrum antibiotics out there and give cycloplegic to reduce the pain and also and topical cortical steroids uh to basically relieve the inflammation, but bearing in mind, this is not commonly given, not as commonly given as cycloplegic because if when on diagnosis, if you're not very sure, there's a chance it could be fungal infection or I can to amoebic infection. In that case, this is actually contra indicated, catered in these conditions, and if these topical antibiotics and does not help you can consider giving an, for example an oral doctor cycling and also vitamin C in this case and I was gonna ask if anyone knows why you would like to get vitamin C and it actually does prevent characterises in severe cases and moving on to herpes simplex virus. So in this case, questions uh them normally like to have an association with blepharoconjunctivitis, so basically a content of itIS or blepharitis, or the infection of both. So questions then would normally present with a patient with a previous history of blepharoconjunctivitis or they'll tell you that's like signs and symptoms of that previously or associated with keratitis science as well, and some hallmark signs for hSV infected uh HSv causing keratitis is multiple small branching epithelial dendrite on the cornea service and it'll be very obvious in the question when um if they want you to pick hSv, it's a correct answer and obviously because it's a viral causing infection, antiviral will be the treatment of choice and moving on to next slide so I cancel amoebic infection, so basically there are two main types of accounts um a media which causes keratitis. I think this is a bit beyond medical school knowledge, but just for completeness, so you got castellani and poly figure As the two main types uh. Of course, keratitis you can actually get these from all sorts of contaminated water and soil soil and in fact a few years ago and there was an outbreak of contact lens solution in can id a, regarding care, otitis, and they need to recall all the products and obviously send out a health alert, so as a result of that you can imagine contacts users at the higher risk and some hallmark signs of this is that uh as mentioned, the question there's going to be a trauma, ring shaped infiltrate, but also a pain out of proportion compared to the other types of keratitis, So management wise, uh Other than stopping contact lens youth, you get something called topical big wine nights, so what these chemicals do, for example like chlorhexidine of p h. M. B, is that they directly kills the Akon thora media, which is basically a living organism. So you need these highly sterile uh disinfectant to uh help with the management of this condition, which is actually quite a difficult condition to manage compared to the other types of care otitis, and obviously you got cycloplegic as well to just to help ease the pain and the information as well, and we got fungal infection, um which it's not correct here. Um I would re update the slide and send it send an update once to you guys, uh once you fill in the feedback link and last, but not least, we've got on closer uh basis and can you guys put in a chat, what is the other name for this condition, which is the more commonly known name within the general public. Yeah In fact, uh it's basic basically because it's endemic in rivers and streams in Africa, so one of the most common name, in fact it's actually river blindness in Africa, river blindness, I'm not entirely sure about West now, but I would assume it's appropriate as well because uh rivers in africa, but in fact uh yeah yes got to correct a river blindness and this is classically it was very endemic in places in Africa. So questions then we always say uh this patient has been swimming in uh some african rivers or has been volunteering there and went for a swim, and then he came back with symptoms of keratitis, and in this case because this is caused by a parasite and ivermectin will be used instead of any antibiotics, antivirals and obviously you got cycloplegic to help with the pain as well and then moving on to question eight okay. I hope that answers your question regarding content fighters and care, otitis right that's I'm going to give this another 10 more seconds for this question cool, so let's end the pole here and A is the most popular answer followed by a mix of b. D. Any but we've got the answers from all across the board and in fact the majority of you guys have actually got a correct congratulations and this is a classical presentation of uveitis. In this patient can see this bilateral red eye and then and also the russia race purple plaque, which is not painful or itchy, can anyone put on the chat, what this sign might be or what this. What yeah what sign this might be perfect well very well done, million is nazir, so this is called lupus pernia, which is actually quite a quite uh 11 of the hallmark feature of sarcoidosis other than be eggshell and some respiratory conditions and a fever and so this patient has a background history of sarcoidosis which is one of the can, someone also put in a chat what condition uh This group of condition is cyclo doses Ibd and closing spondylitis. What do they have in common very very very nice and very well done and indeed and that is actually one of the risk factors for you, the itis, so moving on to you the itis as you guys are very correctly pinpointed that shell a. B 27 being the highest risk factors for uveitis. This patient in that in fact, got cyclo