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Hello. Hello, everyone. Uh It's Lachman again. Welcome to our session on ophthalmology. Um Someone quickly type in the chat if you can hear me, please. Anyone, if you can hear me just say yes in the chat. Okay. Nice. Okay. So let's give it a few more minutes before we start. Um I think we've got quite a hefty session today because there's a lot to covering uh ophthalmology. Um So we might overrun, but I'll try and make it as, as quickly as possible and as concise as possible. Hopefully, let's give it a couple more minutes. Okay. Well, you guys know how this works. Um So it's M C Q questions taking from pass med. It'll cover some major themes um, of the topic today, which is ophthalmology and then we'll use poles again. So we'll show the poles on the screen. Uh And then you guys can answer the questions using the polls and then we'll give you about 60 seconds, maybe even less depending on what the question is. And then we'll talk through, um, sort of the questions together. Okay. Uh All right, we've got a decent amount of people. So I'm happy to start. Don't want to, don't want to waste no time today. So quick recap on anatomy of the eyeball. Um So from the front, you can see the pupil in the middle sclerosis, the white bit and the iris is the is the circle around the pupil is the one that's usually colored. Um And on the right, you see the eyeball or the orbit itself. Can you please upload this session as a catch up content? Yes, of course. We out load every session as as catch up content. If you don't get any of the catch up content from the previous um from the previous sessions, you can just email me or, or let me know in the chair and I can send you the catch up content from before. Okay. So um on the right, just have a read through on what it all is. You know, the sclera is the outer wall and then the Epis Clara's the very um just above the sclera, the conjunctive of the iris, the lenses right there in the middle of the cornea is right above the lens and then you have the anterior chamber and the posterior chamber as well and the vitreous humor and the optic nerve. Okay. So a quick overview of the recap. So what do you ask in someone presenting with eye symptoms? Okay. So what, what would you ask type in the chat? Anything you think might be relevant in an eye history? Yep. Diplopia, visual changes. Anything else? Yeah, restriction in eye movements. Anything else? Photophobia? Yep. Yeah. Pain, always gas about pain. Um Good. Okay. So you ask photophobia, you asked about paying visual changes. Always ask discharge very good. Never forget to ask about contact lenses. And if they're wearing glasses, that's very important in a nyhistory. Always always ask them about contact lenses and contact lenses and glasses. Okay. Um So for pain, always do Socrates, visual disturbances redness discharge. So um I ask what the color of the discharge is and how much flashes and floaters? We'll get a bit more into that later on. And do they use contact lenses or glasses? Okay. Now, the most common presenting complaints for eye symptoms are visual disturbances, redness and pain in your exams. It'll pretty much be these three if an eye symptom were to come up. Okay. Now, what are some causes of visual disturbance? You know, just, just drop a few just to see what you guys might be thinking. Anything that can cause a visual disturbance? Yep, macular degeneration, retinal detachment, diabetic retinopathy. Good, good. Um Well, there's a lot, there's a lot that can cause visual disturbance. Okay. And, and these are our list and we'll go through quite, quite a bit of this today. Uh Palsy. Yeah, it can cause diplopia. Um a lot of the policies cause diplopia. Um Yeah, we'll, we'll be going through a lot of these today. Um I watch some causes of a painful red eye. So not necessarily visual disturbance but painful red eye. Very good. There's a medical emergency right there. Cute angle, glaucoma. Yeah. Um orbital cellulitis. That's again another medical emergency. Um Yeah, uveitis, any injury, conjunctive itis. Um and a bunch of other stuff. Now, episcleritis and sub sub conjunctival hemorrhage present with a red eye but they're not painful. Okay. Which is why I have that asterisk there. But these are some causes of a painful. I all right, quick question before we move on, I just want to clarify what a relative afferent pupillary defect is. Can anyone, does anyone care? Can anyone care to explain it to me in the chat? If they can, if not, I can just explain it here. You know, I'll just explain it here. So it's, it's basically just a condition where one of the pupils respond differently to light stimuli compared to the other one shown consecutively. So they use the swinging like test. I'm pretty sure if you guys have done sort of like the eye exam. Yeah, you, you have to do the swinging like test and that's the test for this R E A R A P D rapd. Yeah. So basically what it's testing is testing for um, the optic nerve and to see if it's actually working properly. So what happens in a swinging light test? So if you swing a light in one eye, both eyes should technically constrict. Okay. Because there's the direct reflex and the consensual reflex if you swing it to one eye and you find that both eyes actually dilate, that means there's something wrong and it's not detecting the light. And that means there's a relative afferent pupillary pupillary defect. Okay. So that's what happens when you do the swinging light test. Okay. So that's R A P D now, snelling charts. This is one more thing like you just listen about it, but you don't actually know how to, how I didn't know how to like um interpret. Can you go back to rapd? Yeah. Yeah, of course, definitely. So, so, and, and don't worry, you'll, you will get the slides at the end of this, but basically Rapd is when you're just testing to see if the optic nerve actually detects the light. Okay. So if the optic nerve detects light, what it does is it constricts the both pupils actually because there's a direct and consensual reflex. So if you shine light into your left eye, it constricts. But you're right. I constricts as well because of the um consensual reflex. Okay. Did I say that? Right? Ok. I think it's called consensual reflex. But basically, if you say there's a problem with your right eye and you swing the light to the right eye, the right eye does not constrict, it dilates instead, which means the optic nerve isn't detecting the light. Okay, which is why it's dilating. And if this dilates, then this side should dilate as well because it's consensual. Okay. So that's, that's rapd. And if you swing it to one side and it dilates, that means there's a problem on the side that dilates essentially. Hopefully that makes sense. Okay. So, Stella charts, people always talk about 2020 vision, but in the UK, we actually use 66 vision because 2020 is feet is in feet, uh six sixes in meters. Okay. So what what does 2020 or 66 actually mean? Okay. So 66 means or is used to describe normal vision. The first number is the distance the chart is viewed by you. So that's the distance you view the chart from. So let's say usually people view the chart from like 6 m. Okay. So that's the first number. The second number is the distance a person can see the letter clearly. So how do I explain? This is like 66 m at 6 m. Someone with perfect vision can see line number eight. So it's just above the red line. So from 6 m, people can read the E F P O T E C. Okay. So that's what that's what normal people with perfect vision can, can read. So if you can read D E F P O T E C, that means you can read from 6 m as well. Okay. So that's why it's 6/6 or 2020 vision. That means you can read the same distance as someone who has perfect vision can read. But let's say let's say from 6 m, you can only read the line above the green line. Okay. So or you can only read line number line number five, for example. So that means at at five at 6 m, you can read line number five, but someone with perfect vision can read line number five at 12 m, for example, okay. The example I gave here is like you can read the fourth line at 6 m, but someone with perfect vision can read the fourth line from 15 m, which is why it's 6 15. So 6 15 isn't great eyesight. Okay? Because what you can see at 6 m, someone with perfect vision can see at 15 m. I hope that makes sense. Okay if it doesn't make sense, just let me know and I can re explain it. But but that's basically what snelling charges. So like 2020 is perfect vision. Basically the worst your vision is the higher the second number gets. So it becomes 2030 vision or 2040 vision essentially because what you can read at 20 ft, someone else can read at 40 ft. Okay. That shows that your vision isn't perfect. So that's how you interpret a snelling chart essentially. Okay. Just, just, just for your guys information. Now someone tell me what the difference between myopia and hypermetropia is. I've got myopia, that's what I've got. Yeah, which one is which? Yeah, myopia is shortsighted. Yeah. Myopia is shortsightedness and bang sinuses. Hypermetropia. Okay. Um So basically shortsightedness. So shortsightedness