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perfect. So I think we are live. So welcome everyone to med school extras Career life session, series. Um, I'm Chantel and I'm part of the events team and we have Doctor Sean here who's going to be delivering our talk. So before we get started on the session, I just wanted to talk a bit about what med school extra is all about and then give a little introduction to Doctor Sean and, um, what he's involved in. So med school Extra is an independent organization which tries to identify areas that medical students, doctors and dentists don't really, um, get a lot of teaching on during their curriculum and also things outside of the A curriculum such as finances and, um, living accommodation and things after you graduate. So we have a website called Medical Extra dot Co that dot UK that you can visit and we have webinars posted there, and we're in the process of, um also recording a bit more webinars for you. So right now we have access at 3 lb 99 per month and, um, per year sorry, and that's going to increase the 3 99 a month so you can get that deal currently while it lasts in terms of Doctor Sean. So he's an ophthalmology registrar in the UK based in the east of England, and he graduated from Barton London. Queen Mary University of London. He has an interest in medical education, which has led to involvement across both undergraduate and postgraduate education at a local, regional and national level in terms of medical education. His highlights include chairing various groups within the Association for the Study of Medical Education and leading national workshops and conferences. He has since taken a leading role in the development of the virtual learning space with technology enhanced learning for the School of Ophthalmology in H E, east of England and now a part of the team working in the inspire platform. So the talk itself this evening is going to focus on a more practical approach to read I, and it's going to summarize common presentations and how to spot key red flag conditions that you shouldn't miss as a junior doctor. Um, and it's aimed at non ophthalmologist because no matter which aspect of medicine people work in, you will inevitably have a red I show up at your door So I'll just hand over to Doctor Sean evening, everyone. Thanks, Chantel. That's a very comprehensive introduction, that there's a long list of things they're hope everyone's keeping well. And so, uh, the goal of tonight is to take you through red eyes, and I think that's probably because because in medical school, unfortunately, ophthalmology is not taught a huge amount, and that might be partly because there's not a huge amount of space in the curriculum, and we completely understand that. So my goal for all of you here tonight is to have you leave here with a good practical understanding of, um, uh, red out. And I'm hoping by doing this, you guys can manage red eyes if they appear in your clinics, whether you end up working in A and e g p or whatever specialty that you work in, um or maybe inspire something to become optomologist. I now that this talk is half an hour, it will take. I'm happy for you guys to post things in a chat, and we can you know, if you have any questions, we can stop at any point talk about things in particular. I kind of want to know a bit more about the audience I'm talking to, because it would help me sort of pitch this talk at the right level. And for those of you who are watching, if you've got, like, a mobile phone with you or something, I'd be grateful if you could just let me know what sort of level you are. Uh, there is an other option somewhere as well. So you can either just open your camera app and scan the QR code. Um, or just use slide O. That would be great. Wonderful. So I'm expecting, I think, mostly medical students. But I will be curious if there's so many one more advanced here. Just so I know. Sort of What? Fantastic. Okay, cool. OK, it's great. So that's the sort of level I was hoping for. And I think the sort of level I've pitched this at and the goal today is to give you a framework so that you know, if your if your if your family member comes in and says I've got a red eye, you kind of have a structure in your head and think about what you don't want to miss tips and tricks are making diagnosis. I won't cover management a huge amount because I think making a diagnosis or things to exclude is probably crucial to you guys right now and actually for your exams. While treatment important, there's a few common conditions that they love to put in for finals exams for ophthalmology, so I'll cover those things as well. It's going to quite quick fire, all right, we're going to cover lots of different conditions. Um, so if you got any questions, pop in the chat and we can pause and chat or leave them for the end. A little disclaimer. This is not going to cover every possible condition because a lot of things give you, give you red eyes, right? Even rare things can give you red eyes and also pediatric ophthalmology. So, kids, I'll talk a little bit about it. But that's a whole other cup of tea, but I'm going to go through at least all the common and serious things. So let's start with this picture six pictures and they are all potential presentations of a red