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Hi, everyone. Welcome to our revision session. I'm VD. I'm the vice president of the Aberdeen University Ophthalmology Society. Um Can I just check, can someone put in the chat if you can hear me? Hello? Thank you. Ok, thanks. Um So I'll just give like 11 or two more minutes and then we can get started. So today's session will be hosted by Doctor Matthew Mo who is an ST one in Ari an ST one in ophthalmology. And the topic today will be about the red eye and how to approach a patient or a clinical vignette that has a patient with a red eye and what differentials and diagnoses will come up? There will be a feedback form at the end of this session. So if you could please fill that out and then you'll be able to get your certificate that way. Mhm. Yes. Can you hear me? Ok or can anybody hear you? Yeah, I can hear you. Ok, cool. Just um let me know when you want me to start. Do you want me to just start from now or do you want? Yeah. Um Are you good to start a few minutes? I'm happy enough with whatever. Ok, I don't mind. Let's go. Ok, go. Um, let me hear. Uh I'll put my camera on, let me know if you can, can you see me? Ok. Yeah, we can. Ok, cool, cool. So, um, um, yeah, that's fine. Ok, we'll just make sure the slides change as well. Can you see that second slide? Yes. Yeah. Ok, cool, cool. Um, so yeah, thanks everyone for attending this evening. Basically, I've just, I'm one of the ophthalmology ST ones and I've been asked, um, just to make a short presentation really on Red Eye and what you'd, you know, the things you'd expect to see um in your exams. And um, the idea behind this is I want to make it interesting for you guys. Um I want to make it relevant and I also want to make it concise and high yield as well. So hopefully this will be um fairly, you know, interesting for you and hopefully you take something away. So the plan tonight is really just 30 to 45 minutes max session. Um I don't like, I don't want to waffle. I don't want to go into too much depth. I just want to keep information relevant for you guys and relevant to your exam. So I thought maybe I'd give you a bit of an intro to ophthalmology from the perspective of the brief overview of anatomy that's relevant. And then I thought then it would be worth, then we'll go through sort of the top 10, um, red eye cases that are worth being aware of. So, I've had a look at what you guys need to know for the UK MLA exam and I'll try and I can cover everything in one session, but I'll try and cover what I can, um, in the next half an hour or so. All right. So we'll start off with a bit of anatomy. The first thing um and this is all relevant because when you're examining the eye, you want to know the basic structure. So when I'm talking about different parts of the eye and inflammation or parts that are affected, then at least you have some form of basic knowledge and understanding of it. So obviously, um the first thing to know is when we are examining the eye, obviously, this is what we see on the right hand side. But what we want to, what we want to do is understand the different structures of it in order to be able to understand what part of the eye is affected. And therefore what part is relevant for, you know, for the condition that we're looking at. Um the best way to do it is to take a nice systematic approach. And this is what we do in ophthalmology. Every time we examine a patient using the slit lamp, which allows us to look at the different cross sections of the eye. We can we can get a good idea of what's going on. Um So starting, starting with the front of the eye, which is just here, the things we're looking at are often on your, on the outside of the cornea. It's sort of like the skin on the outside surface of the eye is your conjunctiva. And that's where you can get different areas of inflammation. All right. And it's normally white, but often in many cases as we'll see tonight, that can be read from inflammation, looking at the clear part of the eye. Um then this is the cornea. So this is your see through part. And then if we and the cornea itself is made up of five layers and each of those layers are relevant for different conditions. But for the sake of this talk, we'll just talk about the important and relevant things for you guys. Then behind the cornea, what we've got in this sort of slightly darker blue area is your um is what we call our anterior chamber. And then the anterior chamber houses aqueous humor. And the aqueous humor itself is made by the ciliary body, which is just where my little arrow is. And the ciliary body pumps out this aqueous humor into what's called the posterior chamber. It's, it's basically pumped out and into this little blue area and then moves between the lens and this little iris and moves into the front and then it rains out and there's a nice little pathway there. And that becomes relevant. When we talk about things like ankle closure, glaucoma, then what we're doing is we then look at the, we've got our lens and our lens is obviously very important for from a refractive perspective, but can also be very relevant in patients with cataracts as well. And then looking at towards the back of the eye, then we're looking at the vitreous. So the vitreous is full of a jelly um and sort of liquid like um substance called the vitreous humor. Um And the vitreous is, is just like a jelly, um which is quite different consistency to the aqueous humor, but very, very important and it sits against our different structures at the back of the eye. So then what we have is we have our light peel area here, which is our retina and then you've got your very vascular choroidal area behind the retina and then behind that, then you've got your SCLE and all of these structures are important for being able to just understand different pathologies in different conditions. What you can also see here is your optic nerve as well. I mean, the optic nerve is probably a little bit less relevant for the red eye, but it is relevant, I suppose in some respects for conditions like glaucoma. So that's the a brief overview of the anatomy. Let me see if I can get to the, the next slide. So, um I hope this is clear enough to you guys. I just took this, I came across this was on I news, I don't know if you guys have heard of it. It's a good website with some good resources. But um it gives quite a good systematic approach to actually looking at a red eye. And the most important question to ask initially from the perspective of a medical student in your head for your exams or from a doctor when you are F ones F twos or ophthalmology trainees, um is to think is the eye painful or not? Because if there is significant pain associated with this, then we are more concerned. If there's less pain, then it's less likely to be, it's less likely to be serious. But still could, you know, still a lot of, a lot of conditions don't present. They typically and sometimes there are painless eyes that are and have a lot, a lot still going on. But from the perspective of a red eye, the