 right guys thanks for showing up on time there's a really really important in this chapter so I'm gonna go ahead and start. Rob did some questions so we're gonna have a reading assignment quiz read so I did not edit her questions at all so just keep tabs on your some of them are a little bit more worried than I would make them but look at that and give you like 15 seconds to read it we're gonna go over the answers man for the younger the more naive to the OCAPs process if you there's a question you're like not sure get in that habit of like marking it you know saying well I'm not sure about this one but I'm gonna make a little more by itself I'm done at the end of the video. This one's really long. It's like Strav, huh? Yeah. She's just... Oh there she is. Thank you. Yeah. Like let's write a treatise on that. This one will take a little bit more time. The pictures are not ideal but this is very representative of something that you might see on a test again for the younger users this would be like a gonioscopic view we're gonna go over these some of these are shades of gray Strav and I didn't really talk about these but you know I think it's more important to understand concepts hopefully you wouldn't get a shades of gray question this is directly from the book so if any of you can't read that come see me for a reflection of us to the prior one this should be a quickie this chapter was really good because there's so much relevant to call not only just the book learning but really relevant stuff for all you guys this one the wording is a little bit shades of gray but I think you can pick the best answer there are two answers that are reasonable but one that's best okay now this is where the big encyclopedia comes forth and again well this one's actually pretty simple but some of the answers are a little bit longer so any questions about this limbo vascular injury is more poorly prognostic than we'll talk about this more tetracycline's depleting calcium which prevents PMN degranulation in the acute phase in the chronic phase of ocular surface disease or injury you know there's other effects of tetracycline which we probably know about we talked about that there's some you know vague effect on membrane metalloproteinases which are different than PMN degranulation products and also more known effect on just my bomean secretion so there could be more than one effect in the later phases vitamin C you know it's something that you would think okay that's a cofactor for colleges the other two are pretty self-explanatory this one is I've actually seen this in Utah Cornelidema due to cold I've seen it I think Dr. Katz wrote a little case report on this actually somebody was biking or something it seems like but anyway if you cool down the enzymatic process the you know process you can inhibit the endothelial pump and get cornelidema this one anybody have questions about this or understand this one what is that one show there okay you can see the angle structure I mean it's a little hard to tell as opposed to this one which shows what yeah I'm sorry the pointers looks like it's losing where to go I see it there but yeah B that's supposed to represent sclera that you can see below the angle structure so that one is like the dialysis is this basically the solar your body pulls away from this clear and then analysis is the most obvious trabecular damage is the least obvious how many of you have done gonioscopy of most of you done any questions about this one sickle cell disease we don't see that much here I mean just because it's so much more likely to cause blood staining and rapid elevation of pressure escalation within a short period of time the indications for wash out are much more aggressive and then the other one is obvious it is pressure is the most important actor none of those other things are actors this was the easiest question it's interpolate means Rob it's in the book but I'm not even sure I mean it's a math term but they talked about the yeah the glaucoma tube thing I don't know exactly what they're talking about there but anyway we know those of you who've been on a trauma call know that you try to tuck you the old tissue back in unless it's grossly dirty or chronic or infected this one basically the point is if the pH isn't normal irrigate more so the right answer would have been actually in my opinion see even though it says be there now be is correct also but and it you know again this is a gray zone answer because if you haven't irrigated enough cement would be the most or grout or that's a pretty common injury as people get cement splashed in their eye and there'll be some particles down in there now keep you from getting the pH more illustration of principle this one slet is we're not really going to talk about that but if you have a unilateral burn and healthy stem cells healthy corneal cells on the other eye you can use the autologous graph to repopulate the cells you don't need immunosuppression there's only one problem with this answer and that's that if you have aggressive scarring from the conjunctiva you really need a barrier to keep those vessels and cells from going on to the cornea so some other type of surgery to kind of fix the limbus but so that's the answer so can anybody remember what the highlights were reading any of your game tuck tuck issue tuck it in I mean I don't know why those highlights are there you know the people who write the BCSC or the same people who may be right this questions and they're going to be referring to BCSC now a harder question what mistake did you find in the text actually I forgot to look on the online version I have them I looked at I found it in the print the most recent print revision so I don't know that