 Okay, this is quick pattern recognition All right, I guess start because you're in the front. We're okay layers of the eyelid Okay second Okay All right very good So this you can see and Cross-section skin Tarsis and conge and all right, let's talk Let's talk about some of the commonest entities that affect the eyelids. I guess we'll go Eileen What do we see here? What's your differential and something like this? Okay. Yeah, this is this is more acute. It's come on. It's painful. It's tender. It's acute All right, so you think of a Shalazian you can think of a you know, Hordiola or something like that and so when we do the We flip the lid over we can see that sometimes these can occur internally Sometimes externally and what's the classic path? Giant cells exactly so when you get a Shalazian you see Lipo-Granium Luminous Inflammation It's backup of fat and then you see giant cells in there now all these little Evacuated spaces those are not artifact. That's actually areas where there's lipid in there But it's dissolved now you'll often you'll also see lymphocytes and plasma cells with these two and then remember the differences between Shalazia and Hordiola, you know Hordiola can be infectious and Cists what's the most important thing if you have a cyst that you look at? The lining exactly so you want to look at the cyst linings All right, this is the original Olympic Stadium and well not the original the original modern Olympic Stadium in Athens All right, so we're looking at eyelid tumors Ashley. What do we suspicious of here and what makes you suspicious? All right loss of lashes Elevated pearly borders with an ulcerated center. What is that characteristic of? 50-50 chance Okay, good, and you set it with conviction good good so basal cells will often have these elevated pearly borders And I'll often have the ulcerated center You only be careful because you see that the lid margin is thickened all the way out to here You've lost lashes and so that's indicative of a tumor and what's the classic findings when you look at a basal cell? So you see that the nuclei line up around the edge of each of the nods and you get the so-called Palisading and what's the most common type of basal cell? So this is a nodular or nodular cystic they can sometimes form cysts But you see these multiple nodules of these tumor cells. What's the one you need to worry about? Exactly, it's called Morphea form And so that's when you need to worry about so you see that there's little tiny Fingers of the tumor cells and in between them. There's this decimal plastic reaction There's this proliferation of connective tissue and that's what makes these tough to remove because they can sneak out underneath and you don't You know you're not able to do it. What's the surgery you want to do if you have a morphea form? Moes exactly sometimes if you don't you end up with this so basal cells by 9 tumor except when you let it grow for 10 years So you don't know that it grow for 10 years. All right, so just to confuse me. We've got Chris's squared here So just to make me Confused all right, so Chris the younger What do we see in here you look at that you look at it It's got this kind of a parchment look to the surface of it. It's kind of the epithelium. It's got this parchment Look, it's got a little bit of an orange-ish color to it some keratin on there So this should be more of a squamous cell than a basal cell When you look at the squamous cells, what are these characteristic findings that we see here? Worlds and what are they made of Keratin exactly so they've got these keratin worlds now. You don't have to take it this year So you have to worry about this. You're just like going yeah, whatever. I'll just see call patients So you can see these keratin worlds and keratin pearls and then you see that these cells are more active and they're more pink You know the basal cells are blue if you're looking at a low power and you're not sure what it is Basal cells are blue squamous cells tend to be more pink And so you see that Okay, Chris the elder Exactly so you've got lash loss you've got Pigmented bumpy irregular dark lesion And when you look at the cells sure enough you see the nucleolide you see the clump chromatin These aren't necessarily pigmented when you show it on the cells. And so this is a melanoma You really worry about these because these can spread All right, I can't even see who's behind the light back there. Okay Exactly when the melanocytes come come out from the neural crest to go to the junction first And so when you see an evas originally it will have some junctional component Eventually it can drop into the dermis or the sub epithelial space and get a compound in evas And then if it keeps maturing you'll actually lose that junctional connection and just be left with a dermal nevus Or sub epithelial if you want to be technical and once you've lost that junctional component you lose the malignant capabilities So that's important. All right. Why would I be showing you this? God you got a small group today. What people must be feeling really confident about boards Yeah, this is the classic masquerade syndrome they talk about where it's it presents as a keratoconjunctivitis If you will and so people will often mistreat these as you know inflammatory or as infectious But if you look carefully look at how thick the lid margin is look at the loss of lashes And when you look at these pathologically, these are nasty nasty actors