things to keep in mind is, is it painful initially? And if there is severe pain, um then, you know, we need to see that patient but things to think about and will not go through all of this because this is the whole point of the presentation, I'm going to go through these conditions. But you sort of ask, is it painful or not? And then you think about, um is there infiltrates pre present and we'll talk about these things. So, you know, is there, is there a sign of infection on the cornea? Is there like a white blotch on it? And then you can start going down the infection of, could there be a bacterial cause here or is it, you know, is the patient a contact lens wear? What's going on? We can think about viral infections, signs of trauma, we can think about things like angle closure, glaucoma And it's very important to be aware of the condition and ophthalmitis as well, which is OK, we'll, we'll talk about all of this. Um but it's just to give you a brief overview of how we should typically approach the red eye. So the first step is really to think about the pain and then to think about whether and, and what you know, is their vision affected and how much is it affected. Um And often, you know that that's the key approach. Now, if there is no pain, but the eye is still red, then it is less likely to be to be, you know, serious, but often it still will be significant and we often end up going down the route of episcleritis, which is um an inflammation of the episcleral vessels. And then thinking about things like a conjunctivitis. So we're thinking about inflammation of your conjunctiva. Um and then you can get blepharitis, which is inflammation of the, of the lid margins as well. Ok. But like I said, this is just a brief over a few, I'm not going through every condition on this and I don't want to bore you with all the, all the ins and outs of this particular table. So again, just to give a bit of a background of what we do, so we've talked a bit about the basic anatomy so that you're aware of what structures might be affected in the red eye. The other thing to think about are what investigations are relevant and what do we do. Um And a lot of the time this is important because when you're doing your exams, they will reference these and they'll reference things like visual acuity or what, you know, the Ishihara chart and things like that. So it is important and it also will help for your clinical management in the future to be aware of the different investigations that we do. So you can see on the top left up here, we've got, we've got a Snellen chart and Snellen chart is very, very good for assessing a patient's distance vision. It will not assess their near vision. Um but it's, it's, and the normal value for that 2020 vision is 66 as you go up higher on the chart, and then obviously, then the values will become, they'll become higher. So the bottom number will become higher. Um So it will become like 675696, 12, 615. And as you go higher in on the bottom number, then you are getting worse vision if the if the numbers start to drop. So you're getting something like 656463, the vision is better than 2020. So that's, that's all um that's important just to be aware of the the second image there on the top is, is basically for checking pupils. You know, as you all, you guys will know the the key things are to look for a direct and consensual response initially. So when you're looking at the pupils, you're thinking well, are both pupils the same size. And um and then what you're thinking is, well, is there a direct response? And is there a consensual response? So a direct response is when I shine the light, say I shine the light into the right eye. Like in that picture there, you will see a direct response in the right eye ie the right pupil will constrict if I want to assess the consensual response. What I'm doing is I'm shining the light in the right eye, but I'm looking in the left eye and the left eye should constrict. Now, the next thing is to do is swinging the light test where you swing the light from one pupil to the other. And that allows you to determine whether there's a um an R APD or a relative afferent papillary defect. And that allows us to determine whether there's a problem with the nerve function at the back of the eye. The third image is an Ishihara chart that allows us to assess someone's color vision. Obviously, it's not going to work if someone is color blind from birth. But it's very, very good for allowing us to determine whether the optic nerve is also compromised. You'll probably see if you've been in the ophthalmology clinic. You'll have seen a lot of slit lamps and that's sort of our bread and butter. That's what we use in order to make a cross section through the eye and have a good look at all those different structures we talked about. Then you've got on the right here is A B scan. So A B scan is an ultrasound scan of the eye, which is quite portable. We can do that and have a look particularly at the back of the eye, looking at the retina, the choroid, the nerve. And you know, it is one of these things which is a skill and it takes time to master. But for the initial stages, it's good to be aware that we do that on the bottom left, you've got the eye care. So another thing that you'll often see is that we check the pressure in people's eyes really when we're starting, you know, where we often get worried about pressures if they start, you know, normal is really up to 21. But, you know, often clinically, we allow it up to potentially 2425. But once patients start to go higher and higher, then we start to think about um actually doing something about it and bringing that pressure down. And that obviously depends on the context the patient and what the baseline pressure is as well. OK? And then I won't talk too much about these other things. So Opto is a really good imaging piece of software. We can take some pictures, color, correct pictures of the back of the eye um OCT which is that middle image there allows us to look at do a cross section through all the different layers of the retina. And then this is just for assessing the visual fields which are very, very useful as well. And I think you guys will probably have a session at some point on visual field defects as well. OK. So moving on, right, we're getting into the conditions. Now, I've got, I'm just going to fly through them, hopefully not too quickly. But um I want to just be concise and give you the information you need to know cos I know you guys have your finals come up and you're probably keen to revise. So for the following conditions, what we're gonna think about is what is it, we're going to think about who gets it or what the risk factors are for it. And then we also want to consider how it presents what will you see in your exams? You know, I suppose in theory, you could have a ophthalmology scenario in your acies. But I suppose from the UK MLA point of perspective, you're thinking, you know, what are the key points that I should look out for in order to answer the questions correctly? And I know