eye, right? And I'm hoping by the end of this talk, I can kind of get you guys to start teasing together some differentials. And which of these pictures are you most worried about? And which ones are you less worried about? All right, So how do you approach a red eye? Well, hopefully I can convince you whenever you're faced with anything like, you know, if someone comes to your shortness of breath or chest pain, you may have been taught a surgical sieve approach. Well, you know, a way of thinking about differentials and categorizing them, and one way to think about it would be, you know, what's the cause? Where is it? An infectious cause. Inflammatory cause. Trauma can cause almost anything. Iatrogenic. Is it from a medication or treatment that we've done malignancies? And I've also put an ophthalmology specific one when it comes to red eyes. And that's glaucoma. Because nothing if you Google red eyes and ophthalmology, glaucoma will come up as a cause, and I'll explain that as well. There's a few more potential in that category, but I think these are the main ones we will cover today. So let's get started with infections and inflamation. Most common one. Now, when someone thinks of sticky red eyes, I think conjunctivitis is something everyone's heard of. And conjunctivitis really just means inflammation of the conjunctiva that clear covering, um, of the eye above the sclera, which is the white of the eye. There are a few classic things in conjunctive itis. Firstly, their vision's usually intact. What I mean by that is they have good visual acuity and they can see things. There are a few subcategories. The infectious causes of conjunctivitis can be typically split into bacterial and viral. And if you're doing exams, bacterial tend to be the ones with the gunky yellow discharge. Viral tend to be watery, more itchy, maybe more uncomfortable, and especially if they say they've had an upper respiratory tract infection recently. Or, I always ask, Have they got little kids at home? Because if you have kids at home with red eyes or snotty noses, then it's more likely to be a viral Conjunctivitis. Also, viral is more infectious, so they tend to be more bilateral, and the general treatment is pretty conservative, so you might give them some antibiotic ointments, like corn, fenical, lubricants, cool compresses for comfort. They tend to resolve if they don't resolve again, you have to start thinking Is there something that we are missing? No. If a conjunctivitis doesn't resolve is just to let you know there are other causes for junk. Conjunctivitis is not just bacteria and viral. Unfortunately, we are seeing chlamydia. Conjunctivitis make a bit of a resurgence. Um, especially in the UK and the younger population. So those were the non resolving conjunctive itis in the right sort of age group. That's for consideration and itchiness, especially those with long haired animals or a topic history In general, remember, itchiness is typical. Allergies and allergies can give you a contributor fighters as well. So these two are more for those that are non resolving and slightly atypical. Let's move on a little bit more so that's conjunctivitis, which is fairly benign. We're not very worried. Now we're starting to get a bit more excited. What if someone comes to you with the red? I I just wanted to focus you on the top left hand picture. What if it's a red eye, but it's not the whole of the red eyes, only a section. While that should stimulate you to think, is it an Episcopal writers or scleritis? These are inflammatory conditions, Scleritis been obviously, inflammation of the skull era, which is the white of the eye and Episcopal right, has been more of a super superficial layer above it between the conjunctiva and sclera. Well, again, the differences in history epis Claire itis doesn't really cause much of a problem. They get some discomfort, some gritty dry eyes. Their vision is not affected. These are benign things as episcleritis, and they don't tend to look to nasty tends to look at a little like this, a bit red in a section and their treatments quite straightforward. They can take ibuprofen or something, lubricants for comfort, and you'll go away. Square right is is a bit different. Remember, Scleritis is deeper right? The white of the eyes inflamed. It is potentially visually threatening because this clearer, the white of the eye is not only at the front. The sclera stretches to the back so you can get inflammation that travels to the back of the eye. The difference is, scleritis is very painful. The typical textbook description is a boring pain, like a pain in the eye that tends to be worse when they're lying flat in bed. Because the I sinks back in the global bit is a tender. I is tender to touch. Episcleritis is not tender. So this is more basically writers, screenwriters is perhaps more diffuse This kind of white patches and thinning of the conduct of this clearer. These are bad, bad features. So if you see someone with the red eye and then the sclera looks almost translucent, you're worried. And if you're not an ophthalmologist, you should be referring that to ophthalmology. So remember, the difference is pain. We've got a nice little one slide here to tell you the difference between episcleritis scleritis and I think the key