doses, which basically predispose them to you the ITIS and a classic sign of uva high itis is called celery flush and basically is when the there's the inflammation of the iris and ciliary body and you can just see a lot of red lines, so basically like a flush of different red lines in this hillary body and also associated with that is red eye pain, blurred vision, photophobia hypo p. In an investigation for uveitis. Is the clinical diagnosis you can see from very obvious sign of axillary flush but also uh some back past medical histories of the xl a. B 27 associated conditions and even if they don't have any background history, you can consider doing some investigations in regarding hla b 27 conditions because given the fact that they are one of the high highest risk factors uh for uveitis and given the fact that these are all caused by hla b 27 so topical steroids will be the first line of uh management and together with cycloplegic to reduce the pain and inflammation and manage underlying condition or the causing uh condition which causes uveitis and someone also put on the chat then and let's say in in this 40 year old male. If you is there one specific blood test, you can also considering doing to basically uh pinpoint that this patient got cycloid osis, serum Ace, yes indeed perfect, well done everyone and then moving on to question nine. Uh Next, question two all right let's call it there. Then uh the majority of people have choosen be followed by a. N. C. And uh and yes also another answer which some of you have chosen and she is actually the correct answer. So um just going back to Janabi's question an systemic steroids referral, the topical uh steroids. In fact, uh there's some recent research saying that both topical and systemic steroids are both useful in the treatment of uveitis, So, in this case, if it's not a severe form of uveitis of, there's no extensive uh discomfort, topical steroids would normally be started first before uh doing systemic steroids, which as a result I put in it uh in the question that treating underlying conditions, uh which basically covers uh most of the conditions you would be giving uh systemic steroids for that. So uh topical steroids is mainly for the eyes, but the systemic steroids as uh from the previous question is that it will be treating the under cover for the underlying conditions as well, and sorry just getting back to this question and classic this is a classical presentation of scanner ITIS and for scare itis. Uh Specifically, topical steroids aren't as effective as oral steroids or even iv steroids for a very severe case, and I believe you might be possibly talking about uh scala right, it's rather than uveitis for your question and rather than putting oral ibuprofen, I put an oral indomethacin because it's another commonly used uh answers or cox inhibitor in this case, which uh we we can also prescribe and just quickly dissecting this question as well, uh and the reason why this cannot be um uh episcopal rightists, it's the fact that the sclera is violet in color. It's basically it's already changed. A bluish violet color seems basically shows that the inflammation is much more severe than uh much much much more severe and also despair of vessels cannot be moved by uh sterile cotton tip, which is a key differential of our hallmark feature scare itis, and the history of joint pain points to what one specific condition can someone put on a chat, what I mean by that. Indeed uh yes, it's rheumatoid arthritis so that's uh so can you just also put in a chat, then, so does this mean if someone comes with with another h. L. B. 27 conditions, for example, an IBD have an increased risk of having scala, rightists, is that a yes or no okay. This is a bit of tricky question and you will know the answer. Next slide It's only actually if um particular rightist, there's only affect. Uh rheumatoid arthritis is associated with scale rightist, but there's actually no association with any XL. A. Other XLA conditions oops sorry about that, so, I'm just going through some basics about episcleritis, so uh as the names are just episcopal rightist so inflammation of Episcopal ERA and it's more common than scare itis, which is the inflammation of sclera and it's classically pain. It's our little pain compared to scare itis, which is very classically very painful with redness and photophobia and other uh more sinister visual changes and the fact that's the rightist it can cause potential site uh site, permanent site damage. It is one of the relatives like emergency conditions in ophthalmology and one of the key differentiating factor as I mentioned before is that episcleral vessels are not movable and scare itis. While in epis, care itis, you can move them around and the management for steroid itis is an answer together with oral or iv steroids apologies for that and and obviously to treat the underlying condition, which will be rheumatoid arthritis in this case and moving on to question. Uh 10 just gonna relaunch a pool and I'm afraid I might have yeah okay. He's given 30 seconds all right, I'm just going to call it that my deepest apologies for accidentally reviewing the answer this question, but the majority of you guys have got it correct and as posterior vitreous detachment and the fact because this patient has only flashes and floated, so do remember in retinal detachment. You have the four fs which we go through in a bit rather than only the two F or if you guys once you can put it on a chat with the