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had everyone, um, think we have started now. So welcome. Teo stays in the blue Torrey away on ophthalmic manifestations or systemic disease. So let me just start off for sharing my slides. You'll see my slides. Okay? Yeah. If you could. Just also in this chart, if you could say to see my slides. Okay? Yeah, I seem so So, uh, just introduce myself. My name is same run academic foundation doctor at in the oxygena reason, or Marco, working currently in State Medical Hospital on today's lecture will be on ophthalmic manifestations of systemic disease. And so what? I'm going to go a range of things. Trying to have more, more common things that you will likely see in sort of everyday practice where that's your energy, presurgery or hospital. Just really Common things are common and starting off. Um, that's sort of what comes first. Really. So there's often times where we sea ocular symptoms and from those referrals, amazed ophthalmologist or other specialists. And as a result, systemics disease is a diagnosed. Other times, patients already been diagnosed with this systemic disease on do over time, they develop Parkinson symptoms that then require theater, ensure of an ophthalmologist referral. So it's that reason that so she's been in the primary. Cat condition should be quite familiar with sort of ocular complications is common systemic disease. So today we're going to cover symptoms related to dramatic disease, congenital vascular water immune and very briefly. At the end, we'll cover metabolic and enter crying. So I know of. The previous lecturer is on went over to the house to a usual examination and assessment. It was covered in the first lecture that was done. So I want to go into sort of helped to do another examination for each patient on that's those lectures should soon be up on the YouTube page for mindedly where you could have a look on that. So first things first. So I think we've got the metal chapped features. If you guys could just answer in the chart box on, got a picture up here. But if a clear that the the issue that happened is from the traumatic cause, so if you could write in the chart what this picture is a future off. Just have have a guess, really. If I give you a clue, it's patient has come in on their nine months old, Onda funded. Same nation is performed on this is seen No. Okay, uh, so this is a sign off shaking baby syndrome. So I'm here with see, We've basically got, um, a hemorrhage. So here we've got an intravesical hemorrhage on. But it's not some of something you'll see imminently when a child presents with a traumatic injury. But where you see in whether than any or on your pediatric placements or anything like that and injuries in a child that will answer to in keeping with no more injuries that would happen in a child. You should, if you have a race sufficient for child abuse on you, should actually probably arrange to have a dilated fundus. Examination is that could reveal rattle hemorrhages. And these can preretinal intravesical or vitreous hemorrhages. And then, as you can see, actually, it's white center temperatures as well. So this is the obvious bit. We've also got this these white said to temperatures on these other intraretinal. Once on back, chew away. You should get it too quiet for document documentation of these findings on a Zack chew A lease. Sometimes he's finding the quite fleeting and so quite quickly. And given that yeah, So next we'll cover congenital. So I'll start off by saying in the trap box, you can put it at 12 or three. But what sort of each one is, um, because I warn, is X two excuse axe. So give you sort of a minute to sort of say, what conditioned person? My half in these three pictures? Yeah, plus ones. Correct. And the second one? Well, you could start out by saying, What is the sign that showed in the second picture? Oh, I guess. What? It looks abnormal in this picture of the eye. Okay. We wanted that one. Where you guys having? A lot of brown spots. Okay. Any ideas? What these brown spots are called called Deposit. Okay. Any other right days? Okay on. Then I'll cover a or three of them are just sort of your answers first and then the third one. And your ideas, What they have in a while it's in the third one is Okay. Well, sort of. What's the difference? Better than last time. Okay, that's good. Good shout. Other sort of gases. So what's different between the two Until coma okay? Yeah, This's difficult this week. Sorry. Is Theo trying to make it very interactive? I promise I will explain what all these things are, so I'll go from the beginnings. The first one is down to your correct Yvonne Cataract Good s O. With Children down, very characteristic that become to fold that sort of a common finding. And it's acid from day one and what's not actually on? Actually, often times the individual's will have problems with sort of the extra business and their eyes. A second misaligned so often times in this common type of missile, I'm in that they get It's a strip here, which is went there ized drift in and on. Sometimes you can get extra pills over the addressed