what it's like. It's, you know, you're looking for the pattern recognition, you're looking for the thing that gives the answer away in the question. And then we also want to think about how we actually manage the condition as well. So number one, this wasn't actually on your UK MLA list, but this is one that could definitely come up. It's very, very important and it's one of the most worrying things that you can probably have um in an eye, especially if you've been the person that just operated on a patient. So, endophthalmitis, endophthalmitis is inflammation of the fluid inside the eye. Remember we talked about the anterior chamber and the fluid inside that the aqueous humor or at the back of the eye in the vitreous, you've got the vitreous humor. This is where you get inflammation off these fluids and it's most commonly related to an infection of those. It's a potentially devastating, devastating um for the the vision patients that get these that aren't treated promptly will often it's not uncommon to have a significant permanent drop in vision or even in some cases, completely lose the vision, most of them. So from a question point of view, you're probably thinking right. What do I need to know for my exams? And if your question says a patient has just had cataract surgery or they've just had an injection, an intravitreal injection or some form of surgical procedure on their eye, or they've had a serious trauma as well, which is possible. And then 1 to 2 weeks later, they come in with a significant drop in their vision by significant, I mean, the vision typically drops to a point where it's often 660 or less, which means that we're getting into the stage of counting fingers, you know, hand movements, like perception. This is where we become really concerned about endophthalmitis. Ok. Um And there are two main types, you can get, you can get endogenous, which means it comes from something within so like a bacterial or fungal infection, um or you can get exogenous causes. So you want to think about outside sources and the exogenous course is probably more common in that it comes from surgery, ok. Or intravitreal injections, previous corneal ulcers or, or trauma. What will, what will the patient present with? Well, typically they'll present with severe pain in their eye. The eye will be red as we would expect it will, they'll often have swollen lids, they'll have a really watery eye, but most importantly, that vision will drop significantly. So looking at these two pictures, what you're actually seeing here, so you can actually gain a lot from just looking at a picture. And what we're looking at is obviously the, the front surface of the eye. If you were to describe this image, what I would say is that you've got um a lot of conjunctival injections around the cornea. The clear part of your eye is no longer clear, it's hazy. And you've got this white substance located in what, just behind the cornea, which is your anterior chamber and that is pus, it's full of inflammation, it's full of white blood cells. And that is um a significant sign up to 85. Well, approximately 85% of patients with endophthalmitis will have what's called a hypopyon. And that is the pus in the anterior chamber. OK. And then we also 80% will have what we define as hazy media. So everything will be a bit hazy looking and 25 26% of patients will actually have vision that's so bad that they can actually only perceive light and they can't even see your hand moving. Uh And then the picture beside actually just shows a similar, a similar thing. You can see a hypopyon with a little bit of blood in it in it as well. So we've talked a bit about endophthalmitis and about how, how important it is, you know, to identify it, the way to identify it is the patient's just had a procedure one or two weeks ago. And now their vision has dropped significantly And then the next question is then how do we actually manage it well. There's two ways the first thing we can do is either we can take a sample from the anterior chamber. So from the aqueous humor and send that to the lab. And then what we also do is inject some antibiotics into the eye. But then on the other side, if the vision is bad enough to the point where, you know, they can't actually, they can't actually um perceive light. So they have light perception or worse, then we can think about what's called a pars plana vitrectomy. And that's where you go into the eye, you go to the back of it and then what you do is you chop up all the little, all that fits jelly and you suck it out and, and essentially what you're trying to do there is you're trying to take the infection out of the eye. Ok. So that is endophthalmitis summed up. Anyone that comes in with a significant drop in vision after surgery or an injection that's endophthalmitis until proven otherwise. Ok. Next is one of the big ones, one of the things we get referred all the time and it's orbital cellulitis. So, what you really, I think from a medical student perspective need to understand is the difference between what's defined as a preseptal cellulitis and an orbital cellulitis. OK? And um the difference is anatomical, but you will also see lots of differences um in symptoms as well. Looking at that picture. So that picture on the top right here I am, I have two screens. So that's why I keep looking. But the picture on the top, right, what you can see is you have this area here, which is your preseptal area. OK. And then you've got your globe here. So this is your eye. And then what you've got in between is this little area. OK. Called at the orbital septum. And it's like a, a very thin sort of area of tissue. And once an infection breaches past that area, you by definition have what's called an orbital cellulitis. If it's anterior to that area or in front of that area, then it's a preseptal. So the question is, you know, how do we tell the difference? Well, a preseptal cellulitis is not as severe by any means and the way you can manage it is with some oral antibiotics usually and then often it will self resolve and we're not overly concerned about a preseptal cellulitis. Um but an orbital cellulitis is significant and requires a scan of the, of the orbit and requires further intervention. Most commonly orbital cellulitis are actually caused by these gram positive staph or strep infections. And what you'll find is that these patients may have a prop toes in the eye. So what that means is typically the eye, the eye is sitting out more than the other. So we use a device called an exon thermometer, which just basically allows us to measure how far the eyes are sitting out. And we compare the measurements if there's more than two millimeters difference between the eyes. And that's say one eye is sitting out at 25 millimeters and the other one's sitting at 21 millimeters, then that would be a proptosed eye. Another basic way of actually determining whether someone has a proptosed eye is you get them to um look straight ahead and then you get them to tilt their head back and you look over their head. And sometimes often