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Hi, everyone. Um My name is Denise. I'm 1/5 year medic at Manchester. So today I'll be giving a teaching on ophthalmology. Um So I'm just starting on time because there's quite a few conditions we have to cover and there's a lot of slides, I'll try and be on time, but I might have to skip through a few slides if um I run out of time. So this is just a disclaimer. This does not replace any formal teaching by your university. We're an independent platform led by students. OK. So the learning objectives for today are history taking for a painful red eye and visual loss and also common ophthalmological conditions and fundoscopy findings. OK. So this is just a practice question um to get it started. This is a 50 year old man presenting with a red eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected. What is the most likely diagnosis? So if you guys wanna type on the message screen and have a go Yes. Yes, I can see ad and ac OK. Just a few more seconds before I move on to the next question. OK. So the next question is a 63 year old man is being seen in the ophthalmology Clinic with a presenting complaint of gradual loss of vision. Sonometry reveals an intraocular pressure of 25 mgs of mercury and optic disc cupping can be seen on fundoscopy. Examination of the man's visual fields show a visual loss in peripheral areas and he is prescribed timolol eye drops to be used twice daily. What is the mechanism of action of this drug? OK. So I can see someone answering a um the same. Yeah. OK. So I'll give 10 more seconds if anyone wants to try answering the question. OK. And then the next question is a woman presents with reduced vision in her right eye. She is unsure when it started but but can now only make up hand movements with the right eye. Fundoscopy reveals the following. What is the diagnosis? OK. I can see some A's and es OK. So people are mainly answering A&E OK. So we will be going back to these questions at the end of the presentation and hopefully by the end of the teaching, you'll be able to answer it without um me telling you the answer. OK. So let's begin with history taking for painful red eye. So we start with introduction as usual Socrates for the pain. Is it your lateral bilateral? Is it the whole eye or part of it when it started the character of the pain and radiation, including headaches or jaw claudication, uh how long the pain lasts and if there's any exacerbating or relieving factors. So, does anyone know what pain worse, an eye movement can mean? So, um photophobia is also one of the um red flags and exacerbating factors. Trauma and for an object is important to ask. Yes, I can see some answers now. Yes. Optic neuritis can um present as pain worse on eye movement. So, photophobia has several differential diagnoses. Um It can be divided into neurological and ophthalmic. So for the purpose of today, um glaucoma scleritis, keratitis, corneal injury, and Antero uveitis are some of the differential diagnoses and severity. You can ask the patient to rate the pain from 0 to 10. So for eye symptoms, there's quite a few symptoms or signs or symptoms that we ask about including vision, discharge, any itchiness which can present an allergic conjunctivitis, dry eyes, halos around bright lights and acute glaucoma. Um any systemic symptoms like recent illness or fever, any bowel or urine symptoms and musculoskeletal symptoms like pain in the joint or rashes. And this is because um some inflammatory conditions are associated with eye conditions like um anterior uveitis. Um And if you can look at the slide down below, it says inflammatory arthritis slash IBD, um there's an increased risk of anterior uveitis or scleritis. So that's what we are concerned about basically. So you ice the patient and then in terms of past medical history, always, always ask about contact lens use because it's a major risk factor for microbial keratitis which is slightly threatening. Ok. And then moving on to drug history, ask about any topical steroids or eye drop use. And then family history, especially for glaucoma and um social history, including occupation um to screen for any risk of foreign body and also any driving. So first we'll be covering common conditions associated with a ple red eye. So as you can see, there's um a few red flags around the ones that require urgent ophthalmology, um referral. Um So let's start with conjunctivitis. It's um also called pink eye. It can be bacterial, viral or allergic. Um You can catch it by touching infected fluids or having a upper respiratory tract infection, contact lens use and in rare occasions, it can be caught by sti um so signs and symptoms include a red or painful eye, swollen eyelids is more common in allergic conjunctivitis and purulent discharge is often bacterial. So patients would often describe