it's been anybody find a mistake in the text it's a glaring error I read it I cruised through it and I was like whoa it's exactly right it's on that table it's said don't do a CT scan if there's if you think there's metal in the eye and then on the bottom of the table it says the same thing for MRI so somebody absolutely CT scan is the test of choice right if you think there's metal in the eye or any form body really that you just never know it's really obvious but why would you not do an MRI if there's it acts like a little blender blade you know couldn't could move right one of my friends was a radiologist and so I did a radiology rotation early in the days of MRI that's how I hated radiology so boring but he would take his keys and throw it down into the into the magnet and they would shoot back out all right so just a quick word about healing this isn't actually in the material but I think it's really important is think about your eye and all the structures and one thing that's not addressed at all in this which is really critical important is eyelid you know and because of the way the BCSC books are there's a lot of overlap you know and where things are presented but the eyelid if the eyelid is messed up that is that is almost a dead end for you know ocular surface disease issues so eyelid scarring from trauma and more importantly from burns chemical and otherwise is probably the most important thing actually but just think how the conjunctiva heals compared to the cornea obviously think about stem cells because those are really always as resilient as we would like them to be and then the most obvious is the endothelium we know is pretty delicate fortunately it's internal so it's pretty protected and then also how healing can be adaptive or maladaptive and that's a really important thing in the eye because the eye most parts of our body you know we want inflammation growth etc but obviously the eye we want the media to stay clear and we require this very special skin to stay healthy so chemical injuries there's you know basically there's two parts to this chapter there's kind of the chemical and non trauma part and then there's the trauma part so we'll try to cover both because I think there's a lot of practical stuff basically think of alkaline injuries as kind of melting the cell membranes because of that there's no barrier set up just it just cruises right into the eye once a cell membrane so you can really get a lot of damage that's why irrigation is so important have you guys heard of the saying the solution to pollution is right so in that that applies to a lot of things in ophthalmology it applies to infectious risk because if you're really you know decreasing the bacterial count that you're less likely to get a pathologic response but it applies really specifically to chemical injuries so you've all been on call you know you know how that goes and pH strips are not always accurate so whenever there's a doubt please irrigate more have the patient irrigate so this picture just shows some eyelid injury I'm going to actually go to the book too if I can get it to pull up because I think there are a lot of good pictures in the book won't spend acid injuries tend to be less severe although this is a picture that one of my fellows found in a previous iteration this is an acid injury so you can see it's this pointer so you can see there's some limbo blanching I mean that looks pretty wiped out so acid injuries and the book mentioned specifically hydrofluoric acid even though the pH is like three years I don't know why that's more likely to penetrate but generally acid will coagulate the protein so you can think of acid as more of a cooking type injury it'll create some barriers and coagulant which stops the alkaline injury which just kind of breaks down the cell membranes and cruises on into the eye so if you were called by the ED which happens all the time and you this guy had you know an alkaline splash to his eye eyes both eyes are injured what would you do we've already mentioned some of the things so what would be the first step Tina yes I just yeah so how do we irrigate again part of this is basic for the more junior people what would you tell them emergency position yeah so if they have a lot of times they use what's called the Morgan lens most of you heard about that it's just an irrigating contact lens you stick that thing in there whatever you have but if you don't have that yeah you can take bottles of safe so what what solutions are okay to use water I mean why wash stations are water right yeah the point is doesn't matter you have a gallon of milk honestly it's like irrigated solution to the pollution you know people not gonna really be in a setting where you're counseling people hey get a jug of milk out of your eye but so yeah you're gay then I mean usually you have to see the patient right and then you assess all the layers like this guy is going to be a big trouble because he has eyelid burns to you know he has facial burns he has some actually that there's some vascular damage but it doesn't look like some of the pictures will look at where this is wiped out let me see if I can go to the book here I tried to download it comes up because there are a lot of good pictures in the book wanted to kind of go through those two the tables are useful I don't know that you're gonna get asked about this is an alkali burn but not you can see there's a lot of clear cornea there you know even there's a little bit of limbo blanching but it's more of a sectoral burn that one the cornea looks awful right and maybe there's some limbo blanching here but it can be worse this one shows a lot of times you'll see sectoral burns and where would you I mean you guys have