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Hello. And good afternoon. It's two o'clock with us here. Welcome everyone who's come along. We are gonna have a teaching session today from Tim Fetherston who is an ophthalmologist. Um, what I'd love for you all to do is pop your questions in the chat as always and we'll get to them at the end. Tim will chat for about 40 45 minutes and then we'll have hopefully about 15 minutes. Q and A at the end, right at the end of this event, you will have your feedback form in your inbox, er, which we would love for you to fill out. Tim would really appreciate all the feedback you can give him and you're, then once you've completed that your attendance certificate will be on your medal account. So I'm not gonna chat anymore. I'm gonna hand it straight over to Tim over to you. Hi. Hi, I'm Tim Featherston and I understand that there are people tuning in today from up to 21 countries. So it's a real privilege to be able to talk to you. Um, I'm an ophthalmologist. I'm a retinal surgeon, a Vitria retinal surgeon by training. Um, I've retired from the NHS now, but I work for two human rights charities in the UK. And I also worked for the last 10, 15 years in a developing country setting in Esti, it used to be called SSI Land. Um, so I think I wanted to make a couple of points first. Um, ophthalmology is really, really interesting. Um, I hope that you'll still feel it really interesting when I've finished talking. Um, and the second point is as sue was saying, please do help me out today by asking questions in the chat box. Um, it really does help, er, I know every, I know you're all still there. I know people are still alive. Um, and, er, it really does sort of help things get to get going. I'll keep one eye on the chat Boxx as we go through. Um, so I'm hoping you can see my, my next slide. I, I can't show you a pointer but I, we'll have to talk to the slides. I'm sure we'll be fine. So this talk really is about how to assess red eyes. Um, there weren't many good things that came out of the pandemic, the COVID pandemic. Er, but one of them is that we've had to learn to work differently and we've had to learn to work remotely and it's made us think about, you know, how we approach things that made me think about those things. So, in the talk today, I, I want to outline a scheme to use. I want to talk about some interesting facts and tricks and pitfalls and things you may come across. Um, and a little bit about how to recognize urgent eye problems. And if you haven't asked any questions during the talk, I hope you will do, um, we'll deal with any other questions finally at the end. Um, I can't hear anybody. So I'm assuming you're still all there and you haven't all left for some years. I, I've thought that, um, in a sense we often do talks backwards because, um, if an ophthalmologist is asked to talk about the red eye, normally they would talk about certain conditions. So you'd give a talk on conjunctivitis and iritis and glaucoma, which is fine except that patients don't come to you with a diagnosis. They, at least they don't in the UK. Um, they come to you with, with symptoms and signs, er, and textbooks tend to be written the same way. So, what I want you to try and do now is concentrate on the symptoms and signs that patients will come to us with, er, and also a scheme of, of what kind of questions we're gonna need to ask, er, what the clinical signs are like and how we interpret them. There's a little box at the bottom there. A disclaimer basically saying that not every clinical presentation is typical. So what I'm going to tell you today is, is basically the typical stuff but I'm afraid as you will know in real life, not everything is typical. And, and secondly, I, I can't cover everything. One of parts of ophthalmologist's life is that you get asked to talk and to do lectures, which is great. And you say, well, ok, what do you want me to talk about? And people often say, well, everything and you just can't, it's like you wouldn't ask your cardiologist to cover everything. So, um, I'll do my best anyway to cover what we can in, in 40 minutes. Ok. So first of all, I want to come up with a scheme for questions, um, that we would ask people that present with a red eye. One of the difficult things about medicine is that patients often don't give you a good history and it used to confuse me and worry me and I would think people were holding withholding information, but actually there's a whole load of reasons why patients won't give you a decent history. They won't tell you the crucial bit of information. The thing that would enable you to make the diagnosis easily. The reasons can be, oh, anything. They could be just frightened out of their wits, they could be embarrassed about something that's happened. They, they, they're frightened of, of, of, of telling you some of the things that have happened. Um, and it's, it's not personal. People aren't, aren't trying to withhold information, but often, you know, they just don't come up with the right bit that would help you. So this is a scheme to er, prompt us to ask the right kind of questions. So, uh the slide is going to get a bit complicated. Um, but we, we'll