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Hi, everyone. Thank you for joining us today. I'm Rashida. I'm one of the social media leads at softer and this week our focus is going to be on ophthalmology. We have Vin who is 1/4 year medical student at um, Ausin, he's currently integrating at University of Birmingham and he's gonna talk to us a little bit about anatomy and a couple of conditions are related to ophthalmology as well. If you guys have any questions, feel free to pop them in the chat. And yeah, we will be putting out feedback forms at the end of the session. So once you fill those in, we will, you will be able to receive your attendance certificate along with discount codes for past the MRC S and teach me surgery without any further ado I'm gonna pass it on to. Thank you so much. So, yeah, my name is VS er, I'm one of the fourth year medical students but I'm into at University of Birmingham right now. Um, and yeah, today's session is gonna be on ophthalmology, so I'm gonna be covering um, the major like anatomy, um, and like a couple of conditions related to red eye Um and then my colleague, er Aita there on Wednesday is gonna be doing like more clinical conditions looking into the rest of ophthalmology. So, yeah, let's get started. So um have a can you guys see my screen moving? Here we go. OK. So yeah, firstly, thank you to all the partners um who have helped run the session and the key learning objective. As I mentioned, looking mainly at the anatomy of the eyeball, um the structures, the layers and the vasculature, we're going to be looking at the physiological processes. So for ophthalmology, the main ones are like refraction and accommodation. Um for vision, we're gonna be looking at red reflex in infants. Now, this isn't generally like the most relevant condition when it comes to like clinically, it's not the most common, but we're gonna cover it in this session. Anyway, cos most of the bigger conditions are going to be in the next session. Yeah. So the presentation, the management um conjunctivitis, uh the bacterial viral and er allergic subtypes of it, looking at the clinical presentation and diagnosis. Um and then we're gonna look at uh ad eye syndrome, blepharitis, and anterior uveitis I haven't mentioned on here. So starting off with the basic anatomy, um the key bits you know of the eye, the key bits you need to know the cornea, um the lens. So, so these are like two of the main parts that are responsible for uh like directing the light at the back of the eye, which is the retina. Um And of course, the retina, as I said, yeah, the light targets there and it's then picked up by photoreceptor cells um which convert um the light into electrical signal which is then transferred through the optic nerve to the brain, which is where an image is formed um specifically on the retina. It's the macular, which is where the light tries to focus to. Um and there's a specific point on the macular called the fovea um which is quite clinically important as well. Um Also, of course, the iris, um if you all know the color part NRI um and you know, there's loads of diagrams of this kind of stuff. This is just a very basic one. This here shows the fovea which is on the macular. Um And the thing is the eye is split up into the anterior chamber, which is all of the front bit and obviously the posterior chamber. And if you want to categorize it a bit more. So the the the retinal layer is the pigmented layer, as I mentioned, that has the neural cells as well. Um We have the fibrous layer which is the sclera and the cornea. Um and obviously the vascular layer which is involves the iris ciliary body and the choroid obviously quite important for the blood supply for the eye. Um And if we look a bit closer at the actual vasculature, there's loads of that. You know, you can learn all the vas for the eye. It's quite extensive. But I think the key ones to know, especially at like a medical school level is basically understanding that it's the internal carotid artery that splits into the ophthalmic artery. Um And then obviously central retinal artery is quite important as well. The others aren't too important at this level. But yeah, it's worth, you know, remembering those ones and acknowledging that the central retinal artery is what supplies the retina. Um And you know, the long posterior ciliary arteries supply the posterior choroid. So the posterior choroid, as I mentioned in the previous slide is part of the vasa. Um And then so and then also the short posterior artery supplies the optic nerve head and the choroid as well. So just a couple of things to remember there when it comes to the vasculature. And I think this bit on the right here is probably one of the most important things. It's one of the things that comes up the most in SBA questions purely because um yeah, so much they can ask about it. It's, it's simple. You have to just basically learn um which muscles move the eye and which direction. So sr so sr is superior, um rectus io is inferior oblique. You have your medial rectus, lateral rectus, inferior rectus and superior oblique. So the key bits to know are that the medial rectus for both eyes brings the eyes inwards. So towards your nose, lateral rectus is gonna be towards the um like when your, when your eyes move outwards, um superior rectus, obviously trying to move the eye up, inferior rectus down. Um the superior oblique. Now, it may seem a bit counterintuitive, it's