seen these patients probably stuff splashes in the bottom of the eye right gravity so it's very common to see kind of inferior conjunctiva sparing of the upper part generally the particles that you're looking for would be in the inferior fornix and especially again one that I've seen really commonly as I mean you see a lot of ammonia sodium hydroxide cleaner type burns those are a little bit different but a lot of the kind of construction burns tend to be mortar or cement or whatever you think that's not that bad but those are very kind of splash injuries tend to get the lower part so this is just demonstrating that bad limbo ischemia a lot of weighting nasty looking really bad one here and so what it says in the book but what do you think those are those are sutures what what's going on on this side doesn't say in the caption but what's been done to that eye yeah there's amniotic membrane that's been sutured on that eye if you don't manage things well or even if you do sometimes you end up with this so that goes back to my comment about healing and just you know kind of the body says hey I'm injured I'm gonna bring in the troops vascular tissue scar tissue and I you know save the eye but see and that ain't too easy to fix but it could be worse right what if they get an infection and they perforate so so kind of the approach to a lot of things is what's the worst thing that can happen what can I do to make it be the best and then usually there's kind of middle ground so then we kind of go more to there's some acid burns there and you can kind of see a little bit much clearer almost this kind of coagulated edge which is you know usually more of a barrier function but acid burns can look really bad too and this is an older I'm sure this is many many months or even years out from an acid burn so they can turn out really bad too this is another picture this says some blepharone it's really some blepharone or not I don't think it is actually I think it might be fibrin but anyway whatever it is you can see the deeper structures the cornea isn't horribly trashed Olympus doesn't look great but this is the kind of question you'll get on a board world's question what do you see what do you think it is what's a differential how would you treat it just going through a lot of pictures are good I'm impressed with the current version of the BCSC they have a lot of good pictures most of these pictures are just from clinicians these are like people I know who submit their pictures and say yeah I've got a good picture of that so so it's fairly real life now which is good and I don't know that paper clips too much but you can you can make a little retractor from a paper clip if you needed to in an emergency setting but the idea is to I mean patient's going to be in pain be squeezing you know in the ED setting it might even be appropriate to have them get some sedation material out there and out of there and you really need to kind of clean things up and it's not inappropriate to go to the OR if you have something like a really bad fireworks injury where unfortunately like a room with candle or something where not only is there a thermal burn but you may have some chemical magnesium or something that's deposited in there you can't get that out in that emergency room for bodies etc so we're gonna switch to trauma here so any questions about that oh thermal I'm gonna talk a little bit about thermal burns too because I think that's important for call and what you guys do might have to get my reading glasses out so we talked about most of this stuff in terms of just a really acute first stage treatment but then we use steroids topically to prevent inflammation we don't want an overly aggressive inflammatory response because we don't want all those blood vessels and scar tissue to form preservative free medicines to the extent possible we have the luxury here of having an awesome pharmacy it'll mix up preservative free dexamethasone if you need including the inpatient pharmacy will do that if you want something strong that's preservative free and then I know Maddie knows this and some of you know this but what's another really good steroid that's preservative free there's active that's commercially anybody know I mean most eye drops have preservatives right and why would you not want preservatives in an injured eye because any little extra chemical may impair the feeling that's really what you really want to promote rehabilitation that is like super super important right you know get that barrier reestablished the body's going to freak out and bring in blood so load of predinal ointment load of max ointment we use that in the ICU burn unit a lot it's kind of expensive but it's truly preservative free medium strength steroids so put that in your little call book you know load of max ointment it's medium strength steroid pretty much for you know big time injury patient who's going to be on the burn unit or the ICU who cares it's a 110 millionth of their total bill use a good expensive drug but preservative free dexamethasone is 0.1% and it's cheap formulated in the hospital sodium citrate drops I think do actually work in our pharmacy will make those up and it's a similar thing as the tetracycline to deplete calcium and actually I think if you look in the literature you may see actually a score bay drops to used so vitamin C promote collagen synthesis supporting the epithelium torsor p not in the very acute phase but the epithelium is not healing don't forget about torsor p incredibly helpful can be done at the bedside and it's called that cleanser often appropriate into your amniotic membrane it's one of the best and most important uses which are kind of expensive and overused I mean