the eye eyelashes as being stuck together when they wake up in the morning and watery discharge. It's usually usually in viral or allergic and they can also describe a burning or gritty sensation, itching, blurry vision, um recent upper restrict respiratory tract infection, hi history of AP and to screen for any S ti causes, you ask about dysuria or urethral or vaginal discharge. So this is just a table to summarize what I've talked about. Mainly the important ones are sticky pus, like discharge and bacterial. Um, itching is quite prominent in allergic conjunctivitis and it can be seasonal. Apart from allergic, the rest are contagious and um in viral conjunctivitis, you can have a recent cold. Ok. So in terms of management, um it's a self limiting condition. It usually settles within two weeks as we always start with counseling patients, we always start with lifestyle advice. So wash your eyelids with clean water and cotton wool. So you boil some water and let it cool down and use that to clean your eyes. Avoid sharing towels and avoid contact lens use until settled. So for bacterial conjunctivitis, we we it's quite common to use chlorphenol eye drops. Um It's a topical antibiotic and for allergic conjunctivitis, you use topical or systemic antihistamines and avoid allergens if possible. So for contact lens users, um you couldn't, you should consider a same day referral to ophthalmology. This is to rule out microbial keratitis slash cornea ulcer, which is slightly slight sight threatening. Ok. So next, we have acute angle closure, glaucoma. So it's caused by a raise intraocular pressure secondary to a blocked outflow of aqueous humor. So if you have a look at the diagrams, um in the normal ones, your aqueous tumor basically drains through the trabecular meshwork in the front, like there's a corner there and then in acute angle closure, glaucoma, basically that trabecular meshwork is closed up by the iris. And that's when your aqueous humor cannot drain and causes an increase in intraocular pressure, which can cause optic nerve damage and leading to permanent vision loss. And when you cannot drain the aqueous humor and you keep producing them, it can actually further press on the iris and further close up the angle. Um and that further blocks up the trabecular meshwork. It's quite uncommon to see, but it is um uh an emergency. So, risk factors include hypermetropia, which is when your eyeballs are too short. This means that your anterior chamber can be more shallow pupil dilation as you can see in the previous photo. Um when your pupils dilate, it further pushes up the angle and closes the angle. So patients can often describe symptoms being start or being worse when they watch television and dim light at night or when there's stress or excitement. So that's when your sympathetic nervous system activates and causes pupil dilation, uh thick lens, um second eye with acute angle closure, glaucoma being female and medications can also um worsen ac acute glaucoma. So, signs and symptoms include um patient being quite unwell. Um they can have severe pain unilaterally and their eyes can be quite hard and tended to touch. They often describe a headache and a red eye and reduced visual acuity and they can have halos around, see halos around lights. Symptoms are generally worse at night and they, you can have a fixed semi dilated pupil that can be non reactive. You can see a hazy cornea as you can see on the photo and they can present with systemic upset, like nausea and vomiting. Ok. And in terms of investigations, you can do tonometry, which you measure the IOP, which is raised and gonioscopy. It's basically used to visualize the anterior chamber to see if the angle is closed or not. And in terms of management, um immediately referral, referred to the ophthalmologist or to the ed. Um you can give them a selection of eye drops, including beta blockers, alpha two agonists and um muscarinic receptor agonists. And you give them IV acetaZOLAMIDE as well, which is a carbonic and hydrate inhibitor. You also give them steroid eye drops, analgesia and antiemetic if needed. So, there's quite a few drugs that I mentioned. This is a table to summarize um the eye drops. Um and also the IV acetaZOLAMIDE. So the way I remember it is the inhibitors or the blockers, they reduce aqueous production. So you can see beta blocker and anhydrase inhibitor, they both reduce production and the alpha two adrenoceptor agonist because it's alpha two, there's two mechanisms. So it reduces production and increases outflow. And for the muscarinic receptor agonist, it basically activates the parasympathetic nervous system and then your pupils constrict and therefore, it opens up the angle by increasing and then it increases the uveoscleral outflow. I hope this helps. Um sorry, it's going a bit fast because there's quite a few