out, but that's actually less common on. Actually, in this picture, you can see there is a little bit off and esotropia. They're just on the left eye and then the second one. So I was made. It was quite tricky, but the's a leash. No jewels. So the the sort of like multiple freckles bra freckles in the course of the eye here on day. This's actually manifestation of the newer fibromatosis is which, and you can get new roof fibromatosis type one type two and that commonly in type one. And this is quite a common or to any condition on thing. So it's not a penetrating I injury. It's it's a congenital one. It's a, uh so on was neurofibromatosis. Type 1 to 95% of the patients will actually get this kind of ice in terms by day by the time they're six years old. So it's quite a parent on his quite uncommon autoimmune don't ultimate congenital condition and then the one of the bottom. So quite a few people guest retinal blastoma. I can see what you mean. It doesn't look quite similar. This is actually congenital cataracts. And when it's retinal blastoma, typically, actually, instead of sort of a blue, cloudy circle that you get in the eye, it's more orange colored lot of reddish hued color or not risk. But the other, like I if you sign a flash, as it will show, sort of and the reddish yellow. But the other one worked. In contrast, I guess that's the clear here that the other eye doesn't show, sort of like a reddish orange. You in the middle. So what we have here is actually congenital cataracts. Do you concede Scotch Characteristic cloudiness in the middle of the eye on this kind of seen in many actually congenital conditions so you can see it in down's you can see in Marfan syndrome. You can see it in trisomy 13, just a towel syndrome, closing me 15 at what syndrome you know. So you see it in Children who are born with congenital infections like cytomegalovirus and talk to plasmosis. The's could be operated on, or sometimes actually that it conservatively managed if it's a mild cataract on their way through the trial to grow out of it. And next, does anyone have any questions actually, before they once the next section about this one. Okay, so next we're going to cover a vascular sort of manifestations, autonomic manifestations and patients with vascular disease on. So I thought I would actually put two cases up here. I'm just make it a little interactive, so what I will do is we'll go through Case number one and then go to case number two, so I'll read out Case number one and then give you sort of a minute on day two, you have to think about what the condition is. Could be. And then if you could just pop down in the trap future on D, any ideas about what they could be? Okay, so Okay, so number one a 65 year old man with a history of hypertension and hypercholesterolemia, notices sudden, painless vision loss in his right eye. Visual loss is limited to this to puree nasal quadrant of his visual field. He first noticed the visual field lost approximately six weeks ago. For the past two weeks over here started up blood fishing century, making reading difficult. So any ideas what this could be? So we some things that are vascular related visual lots. It's something related to a blood vessel on. So try and think of a common blood vessel Polish Central Artery. Thomas. Okay, Yeah. Any others on then case number to a 60 year old woman with no pre morbidities presented with symptoms of sudden, painless vision loss in the left eye. Best corrected visual acuity in left eye was counting fingers close to the face. A relative effort, people defect was observed in the left eye ocular funders examination of the left eye was suggestive off and they would rethink fun. This examination was suggestive off. Uh huh. Okay, what's the lowest Tuchman? Any others? Okay, So before I give you the answer to both these two cases, I just want to highlight how similar Actually many retinal basket of the reason of the I. R. When a patient presents to you in clinic or in an e over in primary care to ask the history is a very useful part of your assessment. Actually, a lot of time developed as we get through the ocular fund. It's examinations included through CT scans, which can highlight where the weather fault lives. So the first one is actually central retinal vein occlusion on this causes for typically sort of sudden, painless vision. Loss on this could be mild to severe and usually patients who have a history of having high BP essentially having an open angle, glaucoma, other such of risk factors that would place him a risk of having hardening of the arteries like hypercholesterolemia there smokers. So the initial visual loss that they have when they first don't know what this is all often actually good indicator off how bad or how good their final visual outcome will be. So if initially there vision is quite bad when they're first diagnosed, it's probable that actually, the final visual acuity is also give me a little more worse site on Been fact. Actually, half the people with central retinal vein occlusion the visual acuity remains with instead of three lines on the iron shot on when the first visuals are created, a