you can see um you can just see whether the eye is sitting out from above them. The other things to think about are and we'll move on. So again, peeing when moving the eyes and they may describe double vision. Ok? And if they do describe double vision and you can do an easy test and that you can get them to follow a pen or get them to follow your finger. And if you see that one eye isn't moving quite right, then I would be concerned about an orbital cellulitis. Other things are evidence of optic nerve compromise. So this is where you might have the the vision drops. Um Again, remember we were talking about color vision, if we check their color vision, which is very straightforward. Just using the Ishihara chart, you get them to read the numbers with one eye at a time, if the number is significantly less on one eye than the other, then the concern would be that the optic nerve has been compromised. And this could in fact be an orbital cellulitis and not a preceptor. And then you've also got the assessment for an R APD. So remember we talked about the different pupillary checks that you can do. So swinging the light from one eye to the other and assessing whether one pupil isn't constricting and one's in fact dilating when you swing the light back and forward, that would be a concern for an R APD and therefore optic nerve compromise. Ok. Whereas with the preseptal cellulitis, all these tests are typically negative. Ok. So if you, if you're again, from your exam perspective, they say that a patient has come in, they have been, for example, had sinusitis recently or they've been bitten by a bug or something. And you know, it turns out that their eye they've come in and their eye is red and they basically say, well, they have to be prescribing double vision or they're finding they feel unwell and they're feverish and they have a proptosed eye or the vision is significantly reduced, then these would be all signs that maybe there's um there's something more going on. Ok. So in terms of then actually managing it. So from your perspective, the key is to understand the difference between preseptal cellulitis and orbital cellulitis and know the difference OK. Treatment is IV antibiotics. You can scan the. So in an orbital cellulitis, we would scan a patient. And I suppose why the is why, well, what we want to do is one, determine if there's orbital involvement because we obviously can't see the back of the eye. And number two is to determine whether there's an abscess in one of the sinuses because that will need drainage from ent. So management, generally speaking, is going to be IV antibiotics. Usually we give CF and CF and metroNIDAZOLE. Um And then often we follow up with oral coloxyl as well. Um And occasionally patients will need surgery if they have a significant abscess there. OK. Next is angle closure, glaucoma. So with angle closure, the key thing here is that again, understanding the basic anatomy is important. So looking at this image here, um sorry, it's got a lot of water marks over it. But um if you look at the X, so the red X that indicates um the area of where the angle is. OK. So the angle lies in between your cornea and your iris and where they, there's like there's, there's an area which is where you have this trabecular and that acts to there's also something called the canal of Schlemm. It's basically like a little opening which allows aqueous humor to drain. Now, like I was saying earlier, aqueous humor is produced by the ciliary body and it secretes it into the posterior chamber. So what happens is that fluid then moves between the lens and the iris into the anterior chamber and then it goes out where XX the red X is and that's where it drains. Now, if there is a problem with that angle, for example, if the iris is pushed forward, ok, or there's a blockage for whatever reason that will cause that angle to close. And if that angle closes, then by definition, you can't get the fluid out of the eye. And the, the ciliary body doesn't have a negative feedback loop. So it just continues to pump out the fluid and the fluid will just continue to be secreted. And then what happens is the eye fills up with lots and lots of pressure goes up really high and then that can compromise, that can compromise the the thick nerve. Ok. So again, thinking from a medical school perspective, the key things that you need to know is who is more likely to have angle closure, glaucoma, ok. And the patients that are more likely are patients with small eyes or hyper optic patients or hyper metros, which are people that basically have a high prescription. So a high plus prescription and they're often, you know, they can often see well for distance, but they can't see things close up. So what we would define as long sid um again, females are more likely to have a family history, age are all relevant. Um And then there, there is some predisposition in Asians. So Chinese South Asians Inuits are more likely. Um again, and then you have uh you have some anatomy changes. So if the anterior chamber is a bit narrow, so that's this light blue area in the eye or a slightly darker blue area. If it's very, very narrow, then as you know, then there's going to be less space for the fluid to drain and more likely that they will block and then you also have things like an anatomical thicker lens. So if you have a thicker lens, what's going to happen is if you look at the lens here in this diagram, if the lens is really thick, it's going to push the iris forward. And if the IRS goes forward here, it's going to block off that ankle, right, which is then gonna cause the problem. So how does an ankle closure patient present? How do you pick it up in your exam? So if a patient has angle closure, they'll often describe a severe painful red eye that comes on quite suddenly. But often it's important always to keep in mind that patients with, if they have a high pressure in their eye, they'll often be vomiting or they'll describe nausea or even abdominal pain in many instances. And the things that we typically, you know, they may describe halos around lights, they often do describe a headache. But if they give you a patient who has a painful red eye for the past day or two who's vomiting, whose vision has dropped and you know, who describes a headache a lot of the time it's going to point you in the direction of angle closure glaucoma. Ok. Now, the signs for it that we look for, um, are a fixed dilated pupil and actually, it's not just dilated, it's mid dilated. So you have a pupil which is um, mid dilated. Other things to think about are a hazy cornea. So often. What happens is because you're not able to drain out all the fluid at the front of the eye, it completely cloud it completely clouds the cornea because one of those corneal layers isn't a one of the corneal layers called the endothelium is responsible for actually almost ing like a filter and it pumps out lots of the fluid and keeps the cornea nice and clear. But what happens in angle closure, glaucoma or when the pressure goes up is that the cornea becomes hazy because