slides to cover. Um So in terms of management, it's a laser, peripheral iridotomy that's definitive. Um It basically uses laser to make a hole. And the iris which opens up the angle and mesh works uh contain all the humor. Ok. And then we have microbial keratitis. It's inflammation on of the cornea. It can be infectious or non infectious, which is rare. It can cause a corneal ulcer which is a loss of corneal tissue. Um It's different from corneal abrasion which is used when there's a loss of corneal tissue caused by trauma and not by like infectious causes like this one. again, major risk factor is contact lens wear and um corneal trauma or abrasion. So it can be caused by bacterial um staph aureus is the main one. And for contact lens users, it's pseudomonas and then it can amoeba keratitis is also um like an exam type question. It usually applies to contact lens users and people who have been exposed to soil or contaminated water. So this can be in rivers or even in swimming pools. So ask about swimming and their pain can be out of proportion to findings and viral as well can be a cause. So, signs and symptoms include a painful red eye photophobia, a foreign body or gritty sensation, watery eyes, reduced, facial acuity and hypopyon. So that's um the photo that you see on the left when there's like a white um, fluid in the eye that's basically white cells in the anterior chamber of the eye. Um And in terms of investigations, um, you can use fluorescein staining and you can see a focal staining as you can see on the other photos. Um that usually means like a disruption in the cornea. Um And if you can see a dendritic ulcer, which is the one you see on the bottom one. it usually indicates herpes simplex keratitis. And you can also perform corneal scraping and do culture and sensitivity for that in terms of management. Um urgent referral to ophthalmology, stop contact use, uh contact lens use until fully recovered and we always treat as a bacterial infection unless um examination of history suggests otherwise. So you give them topical antibodies and cycloplegic eye drops for the pain slash photophobia. So, cyclopentolate is um used often, it basically dilates your pupils and prevents the spasm of the ce muscles and gives you pain relief and you can give them oral analgesia if they need it. Complications include corneal scarring, perforation and ophthalmitis, which is infection or inflammation of the aqueous or vitreous humor and loss of vision. Ok. Moving on, we have anterior uveitis. It's also um known as iritis. It's basically inflammation of the iris and the ciliary body. So, as we know, the ciliary body contains the ciliary muscles which um contracts or constricts or dilates your pupils. So most cases are idiopathic, but it is associated with being HLA B 27 positive. Does anyone know what conditions are associated with? HLA B 27? So, yeah, ankylosing spondylosis IBD um reactive arthritis. Um Yeah, Crohn's is right. Yeah. So it's mainly the joint symptoms um that you ask about. Um, so if you think about um like if someone presents with eye symptoms and they have inflammatory conditions, you can always think about anterior uveitis or um scleritis, which I'll talk about later. Uh herpes simplex virus and other viruses and injury are also causes of anterior uveitis. So, um signs and symptoms include eye pain, red eye, wa watery eye and it can, your eye pupils can be constricted or irregular ciliary flush is a ring of red spreading from this um from your pupils. As you can see from the photo, you can also see hypopen reduced visual acuity, photosensitivity and flashes and floaters. So, anterior uveitis is a clinical diagnosis. So you don't need investigations to confirm it before you make the diagnosis. So management include urgent referral and also cycloplegics and steroids and you would treat the underlying condition. So if um you suspect anterior uveitis, you can check for HLA B 27 take a thorough history including joint symptoms, um like symptoms like dysuria, um muscle pain, back pain and find out if there's anything going on and treat it. Ok. So moving on, we have episcleritis, it's not a red flag. Um It's a mild condition. Um it can be bilateral and it's mo most cases it's idiopathic, but it can also be associated with IBD or rheumatoid arthritis. Signs and symptoms include having a red eye gritty sensation and minimal eye pain. So, um this is a common exam question asking you to differentiate between episcleritis and scleritis. So the main difference is episcleritis is quite mild and patients usually don't have a lot of pain and it's a self limiting condition. You can give them artificial tear drops for symptom relief. So, for scleritis, um it can lead to vision loss. It's usually non infective. Half of them are idiopathic and it is associated with autoimmune disease such as the