are very aggressive looking There's my tautic figures all over the place Very very aggressive looking tumor and these behave very aggressively and also so don't miss it Always keep your suspicion up for a my bohemian gland sebaceous gland carcinoma So this is one I showed of the students I used to give me like four hours and then two hours now I do ophthalmic path in an hour for the students and I had to cut out like half of it So and then the students always complain every year. There's too much. It's like well shit They give me an hour. What am I supposed to do? This is all you get. All right. So Conjuctiva So just Eileen tell me a little bit about the Conjuctiva. What's the epithelium made of? Okay, characterized or no What are these little dots right here that you can see? God it sounds good And so remember just the basic parts of the conge You've got the bull bar for the seal palpibral What's the most common entity we see like? Pink wakila. I probably see this in 50% of my patients here in Utah, and then if it crosses the Limbus Turidium and what's the classic path findings? And you can see here's a close-up here's that smudgy Gray basophilic degeneration ultraviolet light induced and then when you get the little squiggly lines That's the solar elastosis All right, so tumors Ashley, what would be what would we be concerned about here? Yeah, you worry about look at that picture gelatinous And so they may show you a picture of a Turidium and then a picture of this to try to fool you now Remember Turidia the epithelium is thin and the tissue sub epithelial e becomes fibrotic and thickens But when you're looking at tumors the epithelium actually thickens and so the tip off here is this gelatinous look It starts at the limb us and it starts to grow and you've got this gelatinous look right here And when you look at this what do we see in here? Okay, what else besides thickened so the nucleol I go to the surface you've lost normal maturation You've gotten a pli here and now you remember this is conge. You're not supposed to have keratin So and in these you sometimes do get keratin and that's from so what would this be called three words Or what what we abbreviate is C.I.N Conjunctival Interepithelial Neoplasia so C.I.N. And we rate it as mild moderate severe depending on What percentage of the epithelium has been involved with the displastic cells so mild is the lower third Moderates two-thirds severe is more than two-thirds, but by definition the basement membrane is still intact Now when we're looking at this Chris What's different here from that previous lesion? That's more white what do we call it if we have a flat white lesion of the conge Actually, it's called luco plakia from the Greek luco means white Plakia white plaque so white plaque so whiter plaque. What do you think that whiter stuff could be? It's keratin good. So it is keratin and so we're not dealing with you know African people with You know vitamin a deficiency so that can give you keratin eyes little plaques on there, too But this is actually a where this is your day again. What is this? World's again, so this is a squamous cell ca. So it's gone from a C.I.N. To squamous cell carcinoma and you can see the worlds of These displastic squamous cells and again it can keratin eyes and so member squamous cell carcinoma can also occur on the conge All right, what do we see in here other Chris? Is it worrisome? Exactly so you'd photograph this if you look at his flat Kind of looks like a dusting of pigment, and it's really not irregular. It's not growing you take a picture of them What if the path shows you this? Pam which stands for? Just melanosis So primary cryo melanosis Pam and again we grade Pam as either with a tippy or without a tippy is so normal Pam Which is what you just saw, but you can even see it in just normal racial pigmentation a line of benign Melanocytes at the basilar layer of the epithelium here no atypia no extension up into the epithelium But you can also have like this. This is Pam With a tippy and if you look right here, this is more irregular. It's spotty. It's thickened. It's darker So this is what you worry about now that this is becoming more atypical And now you look even though it's strictly within the epithelium remember Pam's almost like CIN It's like a tumor in situ if you will and so you see these Melanocytes have become atypical There's no clear lie. They're spreading up into the epithelium and it's important to realize that Pam With a tippy can lead to what? Melanoma so that's the pre-melanomone Pam with a tippy and sure enough, you know They're not going to put this on boards because it's too easy. So it's pretty obvious that this is melanoma Depends on the degree of atypia the more atypia you have the higher the chance Pam without a tippy has virtually zero degree Okay, and just remember if you read a question on board read it real carefully because 80% of conch melanomas arise from pre-existing Pam with atypia But that doesn't mean that 80% of Pam's go on for melanomas and so don't You know flip those around be sure you keep that straight. And so here's your Melanoma that you've got so melanoma so you know by 80% of melanomas of the conch your eyes from Pam about 15 to 20 percent arise from Nevi Yeah, Pam is strictly intrepithelium Where Nevi will have a junctional component to it So Nevi will form nests at the junction so they can go into the substantial propria They can go into the epithelium