this fluid is just seeping in. Um there's so much fluid that the endothelium can't cope with it. And then it just basically imagine it just floods the cornea and the cornea becomes hazy. Ok. Um Other things that, you know, we can look at the anterior chamber um and then the pressure will often be high and sometimes, I mean, what you can do if the patient is in a lot of pain and you don't have access to resources, you can gently press on the eye and it will feel really hard. But again, you have to press on a lot of eyes to sort of know what's hard and what's a soft eye. Um And then we've already spoken about corneal edema as well. So in summary angle closure, glaucoma, what you're looking for is painful, red eye comes on suddenly with associated headache, nausea, vomiting, drop in vision and they may reference mid dilated fixed pupil hazy cornea. There you go. What's going to be an closure. So one of the things we'll do just very briefly is talk about the management. Now you aren't actually going to need to know this as medical students. The management is based around lowering the pressure initially. So we check the pressure, I'll just go through this very quickly. We check the pressure. Um And what we want to do is bring that pressure down as quickly as we can. One of the medications we can give is acetaZOLAMIDE. Um and it's also known as Diamox and it's a carbonic anhydrase inhibitor which helps drop the pressure quite significantly. You can't give it to patients that have severe renal failure. Um or or yeah, problems like that. Um Apraclonidine is also known as Iopidine. So it's another drop that we can give. Um it's a, it's a, an alpha agonist and it's a good medication. But again, you can't give it to anyone with like severe cardiovascular disease and that's probably relevant. They could ask this in the exam. Timolol. Well, we all know beta blockers. You have to be very, very careful in asthmatics and you shouldn't give them to asthmatics and you sh and we typically actually withhold them for patients with CO PD as well. Um And then, and then another option is Pilocarpine. Pilocarpine helps constrict the pupil and helps open up that angle a bit. And um you need to lie the patient flat as well in order to try and help and prevent and reduce the amount of fluid being produced, right? But I'm not going to go through all that, you know, that's fine. You can read that um it's probably less relevant for your exams, but relevant for clinical practice, um the actual way we treat angle closure is we often do what's called a pi which is a peripheral iridotomy. If you look at this picture here, if you look, so what we're looking at is nice um eye here which is now nice and white, you've got a nice clear cornea and then you see the arrows pointing to this little hole. So that little hole is what's called a pi that's a peripheral iridotomy. What we do is we fire a laser through the iris, create a little hole. And that, do you remember I was talking about how the the fluid is produced in the posterior chamber. So just behind the iris. So if we go back, see if we say that the fluid is produced in here. Um So what we're doing is putting a hole in the iris and that allows another pathway for the fluid to drain out. So it's very, very good. Um, and quite, um, and often brings the pressure down. And then the next thing we do is we do cataract surgery for these patients because that helps relieve the pressure on the angle because a lot of the time if you have a very thick lens, the lens is pushing the iris into and closing the angle. Ok. So moving on anterior uveitis, so we've talked about, we talk about ankle closure, you talked about or cellulitis, talked about endophthalmitis just moving ahead. Then we think about anterior uveitis. So I appreciate, you know, some of you will have heard of these terms but know very little about it and that's completely fine. Um But again, it's about being able to pick up the key symptoms and signs. So anterior uveitis, from your perspective, it is inflammation of the uvea. So the I that's the iris ciliary body and choroid and the only one that so there are lots of uveitis is just the term. It's an umbrella term with which there's probably there's tons and tons of different conditions fall under that term. But what we think is the one that's relevant for you guys is anterior uveitis. This is associated with this HLA A B 27 disease. And you know, we're thinking about things like any patient that comes in with a red eye and has a history of rheumatoid arthritis or psoriatic arthritis are most commonly, actually eye closing spondylitis or things like IBD and reactive arthritis. Now, they're all things that are relevant. So if they reference rheumatoid arthritis and a red eye or an HLA B 27 and a red eye, it's in your exams. The answer will pretty much always be anterior uveitis. These patients present with your classic red, painful eye. But one of the important giveaways actually is often they're really sensitive to light. Ok. So if this patient, you know, has a family history of uveitis or has one of these conditions and comes in with a red sore eye which is sensitive to light. I want you to think about anterior uveitis if it's bilateral, which again, probably not relevant for your exams. But if it's bilateral, we start to think about infective causes or if a patient has recurrent bouts of this, we need to send all the bloods do the chest X ray. Um because we want to rule out conditions like sarcoidosis, TB syphilis, toxoplasmosis lyme disease, all of these are fairly rare causes, but we do see them and I've even seen a few within the past few weeks. Um So how do we actually treat it? So we treat it with steroid eye drops and then we can give cyclopentolate, cyclopentolate is not actually really a treatment in the sense of um, well, it is, it is in some ways, but in other ways, it often just helps with symptoms as well and we'll talk a bit more about the signs. So if they say patient with rheumatoid arthritis or ankylosing spondylitis or back pain comes in with a red eye and vision's dropped in your exams, it's going to be anterior uveitis. Ok. So looking at the sciences is more for interest. Actually, these are the things that we see and this is what's so enjoyable about ophthalmology. It's very visual and it's all about pattern recognition. So this is a classic anterior uveitis patient. So what you've got on the top left is something called K PS. These are called Katic precipitates. And these are basically where you've got inflammatory cells and they stick to the back of the cornea. So when we talk about inflammation in the eye, it's inflammation at the front of the eye in the anterior chamber. OK, involving the iris. Often that picture number two. So when we, so what we're doing is we're shining a light through. Remember we talk about using a slit lamp to take cross sections and look at the eye and cross sections. So we shine a light through the cornea. So this is hitting the cornea. This second light is hitting the lens and this is our anterior chamber in the