four f. R. And also the fact that this patient comes in with a peripheral temporal visual field defect rather than a more extensive official d A few defects is indicative of a posterior of a pvd instead right okay, let's just go through. Conditions so the four FS for a retinal detachment are flotus, flashes feel lost and foreign visual acuity and there are three main types of retinal detachment so you got recommend to uh rig mohTAj anus, which basically happens due to normal aging, but also patient's with myopia with actual length of the eye greater than 20 20 millimeter and also cataract surgery is also one of the reasons behind retinal detachment and other reasons such as executive is basically hypertension of vasculitis as one of the risk factors and tractional retinal detachment due to diabetic retinopathy and some investigation for this is for endoscopy and you can also use ultrasound to detect the area where this retinal detachment and the management for retinal detachment is based to be surgeon, surgical repair, and just one small point to note especially for those doing duke out exam in a month's time is that uh once the macula is completely detached, any surgery within 7 to 10 days shows no difference in outcome, so it doesn't require an urgent surgery as you would have thought as you would think uh you would have thought. Otherwise, if the macro wasn't completely detached and moving on to PVD which this patient has suffered. This is actually just a normal aging process and you tend to have just flotus and flashes of peripheral temporal fields rather than any changes in official fields or official equity and an investigation will basically shows no abnormal finding and for this, you just do close monitoring and conservative management, and for victories hemorrhage and this is one of the most common causes of a sudden painless source of vision and as a, as a result of uh some vitreous uh hemorrhage bleeding into vitreous humor and we can be caused by many causes, So for example you got proliferative and diabetic retinopathy, pvd or trauma, which can cause uh at hemorrhage, bleeding as such, and the main key point of this is that investigation you will want to end geography to visualize any sorts of neovascularization, uh so she is a risk factor such as diabetic retinopathy and management wise. Um If it's a small vitreous hemorrhage, you can just manage conservatively while for a large one, you will need an urgent vitrectomy to help with the vitreous uh hemorrhage, so moving on to question 10 and obstacle, so I think we have a limited time sorry for. Uh Hopefully, we won't overrun but I've just launched a pool and trying to keep it as soon as short as possible as concise as possible and you can give it in the uh 10 more seconds. I'm just gonna call it the time sorry about that and the majority of people have put the correct answer which is b. And basically this is uh plastic picture of someone with a central vein occlusion background, history of a 70 year old man, so it's ages, one of risk factors, poorly controlled, hypertension, type two diabetes are also risk factors for c. R. V. O. And because the fact that this patient doesn't have rapd, it rules out uh central arterial occlusion, which normally is associated with our a. P. D. And moreover, and you can see the dilatations of vessels of dot and blocks hemorrhages and tortuosity, which is also another clue that this can be central vein occlusion and moving on to the next question okay So just going through some uh central retinal artery and vein occlusions. The courses of risk factors basically uh if you think about it, this is more or less like the stroke, but it's the stroke of the eye so for central, so basically it also shares the same risk factors. A stroke for central retinal artery occlusion symptoms includes a classic classic question sent would say a dramatic loss of vision in one eye within seconds of occlusion without any pain and also the presence of Rapd, which differentiate itself from the uh central vein artery occlusion and the fundoscopy will show a classic picture of a cherry red spot at the, at the macula and then and also one of one of the quite a high you uh exam question, but quite a tricky one. Uh In terms of investigation is that you can also consider doing e. S. R. And temporal temporal artery biopsy If the patient is a male in greater than 50 years old in order to rule out temporal arthritis, uh If you're suspecting that because bear in mind, headache is one of the most common symptoms of temporal arthritis, but it only appears an 80% of the patient of temporal arthritis, so for the other 20% they can present without headaches, So this is important for you to consider and we'll definitely get you a bonus marks. If you say this in an off ski exam, if you're very unlucky to have a central retinal artery occlusion, which uh that came up, which actually came up with one of my ma, kiss keys previously, So the management for central retinal artery occlusion unlike stroke, There's actually a very limited things you can do these are more tend towards the conservative management wise, so you can consider Aklan massage because they believe. If you do the Aqua massage, you can have uh increased flow and then this will hopefully help to remove the occlusion towards the eye and reduced uh the impact of the central retinal artery occlusion. Interior chamber paracentesis is basically removing fluids, so there's more space for the occlusion to basically leave the