tackle it in, in bits. The first question on, in the little pink oval. There is, is there any discharge? And that's a crucial question because discharge is a cardinal symptom of conjunctivitis. Um So if there isn't a discharge, it, it probably isn't conjunctivitis. Discharge varies. It can be sticky and purulent, uh, or it can be watery. We're going to talk a little bit more about that later. The second question to ask is, has there been any trauma? You would be amazed how many times patients don't tell you if they've traumatized the eye or at least don't give you a, um, a proper representation of exactly what kind of trauma they've had. I'll give you some information about this later, but without spoiling, using a spoiler or giving the game away, I, I'm going to tell you that the trigger words of using a hammer and chisel are vitally important because if you, if you have a patient who says that they've got a sore eye and they've been using a hammer and chisel be very afraid, um, they need proper looking at, they need proper investigations. We'll talk about that in a second. Has the patient suffered an assault? They, they may not tell you they may not want to divulge that they, they've been injured. Next question would be, how long, how long have the symptoms been present? That can give you a clue as to whether you're dealing with an acute condition, like an acute conjunctivitis or something more long standing. In which case you would think about other causes? The next question in the yellow box there, um, does the patient wear contact lenses? You would be amazed how many people don't tell you and assume that, you know. Um, but you need to know that because there are a number of problems you can get damage or irritation of the cornea caused by contact lens wear. So it's an important question, a viable question to ask the patient. The next question is, what is the pattern of redness in the eye? Is it everywhere? Is it just in one patch? Is it just around the edge of the cornea? We're gonna talk a bit more about that and the significance of those different things? Yeah, I'm always a little bit reticent about asking patients to describe their discomfort because sometimes that can, that can take a while. Er, but really again, we're looking for trigger words, we're looking for words like gritty or it feels like there's sound in it. Those trigger words are pretty characteristic of conjunctivitis. So patients with conjunctivitis always say it just feels as though I've got something in there. It feels as though I've got sound sound in my eye. Strangely, patients who have conjunctivitis don't, don't usually use the word pain. Sometimes they can, if a patient says they've got pain in the eye, then that would tend to make you think of other things, things like iritis or glaucoma. Sometimes I can say it feels hot. So you're looking for those kind of trigger words, they're not going to be conclusive, but they would help you to sort of follow the plan in the right direction. The next one is a crucial one. And I, I have to confess, I have been caught with this before because I've had a patient with a red eye, a kind of atypical presentation. And they did not give me the crucial piece of information that three other people in the family had exactly the same thing. Um If you had that, then you would immediately think of a contagious viral conjunctivitis. We're gonna talk about that in a second. So remember to ask if anybody else in the family is affected. And then finally, uh this group of questions, does the light hurt? That's called photophobia? It's an unusual symptom. Um But it's characteristic of iritis. So patients who have iritis will say that the light hurts because when a light is shone into the eye, the pupil constricts and that irritates the iris. So people with iritis get pain when you shine the light into the eye is the vision affected. If the vision is not affected. Again, you're thinking about conjunctivitis. If the vision is affected, you're tending to think about other things, allergies. Uh important question to ask. I'm going to talk briefly about allergic conjunctivitis. And then finally for um remote con consultations these days, people can send you a selfie. Um, it, it can often be a high quality picture and that can make all the difference. Um It's not exactly a selfie but um I work with an organization called virtual doctors and we provide clinical support to clinical officers in Zambia and they will see a patient and they'll send me a picture on their mobile phone. Makes a world of difference. You can really get a good idea of of what's what's going on. Ok. So the four main red eye conditions that we're gonna talk about are, are these conjunctivitis I mentioned under iritis. Uh iritis is inflammation of the iris. The iris is part of the uveal tract in the eye. The uveal tract includes the iris, ciliary body and choroid. Some patients can get inflammation in any or all of those tissues. Uh But the common presentation of a red eye is iritis corneal problems a huge range. It's a huge condition probably require three or four separate lectures. We're going to talk about that briefly and then acute angle closure, glaucoma, which is a