itself. They form these little round nests where Pam will be individual cells that don't nest They just line it up What's that no sis Clinically in in Pam. All right, so again, we go since I was talking about grease we go to the parthenon on top of the acropolis All right cornea So boy easy one here Reese layers of the cornea And endothelium all right, so that didn't count that was too easy So this just shows you this is the basement membrane of the epithelium right here don't confuse bowman's bowman's is not a basement membrane Bowman's is a condensed anterior piece of stroma in the endothelium something we never see in the path lab This is what endothelium looks like because all we see is diseased corneas see there's endothelial cells on the inside of the corn You guys didn't believe me that they really exist This is what I Love these comics here All right, so Eileen corneal infections. What is this a classic picture of? And that they may show you a picture of that but the question won't be what is this the question will be a double level one So you'll say ha I know this is a you know HSV then I'll ask you a question about I don't know subtyping or You know what it does somewhere else and so they love two-part questions on boards Which I hate because you know the answer but then the answer is not in the question, so Right, so that'd be the kind of question they would ask exactly how do you treat this and what are the options and so Know know the party line And but the key thing here is recognition you see the little bulbous Out pouchings that are coming along here, and they may ask you you know where are the viable virus cells? Exactly they're not in the center. That's just bare bowman's layer or bare stroma It's at the ends there where the active infection is going on So when you look at it, you can actually get an ulceration Where you will go it'll go through bowman's layer into the anterior stroma What you worry about though is when the herpes goes deep and they can ask you a lot of questions about deep herpes Ashley what do we see in here? Exactly this was actually one of my guys at Heinz VA in Chicago You know you just get these guys who were contact lenses and it was like It was really bad and so this turned out to be a pseudomonas ulcer So you worry about a bacterial ulcer and why do you worry about it? It can cause a perforation so there you see a white necrotic cornea You see acute inflammatory cells here and eventual perforation so know the treatment You know for corneal ulcers know what you do know how often you use them. They like to ask you that on boards Okay, Chris So if you look around the infiltrate look at how it's got that little halo around it So this one's a little more indolent than the other one was this one's been going on for a week or so What could this be? Do bacterias usually smolder for a week? What does the what other bug can fungal? Yeah, this is a fungal ulcer. Where are you from? Are you here from where? No, but where? Prova alright, so this here is a farmer from down there to Spanish Park You know and you got something in his eye So he comes up here finally, you know to two weeks later. This is a fungal ulcer and And this is a one of our stains bonus points because you weren't here for the stain lecture. What do we use to stain for fungi? You can say no, that's funny. I say you don't know this is a gms stain. Gamori methenamine silver and it stains the yeast silvery black So that's yeast a more indolent one Okay, Chris. What do we see in here? And I didn't have the floor seeing picture here, but what's going on here? Exactly so ring infiltrate painful eye loss of epithelium. What would you worry about? Echinthamoeba and indeed we do a What kind of stain for Echinthamoeba? Gridley Gridley, so I said I was if I were ever in london, I'd have a butler named gridley, you know Gridley bring tea. Yes, sir So this is a gridley stain. So gridley stains it. It's uh Echinthamoeba, so you worry about it because these are really difficult to treat Once they get along the nerves they can actually spread to the sclera. These can be really tough to treat So you got to recognize them early and they may throw you a curve ball and and give you a history that sounds like chronic herpes And it turns out it's Echinthamoeba So these are these are tough to diagnose tough to treat. Okay so we always just Just try to see if you guys are paying attention here. Okay Um, I never use gms stain. So I have no idea what they look like, but yeah Oh, okay Now corneal dystrophies Um, let's see. Back to Reese. Um, what dystrophy is this? Lattice. Now remember there's different layers of corneal dystrophies But what's our mnemonic for the corneal stromal dystrophies that we have you guys memorize? Yes, exactly. And so that's how you remember your stromal dystrophies. So maryland Okay, munro. Yucca polysaccharide Auction blue Auction blue really recessive recessive auction blue gets Can I explore Eileen's because she interrupts mine? Yeah granular gets a granular her uh island island man Mesa and trichrome l Lattice a amyloid california or county congo red very good. So just know those I don't have time to show you all of them. This happens to be a trichrome stain So this would be what? Mesa and trichrome stain. Yucca polysaccharide. Exactly. All right. So just know those. What do we see in here chris? Which one now? This is actually a retro illumination view. This is really deep and you see they call