their use is promoted for dry eye you know stuff like that which is kind of ridiculous but when you have a burn patient prokera or some of the other dry or you can use frozen amniotic membrane super super helpful helps support the surface has a bit of an anti-inflammatory effect then there are different kinds of limbo transplantation which are later in the stage but can be done can be done in kind of the intermediate stage as well and sometimes it's better to go a little bit earlier than too late because if you get that you may remember that really nasty looking vascularized I sometimes it's better try to prevent that before it gets to that stage so OSR just stands for ocular surface reconstruction I think Dr. Lynn gives a lecture on that so we'll go a lot into that slet is simple limbo epithelial transplantation kind of beyond you know going into the detail but basically you take a small area of limbus from the normal eye snip it up into tiny little pieces try to glue it on to the cornea with the amniotic membrane over or on top or both and then a bandage contact lens actually works you don't need immunosuppression other than just you know water topical steroids because it's the patient's own cells so that's kind of cool thing curative prosthesis would be you know kind of the option of long last resort for cornea transplants to work and I think I think it might even be next or two Tuesdays from now I'm going to talk to you about cornea transplants so we can talk a little bit more about what you have to do to make a cornea transplant work obviously if the ocular surface and the adnexia are not in good shape then cornea transplants won't work and that's really the main issues with these patients it's like getting the ocular surface the eyelid etc healthy enough to support a healthy cornea transplant so thermal burns it's not really talked about too much in the book although there's that picture of the cigarette burn I can just imagine you know some torture guy you'll see these patients in the burn unit here you know we get patients from everywhere you're going to see facial burns and I just want to remind you that managing the eyelid and I tell the fellows it's all the time as junior residents and even chiefs you you should not be making the calls on these patients it's okay to see them you know the first couple of days whatever you need to get these patients staffed by cornea and even the fellows it's like high stakes in plastics to me get plastics involved really soon and even if you know facial plastics and stuff there you need to get oculoplastics to see these patients and there are enough attending somebody you can go over at lunchtime and just at least make sure you're on the right track because again sometimes I need lint surgery sometimes you just need some experience to help you sort out sometimes it's hard to tell like is it really staining or just sick epithelium or there's a lot of mucus there that's staining you just need somebody with some experience and some authority to make these tough calls about how these patients are doing because that's my pearl there Roman candles are one of the horrible horrible things that I've seen where people you know teenage boys in general have Roman candle fights so everybody know what a Roman candle is it shoots out a fiery ball of phosphorus and magnesium and you know people shoot them at each other and occasionally somebody gets shot in the eye and then of course what do they do they slam their eyes shut and so they call this fireworks stuff and they're cooking their eye literally they're often unrepairable so fireworks I mean our job is to be good emissaries of eye protection and I don't know if you can do a lot about stupidity but but anyway burns are thermal burns are more similar to acid burns just depending on how serious they are and more I would say the more kind of related problem is the eyelid often gets burned and you'll get cicatrisin changes of the eyelid and you get last position but burn you know thermal injuries tend to coagulate the tissue a little bit so the treatment paradigm is basically the same except just be a little bit more cognizant of eyelid stuff it's pretty much the same in terms of antibiotics what do you guys think would be a good antibiotic regimen for a chemical burn or thermal burn with a corneal or contractile what would you use and moxifloxacin is preservative free you like that right it's broad spectrum but you could start with erythromycin or macetracin you want it you want something general or gentle if you know that they're not effective I wouldn't recommend gentamicin or tobromycin or you know something that may be a little bit more hard this is somewhat repetitive based on what we talked about with chemical injuries so cruise on we have the cold related corneal edema that the quiz talked about but then there you can actually also freeze your corneum which can permanently damage the endophilia cells so just know that I put in there eye banking because occasionally as an eye banker we get tissue that is damaged because it's when it's packaged in ice for trend you know delivery it'll be too close to the ice and the tissue will freeze and it will kill the use cryo a lot right to kill kill cells uses a lot of retina doctors use it to create scar tissue in the retina anterior segment surgeons a few weeks ago where we kill neoplastic cells with cryo ionizing and UV radiation cause you know I think more the acute is what we would be interested in but it has anyone in here actually seen UV keratopathy it looks exactly like that interpalpebral trashing of the epithelium just you know basically really bad punting keratitis but this apparently is a picture of ionizing radiation exposure