condition that everybody worries about, but it's really, really easy to diagnose. Um And it's also really, really rare again, we're gonna talk about that shortly. So the crucial clinical signs that I'm going to talk about, I've already mentioned discharge and pattern of redness, vision affected. And is the pupil involved, is the pupil normal or not? So, first of all, discharge, as I said before, on the, the slide of questions to ask, um is it a purulent sticky discharge? If it is, then really, you're thinking about bacterial conjunctivitis. It's common, it may be unilateral or bilateral. Um It's not terribly common although I have, I have seen it a fair bit when I've worked in Swansea Land. If um, the conjunctivitis is really, really severe with a massive purulent discharge. Think of possibly a gonococcal infection, as I say, it's, it's not common. Um Most conjunctivitis is due to staphylococcus, streptococcus haemophilus, what you might describe as the usual suspects of bacteria. Um, but it doesn't have to be, it can be other things as well and gonococcus obviously would be um very severe. It, it just does look dreadful. I don't know what it must do to wherever else the gonococcus goes. But in the eye, I can promise you, it looks absolutely awful. Again, it doesn't have to be bacterial. Uh It can be chlamydia again, that tends to be a sort of thin uh perent discharge. Uh in chlamydia conjunctivitis. If the discharge on the other hand, is watery and not particularly purulent. You might think of a viral conjunctivitis. Viral conjunctivitis is usually bilateral. It's usually adenovirus. Often there's quite pronounced eyelid, swelling, disproportionate amount of eyelid swelling. One of the hallmarks of viral conjunctivitis is on the picture here. Um and that's conjunctival follicles. I hope your slide is big enough to see it. But can you see inside the lower eyelid there, there are sort of pink lumps. Um and they are actually lumps of lymphoid tissue, hypertrophied lymphoid tissue and that's pretty characteristic of um viral or chlamydia. In fact, um infection, you get a profound um response of the immune tissue in the conjunctiva. So those pink lumps, those conjunctival follicles think virus thick adenovirus or possibly chlamydia. One thing I would say about viral conjunctivitis is it's highly, highly contagious. And that was the basis of the question I was asking before, are other family members infected? Uh Because it's very common to spread to other members of the family. It's also very common to spread to clinical stuff. Um And you do tend to get mini epidemics of viral conjunctivitis. And if everybody isn't really careful in the department about hygiene and hand hygiene, then it's it's not uncommon for people in the department to contract the same thing and I promise you, it's really very unpleasant. We've talked about uh quite a lot of these things on this slide here. Uh I talked about discharge being the Hallmark gritty discomfort, which patients say is like like sand now in conjunctivitis because the cornea is not affected, the vision is generally not affected. Now, sometimes you can get a film of mucus on the surface of the cornea. And if you, if you just said to a patient is your vision affected, they'll say yes. But if you say, well, look, if you blink rapidly, can you blink away the mucus? Uh and does your vision improve then and if the patient says yes, then you know what, what the problem is. There's just one exception and that is that adenovirus, uh the main cause of viral conjunctivitis can involve the cornea. And the photograph on the, the dark photograph on the bottom left here shows the spots on the cornea that you can get with adenovirus keratoconjunctivitis. In fact, to be accurate, it's not really a conjunctivitis anymore. If you've got spots on the cornea, it's a keratoconjunctivitis. So the it still holds true that conjunctivitis, pure conjunctivitis, the vision is generally not affected unless it's because of mucus in the tear film. Ah um I just seen the chat box so I don't know whether you can, you can do anything. Er, Nana that's got um video is blank with no sound um whether you can uh converse with another I that out. Uh uh Great. Thank you. OK. Um You see the chat Boxx is great. I'm I'm absolutely on it as you can see. Um So also slide on the bottom right? There are more um conjunctival follicles. So that could be a virus or it could be chlamydia, there's a little bit of purulent discharge there. So, you know, maybe it's chlamydia, who knows. So these are the main types of conjunctivitis and just a very brief outline of management bacterial are going to be the vast majority. Yes, we you can do swabs, you can send off swabs for a culture and sensitivity. Um It's probably not a bad idea to do that if you have access to um to culture and so cultures and so on. The part of Africa in which I work each year, there isn't really very much access to lab um cultures. So you're a bit stuck. In fact, most cases respond very well to simple cheap chloramphenicol ointment which you need to apply four times a day. Um And vast majority of cases will just get better with that. It's not usually a challenge to treat viral conjunctivitis. You