measurements were taken when they're first diagnosed, compared to sort of the final one couple of months down the line on then. Case number two is central retinal artery occlusion on Do. This sort of actually usually prevents percent of them or found visual loss. That's what caused on to go for a whole I less socially just decrease in visual acuity. Gradually, on D again, it can occur in one eye. Most patients with with this can actually bad you can't think is in front of their face or even see the light from the affected eye. So it's actually very, very profound visual loss. Very sudden paralysis. Visual loss on the central retinal after infusion may be preceded by episodes of visual loss notice that more assists. Few guards were just witnessed. You have sudden just visual loss in that one eye on often of the most common cause off. This is a cultural embolus in the neck within the courted artery on bats. Why, it's very important to do some ultrasound, Doppler's, um, off the neck to diagnose that on. This is essentially a stroke off the back of the eye. That's what it What is it? I guess if you were explaining to patient what they've had to explain, why they had this sudden visual loss is essentially if they've had a stroke of their eye on again, similar to central retinal vein occlusion, most patients that have high BP also on the's was especially so the factor quarter will have a significant carotid artery disease already. So, like after sclerosis or approve his history of fasted disease on or history of diabetes as well. So you don't want me to be too deterred from the history is being quite similar, but the diagnosis is being different in practice. A patient that presents with these kind of symptoms straight and you have an ocular, fondest examination and uh, no CT scan as well To diagnose where, um, weather fault lies on which vessel it is. Because if you can even get branched Retinal artery occlusions on a branch, retinal vein, occlusions and patient. In front of these conversations, you would have to refer firstly, talk about pharmacology, actually. Importantly, refer to the medics a swell because they will need to be admitted and get medical treatments on, but could be in the form of blood thinners and BP monitor. And they may have been lingering BP, malignant hypertension, which needs to be treated. Or should me in the hospital. Okay, um on. But now we're going to look at some order to systemic hypertension, which can cause on changes within sort of the eye. So I have Here is a picture from the space A graph on D Each of them are sort of different features you can see. And, um, hypertensive retinopathy. So, in the chart future would they got formalizes exactly what they would actually. So if they they have a clot. So in separate central retinal artery occlusion, if there is a clot in the course of artery, yes, they would get normalizes. And that's why It's even more important for them to be urgently refer to the medics and or potentially a stroke unit. Yeah, and so so here. We've got a fungus photograph in the chart Future. If you could say, we don't have to go in order to just say which ones you know what? 12345 is a I'm doing a bit more if you'd like, So you can see more clearly what it's pointing out. But I'll sort of give you a minute to how you look at that and say, Well, each of these features is copper wiring A. See that. Which one do we think is copper wiring? She could, yes. So if you could just also say the number and in the future Thank you. But you're right. That one of them is called the wiring number five. Yeah, and the other numbers. Want to take a cast. Six. Cutting more spots. Three swelling off the optic disc toe. Give you gas is at the end and one hemorrhage. What about number two? Um 47 and six for cupping to cotton wool spots. Yeah. See any guesses on seven A. V. A pink. Good on any guesses on? No, but we know going to three. I think we don't have any illnesses for a moment. Even if it more you can see. Okay, that's fine. You guys did very well, actually. Um, you just see what it is. So these are the features there, Number one. Correct. We've got hammered their blood temperature here. Um, number two. We'll see you did some ones yet. Number two, um, sounds of cotton wool spots. So six looks similar. Actually got a more sports, but exit dates on, uh, what did you get? So three is arteriolar narrowing? Uh, which is very subtle. He ever have to say, very resuscitate. Don't ever. I guess compared to this one I wrote, um, a V nicking seven is right before disc a Deemer and I think someone actually just don't sit up a swelling of the disk. I think number three, you're probably pointing up one number four is actually so I'll give you that one. It's well on Ben. Five very correct copper wiring on then six, we said, and seven, we said it will maybe neck ache so systemic hypertension can affect the retinal retinoid. But it can also affect. Actually, the articular of a swell on a variety of little rescue changes can be seen in patients with hypertension when they're sort of more subtle on beginning stage that they weren't necessarily called and changed