retinal artery and also increasing carbon dioxide concentration and it's also uh this I think this is also used in stroke as well and moving on to central retinal vein occlusion and because it's basically very similar to central retinal artery, it's basically shares the same risk factors as central artery as well and it also gives you a lot of vision in 19, but they're technically less dramatic in a. C. R. E. O. And there's an absence of our a. P. D. And as mentioned in a question, so, uh the patient has uh tortuosity and also some dot and bloods, hemorrhages, which showcase the risk factors of diabetic retinopathy and hypertensive retinopathy in our question, so management for this uh patient of c. R. V. O. Is more or less a conservative management if it's a non complicated c. R. V. O, but you can also consider some anti vigia if you can see macular edema and any macular involvement because it's very sensitive to any changes, It's very important that we stop any possible future neurovascular Ization by giving anti veg F before it happens and for patients who have very proceeded to a face of neovascularization. Uh you can consider using a panretinal photocoagulation lays uh to burn those new vascular uh vascular ation to reduce the future risk of further central retinal vein occlusion but also uh vitreous hemorrhage as well and another cost of uh possible sight loss is cataract. Um So you've got the classic symptoms of age, sunlight smoking, alcohol diabetes radiation is sterile use. The reason being that these can be the causes or the risk factors is because the mechanism of cataract is that these can increases the risks are having dehydrated eyes and as a result of the dehydration, there's more oxidation and oxidative damage, and as a result that you cause more protein d naturalization. So your proteins in your eyes are the nature, especially your lenses and this results in your classic lens opposite fication your visible cataract, classic white milky cloudy lens appearance and as a result of the cloudy lens, you have an increased blurry vision and reduced visual equity, but also all the contrast, color, and glare reduce. As such, and you will see a classic uh questions, then they might be saying this patient is seeing double vision or, and at this sense mononuclear diplopia or what we call ghosting images and management of cataract classically, a cataract surgery um which includes a faecal with, together with the insertion of uh artificial lens and there's many different techniques such as divide and conquer and uh different approach of cataracts As well. I'm moving on to question 10 sorry that I'm rushing through this because of the time, but we won't be long. I'm just gonna give you uh just less than a minute to answer this question. Yeah just remember to uh will you read a question first before, before you um answer this question, I believe this should be the final question, give it a 32nd all right I'm gonna call it there, then, so we've got uh three of the answers stands out the most, which is b. M. E, but the majority of participants have chosen e, which as I said, uh If you read the complete question, it says the most appropriate definitive management. As a result, that you will be the most appropriate answer, but you say first line management actually b. C. And e will all be correct. Technically you can say ibuprofen for pain relief, it's it's not as correct as the others, but technically b. C. And d will be all correct if it's not just the word of definitive management, So this is a basically class uh classical uh case of someone coming with acute close angle glaucoma and exam questions. Love examiners love to ask questions uh with some sort of background history of someone watching using their eyes in a dark space, someone using their eyes in a very stressful environment, and in fact one of our questions I've came across previously is um when uh old lady went inside a ton, when they're driving the car they went inside a tunnel, and then they described uh symptoms of acute closed angle glaucoma due to the change in environment from a light environment in inside a tunnel, which is a dark environment and the fact that I put convex lens uh can someone put on a chat while I put convex lens which what what is convex lens useful um so in fact, um and in fact, uh everyone's is very get in saying that um in fact uh the reason why I put convex lens because it is uh used for a long sightedness or as you guys has mentioned um sorry it's not my myopia, but it's hypermetropia and so what it does is basically because the mechanism of long sightedness uh is that uh the eyeball is normally tend to be smaller, so there's less space and as a result causes uh increased risk factor of having uh acute closed angle glaucoma and as uh seen in this picture or in this uh setting, uh this patient is basically watching TV in a dark environment, so do just dark and trusted situation and also she's also aged, in which is also one of the risk factors because biologically and statistically they have a smaller eyes, which leads to a less space and a closed angle for some symptoms. I've seen in this picture is that an acute closed angle. You can have nausea, vomiting together with your eye symptoms such as red eyes, intense pain, blurred visions, and you can be seeing halos and co, corneal adam, as well, an investigation which shows an iop of 52 80 and uh you can also visualize the eraldo corneal angle using agan oscopy, So the management as, as I mentioned