means that your eyeballs are long. Uh and you need to use concave lenses. So I'm using concave lenses right now. Hypermetropia means your long sided. You have shortened. No, sorry, not eyeglasses is shortened, eyeballs, sorry, I'll correct that later on. But basically your eyes short. Uh and it's corrected by convex lenses, okay. And the picture on the right basically explains what I mean by that. So myopia means you're short sided. Um and the image falls in front of the retina because your eyeball is too long. And then in hyperopia or hypermetropia, the image falls behind the retina because your eyeballs too short, okay. Um And this is how you correct them. Um Again, you can, you, you have, you guys will have access to all these uh once we're done and I'll send you guys the slides. So investigations for eye problems, you always do an eye exam, you always do a fundoscopy. Well, for most cases, you would do a fundoscopy, um looks at the back of the eye. And then you will also do a slit lamp which is basically looking at the interior portion of the I like the conjunctive asclera cornea and Iris. And then you can also use a slit lamp like a fundoscopy as well to look at the back of the eye. This is what a slit lamp looks like. Um If any of you have like an ophthalmology block, they usually, they're usually kind enough to let you try it out. Uh Slit lamp. I, I managed to try it. I thought it was really cool. Um Okay. So before we get into the questions, uh some of the just warning, some of the images later on might be a bit disgusting. You, we, I know some people just feel sort of achy around eyes. So just just a fair warning. Okay. So, question one. Okay. 60 seconds. All right, 20 seconds or 15 seconds, we'll try and go through today's a bit quicker because we do have quite a bit to cover. Okay. Okay. So I'm going to stop there. So we have an 84 year old man presenting with loss of vision in the left eye since the morning. Okay. So that means it's been quick, it's acute, it's very quick loss of vision. He's got no pain, he's got no headaches. Uh But he's got a history of heart disease. And you see on fundoscopy, there's a red spot over a poor pale a peek retina. That's classic. A lot of, you know, this, a lot of you answered it correctly is central retinal artery occlusion and that's called the cherry red spot on the fundoscopy. Okay. So basically what century archery retinal occlusion is, is basically like a stroke, but for the vessels in your eyes. Okay. It's the same process. It can be a thrombosis. Um So like a dislodged endless or it can even be something like a vasculitis um causing ischemia to the eye. Okay. Um So it really is just like a stroke but for the central retinal art artery, okay. And the central central retinal artery is a branch of the ophthalmic artery that supplies the entire eye and the epidemic artery is a branch of the internal carotid arteries. Okay. Just for your um just for you guys information. Um yeah, it supplies the inner layer, inner layer of the retina. So there's sudden onset, painless visual loss, okay. Uh And it's painless. Uh and it's usually unilateral just like a stroke and it also presents with rapd, relevant, relevant different pupillary reflect, I forgot what it was called, but rapd, the swinging like testing and it classically has the cherry red spot thing. Okay. Now, in terms of management, there's not much you can do aside from treating the underlying conditions. So controlling their hypertension, giving them um controlling the cholesterol and control controlling their heart disease as well. And sadly, overall, the eyesight prognosis is poor for central retinal artery occlusion, okay. Um There is there is there is this thing like using thrombolysis like the useful stroke but for the central central retinal artery occlusion, but issues mixed results, okay. And this is what it looks like. So you can see the pale retina and then the very classical cherry red spot. This came out in my, one of my, ah, skis recently. Um, and it's really easy to see on, like, even on the mannequins. Right. Very good question too. I'll give this about 60 seconds again. Any questions just pop in the chat by the way. Okay. Right now, let's talk about this patient. Um, a few more seconds. Okay. Yeah. So we've got a 30 year old male presenting with, again sudden onset loss of vision. But this time on fundoscopy, you see severe retinal hemorrhages on fundoscopy. Okay, severe retinal hemorrhages. As soon as you see that sudden onset pain, sudden onset loss of vision um is central retinal retinal vein occlusion. Okay. So it's exactly like the artery occlusion except this time there's hemorrhages on fundoscopy instead of the cherry red spot. So it's what it says on the tin. It's basically occlusion of the vein and for veins, it's usually not caused by like a thrombus or anything like that. It's usually caused by like damage to the actual walls itself. And these things can happen spontaneously or it can even get worse with age. Um cardiovascular disease and hyperlipidemia diabetes. They all weakened vessel walls and they all increase the risk of central retinal vein occlusion. Okay. Um So when there's weakness to the walls of the veins, the blood and sort of serious fluid can leak from the vein. Um and cause severe hemorrhage is affecting eyesight in the eye and in really severe cases, it can also cause ischemia as well just like it did in the artery occlusion. So, symptoms is exactly the same sudden onset pain, painless, painless. Remember, visual loss, it's usually unilateral, just like the artery occlusion. But on the fundoscopy, you'll see something called a stormy sunset appearance where there's these huge retinal hemorrhages. Um and I'll show you on the picture pretty soon, but management is basically conservative treat underlying causes as usual. Um And there are some newer treatments, but for our level, we don't really need to know this for now. Okay. It's got a better prognosis than artery occlusions. 50% regain eyesight completely. Um And the rest do gay nice regain eyesight, partially okay. And this is what it looks like. So it's like people call it a stormy sunset sunset. Some people even call it like a pizza dish appearance as well. So as soon as you see, this is always going to be a central retinal vein occlusion. Okay. Very good question. Three again, another 60 seconds. And if you're wondering why I'm not explaining why the others aren't. The answer is because a lot of them will come up later on and then I'll be explaining that later on, which is why I'm not explaining why the others are wrong. But if there is a question specifically on one of the answers or why it's wrong, just shot in the chair and I'll be happy to explain it to you guys. Okay. Right. Let's stop there. Let's have a look at the question, 75 year old myopic woman. Okay. So she's, she's shortsighted just like I am. Um We've known hypertension presents with sudden painless reduction in her vision. Again, it's sudden and painless. She describes a dense shadow obscuring her right eye that started peripherally and has progressed towards central vision. So you all know what this is. It's is basically, it's it's retinal detachment. And if you can imagine, it's like the retina peeling off the back of the eye, which is why she's, she's having this, this symptom of it starting peripherally and then slowly affecting her central vision. Okay. She can only see her hand movements in the right eye that shows that it's severely affected. But in the left eye, she's got 66 visual acuity, which is perfect vision. So that tells you that it's not, it's not something cysts systemic, affecting both eyes, okay. That's why they mentioned six X vision. So right now, detachment, basically, when the retinal neurosensory tissue comes off the underlying pigment, epithelium and these are just layers of the retina, okay. And this could be due to small breaks in the retina. And when they're small breaks in the retina, some of the echoes humor which is the liquid within the eyeball get seeps through the break and then it separates the two layers apart, which is why you can get retinal detachment So risk factors for retinal detachment are things like diabetes, age trauma is a very common cause of retinal detachment as well. And myopia now, why, why is myopia a risk factor for retinal detachment? Remember I told you myopia means that your eyeball is elongated, correct? So when, when an eyeball is elongated, it makes the retina a bit more taught and tight. So that increases the risk of detachment, okay. Or at least that's, that's the way I think about it. And that, that makes me remember why myopia is a risk factor for retinal detachment. Okay. So, symptoms started onset painless, painless, progressive vision loss. And people describe it like a curtain falling. So they always start peripherally and then it slowly goes central. It can be over the course of a day, a few days, maybe even a week. Um That's how quickly and you, they can have flashes and floaters as well. So basically what flashes and floaters are is that you get flashes of light or even you see like spots floating around in your vision