in the vision. Patient won't notice anything either. So, uh, the moment in the UK there isn't a I know. With diabetes, there is a screening system, but with hypertension hypertensive patients, there's no screening system at the moment. What it is sort of this we optimize thie their BP with medications that when they do start having if they do, start having any visual symptoms, and they are referred for the monarchy quite often. Actually, there are optometry. Tom Straight little optometrist. So notice these findings often when they go to the opticians for, you know, just visual check. Sometimes when they're actually noticed, there were picked up there, and that's whenever I get off the energy on for a decent where the signs of noticed on So actually hypertensive retinopathy is a clinical diagnosis on uh huh on basically what that is. Is that good? So yes, so hypertensive restaurant with E is a clinical diagnosis on basically when you have this kind of characteristic funders finding that doesn't actually one of them, you can just be one of few seen in patients with stomach arterial hypertension on basically originally. So I have a tentative tentatively was classified into four stages, which I'm sure you're You're for your covered in your, uh, doing medical school finals exams on been So stage 123 and four And you've got a tier two, your material the narrowing arteriovenous nipping Axid, a shin cost, more spots and optic nerve a Dema on. However, actually, population studies have shown that the futures that are shown in the fund is, uh, related to those stages. Call it very poorly, actually with the severity of hypertension. And we actually question how useful even is to have these stages and patient into these different stages on. Actually, sometimes patients that even don't have hypertension have certain futures that would place, um, technically in one of these stages. But they don't have hypertension. So and that's why I actually we don't do routine fundoscopy patients with hypertension or when we're managing, um, when we're managing patients with hypertension and so some some others asked what is optic disc cupping. So basically, this is when the optic disc, which would be around here, is thinned because it's tender. It will appear pathologically cupped. On Tend to be tends to be that the middle off the the optic disc, which is here were told to appear, is actually bright yellow, much brighter than this here, Can you see? It's more actually dull, and it's just sort of looks really bloated and brought out When it's optic disc, uh, pink, it tends to be imagine, like sort of a son in the middle of the eye And this part here the circle. It was sharp with bright yellow on, and that's usually happens when there is damage to the optic nerve on Ben. So when patients have hypertensive retinopathy, they may have clinical symptoms like intermittent blurring. They may have headaches, and they may have field defect perform field defects on Very rarely. They may even show up with a red face, which could actually indicate a cutable that high BP, which is called malignant hypertension. And that would be an emergency, which needs to be referred to the medics on for optimizing off their room off the BP on D. Yeah, and as we covered previously with super cents central retinal artery occlusion or central retinal vein occlusion, occlusion and you can get some pain. It's more sufficient when hypertension is poorly managed. On an effect on that any time will effects would have retinal corridor circulation's and could lead to occlusions through artery narrowing. I couldn't So next we will cover. Um, don't on auto immune, um, autonomic signs. So the first one we've got sugar in syndrome On this, this's an autoimmune condition, which patients will typically just swept. Sentence. Tries to have dry eyes, dry mouth, um, complain off having grittiness in their eyes. And then if you do antibody test on them, they'll test most likely positive for onto your own antilock on TSS. And essentially, the treatment for this is very much sense in management. So artificial tears, lubricants for the eye drops. Hypromellose just thinks distant, imagined to help with the dry eye. Next, we've got ankylosis spondylitis. If someone in the chat could right, what is this picture that I've shown here? What is this sort of I related condition here that's in this picture. Uveitis. Yeah, any others. Yeah, so Yeah, this is uveitis. And this is very this is a good a complication that can occur. That closing spondylitis? Yep, correct as well on D Typically patients. If they're exhibiting I symptoms with ankylosing spondylitis, they'll have sort of photophobia readiness of the IRS exhibited here on decreased vision, and you have to refer to ophthalmology for this on. So Iritis is the most common type of uveitis is a type of uveitis because in textbooks, sometimes they'll say patients who have anterior uveitis or iritis. But it's the same thing. A century on day should have I writers, and they referred to often ology that typically treated with topical corticosteroids and dilating agents. However, this should be prescribed by an