can do viral swabs and, and send swabs for viral culture if you, if you have access to that and we have got access here. But basically, we don't bother doing it routinely because by the time the result comes back, the patient's probably going to be better. And in any event, there isn't really a specific treatment just as there isn't a specific treatment for flu or a viral cold, there isn't a treatment specifically for viral conjunctivitis. So a swab isn't really gonna help you terribly what you might do. Um is if you think that there's a chlamydia um uh infection, you might be able to send off slides specifically for, for chlamydia. Going back to viral conjunctivitis treatment tends to be what I describe as supportive. Um like having a cold really, you know, it kind of runs its course. Um I tend to give people lubricant uh ointments, artificial tears or artificial lubricant ointments. I have to be honest with you. Sometimes I do give patients antibiotic ointment, not because it has any effect on the virus. It doesn't. Um, but in patients who are at high risk of a secondary bacterial infection, uh I might give them antibiotics hopefully to try and prevent that. Um, but it's, it's, it's not, I suppose a pure way of treating it but patients tend to be comforted by, by getting some supportive treatment of some sort. And again, chlamydia, if, uh, if you're aware of that it has follicles, you can send off specific swabs but they do need g medicine, genital urinary medicine. Uh, follow up, I've said that virus conjunctivitis in most cases are adenovirus. Um, doesn't have to be, er, the case in the top left which is a really good slide showing conjunctivitis. You can see, can't you, the redness is, is way, it is all over the eye, it's all over the place but it pretty much spares the area immediately around the edge of the cornea. So it tends to be, er, in the fornices and inside the eyelid. Weirdly, this this particular case was COVID. This was a uh a COVID conjunctivitis. I've already made the point that it's highly affected, highly contagious rather and um other family members work colleagues, hospital staff can all easily get infected. I mentioned at the beginning that you tend to get a disproportionate amount of eyelid swelling. The slide here at at the bottom shows this disproportionate amount of eyelid swelling and it's, it's just gonna have to run its course and it can take a week or a couple of weeks really to um to resolve just a quick word about conjunctivitis in neonates. That's babies born within the last 30 days. Um The term which is applied to this is Latin ophthalmia neon. Um And in the UK, it, it's has to be notified because it's usually gonococcus is the cause of that as I explained to you before gonococcal infections, certainly in the eye and probably generally, um tend to be really, really severe and if this is untreated, it can certainly cause corneal damage um, and sight loss. If you do have a neonate, then yes, you do need to take swabs and refer them urgently to the eye unit and the treatment will be tetracycline ointment in the UK. Here, we would generally involve the pediatricians, we would generally admit the child. So we are absolutely sure that the medication was going to get in, er, and mother would have to be referred to the GE medicine clinic but you would, you would deal with us, er, depending on which part of the world you work and what facilities are available to you. Having, having worked in a remote part of the world in the developing country. I am amazingly impressed by the way, people do so much with so little clinical support and backup. So you just have to tailor it to what's available for you allergic conjunctivitis. I'm not going to talk about very much just to say that it's probably over diagnosed in the UK. So people who have a slightly pink eye tend to get diagnosed as allergic conjunctivitis for no particularly good reason. Um In fact, it is quite specific, it has a major symptom and that is pronounced itch, itch is the trigger word. So if, if a patient um has a very, very itchy eye, think at least that there may be an allergic cause to it almost always. There are history, there's a history of other multiple allergies. So you've got a patient who is allergic to preservatives, make up, you know, washing powder, textiles, that kind of thing. So, um if you got a patient my age, I don't have any allergies at all. It would be very unwise to diagnose allergic conjunctivitis in me because it's very unlikely that I would develop it. Um You get, you get smaller lumps, smaller red lumps called papillae in the conjunctiva. I'm not going to show you a slide of that. All the usual suspects of cause is it's gonna be something externally that, uh gets on. It can be vegetable matter, uh, pollen, um, plant material of some sort. That's, that's quite a common one in the parts of southern Africa that I work. Um, there's a particular type of allergic conjunctivitis which you get in springtime vernal conjunctivitis. I'm not gonna talk about that, but that can be a big, big problem. But otherwise the usual causes are what you might imagine. Soap shampoo, eye makeup moisturizer. Um, it's worth asking the questions that I've