ones that you see here. Um So they often present with pain that's tended to touch. Um It can wake the patient from the sleep and can be worse with eye movement. They can present with um red eye, reduced facial acuity and watery eye and photophobia. So, management would be urgent referral to ophthalmology. Oral nsaids would be first line and steroids for more severe cases. And again, you treat the underlying condition by finding out if there's any like inflammatory conditions going on in the background. So, some subconjunctival hemorrhage is bleeding from blood vessels under the conjunctiva. It's usually caused by coughing, sneezing or straining. Um It causes um a transient raise in your BP which can um cause the capillaries to break. It's commonly a benign condition, the only sign or symptom that you see is a red spot of blood in the white of the eye. It doesn't cause any pain or any visual changes. It's self limiting. So you can tell patients it's like a bruise and the blood is reabsorbed in 1 to 2 weeks. Ok. So we will move on to your history, taking for loss of vision or blurry vision. So again, introduction and Socrates um clarify if it's blurry vision or any visual field defect, if it's blurry, is it a double vision or is it genuinely like an unclear vision? So a double vision clarify if it's a horizontal or vertical diplopia and if it's binocular or monocular, so binocular is when you don't have double vision, when you close one eye, it's more common. You can see the causes down below here. And um if it's monocular diplopia, it's um double vision is not not corrected by closing one eye, it's usually caused by structural abnormality within one eye, like dry eyes, cataracts, retinal problems and astigmatism. So, again, slight localized um where the loss of lesion loss of vision is um any changes to your central vision, color vision and whether there's any problems with recognizing faces, reading small texts or seeing light. So if you can't recognize nice faces, um it can it can be a sign of stroke. So it is kind of a red flag. If you don't, you, you aren't able to recognize faces or texts or photos or objects basically. And then ask about triggers or trauma. And then in terms of systems review, ask about pain redness, flashes and floaters, any zigzag lines, weakness or pins and needles changes to speech. Um So the reason why we ask about weakness or pins and needles um is because we want to rule out things like MS or other systemic um causes that are not just affecting the eyes. Um hypertension, temporal arteritis is important. It's a red flag as well. Um You ice the patient and you ask about the red flags, like significant loss of vision, rapid onset pain, trauma and ask about diabetes, hypertension and atrial fib fibrillation and short sightedness. So we will cover these um risk factors later when we cover the other conditions. And then you can ask about the rest of the history. So, common conditions associated with acute visual loss, as you can see, they are all red flags. That means you have to refer them to ophthalmology same day urgently. So that's gives you a hint that if anyone presents with acute visual loss, basically, you need to refer them to ophthalmology immediately. So we have retinal artery occlusion first. So um it can cause irreversible vision loss. It's divided into central or branch retinal artery. It's just the anatomical sites that's different. Um The main cause is by a thrombus, that's basically a clot within the central retinal artery. Um Other causes include embolism. So it's clots that come from the carotid artery or your heart that um gets sent off to the retina artery and cause an occlusion can also be caused by arteritis like temporal arteritis. So, risk factors include um old age, smoking, obesity. And if you read, it's basically cardiovascular risk factors, which explains um the reason the, the fact that central retinal artery occlusion is not killer equivalent of cerebral stroke. So it's a sign of end organ ischemia. Uh It presents with sudden unilateral, painless vision loss. Um And they can have a history of amaurosis fugax, which is a temporary complete loss of vision. So they can have uh an R APD and a classic sign is a cherry red spot on a pale retina. It's quite easy to see once you see it. Um You can also auscultate for any carotid bruise or heart murmurs and check for um af as well. So it's really important to rule out giant cell arteritis as well. So, if anyone presents um with pain, headache, jaw, jaw claudication or they're over 60 you're concerned you can uh order ESR and CRP. Um and then in terms of management, um it's quite difficult to manage. There's no evidence based treatment yet. It has a poor prognosis. It often leads to permanent vision loss. Um Again, it's an ocular version of a stroke. So um it increases your risk of stroke and