eye specialist because if you have long term corticosteroid, therapy can actually have a detrimental effect because it can increase your risk of a coma, cataract formation or fascination of ocular infections on. Actually, if patient has a connective tissue disorder on top of this and they'll be giving well term cortical steroid treatment, you can actually need to be talking a perforation so used with caution on refer um, and then at the bottom We've got a patient with rheumatoid arthritis on these pictures. They look quite similar, but they're actually different. Slightly different things. So if you could write in the chart What? The one on the left on what? The one on the right is showing any ideas? Let's go right to step on. What about the one on the right? Right Episco itis. Yep, that's correct. So, um, in ocular manifestations of limit with the arthritis is most often seen in patients with very active and severe forms of the disease. So many patients will go for the whole life having least on these things. But if the PSA very active disease, they will. Ondo sent these garages and episcleritis on. They could sometimes exhibit dry eyes. Ahs Well, however, usually they will get sort of inflammation of the episclera. So sclera on in the muscular and essentially get a square is more superficial with steroids. The information is more deep rooted, actually, very rarely. But people with rheumatoid arthritis can sometimes also get you the itis interest his, um even perfect corn your pulses of dollars of it breath. So I guess in in this instance, if you're more something to the couch for when a patient has really good arthritis. You don't probably won't be diagnosing the little arthritis based on these sides. They have these signs. Are we? Once the disease has progressed a bit more. Okay, okay on, then. We've got systemic Lupus erythematosus. Andi, actually, patients come off. Very similar ocular manifestations. Is Teo patient with rheumatoid arthritis so they can get dry eyes that he gets? The writers really think it was a perfect cornea losses and or they get sort of optic neuropathies on D. The most common manifestation, however so sorry. Most common in severe manifestation. Leslie, however, does involve the vasculature of the retina on the optic knives. Just something to be aware of a swell on. Do you've got sort of the ways you diagnose them? Which is Do you hate your laser hatred? B 27 patients with SLE commonly test positive and and then we can also have used to have giant cell arteritis, which can also be present with opthalmic symptoms. So what they do get things like draw product, cation, headaches, scalp tenderness, have a fever. They can also get visual changes as well. A lot sufficient haven't. Typically, This is also a medical emergency which would require referrals. Medics and they would patient will be given a short how it does course off on cortical steroids. What? The biopsy is done. And that's ultimately how you diagnose giant cell after writers where you do suspect it. You shouldn't treat the biopsy results to come back on. You should get it straight ahead and give that high dose cortico steroids. Some patients. May you require oxygen? Well, to relieve the symptoms on Ben, we've got this photo here. Can anyone in the chart, right? What? This is exhibiting in a patient myasthenia gravis. Tosis. Yep. Yeah, you're So this is Tosis on day typically disease, constipation's. And by CT agraphis. Especially when she was late. One in the days of more tired, they are, um and we'll profound. This will look on basis. Um, annulotomy condition, which is affects the acetylcholinesterase on receptors on do I symptoms is a very common feature of it. Sometimes, actually, you could suspected patient with cirrhosis. You might. It might be worth actually sending off some investigations for the ACTH receptors to diagnose it off times. It could actually appearance. Certainly more severe disease. And then we've got this photo. Hear anyone? Onda, tell me what condition is that? Causes? What should in this photo, what condition is this woman have? Grace, did he give you on? Can anyone will write in the chart? Future? What other typical opthalmic signs off grave's disease to, Of course. Great. Except, um als, um, a procto See step. Any other features or complications, or are complications of graves' disease Delete clock? That's right. Anything else conducted biters? Yep. Good. So yet this is a graves disease. So actually you could get thyroid. I'm on what this patient has. This I rode I disease on Do so you could get thyroid eyes is actually rarely but more and more commonly in gray's disease, but can also get it in patient of hypo Thyroid isn't That's not well controlled, but more commonly is increase disease most of the time, eso very correct. Taking it did lower. Getting excellent, far more singing. It Tosis in patients who have thyroid disease, they can also get sort of swelling off their Riley's. They get reckless of the eyelids they can get and let this is the conjunctivitis. Well, they get swollen covered. Cover calls on dissection. See how we diagnosed the severity off those