called superior, but it actually moves the eye down. It actually moves the eye more like down and like inwards here as such. Um And then the inferior oblique does the opposite. So here and you can see all the central, you can see all the nerves which are um which just apply in the different muscles. One of those things is worth memorizing for exams. Um And yeah, you can see it all all quite well here. Um this whole diagram and then this next bit of course, is a little bit less clinically relevant. It's not involved in as many conditions, but worth mentioning the anatomy of the lateral glands. So yeah, so the key is to remember, latal glands are what produce basically your tears and like the tear film. So why that's important is when it comes to a lot of a lot of ocular conditions. Um A lot of the issue is when your eye is dry, it doesn't produce enough um like tear, as I said, and tear is important when it comes to not only lubricating the eye, but also um it's quite important when it comes to like refracting the light, which goes into your eye and making sure that it goes onto the phobia, which is what I mentioned earlier. So, yeah, so that's produced by Lacrimal gland. Um And, you know, some key points here, Lacrimal sac. Um and you know, the lacrimal duct as well, probably worth knowing, you know, exactly where they are and it's actual clinical relevance. Um So yeah, so as I said, increased tear production um and certain conditions you have will affect it in different ways. So if you have ones that you know, you have ones that can reduce the drainage, um and you know, if you have less drainage uh of, of the tear and you have too much build up, it's gonna affect your lid position. Um and then o and then other conditions that are quite important are when different glands that I mentioned earlier get obstructed, you're gonna get, as I said, like reduced drainage, um reduced like tear production, lack or pump failure just once to worth remembering. Ok. Yeah. And obviously the, yeah, in the name, it's worth mentioning that the, it's the electro artery which gives the artery like blood supply. Um And the two nerves worth mentioning that are responsible are CN seven and CN five when it comes to the lacrimal glands. Ok. Now, looking at the physiology a bit closer. Um So accommodation basically means how the eye changes the refraction of the light in order to ensure that the light directs perfectly on the retina on the fovea. Ok. So basically, if the eye is not in a non accommodative state, then the ciliary muscles which are muscles that surround the iris are relaxed. Um And that allows the suspensory ligaments which are the ligaments that are attached to the iris um to become a bit more tall and a bit more tight. And what that means is the eye, the um it almost like stretches out as such. Um So it becomes less globular and more stretched. Um And what that means is that the eye is not focusing as clearly and light is being projected almost past the retina. So rather than the light coming together and you know, perfectly hitting the point on the fovea, it's going a bit beyond that. But when you actually have accommodation, the ciliary muscles around the iris contract, the suspensory ligaments become lax. So they become less tight. And then what happens is the eye then goes back to its regular like globular shape and sorry, not the eye. I mean to say the lens, but what happens is when the lens is then in its globular shape, it makes sure that the light can, you know, be focused uh in the right area in the in the Foia. So that's what normally happens. But when you have um pathology related to the eye, you can get issues with it. So the technical term for there being no refractive area, um error is er emmetropia. OK. And that basically means that, you know, the lights coming in er, is being refracted, you know, by the cornea, by the tear film by the lens and it's perfectly um meeting at the, at the fo point which is obviously like the main goal uh ametropia is when you're, when the focusing is disturbed. OK. So you have myopia and this is basically short sightedness and you can see in this diagram here, which is quite useful, the light doesn't actually um it doesn't uh like concentrate, it doesn't like meet perfectly at the retinas a bit before that. Um So that's short sightedness, hypermetropia, that's long sightedness. So the light as it enters the eye actually ends up focusing beyond the retina. Um And what I'm saying is when you have both of these issues, the vision is gonna be distorted, it's gonna be a bit blurry cos the light isn't, you know, perfectly um uh hitting the point it's meant to be. Um And then, of course, I mean, astigmatism where you can see here, the light actually scatters along the um retina. And what that would mean is that you actually get like double triple vision um astigmatism and there's loads of conditions that like can cause astigmatism um not mentioned in this lecture, it might be in the next lecture. Um But yeah, it's quite clinically important and this is quite unique. So this is preop here, I think is how you say it and this is basically, it happens with age. So over, normally over 45 years old, the lens gets harder and it actually can't accommodate. And then what happens is you then um it, it's normally the reason why people end up getting glasses as they get older. Um But it can be corrected by having some sort of converging lens, a a converging like convex converging, same