 All right, let's get started. So of course you guys have to put up with my tourist pictures, and so you can't Go to Paris without seeing the Eiffel Tower You always have to see the Eiffel Tower from From there and here's a close-up. Now. What's cool. I'll show you later on They put lights on this for the millennium and so on the hour Starting. I don't know at night at night till midnight It's lighted up and then the lights go crazy And it's a light school crazy for about three minutes on there So we'll show you that later on in the You know in the lecture series that's your incentive to you know come in so that you could see them And so during the day, it's just kind of a big metal tower, but it's pretty cool at night And this is looking this is from the Arc de Triomphe This is now looking down the Champs Elysees and This is Brad, what's that? I don't know. I thought you were just there. I was I Was calm. Oh, it's the palace. There's no that. There's the louver. Oh There's that louver museum. You know that that's got all them patents in it. I think where's the pyramid? I don't see the pyramid It's just passing by back there Don't worry, we're gonna go there in a minute So then this is just looking in the other direction and so we just kind of got a 360 panorama looking around the Arc de Triomphe All right, so today we're going to talk about the Conjuctiva. So Let's change the order here because you guys, you know, you guys are getting too comfortable Teresa Tell us about the three main parts of the Conjuctiva. All right. Here's the bull bar Conjuctiva Right here. Here's the palpebra. Oh, what's the third part? The for the seal all right, so when we look at it the Conjuctiva What we really think about is Conjuctiva is the bull bar Conjuctiva the Conjuctiva That's sitting on that surface of the sclera adjacent to the cornea But remember now it it goes into the for the seal Conjuctiva And then reflects back and remember the Conjuctiva from last week was the innermost layer of the eyelid And so you've got the palpebra Conjuctiva. So three Main parts of Conjuctiva. So when we looked at the lid last time Remember the Conjuctiva that's the palpebra that's laying the inside surface of the lid is really tightly adhering to the Tarsus and the posterior part of the lid whereas the bull bar Conjuctiva and especially the for the seal Conjuctiva It's very very loose. There's this loose connective tissue underneath it You know, let's go back one layer here. Okay, let's talk a little bit more about the Conjuctiva Brad, tell me about the epithelium of the Conjuctiva So it's a stratified squamous non-catenized epithelium. Okay What are these little Dots in here? Those are goblet cells goblet cells and if you look you can see that the further away you get from the limb Limbuses up here the more goblet cells you have So you don't have many goblet cells here in the limbus But as you get down into the fornix, especially you have lots and lots of goblet cells. Mike What do goblet cells make? I think mucin mucin and why is mucin important? It coats the innermost layer of the tear film Okay, so while we're at it. We might as well just throw it in here How many layers are there of the tear film layers three layers? So this is the innermost layer the mucin layer. What are the other two layers? Which is the kind of middle of the sandwich and then oils on the outside. Okay, so Rachel what What are the cells that make the surface layer? Exactly. So remember we looked at the mybomian glands the oil glands they make the surface layer. What does that do? Exactly So kind of coats the surface of the tears it keeps it from evaporating So even though you make aqueous tears Sometimes if you have mybomian gland disease, they will evaporate rapidly and you'll still get get a lot of dry eye symptoms The mucin layer which is made by the goblet cells is important because it makes the surface of the eye wettable So it it kind of covers the little microvalley on top of the conjunctivus and the cornea makes it wettable Catherine what are we looking at right here? It's kind of a white Really elevated. It doesn't look like You know what you'd see if you get the turidium or penguacula I'll give you a hint. This is a child well, not necessarily like what doesn't have lipo in it, but Dermal it's a dermal It's a core stoma now these to call these limble dermoids and the term dermoid is Tossed around so much it really confuses people And so I really like to use the term dermoid for the the congenital cyst in the orbit And so this is what we call a lipo dermoid, but the proper name for it is a limble dermal Chorus stoma What does chorus stoma mean? So a proliferation of benign tissue that is not usually at that anatomal site Okay, marshal. What does hamartoma mean? Good evening, by the way Benign tissue that is not that is in the right place Exactly Exactly So that's a good way to keep them apart to remember hamartoma is a benign growth of tissue that normally is there Whereas chorus stoma is a growth of tissue that's normally not supposed to be there Although they are benign And so when we look at a limble dermal chorus stoma Chris, what is this thing right here that this is actually from that child? Exactly so you normally shouldn't have hair follicles and sebaceous glands at the limbus So thus the term Chorus stoma, so you've got a little sebaceous gland you've got these hairs You've got this dense connective tissue, but you can even have other Stuff in these Arianna, what is this thing cartilage exactly? So let's go to a higher power So what's interesting is these limble dermal