guys. Seeds is using something called clinical activity. Score on what this is is. It's a table, and it has different features on where patient scored. Oh, the school for and it covers things like of patients. I was in pain. If there's wetness, if they're swelling or first would be impaired function on. That can be a little decreased iron movements in the last couple of months, or decreased visual acuity a smidgen by this instead and chart lines in the last couple of months. So actually, this is a very common complication off grace disease on patients who typically have more complications when their disease is in the active phase, all is in the active face. It's a patient that we refer to ophthalmology whenever paid, the exhibited the ice and tempted they've got thyroid eye disease. Even if they have Hypo Thyroid is, um on. Typically, when the disease is in the active phase on, they will be treated with cortical steroids on plus minus. Immunological therapy is is also you could get a good friend in late the fat and know Sometimes they will also get radiotherapy as well. When the disease is no longer are in the active phase and sort of steroids and other student immunity person to being used to switch a stump in the activity, they can't then be referred to have, um, orbital surgeries think it will. But and decompression and sometimes patients have I need to require actually emergency or with the decompression. That's what the when they have very profound pain that I and it's ridiculous and sudden visual loss of actually that can be managed with steroids drug by itself, in which case they require a nerve agency or two decompression on essentially what that happens is they do cross the opportunity there around the iron to try. First, I back a little bit, force any even when patients receive steroids or other switches immunised person therapies. Think I doesn't do you ever go back to have it was before that see started, it could just sort of hold disease progression is stop it from getting worse. So it is something to actually affects patient's quality of life quite profoundly, and that would be something that should be taking two into account and patients. Quality of life is well. And how that approved with the treatment, Have any questions about that? Okay, so, uh, getting towards the end now. So now we've got the big one diabetic retinopathy on. But so this is a very, very common condition. Diabetes itself is a very common condition on diabetic retinopathy is a common complication of diabetes. Essentially, all patients with diabetes should be referred for diabetic retinopathy. Screening on that's a slight are going to After this one different countries will have to figure out kind as to how common sort of God, Because how often and swimming should be. I'll get into the guard joins to the UK But wherever you're based, you should look into with the cards off that. That's because in the earlier stages of diabetic retinopathy or back, uh, it could be very subtle. The changes and patients were necessarily have actually any visual changes at the beginning. But there's lots of background. What happening that could really done it perfusion as it the disease progresses, Father. So here on the left, we've got a normal retina. You got the macular. I thought the blood vessels going down here and got the optic nerve, so I was diabetic. Retinopathy progresses. Different changes that happened. These changes what will happen at once? They will sort of progressively happen on. So what this picture is straight is very Oh, severe, profound diabetic retinopathy on we've got here. It's actually quite similar to hypertensive retinopathy. Some of these features that the cardinal spots you've also been reading was also you've got the the Optic disc a Dema. We've also got think like new vascular ization which essentially means is new blood vessels. For maybe these blood vessels aren't exactly functional. They actually just increase the risk of having worker and your reasons later on down the line Is this with First on, you've also got the micro aneurysms of the existing vascular tree is fall. You want to go exudates sort of fatty deposits and on d and you, as I said, it's also got a little spots and that's this is too, because shown in a fund, it's photograph. Patients can also get the CT images done, which can show more clearly Thean packed off the retinopathy instead of how severe it is on we great both retinopathy o'clock the instead of all one or two same with Microangiopathy m zero and want him to. And they're considered stage how severe it is and with all the patients were really the best treatment is optimization of their blood sugars. And this is the diabetic screening that we haven't UK and to probably you should get it. So all zero m zero means patient is essentially doesn't have even less trouble. You're microangiopathy. Which case it should really have screening every 12 months. Then you've got background retinopathy. So are one mg zero could have not got any maculopathy and again routine escape screening every 12 months and the way they diagnosed with someone know a zero Cetera is based on