vascular dementia. So a main part of management is a risk reduction. So you treat the hypertension hypercholesterolemia. And if you are suspecting temporal arteritis, you give them IV steroids because they have the visual symptoms. So, branch retinal artery, um it affects only a part of the vision because of the um where the branch artery supplies. It also has the same management as a central retinal artery occlusion. So, in terms of retinal vein occlusion, it's a blood clot in a retinal vein which weakens the blood vessels, causing it to leak fluid and causing macular edema leading to blurry and or reduced vision. Um Again, it's divided into central or branch retinal vein occlusion. Um Risk factors include being an elderly hypertension, hypercholesterolemia, diabetes, smoking and glaucoma. So make note of the complications including macular edema and neovascularization, which is formation of new blood vessels because they will change how you manage the patient. Basically. So, signs and symptoms include painless vision loss or blurry vision. Um So if it's crv, it's a whole visual field and if it's B RV, it's a single quadrant and fundoscopy findings apply in the same way as well. It only affects part of it if it's a branch one. So you can see retinal hemorrhage. Um If it's a central one, you can see a stormy sunset which affects all the quadrants as you can see on the top photo. Um you may see optic nerve head edema and torch was in dilated veins and you can perform fluorescein angiogram to confirm the diagnosis. Um fluorescein angiogram basically looks at the blood vessels in the retina. OK. Management depends uh on whether it's complicated or not. Um If it's uncomplicated, you just observe and you only manage if it um progresses to have complications. So if you have macular edema, you give injections of anti vegf to prevent the growth of new blood vessels. And if they do already have new blood vessels, you give them laser photocoagulation to destroy the blood vessels. Ok. So we have temporal arteritis. Next. Um It's a vasculitis. Um it mainly affects people aged over 50 but peak incidences in seventies um affects female more often and it can cause irreversible blindness due to optic nerve ischemia. So, signs and symptoms include headache, scalp tenderness, which they can notice when they brush their hair, um jaw claudication, a tender palpable or temporal artery. They may have features of polymyalgia, rheumatica. So it's aching or morning stiffness in the shoulders, hips and proximal extremities um without any weakness. Basically. Um they can also have visual changes um like aros fuga and they tend to be quite unwell themselves. So, malaise fatigue, fever, weight loss and night sweats. Um So it's a red flag because it can cause permanent visual loss and on fundoscopy, you may see pallor um swelling of the optic disc and blurred margins. So, um in terms of investigations you do um E SR and C RP, which is raised um baseline blood tests and vascular ultrasound and temporal artery biopsy. And um you refer them urgently to ophthalmology if there's any visual symptoms, um you give them high dose oral prednisoLONE um if they don't have any visual symptoms, but if they do, you give them IV methylprednisolone and don't wait for the biopsy or ultrasound results before you give them any medications. And in terms of long term management, it's a tapering dose of prednisoLONE over 12 to 18 months. So you should consider bone protection and PPI ok, so we have optic neuritis. Next. Um It's inflammation of the optic nerve. Um The exact cause is idiopathic, but it is associated very commonly with multiple sclerosis as you all know. Um it's often a first presentation of multiple sclerosis, um often affects females and people age 30 to 50 associated with um with people who are white. And it's a clinical diagnosis and signs and symptoms include uh visual loss over less than seven days. It's typically unilateral and you can have a central blind spot. Basically, um you can have eye pain that's worse with movement and reduced color vision and red, red desaturation. So how you test for that is you give them some red object like a cap or like a yeah, like a cap and then you ask them to cover one eye, look at it and then cover the other eye and basically, the affected eye will see the red as less bright or less red basically. And you can also have R APD investigations. Um you would do MRI brain with contrast and you give them high dose cortico corticosteroids. So next, we have retinal detachment. It's when the neuroretina separates from the retinal pigment, epithelium. Um it causes temporary loss of retinal function because of the accumulation of the subretinal fluid. It is reversible before the macular is affected. Um So these are the risk factors. Um Myopia is when um your eyeball is too long. Basically, it