previously. Initial management be, IV as a to zola mind, or you can also use iv mannitol or other drugs being used in a chronic open angle glaucoma, as uh seen in a question, but a definitive management will be a laser peripheral, I redocument iridic to me, sorry and then moving two uh chronic open angle glaucoma and it's basically opposite to um acute close angle as more associated to my opio shortsightedness is where the eyeballs are normally longer, the extra length of the eyes are longer, and as because they're longer, so it stretches the trabecular meshwork too, and it can increase risk of the dysfunction, the trabecular meshwork, so as a result, and as a result of the degeneration of dysfunctional drip, particular meshwork, and it causes that uh backflow of pressure, which can eventually build up over time and causes damage to the nerves in the retina and some symptoms of this is that uh you classically, we see that patient's of chronic open angle have a spare central vision, and because uh you know, central vision has more nerve dedicated to it, so normally the damage is built over time as the pressure built over time, so you tend to have a peripheral vision loss before you have a central vision loss, and more more most of these patient's will complain of having like a tunnel vision and IOP for chronic open angle isn't as high as an acute close angle. It's normally just greater than 21 but also you can see the fund this exam luzon, We will classically have like uh cupping and cup optic disc upping as well as a cup to this ratio greater than 0.7, and in fact chronic open angle glaucoma could be one of the most common stations you can encounter in all ski exam because it's one of the ones which have quite a kind of a relatively more difficult exam and specific exam uh Finding when you examine the synthetic, I, I would I would hope they'll be giving you a synthetic I to examine in oscar exam. So as mentioned before management for this, you can give a wide range of different things, but traditionally you would first line will be a prostate gland and a lock like land lantana processed, which increases the outflow and second line you can just mix a much whatever you feel like you want to give and according to the patient's contraindications, for example, if patient's have uh it's already on beta blockers or patient's got asthma, it would also you might consider other choices like the result in mind instead and last, but not least uh the last line of treatment laser traffic lost low plasty, so basically this, what this does is basically burnt the trabecular meshwork, but it's got a 50% failure rate after five years, So this is traditionally like we we tend to try and avoid uh the third line treatment until we have tried everything else to ensure uh uh we can manage the patient without going to the lasers, so I think the time now is 27 minutes past eight, so we actually still got a few minutes to spare, so uh so in that case, I shall go through one of the hardest concept I I found when I first started doing glycoma back in year two is the mechanism behind glycoma, so uh so in this picture, you can see a picture of open angle angle closure or closed angle glaucoma as you would like to whatever you pick, so what happens in a glycoma. In general, is that normally you would have an acquis flow from a posterior chamber at the back to the interior chamber and then what happens, then it goes to the trabecular meshwork and it basically unsolved uh the fluids and then drains it, so it doesn't cause us any fluid builds up and there's no increased pressure, so everything's happy, however, what happens in like home especially angle closure glaucoma. Is that there's increased pressure behind the irish, because improper drainage tropics of the trabecular meshwork, or the angle in it, closed angle is basically closed and as a result of that there's more and more pressure built up at the back of the irish, and when this happens, it pushes the angle to even closer to down, and as a result that's you've got to increase IOP as you can see in the colonoscopy and from uh due to the build up of the pressure and can cause a mechanical damage on the optic nerve over time, but also due to the pressure, you can have reduced blood supply to, towards the optic nerve and that is why you would have optic nerve damage over time for open anglo, die coma and have a tunnel vision. First before you lose a central vision as it progresses, and for angle closure glaucoma because everything's very rapidly closed and you tend to have a more acute onset rather than a chronic build up of pressure and chronic bit of damage of that, So, I think this is the end of the presentation, so we're just on time, so um thank you very much uh for sticking around, and I do apologize if uh for making a few mistakes, and I would send you guys to updated slides uh after the presentations and for those who are sitting your uh Duke out exam. I wish you all the best of luck, which is exactly a month and a month and a day before, so yeah, so we're gonna march the eighth so good luck for everyone sitting in the Duke Outer and obviously in progress test as well. If you uh medical finals and all skis ahead Yeah, we have a wonderful Loski series in collaboration with psychemedics, coming up early next month, so stay tuned Thanks Clinton. It was a good session cool. If there any questions, please put it on the chat, I think we have one final it's easy session which is the interventional radiology.