how much of these they have, and it's sort of, you know how the hypertensive gastropathy is characterized different stages. Based on whether they have either one of these features. It's the same with. And if that's on day to actually stages, especially in the beginning stages, we really advise patients to have auto management of the diabetes. At these stages. Patients don't really need to be referred out there where you can, uh, think citing is going on and really the best treatment is to just optimize the diabetes and the blood, sugars and other vascular risk factors like the lipids and BP on there should also be seen ideally by the diabetes nurses at the practice is to ensure that sort of the top of their treatment, and they're getting the HBA one C levels to assess how well the diabetes is controlled. Then this is when we were for patients so distraught surveillance clinics. That's when they shoot. For to these referrals, do digital surveillance connects can come from Judy practice. Or they can come from opticians. When patients with having a routine visual checks for their glasses things could get picked up, there was well, which could refer, which could lead to them being referred to civilians, clinic and that and what? How often they need to be reviewed. Mr. Million's clinic. Um, really a very spending on how severe the time the retinopathy in my company is typically is an optometry that sees patients in addition surveillance clinics on on. But this thing gets father civilians. So where they swift friend develop later stages for Timoptic or they develop that Mycolog. In addition to that, then they refer to hospital I services ophthalmology on. But were they expletive could have for a test and treatments. Okay, um, you have to want to be aware that someone in developed gestational diabetes. So actually patients with gestational diabetes should also be considered for three need for diabetes. And because I just it's really at risk of developing a diabetic retinopathy maculopathy at the other population, especially if they've got sort of other risk factors, like high BP or or highly pitch levels. Okay, so that's a very recent tour off the different kind of eye manifestations of symptoms that you can get a systemic disease. It was sort of firm was giving a flavor off the different types of diseases, of course, on. But you could get tons of eye symptoms by hope that that was helpful for you. Garden on Diffuse got to any questions as well. Just feel free to pop them in the in the chart books, and I'll stay around for another 5 to 10 minutes to also them. I need a next lecture will be on, um, sort of opthalmic side effect off different medications as well, with the most common presentation that you see. And I guess out of everything in this in the slides it would be the diabetic retinopathy maculopathy that's really the the most common on. Or least it's the one you should be aware off. Really? Really In a session. Yes, we will be She I'm just awaiting for Thebe Center to send me the slide. Thie slides. It should be recording as well of the electric started. Probably just want you to pages. Well, we'll just keep an eye out for that. So all I need to page if you write like the sleep on it should it will be purple. Never. So see more CM video recording as well. No problem. I hope you guys this helpful on deal See you in the next ophthalmologist tomorrow. What's the difference between proptosis and accept family? So they're actually the same thing, the different names for the same thing. You need to get them both in grave's disease that produces when you get bulging off the eyelids on. That's the same with, except almost up and up Normally wonder I something in and ups on that, except for mold, is when it's quite a bulging out and coming up to Proptose is next. Thomas are the same thing. Essentially. Yeah, Basically sort of abnormal protrusion off the off the eye. I didn't know. I just it for the next presentation, and I still got one. Of course you can still come the next presentation. I think the registration legs is still open, and it will be in the next four nights. Time on. In fact, let me see if I could let me stop sharing. Let me see if I can find the link. Actually, Fuller next one c you can register. Just bear with me a second. So this is gonna think I'm just gonna send to know how with me. Okay. And we've also Oh, well, that's that could be a second, and I hear pasted it here. So you should be able to get it here on both. Also, I'll just open up the feedback for, uh, 40 days tutorial so you can give your feet back and see what you like, or you didn't like, um, I'm just going to Yeah, feedback should be a production, you know, And you were accepting responses, so there'll be emailed out as well. And this is the feedback link. Sorry, I'm doing a tour by myself today. See? Usually I I was the one person while the speaker's talking, but I couldn't multitask today. Yeah, that's the feedback, Linkous. Well, okay, so if no one has any other questions, um, style be it for today. And then we'll see you in thes in the next tutorial, and I look forward to seeing you all that okay?