middle. Um inside, you can see all these little white dots and what they are actually are actual white blood cell, they're actual white blood inflammatory cells floating around and you can actually see them. So it's, it's, it's cool. Um looking at the third image, what you've got is this is called posterior sine. So this is when the iris, the iris becomes a def so the pupil becomes a deformed shape because parts of there are little bits of the iris stick down to the lens behind it. OK. And that's why we give cyclopentylate as well in these patients because it dilates the pupil and helps break all these little attachments which form, looking at the bottom left. Here, you've got a hypopen. So, remember we talked about that before. Um you've got these white, this white pus. Now you don't always get this on anterior uveitis, but it's very important to rule out. Um This is a lot of fibrin. So this is a lot of inflammatory pro protein like material which um is inside the anterior chamber if it's quite a severe fibrinous uveitis. And then here we have these little things called creepy nodules and they are actually more common in sarcoidosis. So just that's just for interest. But um again, it shows that anterior uveitis is a very fil specialty and it's very um it's a very visual condition and the uveitis in general is a very visual specialty, which is quite nice. So, next is microbial keratitis. So, we've gone through endophthalmitis, orbital cellulitis. We've gone through anterior uveitis and ankle closure. Microbial keratitis is the one you wanna look out for. See in your exams. If they say I have a patient who's come in with a red painful eye and they wear contact lenses, it's almost always going to be a bacterial keratitis or a microbial keratitis, which are essentially the, you know, microbial is just uh it's an umbrella term. So what you've got keratitis is inflammation, itis of the cornea, OK? And that usually presents in the form of a corneal ulcer which you can see in these pictures. Now, you can see when you look at this top picture, you've got this little white thing on the, on the front of the cornea. And what we would do is often we would put a little bit of fluoresce, this sort of like fluorescent yellow dye into the eye. And then we look at it under a blue light. And if that blue light, if when we shine the blue light in and the cornea itself is nice and blue. And I he is, but over that lesion, there's like an orange glue that would be indicative of something called an epithelial defect. And an epithelial defect is an area which indicates that part of the epithelium of the cornea has become damaged. And that tells me, you know, there's, there's damage to the front of the eye, that white, what you're seeing any, anything you know, see this white blob that indicates that there is an infiltrate tear. So there is some form of infection going on. And my concern would be that this patient who's a contact lens wearer has microbial keratitis, which can be potentially devastating to the vision if not treated quickly. Ok. The majority of the causes are bacterial. And um again, you know, like I keep mentioning, see the people that come in, we always ask them, do you swim? Do you shower or do you sleep in your contact lenses? Ok. The three ss swim shower sleep because if they do, then there's a higher risk of this. But often, you know, we can treat it, but it depends how long it's left and it is something that we would class as an emergency. It's, you know, certainly if it's this size, now the other things that can cause it are trauma, you can get if you have chronic corneal disease. So let's say you have severe dry eye that's ongoing. Then if it's very, very severe, it increases your risk of little epithelial defects. Like I was saying this damage to the epithelium on the cornea and that allows infection in and can lead to a bacterial infection. Ok? Um This is important. So now again, this next condition wasn't on your UK MLA, but it's one of the most important conditions we look out for in contact lens wear. Whereas, and you get this white ring where it often doesn't look like this. But for the sake of exams, it does in that you get this white these infiltrates, ok? And it forms this ring and this would basically indicate the presence of ac can Amoeba if someone gets acanthamoeba in their eye. This is like bad news. It doesn't mean they'll lose their vision, but it does mean often that there will be some form of long term damage to the front of the eye which can even lead to patients needing a corneal replacement or graft. And then just as a side point, sorry, I meant to say this before for microbial keratitis, um we give antibiotic treatment in the form of drops and we usually give ofloxacin which is a fluoroquinolone drop. We normally give it orally for 48 hours and then two hour for a few days and then, and then wean them off it um over the space of a week or two, but it depends on the nature of it and it depends how, how significant the infection is. Ok. Moving on, this is a little bit about acanthamoeba. So just for you to be aware of, if they say in your exam that you have a contact lens wear, who has a dendritic ulcer, which is what this ring thing is. That's the staining um in the contact lens wear, you need to think about ac can amoeba, ok. Normally dendritic ulcers make us think about herpetic disease. And they should, but if they wear contact lenses, I want you to think a can Amoeba because it's an amoeba that actually lives in pools and tap water on soils and contact lens solutions and everything. And that's, it's just an absolute nightmare. And, you know, patients that don't look after their eyes when they're wearing contact lenses, often, well, not often, it's very, very rare, but they can run into problems and it can be, it can be devastating to their vision, right? Moving on. So next day, um we have a, we actually only have another few slides and then we're, we're sort of nearing the end. So we'll be glad to know the next thing to think about is scleritis versus episcleritis. Ok. And how to just compare it from an exam perspective. A scleritis is a pain that wakes people up in the middle of the night. Their eye is really, really sore and they describe it as like a boring pain. I had a patient today who came in into the urgent referral clinic and he said to me that he woke up last night at 2 a.m. with a severe stabbing pain in his eye. His eye was really red and he has a background of rheumatoid arthritis and you've treated as scleritis because that's what he had. So here was a classic sort of a classic example of scleritis. So what you actually have is inflammation of scleral and episcleral tissues and you can read about all the pathophysiology of it if you wish. But I think the thing from your exam perspective is a severe sharp, boring pain that wakes patients up in the middle of the night, but can also be present long term or over a few days. It's like a dull, um boring pain. Almost patients describe it like it's almost like someone's sticking something in their eye