thing like lens to make sure that the light focus is exactly where it's meant to be. Ok. Now, this is that I mentioned the red reflex. So the red reflex is the red orange reflexion seen through an ophthalmoscope when light is shone on the retina. So it's, it's good, it's normal. Um And I've written here that it's only cataracts and retinoblastoma, which is a type of like ocular tumor. I've said that those two are the only ones that can, that will prevent light from getting to the retina and will cause this condition. Um But basically, it's not actually as simple as that, basically anything that's going to um anything that's going to like block the back of the eye. So I've written here like a cataract, for example, any type of hemorrhage, any retinal detachment, all of them can cause a red reflex. So for your exams, it'll normally be one of these two, but clinically, er it's normally much more than that. So as I said, this is what it should look like with a red reflex and this is with it, you know, being absent and this is abnormal. So you can even see like the pictures here. So the the eyes of these o of the people in this picture are from Children because retinoblastoma is actually generally found in Children. And I've got a slide here actually, which is here. So as I said, it's a, it's like a um ocular tumor retinoblastoma predominantly found in Children. And when it comes to diagnosing it, the key bit for this kind of thing is the examination. Um the examination is what basically determines the diagnosis. So um leukocoria um is basically the white is the white pupil which you can kind of see here. Um no red reflex, but there being a white pupil er history will obviously give indications of deteriorating vision in a person who has this condition and strabismus. So do any of you guys know what strabismus is? You can write on the chat if you want to or you can unmute your mic strabismus. So I have someone here see lack of coordination between the eyes, lack of coordination between the eyes. Yeah. A squint. Yeah. So yeah, I can see the abnormal arm. Yeah. So that's basically all correct. So yeah, so Trismus is a fancy word for squint. Um I've got the types here. So you can literally see it on the screen. So you have esotropia, which is where you know one of the eyes you know, falls inwards, exotropia where they go outwards, hypotropia downwards and hypertrophia upwards. There's loads of tests. I think you guys learn a lot in Aussies. I'm not gonna go into detail now, but there's different tests you can do where you cover, you know, certain eyes and you, the squid becomes more obvious. Um So yeah, that's, you know, something worth noting. And as I mentioned earlier, one of the key bits is the fact that the red reflex is absent. Um I've written here, most common intraocular tumor of childhood. Um and I've written here urgent treatment, radiotherapy chemotherapy. That's what it says on the websites for medicine. Um But I think generally speaking, this is only two of the options. Normally with this kind of thing, there's way more way more treatment options than, than just on the paper. So I spoke to a consultant and he told me um that at its most severe form, it can require um inoculation which is basically the removal of the whole eye. Um And that's why this kind of thing can only really be treated in like specialist centers. Um So yeah, quite a severe problems going on the side. So, conjunctivitis. So I think what I found when I was doing my like 2nd, 3rd year exams, um when it comes to ophthalmology, they do try and focus more on these like red eyes, the red eye conditions. So if you guys know any other red eye conditions apart from conjunctivitis, just put them in the chat. Any other conditions that you've linked to red eye that you've learned about someone? Put, how common are benign retinoblastomas? I'm not actually sure about the numbers, but it is, it is obviously the most common um childhood ocular condition, anterior uveitis. That's good. Any other ones? Sclerisis? Excellent. A right is good. Excellent. Any more? Hannah. Do you mind saying what A A CG stands for? Um Sub Conjunct impairment? These are all excellent answers. These are all excellent answers. This is really good. Yeah, so this is good. I think the key thing for um for for the, you know, medical school exams is, you know, obviously learn the main ones. So conjunctivitis, definitely anterior uveitis, pitti Riis, um you know glaucoma, which A's gonna mention in the next lecture. Um There's a couple more but they're the main ones. I think it's definitely worth becoming familiar with conjunctivitis. Um not only cos it's big in ophthalmology, but you guys will learn it in all your blocks cos it's just that clinically relevant. It's it's indicative of so many um other conditions. So how does it present? Um as I mentioned, red eye or hyperemia? Do any of you guys know what hyperemia um means? Just put on the chart if you know what hyperemia means quite a technical term, but it'd be good if you guys know what it sounds what it means. And yeah, Hannah, the acute angle, uh glaucoma. Yeah, exactly. Definitely more than the um the open angle. Um we'll give you a red eye. Increased blood in the eye. Yeah. So basically, so hyperemia. Yeah. So yeah, increased blood in the eye. And the reason for that is basically you have so much inflammation because of the condition that you get a lot more blood flow to the eye and obviously it