stretches out the retina and therefore, it's more easy for it to detach. So, signs and symptoms, um the most classic symptom is new onset flashes and floaters um associated with being described as um a curtain or shadow coming down. Um It can cause sudden onset pain or and progressive visual field loss. Um If there's macular detachment, you can have reduced central vision and that can have a poor outcome. And you can also have reduced peripheral visual fields and ra PD if the optic nerve is involved. Um on fundoscopy, there is loss of red reflex because the retina is basically um detached and it's not reflecting refracting the light properly. And you can see a pale opaque or wrinkled retina. So you can see like the crescent shaped um retinal tear, which is like if you see that that is a retinal tear and you can see the pale retina um compared to the normal retina, which is a lot more redder and warmer toned in terms of uh management. Um urgent referral to ophthalmology and management depends on the type of retinal detachment. So, posterior vitreous detachment um happens because the vitreous humor shrinks when we age and it's not able to fill the entire vitreous cavity and it pulls the membrane away from the retina and it detaches from the retina. Basically. Um it's common in the elderly population. It does not cause any pain or loss of vision. However, it can cause retinal tear and detachment and this needs to be ruled out. So, posterior vitreous detachment itself isn't a red flag, but because you need to rule out the retinal tear, it is a red flag because you have to refer them the same day. And um risk factors include old age, um females and myopia. So again, um myopia, it's the vitreous cavity is huger and therefore, it's there's higher chance that they will pull the vitreous membrane away from the retina signs. And symptoms include sudden onset flashes and floaters. You can see a wise ring on fundoscopy which is a ring shaped floater and the symptoms usually become less intense over several weeks. And um if you have any eye symptoms, any visual symptoms, that means there is complications like vitreous hemorrhage or retinal detachment. So, if you see a dark curtain coming down, that means there is retinal detachment. So often an exam question is um someone presenting with flashes and floaters. Is it PVD or is it retinal detachment, um, on pass med, if it's, if there's no dark curtain coming down or any shadows, then it's usually PVD instead of retinal detachment. So, investigations wise, um, you just refer them urgently to ophthalmology and it's a conservative management. Um, if it doesn't involve the retina symptoms gradually improve over 3 to 6 months. If there's persistent floaters, you remove the vitreous humor and if there's any retinal problems, you do surgery. Ok. And we have vitreous hemorrhage. Next, it's bleeding into the vitreous humor. Um It's a common cause of sudden pain, loss of vision. Uh It's associated with proliferative diabetic retinopathy and PVD. And in young people you think about ocular trauma. So it symptoms varies from floaters to complete visual loss. It's painless. Um You can see some hazy or red hue in your vision. Um You can see some dark spots or shadows in your vision as well and vision may be worse in the morning because the blood settles in the back of your eye when you lie down and you can see hemorrhage in the vitreous cavity on fundoscopy. Um So for investigations, you do slit lamp examination, ultrasound, if um the blood is obscuring the retina and ultrasound is really helpful to rule out PVD or retinal tears or detachment. Um Thos angiography, again, it looks at the blood vessels to identify any neovascularization such as in diabetic um retinopathy, which is a risk factor and management wise. Um Again, you urgently refer them to ophthalmology. Um The management depends on the clinical situation. You can do um laser photocoagulation, vitrectomy. And um the blood clears from the retina slowly and can take weeks, advise the patient to avoid strenuous activity and sleep with the head of the bed elevated so that the blood does not um accumulate in the back of the retina. So um we have amaurosis fugax, which is a sign of tia a um it causes painless vision loss which lasts seconds to minutes, followed by full visual recovery. It's described as a curtain coming down. So the management is the same as any other tia um 300 mgs aspirin, urgent assessment by stroke specialist and the usual tia workup like BP cholesterol glucose. And we have homonymous hemianopia, which is um a stroke. Um So it can present with or without macular sparing. Um visual oxia, which is when you can't recognize people or things or objects. Um It represents a contralateral lesion. So, um so if you see on this picture, there's um a left sided homonymous hemianopia. Um If you follow the