thing is pain. If you're not sure for those of you who are a bit more advanced A MPs perhaps, um, you know, we occasionally dilate people's eyes with different eyedrops, 10% for anefrin, which is a concentrated kind of adrenaline kind of drop. If you put that drop in someone's eyes, normalize or epis clear itis the I will go nice and white or the blood vessels were constrict on the surface and the eye looks White square writers. The vessels are deeper. The phenylephrine doesn't affect those vessels so much so after 10% in an effort in sclero itis. The I will still look red and angry, and that can be if you're not sure A good way of differentiating between the two and square itis is the one with loads of associations. Here's a list for your exam. Good luck. You don't need to know all of these, and I don't think anyone really expected to know all of them. But it's worth knowing that there are some rheumatological associations. The one that people love is, um, rheumatoid arthritis should be on this list somewhere. Yes, psoriatic arthropathy expand. They tend to cause both a spectrum of this and uveitis which are talking about. But, um, Just remember, rheumatoid arthritis is more with this than uveitis jumping back to infections. When are you a bit more worried about a red eye? Well, here's the thing. Remember when I said vision shouldn't be affected if someone's got a red eye? And they said that vision has gone down and you've measured their vision and it is reduced, and you look at that cornea and you see cloudy patches. You see a pacification that's not great care. Otitis means inflammation of the cornea. Now Commonly, we see these in people who wear contact lenses in the UK. Actually, we don't often see young patient's with this sort of problems without contact lens wearers. So in someone who comes to your clinic or sees you with a red eye and they wear contact lenses, do you have a careful look at that cornea? These are obviously very dramatic examples, but if they are more subtle, but if you see white fluffy patches on the cornea, that does require fairly intensive and urgent treatment, and I'd have a consideration for referring to ophthalmology. If you are not an ophthalmologist for your exams, contact lens wearers should really make you think. Could they have a microbial keratitis now? Obviously, we talked about conjunctivitis earlier, being bacterial and viral. That's true of keratitis as well, and they can have viral infections. Herpes simplex, herpes zoster, herpes simplex Being more the cold sores type of virus can give you this very pretty Christmas tree. Dendritic. Also, that's the key term. So this is a try to think what the word is is a, you know, sign way. If you see it is path a pneumonic for this condition, so dendrites make you think of viral keratitis, which could be simplex or zoster and zoster tends to present in adults more like shingles than chicken pox. As you remember bouncing back to inflammation. Can you see what I'm doing here between infection and inflammation? Just I'm going up in the trajectory. Yeah, so those were more serious stuff now, and I'm talking about uveitis next, which is a huge spectrum of conditions. Uveitis essentially means inflammation of the UV attract, which in the eye involves the iris and the choroidal body, which essentially can encapsulates the whole of the front to the back of the eye. The key thing in history here is if a patient comes to you with red eye and they tell you they are very, very photophobic, so they are light sensitive. You should think well. Have they got inflammation in the eye then? Because that's a classical symptom for this, especially if you see that their pupils are not completely around. And that's because if you have inflammation in the front of the eye, it can stimulate the iris to become a bit stuck to the lens. It's called, say, Nicki, I and that can give you an irregular pupil, uh, shape. So patient coming to you with a diffuse red eye, especially if it's red around the limbus, which is the edge of the clear cornea. So if they're red around there with lots of photophobia light sensitivity, maybe an uneven pupil, especially if they have an autoimmune history, you have to think, Could this be uveitis? And these often require treatment with steroids? And if this first time presenting might need investigating, so these often do need to go to ophthalmology, there's a long list there for those studying for exams. Uh, Uveitis is exam favorite, I think, for kind of M. C. Q s and you know, conditions like Hank Spahn HLA b 27. Having association with UV itis is a a common scenario. I'm gonna talk about a more serious condition now if someone comes to and they said, Doc, I've got red eye. I've got some light sensitivity, whatever it is, and you look at the eye and you see, can I convince you? In all three photos of the front of the eye, there is almost a little white fluid bevel at the bottom, and that's Puss in the anterior chamber. So that's puss inside the eye between the cornea and the iris. And that's a sign of one of two things. One is extreme inflammation. Yes, you can see this in Uveitis. But really, you have to think, Is there an infection in the eye? And that term is endophthalmitis. This is a cause of red eye. You do not want to miss if