like dark spots. And that's basically just the pigment, epithelium cells entering the victorious, okay, because of the detachment. Um if the macula is involved, severe vision loss is possible and if you don't know what the macula is, is basically just the center of the retina where all the cones and all the high acuity vision is produced. Okay. So your macula is where most of your clear vision is produced and if the optic nerve is involved, you get rapd. Um So when you do a fundoscopy, you may realize that the red reflexes lost and then you can see wrinkles in the retina that are opaque or pale management. Uh So this is uh this requires a same day, I think. Yeah, the same day referral to an ophthalmologist with the slip and so that they can diagnose it, it is an emergency. Um and it can cause permanent eyesight loss if they don't. Um if they don't treat it immediately. So they use something called a pneumatic retina pexy, which is basically an injection of intraocular gas bubble and that pushes the retina back into the wall and then they secure it okay. And that's what it looks like. So you can see sort of retinal folds and wrinkles. So if you see that at any point, that's a, that's a retinal detachment right there. Very good. Right. Question for. So if you guys notice the pattern of today, it's basically a single condition for every question, which is why there's a lot, okay. 45 seconds from here, okay. Five seconds. I'm sorry if I'm giving you like a little time for the questions, but because we, we actually need to go through this pretty quickly. All right, let's discuss the question first. So 66 year old man, funny symptoms in his eyes. That's very helpful, isn't it? Um So he describes flashes of light in his eyes for several days. And he's got noticing darker bits floating around in his vision. So that's basically him describing flashes and floaters. He's shortsighted, okay, like me. Uh he's got myopia. Um and there's no significant medical history. So he doesn't even have visual, he doesn't even have like a reduction in his visual acuity. He just has flashes and floaters. That's it. So what this man has is he's got a posterior vitreous detachment. So right now, detachment can present with flashes and floaters as we said before. But right, no detachment also has that descending curtain like loss of vision. This guy doesn't have that. He's just got flashes and floaters, but he's got risk factors for posterior vitreous detachment. Okay. So what app arterial vitreous detachment is is in front of the retina? Um There's the Oculus humor or the vitreous humor. Sorry, the vitreous humor is the liquid within the eyeball that keeps the eyeball shape. So basically what happens in the posterior vitreous detachment instead of a retina coming off the back is the vitreous just coming off the retina like this. Okay. And that leaves a gap in between. Um And for some reason that causes flashes and floaters. I'm really sorry. I don't actually know why, but in a posterior vitreous detachment flashes and floaters is the most common initial presenting complaint. Okay. Um The reason it happens is it's associated with natural changes in the eye aging myopia is also a risk for the same reason that it was a risk for retinal detachment. So myopia has long eyeballs um and the vitreous is sort of stretched out, which is why it's more likely to peel off the retina. Okay. The last one, retinal detachment is the retina peeling off the inner layer. And then this one is vitreous, peeling off the retina for vitreous detachment. It's more common in women as well. If Ronald attachments like curtain going down, how is it going peripheral to central rather than superior to inferior? Um because well, it's not necessarily like a curtain going down, it can sometimes be like a curtain coming in words, you know what I mean? So that's what I mean by a curtain, you're not necessarily going downwards, but sometimes it can be a curtain going this way. So it can be from peripheral all the way to central. It can be superior to inferior as well, but it can start from the peripheral, superior up to the inferior, central is what I mean. Hopefully that makes sense. Aisha. Um Okay. So more common in women um and it can sometimes progress to retinal detachment as well for vitreous detachment. Okay. So the symptoms mainly sudden onset painless, painless, again, flashes and floaters. Um you can get a cobweb appearance across the vision and on fundoscopy, you see something called a wise ring, which is basically just a ring or membrane or it's like a ring shaped floater, essentially like the picture on the right. Um In terms of management itself resolves over six months. So treatment is not usually necessary for fisheries attachment. Okay. So right now, detachment was an emergency. Victor's were detachment self results over six months unless there's a retinal detachment associated with this vitreous detachment. Hopefully, that makes sense. No question. Five, a retinal tear and a retinal detachment is more or less the same. Well, a retinal tear is basically what can lead to a retinal detachment. So there's breaks in the skin and the retinal tear is usually caused by stuff like um trauma. Um And it wouldn't present as mm actually retinal tear, a retinal tear may not present with anything. Actually, it can be a symptomatic until there's detachment going on because it's just a tear. It hasn't actually detached from, from the back, but I'll get back to you on that roughy. I, I do need to confirm that. Yeah. Okay. Let's give you guys another 20 seconds for this question. Again. I'm really sorry if I'm going really quickly through all this or not quickly enough. I don't know. Some of you a lot are really quick. Okay. So now let's go through this question. 67 year old patient, poorly controlled type two diabetes, sudden onset visual disturbance. It's painless again, present for the past three hours. He reports dark spots. Um So he's got floaters, but he's got a red hue in his vision. Okay. So that should give a huge clue in its own and a lot of you got it right. It is vitreous hemorrhage. So what a vitreous hemorrhage is basically just um one of the blood vessels in the retina, you know, has ruptured or has leaked and that has leaked blood into the vitreous, which is why um uh which is why he has that red hue non fundoscopy will look like the picture on the top, right? So you can see a slightly red issue or throughout the entire retina because the vitreous is uh has been dyed red color because of the blood essentially. Okay. So you can come from destruction of any better in the retina. Yep. So common causes or risks include diabetic retinopathy, posterior vitreous detachment as before and ocular trauma, trauma especially. So, symptoms, um like the patient mentioned, you can get a red hue, you can get flashes and floaters, um hazy vision but not complete loss of vision. It's usually just hazy vision, okay. And in terms of management is usually just conservative for vitreous hemorrhage, okay is conservative. Uh And then once the bleeding stops blood clears at a rate of 1% per day. I don't know who actually measured that, but I just thought it was cool thing to include. So we've talked about retinal retinal detachment, vitreous detachment, and vitreous hemorrhage. And all three can present with flashes and floaters, okay, retinal detachment. Presents is presents with visual disturbance. Vitreous detachment does not present with visual disturbance or less, does not present with vision loss. Sorry, that's what I meant. Vitreous hemorrhage presents with a red. He'll okay. So this, this is how you differentiate these three because they all present with flashes and floaters essentially. Okay. Question six. Yeah. So Rafia retinal tear is just what leads to a retinal detachment. So it breaks in the skin. That's a retinal tear. The retinal tear itself may not present with any symptoms. So that's why it's not the right answer. Sorry. Which, which one do you want me to repeat? Faisal? Is it just about the three, the three, the three things? Well, if you want me to repeat that, it's basically just retinal detachment, vitreous hemorrhage, sorry, retinal detachment, vitreous detachment and vitreous hemorrhage, retinal detachment. They all present with flashes and floaters, retinal detachment. There's vision loss, vision loss in like from periphery to central. Okay. That's essentially what retinal detachment causes in vitreous detachment. There's only flashes and floaters and maybe some um some cloudiness or some web like floaters in vitreous detachment in vitreous hemorrhage, there's flashes and floaters and there's a red hue in vitreous hemorrhage. Okay. So retinal detachment, vitreous detachment, vitreous hemorrhage. Those are the three differences. All right, you guys have had time for question six. I'll give you guys 20 more seconds, 20 more seconds because just because I was explaining just now. Okay. So let's talk about this question. All right. Um Okay. So 35 year old man presents with visual problems. He has had very poor vision in the dark for a long time, but it's not worried he's developing tunnel vision. Okay. Um Now