chorus stomas can have cartilage in them It can even have this stuff in them Sneha, what is this stuff? Glands what kind of glands? Ekring glands so you could even get ekring glands like like lacrimal glands in there So you can get lacrimal gland you can get Cartilage you can get hair you can get fat you can get all kinds of of things in these chorus stomas What systemic disease do you get concerned about in a child who's got a limble dermal Chorus stoma shot golden hearts. So what else do kids with golden hearts have? Uh Exactly so you look in front of the ear skin tags and they have funny teeth and bony abnormalities all kinds of things But the key is is you may see a picture on boards of a limble dermal chorus stoma And then I'll show you a picture of a near tag or something And so you need to know that that's associated with golden heart syndrome There's the cartilage. It's a very interesting stuff Alley, what is this thing? Sorry, it's overexposed picture. I took that myself that shows how What could that be? Pinguicula exactly. So if you guys look carefully Virtually every person in utah over the age of 15 has a pinguicula. I mean, it's just Automatic that's part of my normal you know, um Smart phrases is pinguicula every person has it diagnosis one pinguicula Diagnosis two dry eyes. And so those are the two things that occurs in everybody in utah Why do you think we have lots of pinguicula in utah? What part of the sun UV exactly so this is ultraviolet exposure because we're at altitude We have lots of UV. But secondly, what do people do a lot of in utah? They do outdoorsy things. They ski Hike climb all kinds of things outdoors and we get 300 days of sunshine a year as opposed to the midwest which gets, you know, 30 And so we get 300 days of sunshine. So everybody in utah has a pinguicula. It's very very common I'm treated. What is this now? It's a thrygium. Thrygium. What's the difference? It's grown pastel and miss onto the cornea. Exactly. So a pinguicula thrygium are really the same pathologic features there You know UV induced degeneration, but it thrygium grows Over the limbus onto the cornea So what do we find pathologically when we when we look at these? All right, so here we have this is the substantial propria underneath the conjunctile epithelium You see this little squiggly Characteristics here and so it's as if someone has taken the collagen you bombard them with UV They almost look like frayed rubber bands. So you get this solar elastosis coming here What else do you get in these? Uh basophilic degeneration basophilic degeneration this smudgy Blue gray again, UV induced degeneration. What the heck is this stuff? So it looks like calcium calcium So you can actually get calcium in these and so when you look at terigia With your slit lamp you can actually see Little white specks sometimes of calcium in there too. So that's just a sign of longevity A mic is the epithelium in a terigium thick or thin thin and how does that help for If you're looking for a malignancy you expect something to be more thick Whereas terigium is more kind of thinned out Just some damage Exactly so a terigium the disease is under the epithelium It's in the substantial program Whereas in a you know disease affecting the epithelium, you know a tumor or a cian something like that You would see thickening of the epithelium and you can actually tell that a slit lamp So if you're looking at a lesion of a slit lamp you can actually see Thickened epithelium when you're looking there. So that's important when you're trying to differentiate lesions All right boy keep going around. What the heck is this thing? Yeah, if you put a little fan off head on there, you'd see that that would transaluminate So we look at it and what this is the lining of that lesion. What are we seeing for the lining here? So what is that lining made of what's that epithelium? No, I wouldn't buy that as cuboidal. I would say that's more Stratified squamous looking What is this thing? Yeah, so there's goblet cells in here and there's a stratified squamous epithelium. So what do we call this lesion this? People call this an epithelial inclusion cyst And so there's been something happen to Put a little bit of epithelium underneath the substantia propria and then what happens is then it starts to grow and it'll form a cyst So either trauma previous surgery something like that. So they call these epithelial Inclusion cysts All right, we'll just keep going around the table there Catherine. What is this we're looking at? All right, so there's a bunch of these guys down here. These are follicles And when we look at a follicle pathologically, what do we see? Exactly and and you see it almost looks like you're looking at a lymph node You know, you see this cluster in the center here of these lighter staining Lymphocytes and then surrounding by some darker staining lymphocytes. So it almost looks like A lymphoid follicle. So that's how you remember that follicles the follicles have These gathering of lymphocytes now if there are vessels the vessels are around the periphery Of the follicle so the center of the follicle doesn't have a vessel in it It's got just these gathering of lymphocytes almost like a lymphoid follicle Marshall what are entities that give you follicles? All right, so viral conjunctivitis is one that you commonly see So when you're looking for signs of say an adenovirus conjunctivitis You want to pull that lower lid down with the cotton tip not with your fingers? Don't get those viruses on your fingers And you look for these but also these are really indicative of