this A beaten metal appearance. So we've got little dots on the inside surface of of decimals man I like someone took a little round hammer and just pounded it And this is the pathology here. What are these little dots made of? What do they call? This is fuchs fuchs Fuchs dystrophy and these are called gutata So thickened decimates membrane These gutata loss of endothelial cells. So fuchs dystrophy What are we seeing right here other chris? Months in signing. What is this characteristic of? Keratoconus so you see the cone shaped out pouching when the patient looks down And what do we see on the path that that we can call this keratoconus? First of all, is the cornea thin or thickened centrally? Thin and that includes epithelium and stroma What's the classic finding we see? It's right here You get these focal breaks or discontinuities in bowman's layers So some people would say this is even a bowman's dystrophy if you will So the corneal epithelium stroma thin you get these breaks here. You see posteriorly the endothelium is normal So keratoconus. All right, what are we seeing here adam? Exactly. So you see edema here bow eye. What stain is this? Why would I use this? PIS stain and what is this right here? Yeah, so this bowman's you see does not stain the basement membrane epithelium does stain So you get edema percolates through the stroma and then it'll gather In these basilar cells of the epithelium and then the cells will pop And you'll get this bow eye this big blister. So bow is keratopathy All right. Now I show this to the medical student. So this is just Bartisch Who was in the 16th century said what you should these are requisites to be an Oculus and a surgeon and so my favorite ones here were to be Not to be a drunkard not to be greedy for money or hottie Not to be presumptuous or vain glorious and so by definition now Half of the people trying to become surgeons are like, you know booted out there. So All right, this was my favorite one since I could not afford a high school and university education I had to restrict myself to surgery so Sometimes I wonder about some of our surgeons who advertise a real lot. So this is Bartisch's criteria. Okay What are we looking at right here adam again? Okay It's your regular mesh work. And so we don't have time to go over the layers here, but no Your landmarks, they'll often show you Sometime collages of pictures of the angle. Some of them will be Narrowed some won't be recess. Some will be closed off. And so Know what your normal angle architecture looks like and this is a schematic I do for this dudes Back to Reese. What are we concerned about here on this patient? Which eye right eye right eye. So what makes you worried here? Uh, there's antiquarious so the pupil on the right is more kind of in a mid dilated position. Mid dilated that eye is very red. It's painful. It's blurry. And when you put the slit beam on there All right, so we call that iris bombay. And so you see the iris bowing forward there So that's indicative of angle closure or pupillary block glaucoma Yeah, what are we seeing right here? There'd be a PIS peripheral anterior sneak. Yeah, there's the angle there And the iris is ending up stuck to the angle now that can happen as chronic angle closure What are other conditions that can lead to this? Exactly and if you look real carefully look, there's a thin line of blood vessels right on there. So this is Secondary angle closure due to neovascularization of the iris. Okay now know your glaucoma this optic cup changes Because you definitely need to need to know what they look like and You know, obviously we want to stop glaucoma before it gets to this 0.999 cup. This is even more than that. It's excavated. It's a 1.1 cup And so here's an end stage glaucoma. You can see you've completely lost Your nerve fiber layer. Here's the vessel diving around. That's why vessels disappear When they dive around the edge of the cup they're literally going out to where it's cupped And I like to say this because I school in Boston. This looks like a beanpot You know the beanpot so when you go to Boston and you speak at the new england cataract decided meeting they give you a silver beanpot As you're kind of your speaker prize and so you get this beanpot tradition They make a big deal when they give it to you. So you get a beanpot from Boston So think of boston beanpot and stage glaucoma All right, again, this is the famous five maidens that are on the temple on the side of the acropolis there Um war and pollution has ravaged these they've all been destroyed the originals. So these are copies So they couldn't save the originals All right, so we're going to talk a little bit about the crystalline lens Okay, what do we see in here eileen? Okay, which would uh the most common entity be to cause this It's superior temporal. So this is marfan. You can see the afake contact lens on the patient So up and out as marfans down and in is Almost just in your eye. I've never seen one before but they're always on boards And here's the marfans guy All right, so now there's one other one you need to worry about There's there's an entity where you can get a lens that will dislocate anteriorly. It's a small spherical lens Wheel marshes on you see you want to worry about that and you could tell them a part if they ever asked you because remember Marfans are tall spindly You know think abraham lincoln people wheel marches on you're short stubby people with short stubby