normally. Um The pain can radiate and it can radiate to the jaw, scalp and face. And the way we typically manage it is we give oral nsaids initially, um which we can trial but often, you know, often what we do in clinical practice is we often depending on the patients symptoms and obviously the story, but often we'll give them a weaning course of steroid. Ok. In other word, episcleritis is much less serious. Epis scleritis still presents as this sort of discrete elevated area from flam tissue. And I'll show you a picture actually of what it looks like. Um And again, a quarter, a quarter of these can be associated with other systemic disorders like rheumatoid arthritis, Crohn's, et cetera, but less so than maybe scleritis, often, you know, half of these patients will have an underlying rheumatoid problem or an infection or surgery or have had previous surgery. Episcleritis is also something where the pain. They're often the patients are quite uncomfortable with it, but they, they won't generally speaking, have a severe pain that wakes them up at night. Um, it shouldn't wake them up at night if it wakes them up at night, there's concern that this is actually scleritis. Now, there are different types of scleritis. You can have anterior, posterior and it can become, it can become quite complicated. But for your sake, all you need to do is know, scleritis versus epi scleritis, know the difference and know what to do. Ok. Scleritis, oral nsaids, oral steroids. Um if the nsaids aren't working episcleritis, reassure them, cold compresses, artificial tears if they are really uncomfortable and they want the treatment. Oral nsaids are an option like ibuprofen. Now, the other thing for medical school, which is relevant is giving phenylephrine. So in episcleritis, generally, phenylephrine will cause blunt or it will cause these um vessels basically to to become white. So the redness will go away in episcleritis with phenylephrine. Whereas with scleritis, it won't. Ok. Just a little point to note um for exams. So anyone that comes in with a severe sharp pain in their eye that wakes them up from their sleep, I would put my money on the fact that it's a scleritis. Ok. So quick picture just to what you can see here on the right is an episcleritis. It's also that's probably a nodular episcleritis where you can see a little nodule in the middle, like a little see through sort of translucent raised area. And then you can also see that temporarily they've also got this, this sort of redness of the vessels, but the rest of the eye is quite white. Now, on the other side, on the left hand side, you can see that the eye is, the eye is like AAA violet blue. He is um and you've got the eye is very injected and very red and that, that would be indicative of a scleritis. Ok. And then just to, so what I'm going to do, so this is what I'm going to do. Just finish with these two corneal common. They're not even corneal problems. I don't know why I put corneal. They're, um, but they're, they're more about the conjunctiva and blepharitis. And then I just, I have my own little feedback form and then I'll go through three questions. All right. Um, my feedback form will literally take 20 seconds to do five short questions and then we'll go through three Bs and then that's me done. Ok. So what I want to do is briefly talk about conjunctivitis. So the classic conn conjunctivitis questions in the exams always typically start with a patient presents with a red eye and she has, uh, she might be young or he might be young and have an often, the sexual history is often relevant because a lot of the time if a patient comes in with a red eye, lots and lots and lots of purulent green or yellow discharge out of their eye, it's relevant to ask about sexual history because often you do have an underlying bacterial cause, which can take the form, you know, which can be chlamydia or gonorrhea. So that's important. We need to swab these patients. The other one which is very, very infectious is adenovirus. So these patients describe, you know, someone at home has a red eye and then they themselves have developed this red eye which has then gone from the right to the left or left to the right or whatever. But generally speaking, they'll come in with the bilateral red eyes and a lot of irritation. But the vision is not normally affected to a significant extent, the vision may be a little bit reduced but not to the point where, you know, they're counting fingers or heart movements. Ok. And then, and then of course, then there's allergic conjunctivitis and I'm sure some people have experienced this even if you have hay fever or, um, or you get a type one hypersensitivity reaction in the eyes flare up. Ok. So that's conjunctivitis, blepharitis. So again, from an exam perspective, conjunctivitis, think about one eye and one eye. Um, and then a few days later the other eye becomes red or there's someone at home with a red eye or there's a young person who is, um, you know, I don't know, very sexually active and they've got lots of purulent green discharge and you're thinking more along the lines of chlamydia gonorrhea. Ok. And then you would just treat that as you would. Normally. The next thing then is blepharitis. So this is inflammation of the eyelids. Um, again, it's often associated with staphylococcal infection. These patients get eyelid margin diseases. Um, and it's very, very common. The way to manage it is with lots of warm compresses and lubricating drops. I'm not going to go into that too much. It's very common. You can have a brief read about it. Um, it could come up in your exams. But yeah, but the way to detect it in the exams is patients that have a known history of dry eye, it affects both eyes and they have a bit of redness and irritation, but the vision should not be significantly reduced. Ok. I just give everyone if that's ok, I'll give everyone a breather for 30 seconds. Ok. Just if everybody wouldn't mind doing that feedback for me and I would really appreciate it. Uh, and then I've got three SBA S to go through and then we will, and then I'm happy for a few minutes if someone want, if anyone wants to ask questions and then, um, on, on the chat box, so I'll just give everyone 30 seconds. And by the way, the other thing is, um, feel free to email me. That's my email there. Um, I'm more than happy if anyone's, you know, wants any, um, wants any advice on anything or wants to ask me any questions, um, or even if anyone's interested in ophthalmology and would be keen to apply when they're f, you know, when they're f to applying for the specialty training, I'm more than happy to help with things, um, because I was in the same boat as well. So I'll just give everybody, uh, just another 20 seconds and then I'll just go through three quick questions and then that's us. Ok. Ok. I appreciate everyone that's done that for me. Um So first question, I'll just give you about a minute to do it. All right, let's see. There might be a timer here. I don't know. Anyway, um, a 21 year old presents with reduced visual acuity in his right eye, photophobia