he's a young, he's a young guy. He's, he's only in his, he's only in his thirties and he's already having like uh eye problems and he's complaining of tunnel vision and his grandfather had a similar problem as well in his fifties. Okay. Um Now the the answers are split between primary open angle glaucoma and retinitis, pigmentosa. And I would say those two would be the closest answers. But the answer is retinitis pigmentosa. And the reason why is, is because primary open angle glaucoma tends to be in the elderly. Okay. It tends to be in the elderly and it tends to be in people who have hypermetropia. The big clue in this that shows that it's retinitis instead is that his grandfather had a similar, similar problem. So, retinitis is a hereditary condition. So it's, it's very gene focused. So young guy with a family history of going blind in his fifties, like his grandfather went blind in his fifties. So that's quite early. Definitely points to something more like retinitis, pigmentosa. Okay. So it's caused by the degeneration of the rods and cones in the peripheries. And there is a strong genetic link. Okay. Night blindness is often an initial sign and people get tunnel vision because the rods and cones on the peripheries are more affected than centrally. Okay. On fundoscopy, you see something called a black bone spicule shaped pigmentation. And there's these black bony structures around the peripheries of the um of the retina essentially. So there's general treatments for retinitis, pigmentosa, like vitamins, minerals. But for our level right now, we don't really need to know that. Okay. And the prognosis usually depends on inheritance. So since the patient's grandfather went blind at 50 he can sort of expect the same, the same progression essentially. Okay. Uh And that's what it looks like. I know it's not very clear, but if you see at the very peripheries, you can see some, some black bony spicule, well, you can see some black structures surrounding the peripheries essentially. If you just tight retinitis pigmentosa on Google, I'm pretty sure there's like a better image is in this. I probably should have chosen a better image, but that's what retinitis pigmentosa is. Okay. Now, questions seven. Let's give this 1 45 seconds. Sure. Okay. Alright. 15 seconds. If you don't know the answer, you can just have a guess. Okay. Right now, let's have a look at the question. Okay. We've got a 74 year old retired artist attending GP with longstanding painless loss of vision. So it's painless again. Now, the loss of vision now is gradual and it's affecting reading. So straight lines in her paintings are starting to appear wonky and this is picked up on Amsler grid testing. Okay. So as soon as you see Amsler grid testing immediately, you're thinking age related macular degeneration. Now, what's the difference between dry and wet? Okay. For wet A R M D, it usually progress is pretty quickly, it wouldn't be very gradual. Um And dry is often more quick and that's the difference in terms of their symptoms. We'll talk a bit more about their pathophysiology in a bit. Okay. So it's degeneration of the photo receptors in the central retinal, which is the macula, okay. Um And that can be disastrous for your eyesight because that's where most of the high acuity eyesight is. Um so when the macular degenerate, sit also forms these yellow deposits of proteins and lipids called drusen. And it's between the membranes of the retina called the Bronx membrane and the retinal pigment, epithelium. Okay. You don't really need to know this. But um it's good to know, it's good to know. So some of the risk factors include just growing old age is the strongest risk factor for macular degeneration. A lot of elderly people event can develop a RMD. Smoking increases the risk as well. CBD and certain ethnicities have a higher risk as well like um Caucasian or Chinese ethnic origins. And if you have a family history of a RMD, you're more likely to develop a R M D as well. Okay. So it's degeneration of the photo receptors in the macula, which is in the center of the retina. 90% of cases uh are dry RMD. You find gruesome in wet A RMD, you can, but uh in wet A RMD, what defines wet RMD is the neovascularization. So you can still find drusen in wet. But the thing that actually decides if it's wet or dry is the presence of neovascularization. So if you see new vessels that sweat A R M D as well as the onset of the symptoms, if they're having generally rapid onset within like days or weeks, it's more likely to be wet. A RMD. Okay. So gradual reduction in central vision, not peripheral for macular degeneration, crooked and wavy lines, appearance of straight lines. Well, what is this test called? Yeah, you, you guys saw it just now. It's an absolute great testing, uh reduced visual acuity and presence of drusen on fundoscopy. So, on fundoscopy, um this is what the gruesome looks like. So it's just these yellow deposits everywhere. Okay. So that's what Drusen is. Um management is a combination of vitamins and sometimes they use anti veg F which is a vessel endothelial growth factor, but anti veg F is more often used in wet A M D to stop the neovascularization or the formation of the new vessels. Okay. Um And there's just a quick diagram from zero to finals, which is an extremely good website. If any of you don't know what it is. You should definitely go see zero to finals. Um That explains what Drusen are where they are in between the epithelia. Okay. Now, quickly on wet, it's characterized by new vessel formation in the court right layer. Um not necessarily drusen. So this causes leakage of fluid and blood causing rapid vision loss. The symptoms are exactly the same as dry MB but presents more acutely and the, and the mainstay management is antibact Jeff. Okay. So, question eight really quickly on anti Veg F. Uh it's, it's basically what, what they do is they inject it into your eyeball. And that's that halts the formation of the new vessels essentially because VEG F is used to create new vessels and what they're injecting is anti veg F. Okay, let's say 45 seconds for this one. We're burning daylight. Yeah, it is intravitreal injection. Correct. You inject it right into that vitreous. She's kind of disgusting, isn't it? Imagine needle going directly into your eyeball? Okay. Five more seconds. Okay. Let's have a chat about this chap, this lady, 57 year old woman history of type one diabetes for the history of decreased left sided visual acuity. So it's not, it's not really super acute, it's like sub acute, but it's not chronic as well. So when you assess her blind spot, the patient states that the object used appears a different color when using her left eye done and that's when with her right eye. So if you, if you remember if I'm not sure if you guys learned this the blind spot test, they use that like lip like that red pin thing. Okay. Um So she's got, she's got changes to her color vision and the saturation desaturation of the red color. Okay. And that's very classic for optic neuritis. Okay. The pin that they use to test for blind spots is usually red, which is what they're trying to get in this question. So, optic neuritis is basically inflammation of your optic nerve and it can be caused by a lot of things. But I was gonna ask what, what I was gonna ask what is associated with optic neuritis. Um Do you always investigate for M S when diagnosis object charities? Now, the thing is, what's the definition of M S? Can someone tell me like what, what, what is the classical thing about M S that makes it a mess. Yes, neuronal demylination. But there's something about the neuronal demylination that makes it M S. Have you guys heard of um disseminated in time and space? Yeah, that's, that's, that's what it is. So, if someone presents with optic neuritis for the first time, you can't actually diagnose them with M S or you can't even investigate for M S because it's only the first time you can only diagnose and investigate for M S when they present with something else. So if they present with sudden weakness, a few months down the road um in a completely separate location in the eye, then that's when you can diagnose M S but you would still do something like um uh you will still do something like a contrast MRI just to confirm that it is in fact opting your itis. Okay. Um So remember M S disseminated in time and space optic neuritis commonly the first presentation of M S but etiology, inflammation of the optic nerve most commonly associated with M S. Um So it can also be associated with diabetes, syphilis and post infections. So, a lot of infections can trigger auto immune responses as well. And that attacks the optic nerve um symptoms, they're usually unilateral, very rare. You find bilateral optic neuritis, decreased visual acuity over hours or days, poor color discrimination and red desaturation. So the color red becomes less vibrant, essentially, you can get ophthalmoplegia or pain on eye movement in the optic neuritis and rapd because the optic nerve is directly involved. So you would expect rapd in this case and it's usually central vision that's affected, okay, because it's right in the center management