someone comes to you no matter what, especially if they've recently had surgery in the eye of some sort. And they have a red eye and they have This is called Hypo P in so that white kind of fluid level in the eye that needs an urgent opinion because this is site threatening, along with some other things we've talked about already today and requires treatment and investigation urgently. Um, this is probably a bit more advanced, but I'll tell you about it anyway. And opt immitis, you know, broadly speaking, can be caused by exogenous courses that things we've done to patient so injections surgeries like cataract surgery and often they they're in a lot of pain. Divisions dropped that and then a lot of pain. You see that Hypo P in. You're worried. It's just to let you know patients who are immunocompromised, perhaps, or have endocarditis. They can get an endogenous and Optim itis, and it's not. It's a fairly rare thing, but not uncommon, so those who are immunocompromised might develop where they're wonderful. Fungal infections that contracted the I endocarditis can throw, you know, septic embolize all over the body, including the eye. So that's something to consider as well. Special mention in terms of infections. Cellulitis You know you've got skin around the eyes, right? You've got your eyelids. Like anywhere in the body, you can get superficial infections, and the only thing I will say about cellulitis is the image on the left. So the the image was just one eye, and there was slightly more adults. Patient That's probably less concerning. That needs, obviously examination, but you know, redness around the eyelid. If the eye is nice and white, the patient's not complaining of pain. Vision's great. You know, a G P might even manage this with just some more antibiotics to start. But we're worried in ophthalmology about cellulitis because actually, if the infection goes deeper, it can travel to the orbits you can travel to the orbital space behind the eye and cause an orbital cellulitis. That's a completely different story, because if you have an abscess behind the eye in the orbit, it does a couple of things. You can push the eyeball forward. Patient might have double vision because the eye is restricted in the directions that can move in. UM, they also tend to be more unwell, the eyes a bit more red there in more pain and actually in severe cases, it can also spread to the brain and all sorts of serious life threatening problems. An orbital study litis tends to be more common in two groups. One is immunocompromised patient's, and that includes diabetics and, unfortunately, young Children. And that's just because the anatomy hasn't developed it, so they're more prone to a cellulitis. I'm happy to chat about this one further if you have questions, but just remember cellulitis. There's the orbital, which you're worried about, and the preseptal or not or not, you know, more periauricular cellulitis that were less worried about both need antibiotics, but of different urgency. One needs IV, and the orbital might sometimes even need drainage. They often actually have a ent infections at the same time. Good. Let's take a quick pause there. We covered quite a lot of topics. We talked about lot of infections. We talked about simple conjunctivitis. We talked about keratitis corneal infections. We talked about infection in the I end up thumb itis and infection around the eye cellulitis. We've also talked about inflammatory problems. Epis clear itis not too worried about those more worried about scleritis and the more interesting uveitis, which you know might not have a might have an idiopathic cause or might 0.2 more systemic problems. Next. I want to talk a bit about trauma. Uh, this is some cool stuff. I am going to show some gory images of ice. I apologize in advance hope no one's to scream ish. I'm going to start with this. Just think in your head, um, the top left picture if someone comes into your clinic and they said, Doc, I've woken up this morning and I just looked in the mirror and I'm horrified by this red eye, but, you know, it feels a bit dry, a bit gritty. I I feel fine. My vision is fine. Are you worried about that patient. Just have a think. So I think you're right to think that that is an impressive looking red eye. But the good news is we're not often too worried about this. This is something called a sub conjunctival hemorrhage. So for a variety of reasons, sometimes from trauma or sometimes even just someone sneezed too hard, you can get little burst blood vessel under the conjunctiva. And it looks really impressive because you've got that potential space that blood's just bled into between the conjunctiva and sclera. It looks really impressive. Gives them a dry eye because the surface of the eye is a bit more rough, but they they settle. And the important thing is the bottom right images. Just to show a subconscious hemorrhage that is settling the blood turns a bit yellow whitish, then disappears over time. And it's generally speaking harmless on his own. That is, uh, but obviously history is king. Uh, and you might see this instead. This is a really common scenario, you know, if someone who works with metal grinders, they said, uh, I saw a little spark. I wasn't worrying. Ari Protection got a bit of a red eye discomfort