put here. You know, what is the soap perfumed one? How long has the makeup been open? You know, sometimes fine eye makeup is positively antique. You know, it's, the pack has been open for months and years anyway. Um, that's really all I'm gonna say about allergic conjunctivitis. The next thing I'm going to mention is, is trauma or foreign body. Now, this too is an absolutely huge topic and there are just innumerable causes and variations. But the main point I'm gonna say about, um, I'm gonna make a couple of main points. One is that patients often don't give you proper history and that can be because they don't want to divulge what happened to them or they're frightened or they're hoping that some, what actually happened to them somehow didn't happen to them. Uh, but there's one big, there's one big pitfall and I'm going to show you this. Hopefully in the next slide, if you have somebody who sits in front of you and says they've been using a hammer and chisel take them very seriously because I don't know whether you can see on this chisel. What ha what happens is that with repeated use over months and years, the head of the chisel becomes mushroomed over. And when the hammer hits it, sometimes a little particle of metal will fly off with huge speed and it will strike the eye and penetrate right inside the eye. And it happens so quickly, the patient almost doesn't blink. It's a weird injury, but the the forces involved are so great that you can get these occult foreign bodies penetrating inside the eye. The slide at the bottom, right shows you a patient who has experienced this and every year, these cases, certainly in the UK, every year these kind of cases are missed. I bet, OK, you can see there's a whack and great cataract there, but you possibly wouldn't have noticed that towards the right hand side of the picture, there's a sort of pale spot on the edge of the cornea that is the tiny entrance wound of the metallic particle as it shot in through the lens of the eye causing a cataract right inside the eye. So if you remember absolutely nothing else from today's talk at all, please do remember this one that if somebody's been using a hammer and Chisel, you have to examine them very carefully, you have to find out exactly what happened to them and if you're not sure about it just x-ray them. Um, because the metallic foreign body will almost always come up on an x-ray or ultrasound if you've got it. Um, but certainly an x-ray should pick it up, but just to alert you to this very, very special particular case. And as I say, please forget the rest of the talk if you will. But remember this bit hammer and chisel equals take it seriously. Yes. What are the kinds of trauma? Well, as I say, there's just hundreds of different types, but the common one is abrasion, corneal, abrasion. Just a million different causes can be an assault. A really common one actually is a baby's fingernail. Strange really. You know, because you pick up a baby and you co at them and they smile and then they slash your face with razor sharp nails. So these nails, this is the picture there shows the eye of the adult just been slashed by a baby's fingernail. You can see it stains with the fluorescein dye and there's a little irregular area at the top which is the corneal epithelium, which is rolled up. So again, by all means, hug babies, but watch their er, flashing fingernails. Uh You can also get abrasions from contact lenses as you might imagine. And then foreign bodies, vast majority of foreign bodies, you know, aren't particularly serious, they blow in with the wind if they're metallic. Um as the top picture here, they leave a rough ring. So on the surface of the eye with the moisture and all of the oxygen, they will metallic particle will rust and it will form a rough string. Um The lower slide there shows can you see it a tiny black speck underneath the eyelid? You should be able to know how to avert the upper eyelid. There are some very good videos on youtube. You have to get the patient to look down. That's the secret. You must get the patient to look down. If they don't look down, you cannot avert the eyelid. Increasingly people get foreign bodies using power tools, do it yourself, stuff at home. Generally speaking, domestic power tools don't have the momentum or don't give a particle of steel, the momentum to penetrate the eye. It's really only hammering and chiseling. That does that one final aspect of trauma. I'm not going to talk about chemical injuries. Er, because again, that's a huge subject. Er but remember to ask, I didn't include it on the first slide, but remember to ask about traditional medicine. I was caught out with this in, in southern Africa. Patients who have difficulty in accessing conventional healthcare may access traditional medicine because that's all that they can get at that particular moment. But who knows, heaven knows what's in some of the concoctions which are used, er, it's worth specifically asking. I remember this particular patient here had this massive rash around their eye and he was very reluctant to tell me, but eventually it came out he'd been using, um, I don't know what he'd been using traditional stuff. The next, ok. The