makes it look more red. So yeah, uh increased blood in the eye. That's, that's perfect. Yeah. Um an itchy or gritty sensation discharge from the eye and basically you're gonna have dry eye as well. All right, and I've written here, no pain, photophobia or reduced visual acuity. But I think um in reality, when you see this condition, um it it it can definitely affect the visual acuity. And the reason for that is because you have the so you have the condition and it dries out your eye cos you get less like tear production. And then I remember I mentioned earlier, tear film is important when it comes to directing the light, when it comes to accommodation, when it comes to the refraction of the light towards the fovea. So, you know, if you, if you've got dry eyes, it's gonna affect that. And you know what I've done here, I've actually put the different types of infective conjunct conjunctivitis. So, bacterial and viral and in the exam, there's like a big distinguishing like between them. But in reality, after I spoke to the consultants here, they told me that you can have viral conjunctivitis or allergic conjunctivitis or whatever. And it can, you know, viral and allergic can have the same symptoms as bacterial. So for the exams, it's worth, you know, understanding the difference in presentation, but in reality, it's all a bit mixed up, to be honest. So for the sake of the exams, bacterial has a purulent discharge, um which you can see pretty good in this diagram around the lid margin. You have the green discharge um worse in the morning when the eyes may be stuck together. Obviously, the build up and discharge is um is gonna cause them to the lids to stick to the er ocular surface on the eye, making it harder for the eyes to separate, worth mentioning as well when you have conditions like this because um you've got no tear film for lubrication and obviously you have the er discharge on the eyelid. What ends up happening is um you know, as you blink, you can get almost microtrauma, micro damage to your eye, so it can then lead to infection and it just ends up getting worse and worse. Um So for bacterial, do you guys know any like major types of bacteria that are associated on the skin of, of, of, of humans? Like the major type, the main types of bacteria on the skin. There's one in particular I'm looking for, let's put it in the chat if you know. Yeah. Yeah. Perfect. Excellent. Excellent. Yeah. Staph aureus is the one I'm looking for. So with these ocular conditions, whenever you have any trauma to the eye at all, then Staph aureus is always one you need to be thinking about. I think with these are in exams as well when they ask you questions like, um, you know, they always ask you like what type of microbiology, what type of bacteria is it that's getting involved here. If you understand where the bacteria is in the body. Um and you understand how it enters the body, then you might be able to almost yes, the answer sometimes. So that's for bacterial and then viral, which is the most common type of conjunctivitis um has like a clear discharge. So obviously, not as it's not green, like the bacterial, it's clear. Um And you can see in the diagram, you still have the redness hyperemia. Um And obviously, as all viral conditions are, as you guys will have probably be aware because of your oscular vision um viral conditions. You know, it normally has a whole package. You have the dry cough, you have a sore throat, blocked nose, uh you know, inflamed lymph nodes. So all of those things are really worth um understanding um allergic conjunctivitis, obviously a lot less sinister than the infective types. Um You know, you'll still have some, you know, some, some uh some uh the discharge, um like with the viral, um you still have the red eye. Um And I think the key about this is the cause of it, which is, you know, you have the swelling of the conjunctival sac and the eyelid. Uh and you'll have, as I said, increased watery discharge and itch. So, you know, if you see a patient and they have, you know, the extent of swelling that, you know, that I'm saying here, then, you know, that could be indicative of that. Um As for all allergic conditions, antihistamines, oral topical can be used to decrease allergic conjunctivitis. Ok. But if we look more into the infective conjunctivitis, um investigation and management. So, you know, the key thing here, topical fluorescein staining. Um I'm not sure if you guys have seen it happen before. I should have put a diagram on here. But basically when you put the stain on, um it almost goes into little cracks where you have damage and you can see, you know, where the cornea has been damaged from the conjunctivitis. So this is, you know, a really, really big deal. And you know, if you ever go into ophthalmology on placement, you'll notice that all, you know, in all the outpatient clinics, they always have like a whole box full of the fluorescein um, eye drop cos it's just used so much, it's so good for seeing corneal damage. Um And when it comes to management, self limiting condition that usually settles without treatment within 1 to 2 weeks. Um, but, you know, if it ends up being more severe than that or they want treatment, the topical antibiotic therapy that they often give is chlorophenol and they give that every 2 to 3 hours and then for pregnant women, they can use for acidic acid as an alternative. Um, and that here, I said, you know, treatment is twice daily. Um, and