or no this was UV in the next one I took that one out but anyway so supportive treatment usually in a couple days are fine teach them to wear sunglasses this is one that's not in the book but I think it's really really important and it gets back to the question about avoiding toxic medications you're gonna learn about all this stuff in glaucoma you're gonna see patients that are on four four drops all the time and their cornea looks like heck and they're 2200 and you're like what I mean just think with when you if you're thinking about ocular surface to the extent you can withdraw and simplify benzoconium chloride in particular which is you know preservatives in a lot of eye drops there are some neuro preservatives hard on the epithelium and there can be a synergistic effect of preservative and toxic medications carbonic anhydrous and hithers tend to be pretty hard on the epithelium certain antibiotics like Tobromycin, Gytamycin tend to be hard on the surface and you add a bunch of stuff into an old person you know I mean you've guys you've seen these guys at the VA right and so you look for you know some things that could tell you hey maybe this is toxicity you'll see this the epithelium is trying to mature and you get this whirl or kind of hurricane pattern and that's actually the normal maturation but when the cells are cloudy you can actually say well this is like probably affecting the stem cells or something and I'm getting these cloudy cells instead of nice smooth cells you'll see this kind of necessarily true staining but just sick looking at the epithelium so and it can affect the congenitiva too and with chronic use medications can really damage the ocular surface permanently so that's something to remember it's actually not even in the ECSC book but it's super important for clinical practice and then I don't think this was in there either but you can get we actually saw a patient recently Maddie did you see that patient we saw a patient with I think you did with probably glaucoma drop in these pampagoid changes on your congenitiva very similar to this and then again I think the blistering disease talk would be a different talk but just know that you can get chronic scarring as well we're gonna so the proposed plan is to do a biopsy but the biopsy is going to look the same as ocular sigatricial yeah I mean yeah it's tough you know I mean it's basically drug induced is kind of a diagnosis of exclusion you have to look for other systemic disease you but yeah age you know I think it's much more likely to see what's presumed drug induced sigatricial congenitivitis in older patients and you know if it's any younger you have to assume that it's really bad you know blistering disease systemic kind of thing until proven otherwise like this patient we saw I seen her like 2014 pretty much documented the same things you know she kind of shows back up five years later Dr. Shortcuff said I think it's probably your crops but we're gonna send her to Durham I mean they have better and better blood tests and things and most of the time it's better this is a little bit of a sidetrack but it's better to biopsy somewhere other than the congenitiva because that's pretty high-stakes you know if you induce more scarring you can cause worsening or a seal problem that's probably better than biopsy the mouth so dermatology is amazing you know they're the ones who take care of the blistering diseases so always get a general consult here the drama this also is really important kind of call and just clinical care topic for you guys you know think about always think about these patients you know with the different layers of the eye and what's going on when you're overwhelmed and you're a younger doctor just go back to your you know okay I'm just gonna do my basic eye exam we can talk about specifics of management I think you've all probably managed hyphemes but there's there may be some controversial or questions with regard to management so so what would you guys do if you saw this patient in the ED I'm sorry it's kind of an out of focus picture but so what would be some important clinical things to determine some of this is super obvious but yeah so a lot of emphasis on pressure right because you want to avoid what yeah and but also just all the basic trauma stuff right what's their vision or any chance that there's a foreign body in the eye do they need a CT you know are you gonna get an ultrasound at some point or the end adult so a lot of it's just really practical and common sense how often are you going to see him where they live you know can you keep them still etc so we know most of the stuff for hyphema management which kind changes a little bit not much emphasis at all and not much evidence to support any kind of systemic treatment but we pretty much always use cycloplegics right always use topical steroids you know really common regimen would be long acetate 1% four times a day we pretty much always prescribe rest how often you should you see a hyphaeema patient yeah probably daily if you can I mean when when is rebleeding most likely to happen after what period what window of time yeah about three to seven days so so you know if they're kind of I mean educating your patient is really important does that mean you need to see a patient every day for seven days the answer is no what's going to happen to this side this eye is a lot of stirred up blood what's going to happen if they're really sleep with their head up you know they're still it's going to layer out so then you can see more you can figure this is what you want to avoid and just I don't know that you absolutely have to memorize the sickle patient so what would you do if you felt like this where well this patient