next cardinal sign I'm going to talk about is the pattern of redness. Ok. So I'm gonna talk about four different, um, four different patterns of redness. So, um first one at the top is all over, the redness is everywhere, all over the front of the eye, all over inside the eyelid. It's just everywhere. The second pattern of red redness that's in the second picture down. I hope you'll agree with me that. Ok. Yes, there's a fair amount of redness there, but most of the redness um is around the edge of the cornea, isn't it? Um I don't know exactly what's going on in the cornea. It could be keratitis or something, but I hope you'll agree with me that, that redness is, is not absolutely everywhere. It's just around the edge of the cornea. The third one is like a band or a stripe of congestion. And then the fourth one is in relation to an irregularity or a lump um, or a lump on the surface of the cornea. Uh I've got a thing here from, if you found any patient with ocular trauma, what should you do? Well, good. It's a good question. I think, um, I think you'd use your clinical judgment. Um, it, it, it may, may not specifically answer your question but, um, ophthalmologist, ophthalmology is a specialist subject and it's not always very well taught at undergraduate level and so people don't feel confident with it but repeatedly, um I've come across, er, doctors who are non ophthalmologists who may not know exactly what the clinical problem is but they know that there's something wrong and they're worried about it. So I think the punchline is if you see a patient that's got a significant history and you're worried about it, refer it no ophthalmologist minds seeing uh a patient. If a colleague is worried for, let's go back to our pattern of red in the slide. Um Yeah. How do you refer to an ophthalmologist? Yeah. Good question. Um Again, you'd have to use your clinical judgment to decide whether this is something which was really, really worrying. It was deteriorating quickly, like a metallic foreign body in the eye from hammering and chiseling. They need to see an ophthalmologist today, you know, um, or else, you know, just a referral to your, your nearest um eye unit where wherever it is, I know it can be challenging in other parts of the world. We're very fortunate in the UK here. Um, because we've got an ophthalmologist, well, not round every corner but, you know, easily accessible. Um I've talked about all of these for uh different patterns of redness. So going back to the first one, if the redness is everywhere, you're probably looking at conjunctivitis. If the redness is just around is all around the cornea. Um You think about iritis, um, or glaucoma, I'm going to talk about that for a minute. If it's just one area, you might think that there's something on the cornea, either losa or a foreign body or a patch of, of keratitis. That picture where I showed um a band of congestion. Uh You, you'd think of two conditions which I haven't mentioned so far. Episcleritis and scleritis. It isn't time for us to go into these episcleritis is a peculiar condition where the membrane underneath the conjunctiva becomes inflamed. We almost never find a cause for it. It's benign. It comes and then it goes away again, it can go away sticker if uh quicker if you give a bit of steroid drops, scleritis. On the other hand, is usually part of a systemic inflammatory condition like an autoimmune disease or rheumatoid or something like that. And the eye is very, very slow. Patient won't let you near it. Uh But they both of those things tend to give you a band of congestion on the surface of the eye. And then the final path pattern of redness that I was talking about er, was irregularities on the surface of the eye that could be scars or, or tumors. Um conjunctival tumors that not that common. Um There are also very common conditions like pterygium overgrowth of the conjunctiva onto the cornea, which you certainly get in hot parts of the world. Uh Nuys question with or without bandage. I think I'd just be, be guided again by your clinical judgment if a patient's really got a, a red fat I and is very uncomfortable, prop, a bandage on, er, and, and that will help them feel better. But, er, the important thing I think is to get an ophthalmic opinion, but I, I acknowledge it can be, it's easy for me to say, I know, but it can be quite difficult in some parts of the world. So, back again now to the pattern, pattern of redness. Um I've already said these things, the picture on the left, um the redness is mostly away from the corneal edge and the eyelid and the um surface of the eye, the bulbar conjunctiva um are involved and typically, as I say, the vision is normal and the pupil is normal. Secondly, iritis or uveitis, here's another picture showing that redness, fiery red, really most intense around the edge of the cornea. I write this is a peculiar condition, you know, even after all these years, it's, it's still fairly poorly understood in iritis, the pupil is usually smaller i in if it's unilateral iritis, um, the pupil on the affected side is usually smaller because the pupil muscle is irritated. Patients who present with unilateral iritis. This is just the weirdest thing. It's