contact lenses should not be worn in an episode of conjunctivitis. And they're actually advised against it basically all ocular surface conditions. And the reason for that is if you have the contact lenses, they, they do cause micro trauma to the eye. So it's often recommended you switch to glasses. Um if this is something which you know, someone is, is is suffering with, ok, anterior uveitis. So this is a really we have a question in the chart which is asking what do you do for mixed presentations? What do you do for mixed presentations? Like bacterial? Yeah, like bacteria is super in position of initially viral conjunctivitis. It's a good question. I'm not entirely sure, but let's go back to that slide. So, yeah. So if you had, so are you saying if you had, let me go back to your question? Sorry. Um So you initially had viral conjunctivitis and then it even bacterial. I don't know how common that is. But I would imagine because the thing for most viral conditions in general, there's not really too much treatment apart from like antivirals, which they wouldn't give in this case anyway. Um, you don't really do much anyway. So I assume you would just deal with the bacterial part of it. It's a good question though. I'll definitely look into that. Hey, um, we have the other, um, cta, er, ocular leads a a, are you, are you in the chat right now? Cos he might know the answer to this. He's quite good at this kind of thing. Yes. So, so do you have any idea of what you would do for um a person who has initially viral conjunctivitis and then bacterial laughter, we give a set to um D on, right? So he believes it's similar to normal bacterial management with more of a focus on eye care and cleanliness to stop uh continual infection. So, yeah, I think the key is just to focus on the bacterial side. Um And then as I said, it's self limiting anyway. So the viral part will, will go away by itself. Does that answer your question? Right. It's a good question though. OK, good. So your anterior uveitis. So, uh anterior uveitis involves inflammation of the anterior chamber of the eye. So it's important when you're doing ophthalmology to and I think I make the same mistake as well. I'll be in theater or I'll be watching something in placement and you almost forget exactly the part of the eye. You're looking at. So being able to differentiate in your head, the anterior segment to the posterior segment is really beneficial in the eye. So, anterior Vitis affects the anterior chamber. So what we're looking at is, you know, the iris il body conjunctiva, pupil, anterior, you know the the cornea lens, all of that makes up the anterior chamber and all the side, all the retina from the back and all the area around that is gonna be your posterior segment. OK. The big thing with anterior uveitis and they use it a lot in SBA questions um because it's rarely an isolated condition. If you ever go on placement and you have a shadow in outpatients, you'll notice that the history is like a really important part. They're always asking what other conditions do you have? Because uveitis is associated with a gene called HLA B 27. And if a person is positive of that, then it's indicative of them having, you know, this ends up being a more likely differential. So the way they figure that out is looking at other conditions that are on the same gene. So we're looking at ankylosing spondylitis. Uh There's different types of arthritis here, inflammatory bowel disease, sarcoidosis, and you know, Beckett's Disease. So you ask for symptoms of all of these as a way of figuring out if a person has anterior uveitis. Um Yeah, a lot of stuff on here, you know, I think it helps with these kind of things to actually visualize it and see it. So the key things which you're looking for the painful red eye in the history, reduced visual acuity, photophobia, which means I struggle with looking at sunlight, looking at the light excess lacrimation. So a lot of tear production, you look at the eye, you can see here, something called hypopen. OK? And that's like almost like you look at the eye, you look at the ophthalmoscope and you'll see almost like a fluid level, like a white fluid within the iris that forms and it will look like this. And you have something called an abnormally shaped pupil. And that's the technical term is posterior sine eye. And it's quite complicated. But basically what happens is when you have all this inflammation in the front part of the eye, what happens is you get a build up of all the white blood cells and all the, you know, bacterial pathogens, all of them end up building up and they make like a sticky substance and it almost sticks the iris or the um the pupil like to the back of to the front of the lens. So this diagram here is quite good. So um you can see here, sorry, not the p the, the iris, which is, these two lines here ends up sticking to the lens. And then because the pupil is obviously a whole, um it ends up becoming like a distorted shape and that's how you get posterior S si um they don't teach you that in medical school, but it's good to understand exactly why. Um the other thing to look for in the eye, il flush, which is the redness around the cornea meiosis. So because you have the posterior sine eye, it's all going to be stuck. So eyes going to be stuck, the people are going to be stuck in a particular position. Um you know, the adhesions from posterior sine eye and the hypopyon which is the white fluid and the