and you have a look and you see that metallic rust ring. What do you do? Well, we remove them. If you work in A and E or you ever have an A and e job, you get pretty good at removing these, and there's a it's quite straightforward to remove. Mechanism of Injury Is Key If someone's you know had really high projectile injury, you might just wanna have a second thought and just think. Is that embedded in the eye? Is it cornea? But if it's superficial, we can take that out. Treated with antibiotic antibiotic cream And it tends to settle very nicely. If the mechanism of injury is a bit more severe. Shrapnel injury, that sort of thing, then you're a bit more worried. I'm not going to talk about trauma in huge detail, but you know, simple ABC approach. Think about your general approach to trauma, and if someone comes in as a, you know, severe road traffic accident, that sort of thing. Often a CT is done, and CT will pick up quite a lot of metallic things. On the CT scan, you see a bright spot in the eyeball that shouldn't be there. And you see that in the left? Uh, I not in the right eye. And that's a metallic intraocular foreign body. These do need emergency treatment. They need often removal. Uh, and the eye needs to be repaired. Obviously caution with MRI scans, you don't want any bits of metal in anyone's bodies when you do. Uh, that's not stuck down when you do an MRI getting to the cool stuff. So this is a collection of images that makes you think that someone's had a more serious trauma than usual. If someone comes to a red eye with any of these signs, you should be a bit more concerned and think about involving ophthalmology. Hopefully, I can convince you the top left image. I don't know if you can see my curse or not, but this image at the top left is a pretty good going injuries that that person's had a lacerations through the corner. Yes, clearer and the eyelid. And this could be from a knife injury or something like that that needs an urgent assessment and some surgery to fix that. This is a little bit worrying, so if you see someone with trauma and the first thing you might notice in this scenario, isn't the iris poking out of the, uh, corneal aspiration that virus is plugging the wound? Because irises suspended in fluid, it tends to go towards wherever there's a leak. The first thing you'll notice is that the pupils distorted and peaked. If you see someone with trauma that had previously normal eyes and they have a peaked pupil, I'd be a little bit more worried. And I'd probably seeking ophthalmology opinion. You know, someone's been punched in the face and have a picked pupil that needs a closer assessment, because you might find that you've got a rupture. You said the eyeballs no longer intact bottom left this collection of blood. So you know a lot earlier we have that Hypo P in, which is the white cell level. This is called a hyphema, which is a blood collection, and that's sometimes in MCQ as well. Hypopyon hyphema as options, and it's just worth remember high FEMA's blood hypopyon white cells, and this tells you that they've really had a good injury. Usually, you see these after blunt injuries, uh, among other things, but if we're talking about trauma and It's just from rupturing blood vessels. It just tells you that is perhaps a more severe trauma in his examination by an ophthalmologist because it can cause problems with pressure. Uh, and he needs a thorough eye exam. Great. More trauma, chemical injuries. I won't talk about this too much, but obviously people splash all sorts of things in their eyes. Battery acid is key treatment to chemical injuries. A few MCQ, remember, is irrigation. They need to normalize the pH, and then we have all sorts of tools to treat the defects and the injury and the burns afterwards. But the key thing is irrigation. You need to neutralize the pH of the eye by irrigation. Quick bit on glaucoma. Now I think when people think of glaucoma, remember when I was a medical student, I was asked, What's glaucoma? I said, Hi, pressure. Uh, and I think the consultant said, Get out, have a read and come back. Uh, so technically, some people will say, Well, glaucoma is not high pressures. Glaucoma is a disease. Um, that's a progressive damage to the nerve in the back of the eye. And high pressure is the only, um, kind of treatable risk factor. But I'm talking about a specific type of problem, which is acute angle closure. Technically, it's not even glaucoma I'm talking about, actually just acute angle closure, so we all have a drainage channel at the front of the eyes. I won't go in detail about the anatomy here, but the diagram is actually really quite nice, which is fluid flows from behind the behind the iris to in front and drains through the trabecular meshwork. But in some people, the anatomy is just a bit shallow, and actually they can close off. Their angle altogether gives you really painful spiking pressure. The key take home message is, is a person in angle. Closure is in a lot of pain. They have pain above the brow. They're nauseous because of that sudden spiking pressure, nauseous vomiting. They see halos around lights because the corneas edematous and they have a fixed pupil. So those are the key things to remember for exams of angle closure, sudden onset nausea, vomiting, usually