a of an allergic reaction. You'll see tons of follicles that are down there Here's a close-up You've got these lymphocytes paler staining in the center or pristaining around them in a follicle What the heck are these? Chris Okay, so how are papillae different than follicles? Yeah, if you look at each one of these little bumps, there's a little vessel right in the center of it. And so What papillae have is they have this little central Vessel popping up and then the thick epithelium Around them. So those are the difference between follicles and papillae What's a ariana? What's a common entity that that causes papillae? Contact lenses do and what what condition do they cause? Indeed so you have someone who comes in and they've got a You know real irritation in their contact lens water flip that upper lid and you look you'll see all these cobblestones On the inside surface of how people conjunctivate the upper lid and this is called giant papillary conjunctivitis Because they really do look like giant Papillae if you will and you can see the Vessels in the center. They're very vascularized in the center of each one of these Papillae right here. So remember the difference follicles papillae Sneha, what are we seeing right here? Where are we looking here now? Okay, what could give you I gotta give you a little history 14 year old male itchy itchy itchy eyes Exactly. So people will call you can have a vernal conjunctivitis vernal meaning spring from what language? now from the latin The sneak one in there that's not so vernal from the latin But again, you remember the greeks invented everything the romans they they took from the greeks and took it there So this is from the latin actually so vernal meaning springtime And so you'll often get especially in in adolescent males. You'll get this really itchy itchy springtime Allergy and you look at the limbus and you'll get these bumps Right here at the limbus and so they call this limble Vernal so vernal conjunctivitis. It can give you these limble bumps. They really are follicles. So these little I'm sorry papillae. I said they're wrong. They're papillae. So you get these little papillae at the limbus All right Sean What are we looking at here? Okay. So this is a classic pyogenic granuloma. Why is this one of those terms we have to memorize? Exactly it's a double misnomer pyogenic means literally fever inducing so it's not infectious and Granuloma means giant cells and epithelial cells. So this is called a pyogenic granuloma and it's Been called that for years and you know in literature, but it's not pyogenic nor is it a granuloma. So it's a double misnomer So it is what kind of tissue? granulation granulation so kind of like exuberant scarring tissue think of this as like a Heloid only of the of the conjunctiva. So loose connective tissue Multiple blood vessels coursing through it lots of edema mixed inflammatory cells lymphocytes plasma cells PMNs And so this is usually a reaction to something So something get in the eye. Maybe they had a surgery Maybe they had something fall in the eye and they get this exuberant granulation tissue So pyogenic granuloma All right, Allie, what are we looking at here? Not only injected but really kind of elevated Almost solid looking. I mean you look at that. It's not really cystic. It's almost solid looking What could give you that in the conjunctiva exactly for Jews don't look like that Yeah, and you don't see any discharge coming out of this truly pretty solid lesion sitting there What do you make of the color there? Yeah pinkish red and so I don't know why people often call these Salmon patches and I don't know salmon is pink. I guess that's how they Get that. So if you have this thick kind of salmon patch on here Here's the pathology a sheet of lymphocytes. So don't forget you can get conge lymphomas Not as common as orbital lymphomas, but but you can get conge lymphomas Both extending from the orbit, but also individually and so they call them salmon patches And so you get this thick elevated kind of pinkish red You know lesion on the conjunctiva underneath the epithelium and so these are all Lymphocytes so don't forget you can get lymphoma of the conjunctiva And this is an immunoperoxidase stain showing these are mostly B lymphocytes And so when you see these these lesions both in the orbit and the conjunctiva the mostly B lymphocytes What are we looking at right here? We'll just start over again So it's like there's this raised kind of gelatinous appearing Whiteish like lesion coming from the conjunctiva growing onto the cornea and it has increased vascularity and it's raised and elevated What would you be worried about here? Okay, so if you look you look at that it's gelatinous and so that epithelium instead of being thin Like you see in a teridium. It's thickened. It's gelatinous. And so this has epithelial disease rather than Substantial proprio sub epithelial disease and here's another one These lesions will often start at the limbis That's the most common place and they can grow Onto the cornea or they can even grow back away from the limbis, but usually they'll start at the limbis Now we're looking at the pathology here at low power first of all What is this stuff right here? It looks like keratin. It's keratin. Exactly. So what does that look like when you look with the slit lamp? Exactly, and it'll often look white And so the name people who use is luco plakia literally white plaque And so sometimes when you get this epithelial disease here of the conjunctiva you will see Keratin on it and then it'll look kind of dusky It won't have that