treatment. So initially because it's the kind of condition that you want to decrease the inflammation, looking at steroids, eye drops first and then it would go to AA and then intravenous and then cyclopic. So do any of you guys know what cyclopic actually are? Right in the chart cyclops? Yeah. Yeah. So Han I got it right. Yeah. The dilation of pupil. That's excellent. Yeah. So the way it works is um so what they do is you've got the posterior si which is almost like forcing the pupil constricted. Um This like paralyzes the il muscles which I told you were responsible for the pupil size, allowing the er pupils to dilate, um which will obviously, you know, dilute you, you dilate it and then because the inflammatory area is now more exposed, it can more easily be cleared by the body. Um Something worth mentioning here, cyclopent and atropine er cyclopent that er these are er, antimuscarinic drugs, um, which are obviously quite good, er, when cos er, it's quite good when it comes to the eyes and what it does. Yeah, it reduces the action of the iris sphincter muscles and aci muscles. So, yeah, basically again, it kind of like relaxes that whole, that whole section and then recurrent cases you have DARS anti TNF, which are like last line treatments and then other causes of red eye. So the the there are loads of other causes, some of which I will mention in the next lecture, but I wanna mention blepharitis and these in general um as causes of red eye. So blepharitis, um basically, it means in, it means inflammation of the eyelid. So what is you get other uh system which produce the oil which makes up the tear, which goes onto the surface of your eye and then cos you've got dysfunction there, you're not getting enough like er lubrication. So the eye becomes dry. Um and then that presents with like a gritty, itchy, dry sensation of the eye, sticky eyes in the morning. Cos the lubrication isn't able to help the eyelid from separating away from the ocular surface. How do you treat it? So, this kind of thing you wouldn't approach with, you know, hard medication, you would use hot compresses, hot towels, uh lubricating eye drops just to try and deal with it systematically. And the complications of that um of having blepharis as I said, you know, you're getting more trauma on the eye cos you've got decreased uh, er, like lubrication. So you're gonna get a high risk of infection, inflammation, corneal abrasion and ulcers and sts and chine. And I think you find quite commonly in ophthalmology that a lot of these conditions rarely present by themselves. You normally get multiple things. You have blepharitis cause an infection. Now you've got anterior veit and they're all linked together. I mean, other dry conditions, obviously, you can get, most of us had dry eyes like it's, it's, it's not exclusively, you know, clinical. You can get them from just age contact lenses, uh you know, too much screen time, you know, being in particular, you know, dry or cold air, um similar symptoms to blepharis, you have like a burning itchy, dry eye sensation and then treat it all just, you know, you just, you deal with whatever is basically you deal with the system uh symptomatically again. What are, um did you remember? I mentioned that clas from what I understand, they're like tiny, little like almost like ulcers. I think a a um what's a better way of describing CS? Could you describe it? But basically what I understand. Yeah, it's like um it's kind of like the ulcers but the point I'm trying to make is that you end up getting uh things that are gonna cause abrasion. I don't know exactly what they look like, but they're just, I imagine they're like tiny little pimples almost. Um You know, I think a will clarify in the chat. Um And yeah, other dry conditions, as I mentioned, you know, use glasses instead of contacts limit time in like an air condition room. Obviously, the air is going to be drier and a complication. Same as I mentioned earlier, you're going to get more abrasion, more inflammation. Yeah, so that's the main bits that I've covered more of the clinical side will be in a lecture on Wednesday. Um But yeah, any like general questions you guys have, if you guys have any questions, put them in the chat, otherwise, thank you so much. That was really, really helpful and it was really informative for us to do. Thank you. And yeah, and as you mentioned here, yeah, so small pimples around the edge of the eye due to the blocked glands. So there you go. And what's going to happen is those pimples you have there um because they're normally on the inner rim, what happens is you end getting the abrasion on the cornea which will then lead to the inflammation um making it worse. But yeah, yeah. Thank you so much for her. Thank you, man. So I put the feedback form in the chart as well now, so if you guys fill this in, you'll get a certificate and all the discount codes, we will also put out a recording of this and the slide soon after the session. So just be a little patient with us while we do that. Otherwise I think we can end the session here unless any of you guys have any more questions for him. Thank you so much for attending. Thank you so much. Our next session is going to be on Wednesday by the way at 6 p.m. again. So please join us. It's going to be on ophthalmology again and we'll be going into more clinical details and other clinical diseases as well. So join us if you can. Great. Thanks so much guys. Thank you everyone.