is usually conservative. You can give steroids. Um You would do an MRI brain and orbits to confirm optic neuritis and could reveal underlying M S if it was a second, if it was a second presentation essentially, okay, you give high dose steroids and recovery is usually within 46 weeks, right. So that was optic neuritis. Now, question are in 45 seconds from here. All right, five seconds. All right, lads. Let's go through this. Someone jump the gun with cataracts just now I think, and I can see why it's like difficulty driving, struggling to see cars coming toward him. That's a classic like cataract question. But, but it's not, it's not, I'm just, it's not the answer in this case. Sadly. Um, so 52 year old man, few months, difficulty driving can't see cars coming towards him on the side of his vision. So he's got peripheral vision loss. Um and he's also got occasional headaches as well. So that doesn't reveal a lot. So you should see his past medical history. So that actually reveals a few risks to what he has specifically shortsightedness and he does not wear his glasses. So the answer in this case is primary open angle glaucoma. Um So it's gradual is slow and it's the shortsightedness that kind of pushes you to and, and the and the tunnel vision, sorry. And the yeah, and the tunnel vision that that sort of pushes more towards primary open angle, open angle glaucoma. Okay. So any glaucoma will present with tunnel vision and in this case, he's got shortsightedness. So myopia is a um a risk factor for glaucoma and we'll, we'll get to it okay. So I got all the next few slides. I got this from zero to finals. If any of you don't know what the website is. It's a website created by a Manchester graduate. It's very good. I used it a lot for my undergraduate studies. It explains things really clearly and really simply. Um so let's talk about glaucoma, what it is essentially is um damage to the optic nerve because there's raised intraocular pressure within the eyeball. So why do you have raised intraocular pressure within the eyeball? Okay. So let's look at the i there's the anterior chamber in the posterior chamber within the in front of the lens. Okay. So the anterior chamber is filled with a quiz humor to supply nutrients to the cornea. The anterior chamber is between the cornea and the iris. So the cornea is the very outermost layer and the iris is, is the, is the junction between the anterior and posterior chamber and the posterior chamber is between the lens, the the blue thing and the iris. Okay. So the Equus humor within the, the anterior chamber or within the front part of the eye is basically produced by the celery bodies which are holding the lens. The sillier bodies are holding the lens, they hold lens and they produce a quiz humor as well. So the liquid, this fluid acquis humor flows from the celery body through the iris into the interior chamber into the trabecular meshwork into the canal of shalem. So the canal of slam is basically where the Acquis humor drains out of the eye. Okay. Yep, I've talked about this. So when the aqua humor can't leave the I, that's when the intraocular pressure increases. And that can happen by two ways. Okay. The first way is by resistance in the trabecular meshwork. So it can just be because there's debris or things through the trabecular meshwork that causes the flow to slow down the flow of a quiz humor to slow down. But the celery body still produces aqua humor at the same rate, which is why in this case, primary open angle closure, glaucoma, the pressure and the pain and the symptoms gradually develop. Okay. And the reason is called open angle glaucoma is because the angle between the cornea and the iris is open, it's not closed like this is open. And the only reason the Ecowas humor has difficulty going through the mesh work is because there's all this debris there. Okay. So that's primary open angle closure glaucoma on the right. The other way it can cause an increased pressure is if the Iris itself is pressed against the trabecular meshwork, completely blocking the outflow of the Acquis humor. Okay. And this is a certain, this is a medical emergency. Um So why does the Iris fold forward? Well, we'll talk about it. There's some risk factors that can cause the Irish to just fold forward like that and completely stop the flow of the Acquis humor. Okay. Quickly on what happens to the optic disc and the optic cup. Okay. So in glaucoma. Now, now we know from from the previous lights. Now we know what causes the race intraocular raise intraocular pressure. Okay. Is the trabecular meshwork um being blocked either acutely or gradually, that's what's causing the race intraocular pressure. Now, what does the rays intraocular pressure actually do in the eye? So it affects the optic disc by cupping it. Okay. So, increased intraocular pressure causes cupping of the optic disc. So the optic disc is basically the optic nerve. Okay. The outer ring is the optic disc and the optic cup is the disk on the inside. So in a normal optic disc and cup, the ratio is small, okay, the cup is way smaller than the disc. And again, these pictures are taken from zero to finals as well and they explain it very, very well. So if you see on the pictures on the left when cupping in, so see, look, look at the picture of normal optic disks. Okay. So it's a small cup and a large disc. And that's because the pressure is normal. So it's not pushing on the, on the disc itself. But when there's raised intraocular pressure, the pressure actually pushes the cup deeper into the optic nerve and that causes the cup to widen, which is why there's cupping in glaucoma. Okay. The optic cup becomes way larger than it should be compared to the optic disc. And you have to compare the ratios between the cup and the disk. So in a normal person with a without glaucoma, the ratio of the cup to disc would be 0.4 to 0.7. That's normal. Okay. But in glaucoma, the pressure will push the cup deeper and deeper and make it wider and wider until the ratio is only 0.7 of the disk. Okay. So if it's more than 0.7, it suggests glaucoma. All right. Hopefully, I explain that. Well, if you didn't get the explanation, I do recommend visiting the zero to finals website on glaucoma. It's very good. It's basically where I got most of the most of the pictures from. Okay. So primary open angle glaucoma is because of the trabecular meshwork has debris in it and it's a gradual increase in the risk in the in the resistance. Um So risk factors include age, family history and myopia. Okay. So people who are shortsighted, uh they have long eyeballs so more debris can go in between the angle because the angle is more open. So more debris can go there or that's how I remember it. Ok. So people with myopia are at risk of primary open angle glaucoma. Okay. Um So the symptoms include tunnel vision, okay. That's gradual. Um Hypermetropia is a risk factor for acute angle closure glaucoma. So, myopia is a risk factor for primary open angle, but hypermetropia is a risk factor for acute closed angle glaucoma. Okay. And I'll explain why. So other symptoms of primary open optic disc upping in terms of management. Um You give them some prostaglandin analog eyedrops, beta blocker eyedrops, carbon ian hydrate eye drops. And these are all eyedrops that basically what they do is they reduce Equus humor, secretions and increase um uh quest humor outflow. Essentially, there's a, there's like a whole table on like the mechanisms of actions of, of eye drops and I really don't want to get into it because I don't remember it. I hate, I absolutely hate that topic. Um And there's really no way around remembering the eye drops. You just have to sit down and you just have to memorize it. I'm really sorry. I can't give you guys like an easier way to remember. It is just so convoluted, but let's move on to question 10 before we talk about acute angle. Okay. Okay. I realize it's eight. We've got about six more questions to go. I'm just going to drop the feedback forming just in case any of you have to leave soon. Um Hopefully you don't, but if you do have to leave soon, please fill in the feedback forms and then I'll send the slides out um soon ish, hopefully. So if any of you have to leave soon, but I would say it will only take like 20 more minutes, hopefully, 30 minutes at most from here on. Okay, let's say 30 seconds or 40 seconds from here just because I was talking a lot. Yeah. Okay. So let's have a look at what's going on in this, in this guy. So he's got a one day history of painful red eye hypertension type two diabetes. He wears glasses for his hypermetropia. I gave a clue as to what this might be. So, celery injection, mid dilated pupil pain is exacerbated. Uh When you assess pupillary reaction is a non reactive pupil, visual acuity is markedly reduced in his right eye compared to his left. Um Yeah, so gonioscopy was performed and trabecular measure was not visualized. So it sounds like this guy has an acute angle closure, glaucoma, doesn't he? So what do we do in someone who has an acute angle closure? Glaucoma? Well, there's quite a, quite a quite a mix of answers, but I would say a lot of you got the answer right. So