and mild pain for the past five days. He says that he's had some back pain for the past few months, which of the following investigations would be the most diagnostic in the first instance. So, and by diagnostic, what I'm saying is how would we identify the potential underlying cause for reduced drop in vision? So, MRI Spine, chest X ray x-ray of the Sacroiliac joints, C RP or lumbar puncture. Sorry, I can't see the chat. So if anyone's put anything in there, um I can't see it but sure we can go through stuff at the end. Nothing yet. Nothing. Oh, that's perfect. That's good. Thanks. So, if everybody just thinks about what they think the answer might be, normally I do a poll on these things. But I, um, I didn't know how to set it up on this. Ok. So we've got one thing, a and then a few things c ok. Cool, cool. We'll give it another five seconds. Yeah, that's great. So, the answer in this case is c, and the reason why is because, so if you read the question carefully, he's 21. We've talked about this. So we've talked about this sort of condition earlier. but it's quite af question. So you've got a 21 year old patient, the vision has dropped a bit, they're very sensitive to light. So they're young and sensitive to light with back pain. So what you're sort of thinking to yourself is, you know, this patient possibly has an ankylosing spondylitis which has caused them to have an anterior uveitis. So the best um diagnostic option in the first instance, you would start with an X ray of the sacroiliac joints and um whoever said MRI spine, that was um a good choice as well. That's something that could be done a bit further down the line. But just in the first instance, um an X ray of the sacral joints would be the um best option. OK. Number two, which of the following is not a risk factor for angle closure of glaucoma. So, hyper metopia, family history, Asian descent, shorter axial length or myopia, I've managed to do a pool this time. So the question on the, on the slide and then I put the answers in. What? Sorry, what it's called? Sorry, what did you say? Sorry, I didn't put the question in but all the answers. Oh, that's fine. Ok, thanks. I can't see the pool but you can let me know. Sure. So we've got 13 responses and the majority have gone for e OK, great. Well, that's very good. So, um myopia is where you have a, a very, very long eye And if you have a long eye, then generally speaking, you're gonna have quite a deep anterior chamber, which means the probability of actually getting an angle closure. Glaucoma is much less than someone with say hypermetropia where the eye is smaller and there's a higher risk of that iris moving forward and closing that angle. OK. Uh Family history, Asian descent are things that we talked about already and a shorter axial length just means smaller eye. So that would be um indica or that would, that would sort of lead towards an angle closure as well. And then the final question is um I'll just, I'll read this one out, but 35 year old presents to his GP out of hours with a painful red left eye for the past four days. He reports double vision and a reduction in his own vision. What is the most appropriate management? Ie what would you do? Um If you were the GP so give oral antibiotics and review them again tomorrow. Contact the on call ophthalmology for an urgent review. Ask the patient to attend A&E tell the patient to see his optometrist tomorrow or give some antibiotic or chlor chemical drops. I'll just give these about 30 seconds to think about them. So we've got a couple for D and C and then the majority are going for B majority have gone for B. So B would be the right answer in this instance, but I'll explain it because I appreciate it's probably a bit more of a tricky question. So the concern is actually that this patient, so he has a painful red left eye for the past four days. That could be anything, right? And he's 35. So again, it could be anything. But the fact that he reports double vision implies that his eyes aren't moving uh together an emotion, which would imply that there's restriction of one of the eyes. And therefore, my concern would be in this instance that he has an orbital cellulitis. And the best option in this instance is to get us involved and to call us because we would want to see that patient urgently and assess them. And what we would do for them is obviously do a full assessment as we talked about before. Um probably start IV antibiotics and take some bloods and then get a ct of their orbits to identify whether or not there's a potential abscess there. And then what we would do is if there was we'd contact Ent who would, um and often these patients actually end up admitted on ENT, but we review them daily. So I don't have any more slides. That's, that's, you know, that's the end of my presentation. Thanks very much to everybody that attended and I hope you got something out of it. You know, I did try and make it so that it was distinct for you guys and sort of um relevant as well. So, um, yeah, and like I said before, I'll just leave this up. But if anyone has any questions, you can send me an email. Um I'm more than happy to um take feedback or I'm more than happy as well to help anyone out. So that's fine. Thank you very much. Thank you so much. This was a really good session. Thank you. Thank you. Um, we've got one question. Yeah, that's fine. And so Mariana has asked, why do you get a relative afferent pupillary defect in orbital cellulitis is the nerve affected slash compressed. So, not so with orbito cellulitis, you don't always actually. So it depends on, on what's actually going on and it often depends on the actual cause behind it. So a lot of the time when we see patients, you know, for example, I saw a girl the other, um, a few weeks ago who, um when I, when I assessed her, she had um sinusitis and said that her, um, she had some double vision and her eye and her eye was restricted. But when I looked at her nerve and her vision was fine and the back of her eye and her nerve was healthy. So, and it ended up that she had a small abscess in, in the back of her eye. So it really, really does depend on the nature of the orbital cellulitis. There is like um there are a few different classification systems that can be used. Um If you leave orbital cellulitis untreated, then it will get to the point where it will compromise the nerve and when that happens, you'll get an R APD. Thank you. Does anyone else have any questions speak now or forever? Hold your peace or you can just uh you've got a lot of people saying thank you. Oh, no, no problem. Um So if that's if that's all, um thank you for joining our session, please. Can you fill out the feedback form for doctor Mo on the slide and also on medal. If you fill out that form on medal, you'll be able to get your attendance certificate and we hope to see you soon. We're planning a few more revision sessions. So keep an eye out. Keep an eye out. Uh-huh, get the plan. Bye bye. I try. That's great. Well, here, thank you very much. Thank you. All right. See you. Bye bye bye.