in the evening, a fixed pupil and halos around lights. That makes you think about angle closure that requires urgent treatment. I won't go through this in too much detail. This is. I think you don't need to know this too much, except that we bring the pressure down. We can do some lasers. Um, and there's certain surgery we can do as well. So as I promised half an hour. That is a whistle stop tour of some of the common and emergency red eye causes you do not want to miss. So just to summarize that you want to take a logical approach all right, when someone comes in, you have to think, What's the history? What's the age group of the patient and just be sensible, you know? Is it infectious? Is inflammatory. Have they got risk factors for infectious causes from, you know, being a contact lens wearer? Have they got discharged? Have they got kids at home? Are they immunocompromised? Have they had trauma? Have they got an underlying autoimmune history and work through that kind of surgical sip? Infectious inflammatory trauma iatrogenic glaucoma in acute setting in that very specific type of patient. And that should lead you down the right track. In most cases, of course, if you're not sure just for the purposes when you're working, ophthalmology is usually a very helpful specialty where it was here for people to ask us questions. And if you do an e d job, you very quickly learn how to take a logical approach to read. I. So I guess if you're going to take one thing away from this, remember, if someone presents with a red, I would significantly reduced vision or in a lot of pain or having had recent surgery or trauma. Those are more high risk patients'. So that's it, guys, I'm going to stop the talk here formally, but I'm happy to take questions. I've taken a lot of these images from things like I around and other common resources. Um, uh, So I've got to give credit to those happy to take questions on email or Twitter, Um, and also happy to chat generally if you guys want to. So thank you guys. That's a crash course in red eyes. Uh, look forward to more medical extra talks, and I hope you guys find this useful in your practice and for your exams. Thank you. Thank you so much. Shaun. That was definitely helpful. Especially for me at my stage in medical school and I'm sure, was for everyone else who attended. I've just put the feedback form in the chat for everyone to fill out and you'll receive a certificate for attending. Please put any questions that you have in the chat fish on to answer if you have any. Oh, that's a good question. Um oh, sorry. Sorry about that. Guys. My medal crushed. Can you still hear me? OK. Oh, I thought that was me. Yes, I can hear you. OK, okay. I think it crashed. And there's two of me. Now, Um, I know there's a question in the chat about from making you Do you want me to go ahead? And, uh so thank you for that question. That's a really good question. So? So let's forget the term glaucoma for a second. Acute angle. Closure is the thing I was talking to you about earlier. Where patient suddenly has the drainage channels that exists in the front of their eyes closed off. And that's a very painful experience. They develop, you know, sudden spiking pressure, uh, cornea odoema, all those things that can lead to glaucoma, and that's called acute angle closure. And if they develop glaucoma from it, what they have narrow angle. Uh, glaucoma patient's who don't have that can also develop glaucoma. Patient's kind of have primary open angle glaucoma, which is a disease where they get a progressive damage to the optic nerve at the back of the eye, and they have an open angle, so there's nothing to do. There's nothing, I guess, anatomically wrong with the angles drainage in the sense that is open at the at the entrance. But they develop, um, due to a lot of different complex mechanisms, high pressures in general. And they tend to be in people who have, like previous history of glaucoma and their family and such that can lead to glaucoma that doesn't usually come with pain. These are patients with pressures to normal pressures between 10 and 21 primary open angle glaucoma that might be in the twenties thirties. Acute angle closure tend to be very high, so higher than that of forties fifties etcetera, and that's a sudden event. Does that answer your question about the difference between the 21 Is it acute problem and the other is is glaucoma, but is a progressive disease. Uh, doesn't have that acute pain that comes with it. So perfect, Uh, for the purposes of exams, that's usually how they'll say it. Uh, acute angle closure has the hazy lights, sudden onset nausea, vomiting, nausea. Is the big one? Not very pleasant. Great. Um, it doesn't seem like we have any other questions right now. Thank you, everyone for coming once again. Um, And as Dr Sean said, if you think of anything else, feel free to, um, contact him via email or on his socials, and he'll be happy to answer any questions. Just put my email on the chat surveillance. Got any questions? Thanks, guys. Everyone's had enough of red eyes for tonight. Probably. Yeah. No, it was very good, though. Thank you so much for that. Um perfect. Oh, and the live then. Since everybody's heading off, I'll speak to you soon. Thanks. Have a great night. Bye. Bye bye.