you always give them the eye drops first, okay, because they're asking for first line management. Definitive management would be a laser peripheral iridotomy, but you will always give them the eye drops first just to control his current symptoms. So what the eye drops do is basically what I said before you stop the production of the aqua humor or slow down the production of the aqua humor and you increase the outflow of the aqua humor through the trabecular meshwork. That's what they do. Gentamicin. Eye drops are basically antibiotic, eye drops, which you don't use. In this case, prednisoLONE, you don't use in this case is, is not like an autoimmune condition and cyclopentolate if I'm not mistaken there, dilators. And I, I don't think you use dilators in this case, but you don't use cyclopentolate in, in um in acute angle closure, glaucoma. I'll check about what cyclopentolate is but basically use pill car pine timolol, which is be a beta blocker and brimonidine, which is an alpha two agonist, I think, I think. But yeah, you basically do eyedrops first before peripheral iridotomy. That's, that's basically what this question is trying to tell you. Okay. So let's let's talk a bit about acute angle closure, glaucoma. So instead of the trabecular measure being blocked by debris, what's a fixed? Yes, you do give IV acetaZOLAMIDE as well. You can give that first line as well. Um For acute angle closure glaucoma, a fixed mid dilated pupil which means that a pupil is just slightly dilated, but it doesn't react to light. So it's just fixed. That's, that's what it is. And that means that the pressure in the eyes just so much that the Irish literally can't change its shape. That's why it's got the mid dilated pupil okay. Um So instead of debris blocking the trabecular meshwork is the iris itself that's blocking the meshwork, okay. Um And the reason that is okay. So why, why is hypermetropia a risk factor? So remember myopia was an elongated eyeball, hypermetropia is a shortened eyeball. So when the eyeball is short, the angle between the cornea and the iris is already kind of acute in itself. So let's say something happens that just sort of pushes the iris just to close the meshwork slightly already. The, the Eliquis humor starts building up and when the aqua humor starts building up, the pressure just pushes the Irish towards the trabecular meshwork more and more so it's a self perpetuating problem. Okay. As soon as a bit of it happens, the more it progresses, the worse it gets okay. I hope that makes sense. That's how I remember, hypermetropia causes acute angle or is a risk factor for acute angle closure, glaucoma and myopia is the risk factor for primary open angle glaucoma. Okay. Just remember hypermetropia means the eyeball is short and when the eyeball is short, the angle between the iris and the cornea is also lower, which is why the trabecular meshwork has a high risk of getting blocked off. Okay. And it's a self perpetuating problem. So the more it's blocked, the more acquisitive produces and the more it just pushes the Irish towards the cornea as well. Other causes include um, age related lens growth can increase the risk as well and medications that cause pupillary dilatations. So it pushes the Irish away as well. Again, blocking the blocking the trabecular meshwork. So things like sympathomimetics like phenylephrin, okay. So symptoms, you get severe ocular pain is very painful, decreased visual activity, you get a hard read I um a lot of people complain about halos around lights as well, semi dilated, nonreactive pupil. So the people does not change with light, um dull or hazy cornea and nausea and vomiting is common. Okay. So the management first line, you always give the eye drops and IV acetaZOLAMIDE so well done roughy. Um Yep. Yep. So it was an alpha two agonists and then you give IV acetaZOLAMIDE to reduce accretions. Definitive management is a peripheral iridotomy which creates a tiny hole in the peripheral Irish. So that all the acquis can, can get out and get out, right? And this is what it looks like. So the uh it's very red, very painful. You can see it's maybe even a bit swollen in this, in this patient's case. And the, and the, and the iris is slightly dilated, okay, very, very painful and it is a medical emergency. Um straight to hospital, straight to emergency departments, straight to ophthalmologists, essentially. Now, question 11. Now I'll just send the feedback forms in again in case any of you need to leave, please fill in the feedback forms. Please give honest feedback. Anything you want me to change any things you like about the session and I'll give you 40 seconds from here. Uh huh. Okay. So now let's see what's going on in this patient. Okay. Um So the answers are split between diabetic retinopathy and cataracts and I can understand that. Um So we've got an old lady. So she's seven, she's 75 so she's quite old. She's been diabetic over 25 years. Um, um, and she's attending, attending her regular follow up sessions. Okay. Um, difficulty with vision past few months, blurry vision. So it's gradual. Um, never had problems with the vision in the past. She's taking medications, blah, blah, blah, blah, blah. Everything else is kind of normal. Okay. So how can we tell the difference between cataracts and diabetic retinopathy? Now, the key here is actually the halos at night. Okay. So seeing round figures around lights at night. So those are halos. So cataracts often presents with halos at night and that's because of the blurriness of the lens, diabetic retinopathy would not present with halos. In fact, a lot of them would go by pretty much undetected until something catastrophic. Absolutely happens like a vitreous hemorrhage. So, diabetic retinopathy actually does not really present with anything um unless it's too late. Okay. So usually if it presents us with these blurriness or maybe even like halos around nights is usually cataracts. Okay. And halos around lights at night is classic cataracts. Okay. So the answer is cataracts. Um the white is cataract is basically a condition that causes the length of the eye to become a pig and cloudy is the most common cause of curable blindness worldwide. And it's heavily associated with increasing age, diabetes, smoking and long term steroids. So, diabetes itself is a risk factor. For cataracts. Um, but age is the biggest risk factor, the older you get your increase your risk of cataracts just increase exponentially and it's more common in women. Sorry, ladies. So, um, gradual onset reduce vision, okay. Um, just in general blurriness, faded, color vision. So things become less saturated, less vibrant and then glare so they get glare and halos at night. Okay. Now the management of cataracts is basically just a cataract surgery. Okay. And the fancy term for cataract surgery is fecal impulsive fication, I think. Yeah. So it's a fickle impulsive fication. It's basically replacing the cloudy lens with a clear plastic one and this is what it looks like. Okay. You, it's, it's, it's a, it's a pretty routine, uh, surgery. Um, yeah. Question 12. Okay. 45 seconds from here. All right. Five seconds. Okay. Now, let's go through with the question. So, 31 year old, um, 31 year old woman presents with one day history of unilateral painful. I, she reports pain on eye movements. Okay. She has no past medical history. She was, she was recently treated for UTI and then she takes regular medication apart from, apart from Ibuprofen, which helps with joint, but she does not take any regular medication apart from Ibuprofen, which helps with joint pain in her hands in the morning. What could that be? What could that be like? What could she be having right now, in terms of her joint pain that could be related to what she's experiencing right now. Reactive arthritis. Yeah, could be or even just rheumatoid, rheumatoid arthritis is what she could be having right now. Um So her right eye is watery. Um She's got mild photophobia and both pupils are reactive to light. Okay. So a lot of you and quite a few of you answered conjunctivitis. Um and that's not the case in this situation because conjunctivitis wouldn't present with photophobia. There wouldn't be any visual changes um in in conjunctivitis. And they also usually complain of discharge that's like sticky and like crustiness around the eyes. So, conjunctive itis isn't the answer. In this case, anterior uveitis can have something to do with rheumatoid arthritis but usually presents more severely. There'll be changes to the iris, it'll be way, way, way more painful. Um It'll be a fixed pupil as well and sometimes they can even get something called a hipaa peon. Um And in this case, the rheumatoid arthritis actually has a greater association with sclero itis as well. Okay. So the answer is scleritis. So client is basically just a full thickness, inflammation of the sclera. It's generally associated with autoimmune conditions, specifically rheumatoid arthritis. You can also get it with sle cycled and cycled doses as well. So it's rheumatoid arthritis has a lot of eyes can be associated with a lot of eye symptoms, but I would, I would say scleritis would be the most common