tracks, it leads to a right sided lesion on the brain and you, in terms of management, um It's the same again as any stroke, you do noncontrast ct head to rule out hemorrhagic stroke and aspirin and also the um further management of stroke. OK. So, now we have common conditions associated with gradual visual loss. Um The first one is primary open angle glaucoma. So the same as acute angle closure, glaucoma, it's also associated with a raise in intraocular pressure. The difference is the angle is open now. So there's no blockage in the drainage in the trabecular meshwork. It's due to the obstruct the slow flow of the aqueous humor and therefore, um there's a build up of aqueous humor but there's no blockage. It's just a really slow flow. Um It's quite common compared to angle closure. Um Risk factors include being over 50 a family of black or Hispanic ethnicity. So, signs and symptoms include um it can affect your peripheral vision first. Um It can cause a nasal scotoma which is um like a blind spot near your, like your medial vision and it can progress to tunnel vision, but it usually presents insidiously. So you might not notice any symptoms and it's often picked up in a routine eye test. Um You can not, you can have a raised IOP an increase in cup to disc ratio over over 0.7. Um You can have a pale optic disc which means an optic atrophy. Um And so the in terms of the cup to disc ratio, um the cup is um the how do I say it? So the optic nerve doesn't, it appears as pale on the um on fundoscopy and if there's dying of the optic nerve, there's more whiteness So you can see that there's more a greater ratio of cup compared to the uh disc basically, and you've measured the vertical distance. Um I'll move on to explain further about a bit about to disc ratio. Um So in terms of investigations, you use um tonometry to measure IOP and gonioscopy to visualize the anterior chamber. It's the same as acute angle closure, glaucoma because you need to rule out the obstruction of the angle. You can test the visual fields and do a slit lamp examination. Measurement wise. The aim is to lower the IOP. So the first line is 360 degrees selective laser trabeculoplasty. And then the second line is prostaglandin analog eye drops. And the third line is the ones that you use in acute angle closure, glaucoma. So again, um this is the table that I've taken from um the acute angle closure glaucoma. The only thing I added is the Prostaglandin analogs that you use in open angle and not an closed angle. Um So it's an analog. So it increases um uveoscleral outflow. That's how I remember it. And then again, the beta blockers and the inhibitors, they reduce um aqueous production. So, um cataracts is a pacification of the lens which cause reduced or blurry vision. Um It's a common cause of curable blindness affects females more. And um it's part of a normal aging process. Um signs and symptoms include a gradual reduction in vision, a blurry vision faded, color vision and glare, which is light appearing brighter than normal and halo around lights. So you can see a normal fundus and optic nerve. But the only thing that you can't, uh, you can't see is the red reflex and you can see the cataract if it's really severe. Um, so you can observe, uh, do like conservative management by observing if there's no functional vision impairment. Um, but if there is, then you can offer cataract surgery. Some complications include posterior capsule opacification, rupture, retinal detachment and endophthalmitis, um which is inflammation of the aqueous or vitreous humor. So, next, we have age related macular degeneration. Um it affects the macular, so which is responsible for your central vision and fine vision. Um It does not cause complete blindness and it can be bilateral and it can be divided into dry or wet AMD. Um So dry is when there's dr inflammation, it's more common and it's a gradual worsening of symptoms. Um There's no treatment unless um it develops into wet AMD, but it does have a better prognosis. But for wet AMD, it's characterized by a choroidal neovascularization and it's less common, but it is a subacute or acute worsening of symptoms and there is treatment but it does have a worse prognosis. Um So, signs and symptoms include blurred or distorted vision. Um distortion of straight lines is common, poor night vision colors looking less bright and you can also have official hallucinations so you can do an AMS liquid test which tests for your line perception, which is distorted in a MD um fundoscopy. You can see Dr in dry um Ar MD and you can see some red patches in we Ar MD. So for investigations, you can do a slit lamp examination oct which takes a a photo of your retina basically and to identify any fluids and angiography as well to look at choroidal neovascularization. So for dry Ar MD, there's no treatment but you can give