very rare to find a cause for it. Isn't that strange? You'd think you'd find a cause. But if it's unilateral, then usually it seems that something, some infection, some otherwise possibly trivial clinical infection has tweaked the immune system and the patient responds with this autoimmune reaction, um causing inflammation in their iris. Bilateral iritis is different. If you've got a patient with bilateral iritis, look for systemic inflammatory problems and look hard. And the kind of things you're talking about a TB sarcoid, rheumatoid autoimmune diseases look hard for an underlying cause in the UK. If you had a patient coming with uh bilateral iritis, the commonest cause would actually be sarcoid um in other parts of the world, developing countries where the incidence of TB is higher TB would probably be your your likeliest cause. So, unilateral iritis often don't find a cause. It's very unsatisfactory bilateral iritis, you'd look for systemic inflammatory problems again, as I've said, um in iritis, you have pain, that's the trigger word that patients with iritis use. They usually say they've got pain, uh the vision is affected um and they're photophobic because uh as I've just explained, the pupil muscle is irritated and if you shine a light in the eye, the pupal muscle contracts and that gives the patient pain in the top picture here. This is actually a very severe um iritis. Can you see there's like a little tiny white level at the bottom of the cornea that's called the hypopen. And it's a level of, of um sedimented white cells which are settled down in the bottom of the cornea. And you get that in a very severe inflammation, the white cells, the the inflam, the exudation of white cells is so great that the white cells settle down at that little level. And that's an indication that things are not going well. It can also indicate infection inside the eye. The third condition I'm gonna talk about for a moment. Now is acute glaucoma, sometimes called acute angle closure glaucoma. And it occurs in patients who have just because of the way that they're made a very shallow front to the to the anterior chamber. So the front of the eye, the anterior chamber is so shallow that when the pupil dilates a bit, it closes off the drainage angle. So the aqueous is not able to get out of the eye. So the patient is able to make aqueous all the time, but it can't get out. So the pressure goes up and up and up really, really high. The normal pressure is up to 21 millimeters of mercury. I've had patients with acute glaucoma who have had pressures of 60 70 um patients who have this are very ill and they vomit their eye if they would let you near them to feel it is rock hard. It's an extremely unpleasant condition. I'm gonna say two things about it. And again, you know, by all means, forget the rest of the talk. But remember these two things, first of all, it's rare in general medical practice, you might see a case or a couple of cases, you know, in a professional career. But it, it's pretty rare in an eye unit, we'd see more. But of course, you'd expect that the second thing is that you have to have, you have to have a mid dilated, fixed vertically oval pupil. If you haven't got that, you haven't got acute glaucoma, the pupil has to be like that. In order for that phenomenon I described just now for the drainage angle to, to close, the pupil has to be MD dilated for that to happen. So it's, it's dead easy to diagnose. You have to have a pupil that, that looks like that. I've already said severe pain and headache. These patients really ill. They look ill, uh they get corneal edema because of the high pressure, they get loss of vision and they get a peculiar symptom. If they look at the light, the light has rainbow colored halos around it, weird symptom. But you get that because light hitting the edematous cornea is dirac into its constituent colors, peculiar, peculiar symptom. But it's pretty characteristic of acute glaucoma patients who have this condition can often have precursor attacks. So prodromal prodromal attacks. So they would have attacks where they get a bit of a headache and halos around lights. Um and they would develop these, these symptoms and then they would, they would, the pressure would go down again because the pupil would constrict. So they've usually got a pre existing um, a preexisting um uh set of symptoms. Now again, um was this the first one that you meant um, mid dilated, fixed vertically, oval pupil, er, with a rock hard eye and then finally, uh corneal lesions. Well, again, this too is a hole. Um a whole separate set of lectures really. I just want to say a few things about these. Um top picture on the top left shows a bacterial corneal ulcer and keratitis. It's, it's a big white spot. Um Neil, I was asking again about urgency. This is urgent if you have a bacterial infection in the cornea because of an ulcer, this is urgent an hour or two without treatment can make the difference between keeping an eye and losing an eye. So, with these patients, if you have a bacterial corneal ulcer, if that's your diagnosis, they need antibiotics fast. Um because as I say, they tend to deteriorate very quickly, our eyes have amazing set of defense