one, especially if it's painful. Okay. In terms of its symptoms, usually patient's present with like a red eye pain on movements. Um, it's a dull ache, ok. But sometimes it may not be painful. It can be a mild pain discomfort, but it does worsen on eye movement, watering eyes, they can get photophobia um in terms of management because this is, this is an autoimmune condition. Uh I think you give steroids. Oh, no, you give NSAID, sorry. So if you're suspecting some of his scleritis, you always send for a same day assessment for ophthalmologist just because they need to rule out something more serious like an interior uveitis. And then if they think it's scleritis, then they usually give Ansaids first line. And if it's more severe, you give steroids and if it's resistant scleritis, you give immuno suppressants. Okay. So scare itis is very much an auto immune mediated condition. All right, just remember that, scare itis, autoimmune rheumatoid arthritis and it's painful. Now, next question, 4, 45 seconds from here. How do you differentiate it from anterior uveitis in the history? Well, interior uveitis actually has slightly different risk factors. That's one thing. And then it's the examination itself, I think because anterior uveitis and scleritis can present similarly in terms of like their pain. But I'm pretty sure interior Vitus is like really bad pain. Um but it's the examination itself that really truly differentiates it, I think and the history and like the past medical history. Sorry. That's what I mean. Okay. So let's talk about this. So it's a 28 year old woman. Again, another young woman presenting with a red eye, she denies any headaches, ocular trauma or changes to her vision. Her eye is not significantly painful, but she feels mild discomfort. She's got eye watering and slight photophobia. So this seems very familiar to scleritis but without the pain and if that's the case, it's episcleritis. So, scleritis and Epis Claire itis basically have the same mechanism. Um They're both auto immune mediated. Um they basically affect just two different parts of the same membrane. Um and the only difference is that episcleritis um is not painful. That's it just remember scleritis is painful and Epis Claire itis is not painful, okay. Um So episcleritis is basically inflammation, inflammation of the Epis Claire. Oh Epis Claire A which is the layer above the sclera just just above the sclera. Um and it's mostly idiopathic, but a proportion can be caused by systemic disease. And I think it's like I be be and rheumatoid arthritis as well. Okay. Um The symptoms as we mentioned as we saw in the previous prompt is you get a red eye, you, it's not typically painful, but there can be some mild discomfort. You can get some watering and you can still get some photophobia as well. Okay. Um Oh Another thing that can differentiate between episcopo itis and scleritis is if you gently press on the vessels, on the sclera. In Epis Claire itis, it moves in Epis Claire itis. But in sclero itis it doesn't move because the vessels are deeper. Yeah, episcleritis is the, is the layer above the sclera. So if you press on the vessels in Epis Claire Itis, you can actually see the vessels move. Essentially, it's bilateral, 50% of cases. Uh management. I'm pretty sure it's just conservative. Yeah, it's supportive, supportive management alone for episcleritis. So, scleritis, you gave Ansaids and steroids and immune suppressants. But in epis colitis, let me just leave it alone really quickly on sub conjunctival hemorrhage. Okay. So 100 people hemorrhage is basically when one of the blood vessels in the conjunctival break and blood blood leaks in between the conjunctival and the sclera uh usually happens after strenuous activity or trauma but can be spontaneous as well. So, so the it's episcleritis, scleritis and sub conjunctival hemorrhage can look similar because they all present with redness around a certain part of the eye. So it's important to differentiate between the two. Okay. So it's sub conjunctival hemorrhage. The there's a knot path, there's a patch, there's a patch of bright red blood covering the white of the eye. So it looks scary, but it's actually harmless. So if we compare the three scleritis, you get a red eye that's painful with photophobia and, and watering in Epis Claire itis, you get a red eye that's not painful, but there's also that there's photophobia and watering and in subconjunctival hemorrhage, it's literally just a red eye and it's a patch of a red eyes, not like you can't see the vessels. So in epis clarity's and scleritis, you can see the vessels, but in sub conjunctival hemorrhage, it's just a patch of red. Okay. And it's harmless uh, management. You just leave it alone. Right. Question. 14. I think we've got three more. Just three more. I promised and then we're done. Yeah, 45 seconds from here. Okay. 10 more seconds. Uh huh. Okay. So it seems like we do the a lot of you got the answer, correct. So it is anterior uveitis in this case. Now, I do want to say corneal ulcers okay can cause things like a hypo P in if it's bad enough. So cornea also can progress to something like um can progress to something like endophthalmitis, which is basically inflammation of the eyeball itself and it can cause plus and hypopyon. But in this case, the reason it's anterior uveitis is because the pupil appears small and irregular. Okay. So that's classic. Um anterior uveitis and irregular pupil is synonymous with anterior uveitis. Okay. Every question that says irregular pupil more often than not points towards anterior uveitis. He's also got a history of Chron's disease. So I B D is uh is a risk factor for anterior uveitis as well. Okay. Um And for corneal ulcers for corneal ulcers in the prompt. They will usually say like, oh, he does some uh industrial work or he welds or he, he's doing some gardening or stuff like that that usually points to a corneal ulcer. But in this case, um most of the clues point towards an interior uveitis. Okay. So let's talk a bit about an interior uveitis and what it is. So it's basically inflammation of the anterior portion of the uvea, which is basically just a fancy word of saying the iris and the ciliary body, the front part of the eye, okay. And it's associated with patients who carry the HLA B 27 antigen. And if you guys remember the HLA B 27 antigen is associated with a few conditions which include enclosing, spondylitis, react sorry, reactive arthritis. Um IBD Badgett disease and sarcoidosis aren't associated with HLA B 27 but they can, they are associated with anterior uveitis, but ankylosing spondylitis, very big risk factor for anterior uveitis. IBD, very big risk factor and reactive arthritis. Very big risk factor as well. Okay. Um If you don't know what batches diseases is basically just a vasculitis that causes really bad mouth ulcers and like and like pain around your body. Essentially. Um uh it's corneal ulcer the same as herpes simplex, keratitis. Well, herpes simplex keratitis is uh an ulcer. Well, it's is keratitis is basically inflammation of the cornea. Um I wouldn't say it's the same because a corneal ulcer may not be keratitis, you can get an ulcer without the cornea being inflamed. So I wouldn't say it's the same. Okay. And herpes simplex keratitis in itself is different to normal keratitis. Okay. So it's a, it's a different type of keratitis, but we'll get to that in a bit. So, symptoms of interior uveitis including acutely painful, red, I it's very painful. Um, as I mentioned before, very characteristic, the pupil can be small and irregular. You get photophobia. Hypopyon is basically a fluid level in the iris that's pus and all these inflammatory products. Essentially, you get blurred vision like cremation and celery flush, which is basically just a ring of redness spreading outwards from the pupil. Okay. But until uveitis just just remember very painful, very red, irregular small pupil and hypopyon. Okay. These four things in terms of management, you need an urgent review and ophthalmologist needs to see this person ASAP and you give topical steroid drops because this is basically an auto immune um condition or an auto immune mediated condition. And then you use dilators um because the pupil is so small and it regulates so constricted, you actually need to dilate it. So it doesn't stick to the lens essentially. Okay. So that's what the irregular pupil might look like. And the hypopyon is this disgusting looking fluid level, the white, the white thing at the bottom of the virus. So that's a Hipaa Peon. Okay. Now, question 15. Two more, two more questions I think, I think it's two more. Okay. 45 seconds from here. Okay. Five seconds. Okay. All right. So let's see what's going on with this with this lady. So she went to G P. She's got itchy, she's got itchy red and watery eyes um to start it in the left eye four days ago and have spread to the right eye. So it sounds like it's an infective cause. Okay. So bilateral redness in both eyes with a watery discharge. Okay. So it sounds like this lady has conjunctive itis. Um And from the watery discharge, it sounds like she's got a viral conjunctivitis, okay. Um And it sounds like she