already has blood seeing and that's very characteristic it looks golden you know it kind of looks like golden that's very opaque you can't see through it it's a really obvious question what what what you do if you think they're going to take them to surgery I think the most important thing is don't screw the eye up worse than it already is what do you think some of the risks would be it's on there but you can't see in the eye right you know jab and sharp things in it what if their lens is forward what if they have an intimacy lens I mean you know what if you're their decimates membrane is detached and you squirt this code in there and completely detach their destiny so you got to be careful hopefully you'll intervene before others a little bit of a view so what can you do to get a view you manage it so take them to the OR you're not going to do this under top of my anesthesia block them or do general if it's kid or whatever so make a little sad incision carefully stay pretty flat what's going to happen blood's going to start coming out right you might want to irrigate with a little VSS but then you can put OVD in there and you can kind of get a view usually push the claw to side or get a view and then you can either you know the books as you can just irrigate but most of time you'll make two incisions you'll flush fluid through and again this is more for the more senior you know kind of getting into surgery people but by manual I is awesome because you know those are kind of blunt tips you can kind of keep them way peripheral if you have a really dense clot that isn't coming out there's some space put more OVD in it's important to know how to do that if you're in general practice or whatever so you can if you don't have any of that fancy equipment you can just make a little bit bigger limbo incision and just take the BSS 19 gauge cannula on the bottom and just kind of so we're going to talk more about the penetrating or perforating trauma but just a quick little this is in the book and I think it's this is a really common call thing right you're going to see for bodies and retained stuff in the eye on call and remember to look underneath the lid flip the lid rust strings we're going to talk about that a little bit strings and abrasion it's important clinically so abrasions patch or not patch or if you're getting the usual insta-care call the 15th time you're going to take care of 5 people you won't see this patient now it's a corneal abrasion you take care of it but so so what what would be an ex what's kind of the extremes I'm just going to tell you because we're running out of time patching is fine earth from ice an ointment and a patch is okay that's fine there's some stuff in the literature about patching not patching basically you want to manage their pain so quick word about pain management and this again is us being doing our job to educate our peers I would say it is never ever ever appropriate never never ever ever by any ophthalmologist even and that would be argued by some but certainly not by any emergency doctors or personnel to prescribe anesthetics or give anesthetics it's just wrong it's the complication the risk-benefit ratio is just bad it's malpractice and you need to educate your peers about that you see ED doctors do it all the time and there's some stuff in the emergency literature get your attending involved you know that's all you can do because you know they're not going to really take it we strongly urge that is not the best way to treat this patient but there's such a negative stigma for using strong pain meds now you can understand I mean it's not completely stupid to think about something else it's just you know what if they don't follow you know it's just that what is just the what insides are almost as bad insides are way over utilized in the emergency system and it's also the what ifs insides are pretty effective for abrasion patients I mean if you have a super compliant patient and you want to give them something to help their pain it's a reasonable thing to add to your regimen but the problem is they don't show up they stay on it forever you can get a corneal melt from an NSA literally in days literally in days if you have an MPD effect and it's it's kind of this you know probably shunting things into an alternate prostaglandin slash whatever inhibition pathway where you kind of promote melting instead of you know pain control or whatever you guys can look that up you can just do a pub men search on corneal melts and in general if you're going to use an NSA if they're on a corticosteroid it's better than if they're on an NSA alone so just know that probably again has something to do with kind of general suppression of inflammation and not shunting inflammatory you know chemicals or cytokines or whatever into the say the system that says oh clad in the restraints also really important probably not even a first year procedure honestly if it's central sometimes it's better not to grind out a restring honestly so not really going to go into that too much but there can be huge implications for metallic porn bodies near the visual axis if you are going to take one out make sure you get a good and sometimes it's better to let it fester for a day or two and punt to somebody who's going to get sued instead okay because a lot of times when you let them fester for a few days and you have on a antibiotic and steroid they'll come out a lot easier I mean there's a balancer because you don't want to say okay scar if it's inflamed they're going to be more comfortable but just know that you need backup on a metallic form body or another process on the cornea that's near the visual axis send it up the chain of command no need to now sometimes you'll