mechanisms which we won't go into today. Er, but it's brilliant at keeping out trauma infections, all of that kind of thing. But if, if a bacterial pathogen breaches the the corneal epithelium, you're in trouble the slide on the top, right. I've shown a similar one before adenovirus keratoconjunctivitis, uh virus infection bottom left a dendritic ulcer which is usually herpes simplex, characteristic kind of tree branching type pattern. Um, they use when I first started training, which is a long time ago, there weren't really very good treatments for that, but we now have some very good treatments in the form of acyclovir, which is extremely effective against herpes simplex. Er, but in a sense, it's an easy diagnosis to make when you get this kind of pattern. And then there are, oh, I can't tell you a whole load of different types of corneal ulcers. This is called the one at the bottom, right? It's called a marginal ulcer which tends not to be terribly um severe. It's it's a reaction to staphylococcal toxin and it responds to local antibiotics and steroids. So, in summary, we're pretty much um finished with what I wanted to say. Now I just wanted to go over what I hoped I said, first of all COVID has helped us to sharpen up our questioning for remote consultation. So I wanted to give you some idea of, of the kind of questions we need to ask because patients don't all give us a brilliant history. Uh We need to find out is the history consistent with the findings. Ask the patient, give the patient some time to to explain what their symptoms are. Um and just be just be aware of the trigger words that I was talking about gritty often is patients with conjunctivitis will say that pain and photophobia, patients with iritis will tend to use those trigger words. Is there any discharge? We talked about that? We talked about the pattern of redness and whether the vision was affected and whether the pupil was normal and symmetrical with the fellow eye. And the final one is, I suppose what nil I was was mentioning. Er, do we treat it or refer it? I suppose to be honest, um, conjunctivitis, you would usually feel confident to treat yourself. The treatments are available. It's a kind of self limiting condition. Simple cases are not, er, sight threatening and um I say topical or systemic antibiotics. Um, well, the eye, um, the eye is a very special place and topical treatments are usually very, very effective. But if you had a really worrying infection like that bacterial ulcer, I showed you with the keratitis, the one with the big white spot, uh I would definitely use systemic um systemic as well, but just speaking, as a representative ophthalmologist, I never mind seeing patients when colleagues are concerned about them because I hope that colleagues would do the same for me one day. So there we go. That's really all I wanted to talk about. It's probably just, er, scratched the surface, but thank you for, for listening. Um, and I hope that you have a very good day and, and all the best from the north of UK. Does anyone have any other questions? For Tim or I don't have any, I think everyone knows by now that I'm not medical at all. Um, although seeing those eyes, it's like, oh, I honestly, I don't know how people can, can do some things. I'm just grateful that you do. Um, does anyone have any questions? Yeah, you sir. Thank you. Yeah, everybody's still, still there, still alive. They haven't dozed off yet. You weren't that bad. So, what if there's no questions? What I'd love to do when you get your feedback form is if you could fill that out, um, complete it, er, and then I can pass all of that on to Tim. It's really great. It's just a way of as opposed feeding back as well as showing your appreciation for the time that Tim's spent, er, taken to give this talk. That's all. Er, will you do another p, another presentation in the future? Joseph wants to know. Um, yes, if, if I get asked. Yeah, absolutely. I, I've got witnesses actually, if, could people put in the chat box, what kind of thing you would, you'd find most helpful, um, because I could talk for a, for a week. You know, if you're really unfortunate, um, if, if you can either put in chat box or let, let you know any topics you can think of. I, I'll do my best in the feedback form. There are, there is a question that says, what else would you like to learn on this topic. So if people want to fill that out, like I said, I will get that feedback to Tim. We'll probably give it a week. Uh, and then I'll give it back to Tim. Uh, ne I said is about glaucoma. Glaucoma. Yeah. Yeah, that's a big one. Yeah. Well, that run through General Fay. Yeah, that's like everything you said you had a week of teaching. Did you not know that we really appreciate that Tim, you've come along and, and obviously you can see that we have people watching who are keen to learn more. So thank you ever so much for coming along and spending some time with us today. Like I said, fill out your feedback form, get your tender certificate, I'll pass on the feedback to Tim and then um and we can go from there and hopefully we'll get him back on the platform again soon. Alright, everybody take care, everyone have a good weekend. Bye bye.