got it from her three year old daughter who presented with similar symptoms about a week ago. So if someone is presenting with viral conjunctivitis, there's really not much you can do in terms of management. Obviously, you advise them not to wear contacts. That's one thing. Um And then clean the eyelids and apply a cold compress. You don't give chloramphenicol because chloramphenicol is a topical antibiotic. And you only give that in um bacterial conjunctivitis. And we've already discussed that this is a viral conjunctivitis because of the watery discharge. Uh And they didn't mention anything about crusty nous. Okay. Both bacterial and viral conjunctivitis can spread to both eyes. So that's not just viral thing. Bacterial conjunctivitis can do that as well. It's the watery discharge and the lack of crusty nous that um that point where the viral conjunctivitis. Okay. So really quickly, the, so the picture on the right is what you will see in a bacterial conjunctivitis. You can see the muck and you even see around the eyelashes, there's discharge there. So that's, that's classic of bacterial conjunctivitis. Okay. It's not watery, it's basically inflammation of the conjunctiva which covers the inside of the eyelids and the sclera, there's three types allergic viral and bacterial conjunctivitis. So sometimes it can be, you know, natural bilateral, you can get red eyes, itchy or gritty sensation and discharge. Now it's a discharge and the gritty sensation that separates them. So if it's viral, you get a clear serious discharge. If it's bacterial, you get a purulent, yellowy, disgusting icky discharge. And people and patient's tend to complain that when they wake up in the morning, like their eyes are stuck together and it gets really crusty. That's conjunctivitis. And in allergic conjunctivitis is usually watery discharge as well and there's usually an offending allergens. So it could be something like hay fever or cat fur. And then there's usually a bit of swelling around the conjunctival as well in terms of manage money. It's very, it's usually self limiting. It is very transmissible though. So be careful about touching your face and touching others. Um and it usually settles within a week or two. So, if it's bacterial, you use topical chloramphenicol, which is a topical antibiotic in viral, it's just cold compress and hygiene and allergic. You just use anti histamines, right. And avoid contact lenses. I think this is the last one. Hopefully. Yeah. All right. 45 seconds from here. What? Okay. I'll give it five more seconds and then we'll talk about it. Okay. So, we've got a 23 year old mechanic who visits the emergency department of their long shift. He feels something is stuck in his right eye. Uh, So he's also experiencing pain and photophobia in the right eye. You ask him whether he wears eye protection to which he responds 99% of the time. So obviously, you can't fully trust patient's when they say things like this, especially in like these prompts, but they're trying to tell you that he wears protection. So it may not be something like a foreign body on an abrasion. It could be um you notice gold crusted lesion's on his face. Uh and then on the slit lamp examination flores and I stain reveals a dendritic ulcer so dangerous. They also alone should point you towards something like a herpes simplex keratitis. Okay. Keratitis. Um classically presents with feeling like something is stuck in your eye. So the feeling of something stuck in your eyes very classical to keratitis. But which one? So the Florentine I stain revealing a danger. Take ulcer shows that it's a herpes simplex keratitis. Now, the gold crusted lesions on his face is also a result of herpes simplex as well. Um And it's something called, I think uh I forgot what the condition was called, but there's a skin condition that causes gold crusted lesion and it's caused by herpes simplex virus. So that's what they're trying to, that's what they're trying to point you towards. I'm not sure if they're talking about impetigo, but I think impetigo is more in Children, I think. But yeah. Yeah. But it's basically they're pointing towards herpes simplex cause of the keratitis is what's what they're trying to tell us. Okay. So keratitis is basically inflammation of the cornea. It's not the same kind of to like a corneal abrasion or a corneal tear essentially. Okay, because this has to be inflamed for it to be keratitis. Um and it's potentially set site threatening. Okay. So there can be bacterial causes. So if you, so if you don't wear contact lenses, the staph aureus is the most common cause of keratitis. But if you do wear contact lenses, it's pseudomonas. Okay. Pseudomonas is the most common in contact contact lens wearers for bacterial keratitis. There's amoebic keratitis as well and that's caused by acanthamoeba, keratitis. Uh acanthamoeba does and this is usually for people who go swimming or are constantly in contact with contaminated water. Um and they wear contacts, for example. So that's what causes amoebic acanthamoeba keratitis. Okay. And it's usually extremely painful, like extremely painful, like out of the ordinary type of painful, there's fungal parasitic and obviously viral as well, which we, which we discussed, okay, herpes simplex, keratitis, red and painful, I photophobia. You get the foreign body sensation which is classical for keratitis. And if it's really severe, you can get a hypopyon as well. Like what you saw in the anterior uveitis. Okay. Now, Florence ian staining can, can be used if you suspect herpes simplex keratitis and it will show a dendritic ulcer, okay. And I'll show you what a dangerous the ulcer looks like. Um So management stop using contact lenses. If it's viral, viral, viral keratitis, you give topical acyclovir. If it's bacterial, you give topical antibiotics but not um not common fenical, you give something stronger. So you give quinolones like levofloxacin, for example, I think that's a quinolone. Yeah. So cycloplegic siew dilate the eye to, to relieve the pain and that's what the dendritic also looks like. So fluorescent staining is blue in color and then the dendritic also comes out as this bright, this bright green color essentially. Okay. Now, really quickly on orbital satellite iss okay. It's a, it's an emergency if you should be able to identify it pretty much straight away. And as soon as you see something like this in the child is straight to the emergency department, straight to the pediatrician, straight to the ophthalmologist, sorry. Um So that they can deal with it essentially. So it's an infection affecting the fat and muscle around the orbit, but not the eye itself okay. So it's not affecting the eye itself. It's just the muscles and the layer of fat around the eye. Um, it's more common in Children and can be caused by ascending upper respiratory tract infections. Um, face nose and ear infections are risk factors for it as well. It's got really high mortality and it's a medical emergency. Okay. So, symptoms are redness and swelling around. I it's very visible. You can, you can pretty much see it's severe ocular paying especially on movement of the eye as well. Um They get visual disturbance proptosis, which is basically the I jutting out um uh for that. Uh and the management is basically um admission for IV antibiotics. So we've covered a lot today, but there are some topics that I did not cover simply because I didn't want to overrun. Um And the things I didn't cover today are hypertensive retinopathy, diabetic retinopathy and then not till mightiest. I'm really sorry, I couldn't have the time to cover this, but do look into these topics as well because they can come out in exams as well. Hypertensive retinopathy is basically the Gardener or the Wagner or Wagner system. Basically, it's basically classifying the severity of the retinopathy for diabetic for diabetic retinopathy is basically classifying the severity as well. Proliferative versus non proliferative. And then using pen retinal photo coagulation for proliferative diabetic retinopathy. And an optimum itis is basically, is basically just a severe infection of the eye itself. So do look into these because I didn't cover them today and they can come out in exams as well. But thank you so much for sticking with me for the entire hour and a half. I know it's been a lot. Um, you don't have to stay, but I will, I will stay for, for a few minutes in case any of you have questions, please, please please fill in the feedback form. Um I would really, really appreciate it. Do leave some feedback. Um And yeah, join us this Thursday for breast conditions or breast surgery essentially and I'll be giving that talk as well. Yeah, thank you guys. Have a nice evening, go get your dinner and I'll see you guys in a bit. No worries. I will send the the slides to you guys once you guys have filled in the feedback form. So don't worry about that. Uh And Aisha, I think you, you emailed me, didn't you regarding one of the slides? Was it the neurosurgery slides or was it a different set of slides? Was it a different Asia? Mm. Okay. So if there's no more questions, thank you so much guys. Catch you guys in a few days.