them vision aids. For people with moderate dry AMD, you can offer zinc or Vitamin A supplements. If they have wet AMD, you give them anti vegf injections which inhibit the growth of blood vessels. And you can also give them photodynamic therapy and you should inform the DVLA if both eyes are affected and the remaining vision is below the minimum standard for driving. So, retinitis pigmentosa, um the only thing that I took away from this is it's a hereditary condition. Um and the age of onset can range from childhood to fifties depending on the type. And that's why family history is really important. If there's a family history, you think of retinitis pigmentosa and it's an umbrella term. So there's different types. So it affects peripheral vision first and it can progress to tunnel vision and it can lead to night blindness and impaired dark adaptations. You can see some black bone spicule pigmentation in the peripheral retina here and you eventually lose your central vision as well. Um So you use the chart to assess acuity perimetry to assess and for any peripheral peripheral visual field defects. And full field electroretinogram, there's no cure again, you can offer visual aids. So we have fundoscopy. Next. Um The only thing you need to know about fundoscopy of the ophthalmoscope is the on off switch and the diopal which you use to correct for refractive errors and you look through the viewing window. Um And you start with a QQ, wash your hands, introduce yourself and ask for consent. Um Just to tell them that you'll be using the ophthalmoscope and you might have to um place your hand on their forehead. Um make sure the patient is sat in the chair before you dim the lights and examine the patient's left eye with your left eye and vice versa. So general inspection, you ask the patient to look straight ahead and inspect um the eyes, including the periorbital regions, eyelids and eyes, look for any swelling, redness, discharge prominence of eyes, which can be which you can have in thyroid eye disease. Um Look for any ptosis, miosis, um any oculomotor nerve palsy and abnormal pupillary shape. So in terms of preparation, um ask the patient to fixate on a on a on a target instead of um just look in, look ahead because um they might move around um if you get in the way. Um So you start with the lens at zero and then you keep correcting it if you do have any um refractive error on your own. Um And you as first assess the red reflex, um you assess it at the distance of around an arm's length, you look for the red reflex. If there's no red reflex, then it can be cataracts, vitreous hemorrhage or retinal detachment. So if you think of it a logical way, if something's getting in the way that's not transmitting the light to the retina, it can be something during that journey or because of the retinal problem that the retina cannot actually reflect the light back. And in Children, um it can be retinal blastoma as well, which is a cancer in the retina and then you look at the fundus um sorry, sorry, sorry to interrupt. Um It's 745. Usually we go into the breakout rooms now, I don't know why. Oh Yeah. OK. That's fine. Um So basically the rest of it is just um findings on fundoscopy. Um I'm happy to like share the slides if you guys can. Um But and then these are the common fundoscopy findings. You guys can have a look at these. Um but they are all taken from G medics so you can use those resources as well. And then the um practice questions will be at the end um with some explanation on it. So I hope that's helpful. I'm sorry, I was unable to cover the entire slides, but there are quite a lot of conditions in ophthalmology unfortunately, but yeah, thank you for joining. Thank you for bearing with me. Um Yeah, thank you for that, Denise. That was really good, great detail for everyone else. Um That's the end of this. That's the end of the stop it, man. That's from, that's sorry about that. What an idiot in my room. That's the end of the teaching bit. Um So if you wanna stay for oy something, if you wanna stay for Osk practice, there's three breakout rooms. Um So I'll just split people up between the three. So I'll just read out the first couple of names. So Ashok Bianca, Deborah Faza and Gift. If you all go to Eva's room, if you are staying for ay practice, then Janette Le Liza and Paul go to um sorry about that cut out. But um just as I was saying before. So, um II think I've said the first call people to go into Eva's room but then for the next group. So Yusuf Thomas, Samia and, and Yusuf Thomas and Samia if you go into war's room. So Wara Hafiz, she has a room open and then if I've not said your name, if you go into Sad's room, so people will stay in. Those are your rooms and you can go and do yours practice with the facilitators, everyone else feedback forms in the chat and uh thank you for coming.