fingers and Short stubby lenses. Okay, so that's how you remember them. All right, so cataracts You guys all know they never ask anything about cataracts on boards because of course That's the most common thing you see in the most common surgery. You haven't forbid they ask that on boards So this is a bernessent nucleus Um, you know, you may see these in the third world or people who come from parts of wyoming or You know Utah County There's a bernessent nucleus. Here's a cortical nucleus seen from behind miyaki view And so this is my favorite one. We keep forgetting We do cataract surgery under topical anesthesia. So You know me I love to talk and then we'll be in the room and the residents will be saying Oh, well, did you see that game last night with golden state? It's like You don't talk about that during surgery. Okay, you be serious because patients hear everything So always make sure that they don't Yeah, yeah, we added the name tag All right, here's the acropolis at night. They don't let you go up there at night except once a year So once a year that you go up there at night. All right now Let's go to the other half of this lecture That is glacier. That's the top of um Of logan pass if you go to glacier in montana glacier national park So if you've not been there, they've gots called this the going to the sun highway And just highway goes all the way to the top and then down the other side beautiful just beautiful. So Let's keep our fingers crossed that this is actually going to work. Okay Here we go All right, so retina. I'm going to talk about retina What is this? macula in there Okay, so since we only have 10 minutes Know your layers They're not going to ask you the layers, but you may need to know What it signifies if you have a hemorrhage in a particular layer and what it looks like What is this? Bovia, okay, so retina vascular diseases. This this shows them up nicely. We'll just start over again. All right, reese What do we see in here? This guy gots the sugars. Okay, what do we see in here? Okay, so they're shaped like a Flame the deeper hemorrhages are dot lot. What are these guys here? Heartaches. What is this? Cotton wool spot exactly. So that kind of shows them all And eileen, what do we have here? Micranias so this patient likely has Diabetic retinopathy and here we have Massive heart exudate. We hopefully don't get to that point before we treat the patient and here's what it looks like Here's the exudate that's leaked out. You can see tremendous disruption of the retina from Diabetes Ashley, what are we showing right here? Cotton wool spots and what are they? Exactly. So focal ischemic infarcts of the nerve fiber layer. So they're on the surface They look like little wispy bits of cotton. So they'll block the vessels underneath them. All right. What do we see in here, chris? Okay of the Discs so nvd. This is the so-called medusas snake head Of the disc and if we don't treat them what happens? And where is this bleed? Well, so this is pre retinal. It's in front of the retina Spilling out into between the retina and the vitreous and you see the classic boat shaped hemorrhage flat top Round bottom boat shaped hemorrhage. And if you don't treat Diabetic retinopathy you can get scarring you can get traction retinal detachments. And so A lot of badness. All right. So here we have This is the latest hoopsad, you know on the spot laser treatment All right, so other chris. I'll give you a hint. This patient's not a diabetic What else can look like this? Yeah, exudates, flammulverages Maze, a little bit of obstration of the disc Yeah, this is severe hypertensive retinopathy. It looks a lot like diabetic, but you can get discadema You can get this star-shaped exudate in the macula. So this is severe hypertensive retinopathy And again, you got to treat it before it wipes out your retina Adam, what do we see in here? Blood and thunder and what causes this? Exactly, so this is central retinal vein occlusion You can see that the hemorrhages go all the way out to the ores serata Again could damage the entire inner two-thirds of the retina What do we see in here, Rhys? More specific Exactly branch retinal artery occlusion. So it's white. It's ischemic. It's pale. And what do we see in here? A central retinal artery occlusion. And what is this? And what causes that? Yeah, so you can still see the corridor flow in the center of the phobia Shining through and here you have coming into the optic nerve your Central retinal artery vein. They share a sheath severe arterial sclerosis. Look at that fatty artery Lumen narrowed down so you can get embolic phenomenon central retinal artery occlusion But you can get stasis next to it from that fat artery. So you get Stasis and then a thrombus so central retinal vein occlusion caused by Arterial sclerosis And there again is the damaged inner two-thirds of the retina. This is the greek parliament building And the tomb of the unknown soldier. I won't tell you my jokes about the guys who guard it. No time What do we see in here, Eileen? Juzin and what exactly are juzin pathologically? Exactly and because they're beneath the base membrane of the rpe and on brooks membranes technically they're even called intra brooks And so you see these excrescences here you lose the rpe overlying them And what can happen eventually? All right, so sub retinal hemorrhage that's here and this shows you that on fluorescein and of course if you don't Treat up you end up with this