see metal stuck on the eye okay so trauma unfortunately you've all seen he Moses and squashed eyes and peeking of the pupil towards a rupture site the imaging thing I wanted to clarify when in doubt get a CT scan we've had a there's a litigation patient was settled in our system about 15 years ago where the PGY for a resident happened to think they were good ultrasound and did ultrasound patient and didn't get a CT and there was a metallic form body and patient showed up with cirrhosis nine months later so ultrasound is going to miss and you know we almost never do that but just don't be falsely even Dr. Harry can miss something you need to get a CT scan if you're worried about anything at all just get the CT scan so quickly there's a lot of stuff in the book which is good diagrams how to touch tissue and etc but I want to this is more for the chiefs because you're going to be doing traumas and you know the second current second years at the end of the year you're going to be doing trauma so and a little bit of time that we have left just a couple minutes I won't ask you the question because I need to give you the answer just based on time the book says oh don't make the sutures too tight because you're going to flatten the corny excessively who the freak cares I mean get the dang thing closed make the sutures long and tight and we've all anybody who's done a rupture glove you know you put in a suture and then you you think you've got it kind of tight and then you put in the adjacent sutures and it's still leaking and then your first sutures are loose long and tight this is this looks awesome I love it when I see that looks like one of those little coin purses that these it's just like imbricated that's what you want it to play I this came up recently with Maddie when you guys when you get a bad trauma and you're going to the main or sometimes you have to take the lens out they should roll the fake machine they go the track to the machine but a lot of times I don't take it over there so you might have this very obvious lens rupture with blood in the edge close the laceration first but then what happens if you leave the lens in there we've all seen that right happens all the time then you have this bloody white mess you can't see through you're trying to figure out from ultrasound what's going on sometimes you got to take the lens out you're going to have to align your superior's to make that decision but what you guys can do is make sure you're prepared when you go through first and second years what about anesthesia the book doesn't even say this but general anesthesia right but what is the second really really important not to paralyze the patient how many times do you put something in the infusion patient needs to be paralyzed because if they start to get light and squeeze eye guts may come out you don't need to be paralyzed make sure your anesthetist knows you want to paralyze estimate how long you think the case is going to be I need to be paralyzed other causes of injury Iatrogenic injury including Faco burns I think is covered in the cataract but so the book is good read that look at the pictures and read you know the tables and diagrams about trauma I wanted to go through that but I don't have enough time this really should be two lectures one of the things that I wanted to ask you guys is this is an okay format from the presenters you it's been a long time since I was in the learner chair but lectures obviously are everybody's kind of learning different things and you're you know you may have conflicts that you need to be you know I think there's been a little bit of talk about doing this but I just was wondering whether more of a modular system where you guys can go in and I mean we have our brand internet you know we have some lectures but I think if we really went through and made it some questions and stuff that might be a good a good way to do it I think the cornea faculty we would be willing to do that it would take a year or more to really kind of get everything set up I mean I think it's good to come here but you know people need to leave they need to go other places but then as an adjunct to that I think it might be better to have clinical conferences where we say okay modular learning for lecture you know do your lecture because if you can imagine if you had like a clinical conference with people bringing cases or whatever you talked about some of this kind of stuff then it that'll be a really good learning experience I think and we I think the attendings can offer more because what we can offer is our experience the stuff that's not in the basic science book etc there's just too much to cover I mean you cannot cover I mean we can just do it because you know I've been hearing while we're working on it and that this isn't anything this isn't shouldn't be on residents it should be on Dr. Petty's gonna talk to you about that more but yes we want to do it yeah I think because the cornea faculty like this was a weird year because Elaine or somebody just flipped a coin and we all got lectures we haven't done before in a long time but it would be a good time to just pool our everything you know we're fairly small in you know we can work together and just try to cover everything good things that are in the repository and then I would rather see us spend time and just say okay we're gonna cover this topic let's talk about things and then we you know videos take a long time if you if you're showing a bunch of little you know 30-second video clips you can't you can't even finish a lecture like this but obviously so that's just my feeling thanks for coming thanks for being here on time appreciate you guys thanks for taking care of our patients you of all