Disco form scar. So this is a gliotic white scar that can form underneath there if you don't try All right, so what are the findings of retinitis pigmentosa? Okay, so waxy pallor of the disc Market attenuation of the vessels bony spicule pigment And what exactly causes the bony spicule pigment pattern? Well, the the rp is disrupted But the the little pigment granules get released and they actually will deposit around the vessels So they almost diffuse out and deposit. So that's why you get the bony spicule. It's outlining the vessels All right, and This is my favorite one You should do that with the lasers at the side effects All right, so retinal detachment's chris. What's the most common cause of retinal detachment? All right, so we call it regmatogenous meaning it's forming a tear So here's a horseshoe tear some kind of a vitreous traction the tear forms the fluid will go underneath it You'll get a retinal detachment What is this right here? Yeah So it's a total detachment you see it's attached here at the aurasurata and attached there at the disc and so it forms what's called a funnel So total retinal detachment forms a funnel if you will Okay, and here you can see a funnel shaped detachment extruded fluid underneath it And when you try to repair a retinal detachment and it fails you get Failure due to proliferation of gliotic tissue. So this is called pvr proliferative vitro retinopathy and this is gliotic tissue growing here This is a trichrome stain with gliotic tissue growing and pulling off the retina so chronic retinal detachment This is delphi where the oracle used to live All right optic nerve Normal optic nerve normal optic nerve. Okay, papillodema other chris. You got to be really careful. What is the definition of papillodema? Exactly. So when you see a swollen disc, especially when you do oral boards, you don't say papillodema you say a swollen disc And then if they ask you for further information, you say, okay, if this were bilateral And the pressure were increased in the cerebrospinal fluid. We would call it papillodema So you see the classic findings flame hemorrhage Engorged vessels swollen elevated disc. We look at the path There's the swollen disc. There is the engorged vessels. There's the hemorrhages Okay, and this is my My favorite I love on television when they've got like a gallery where people look never seen that ever Except in Moscow if you order off operating room had a gallery where people would stand up there and watch them operate It also had a Assembly line underneath so they would do the cataract in like six stages on an assembly line Yeah, very interesting. All right, so here's the glaucomodus disc where I looked at that. All right, so this is from two weeks ago Optic nerve tumor is adam young 10-year-old little girl Anise coria and she's got some All right, so this is the left eye. She's actually got some proptosis there also some inferior displacement We look at her scan. We see that What is that characteristic of? Glioma, so a tumor arising from the optic nerve itself. Here's the glioma. What is this structure? Eosinophilic staining material in the cytoplasm It's called a rosenthal fiber and they may ask you this to remember Optic nerve gliomas are simply grade one astrocytomas. They're the lowest grade Grade one astrocytomas. Some people would even call them a hematoma. They would say it's not really a tumor And they occur in kids as opposed to this nice little old lady Ann Reese, what's that? Opticillus shunt. So that's a sign of slow Squeezing so something growing slowly around the disc now that could be signs of other things too Central retinal vein occlusion can give you an optociliary shunt. What's the epineum for the don't know the epineum? Sorry got me there Spencer's try. Spencer's try. Oh, that's a new one. Didn't know that existed. So see you went up on Wow, didn't know that that's not in there. So don't waste neurons memorizing that I've never seen that show up on an exam So here's the classic finding. What do we see on an MRI scan here? Tram track. So you see the tumors in the middle and you've got wires on the other side a tram track sign and Eileen, what are the classic? Some momo bodies these little concentric calcific Bodies that form in a meningioma All right, so we're almost there The daydream alert. Okay, so we just went over this a week ago retinoblastomas What is this material? Um Ashley calcium so you see the viable tumor cells necrosis Calcification What are these guys called chris? Nope Very specific. They may ask you this Named after two people German These are flexner wintersteiner rosettes Classic for retinoblastoma flexor wintercenter rosettes other chris when retinoblastoma spread from the eye. How do they spread? Through the optic nerve so you can see it right there All right, and this is what happens when you don't treat them All right, so again, we're almost Almost done. You'll have to have put earplugs in now. So this doesn't run out of your brain. All right malignant melanomas We talked about this. What is this shape adam? The mushroom shape. All right. So what who's the guy who described the cellular classification? I'll call it a calendar. So this is spindle a epithelioid Spindle be mixed with epithelioid a mixed tumor. How do they spread? Scleral emissaria. Here's a vortex vein. Here's the tumor spreading and where do they go when they spread? The liver. All right. This is Delphi in enough. Okay. Good luck on boards guys