shiny mucous membrane appearance to it'll have a dusky appearance to it and the keratin will often look white Brad, what do we make of the thickness of that epithelium? It's fairly thick. Yeah, it's very thick. Yes No, these are actually epithelial cells that have become keratinized So these are actually epithelial cells that have keratin stuffing there stuffing the cytoplasm Oh, it kind of does because it stains with that really really intense pink eucinophilic staining But if you look closer, I'll see if I've got a close-up here No, it's not similar. It's just staining. Yep. Staining just looks that way All right, we're looking here at the lesion. What do we see in here? I'm still got you there Brad So we are seeing fairly atypical looking cells And it doesn't quite look like the basement membrane has been violated yet All right, so let's say that the basement membrane in this lesion is completely intact What do we call this? CIN. And what does that stand for? Junctival intraepithelial neoplasm Exactly. Someone might say conjunctival What did I say? Conjunctival Conjunctival intraepithelial neoplasm, so CIN And Mike, how do we grade CIN? To grade it With mild or moderate or severe Where are the demarcation lines for that? All right, so if it's the if the atypical changes are in the lower third We see say CIN with mild Displasia if it goes up to two thirds CIN with moderate dysplasia if it goes above two thirds Then it's CIN with marked dysplasia, but by definition CIN has an intact epithelial basement membrane And here we can see this is full thickness. Look at these nucleoli Look at the pleomorphism some big Some small Nucleoli, clumped chromatin Loss of normal maturation all the way to the surface. So CIN with marked dysplasia What do we see in here? We'll just keep going. Yeah, this shows the plaque like leukoplakia better Because you can kind of see that plaque like look on there Now we're looking at the pathology here. How is this pathology different than the previous one? If you look right here, look at these cells right here These are definitely below the basement membrane So this is no longer a CIN this is now Squamous cells so this is now superficially invasive Squamous cell carcinoma of the conjunctiva and we look at another one Catherine what is this stuff right here Exactly. So just like squamous cells of the skin When you get invasive squamous cell of the conjunctiva you can get these keratin pearls associated with it. So you get these round Clusters of keratin these cells are actually in the substantial propria And so growing through the Basin membrane into the substantial propria. So I'm an invasive Squamous cell carcinoma And here's a close-up keratin Whirl keratin pearl, but here you have keratin inside the cells And right here very very dysplastic cells very, you know, aggressive looking tumor at this point Okay, what's happening here? Marshall looks like Looks like there's Some heat to get throughout the sample. I'm not really sure it's Believe it or not. This down here is sclera And so this squamous cell carcinoma is invaded through the conjunctiva It's actually through the epi sclera into the superficial sclera So this is a superficially invasive. This is more than superficially invasive This is a deeply invasive squamous cell carcinoma. It's gone all the way down Onto the epi sclera and even the sclera around the globe So at this point very difficult to remove this by just removing the lesion you sometimes have to consider Removing an eye even removing an entire orbit Now when these tumors spread Chris, how do they spread? What are they known for for when they spread from the eye? Exactly. So here's a nerve In the orbit and here's tumor cells Along the nerve And even some inside the nerve and so you want to really look carefully with these because if they start invading into the orbit They can even start going back along the nerves And so you really want to be careful with these you want to check these people for You know anesthetic areas You know that'll let you look you know nowhere to look and so you want to do an MRI scan You want to make sure that this is not Tracking along those nerves. So this is going to actually leave the orbit Tracking along the nerves and and invade even into the brain at this point And here you see again these cells Around that nerve so these squamous cells for some reason Love to you know escape along the nerves And so you want to keep that in mind when you're working these patients up All right, what are we seeing right here? Arianna, what is this? If you look right there that doesn't look like the superficial Pigmented congenitiva. This is kind of racial pigmentation here at the limbus and then a little bit of pigmentation in the congenitiva That's kind of almost a blue Bluish gray look to that Where would that pigment be located? Yeah, this is even deeper than the congenitiva. This is deeper like in the sclera or even deep to the sclera This is a picture that I really like because this is a patient with oculocutaneous Melanosis And this is a disease entity where you have pigmentation deep And so this is now Deep to the sclera right here. This is not congenitiva And so this is actually the lesion right here. This is just superficial pigmentation. And so in oculocutaneous melanosis You actually get deeper pigmentation. And that's a really important discerning point These patients are susceptible for malignant melanoma Not of the conge But of the correlate And so that's what you need to remember with these oculocutaneous melanosis people So this is that superficial congectable pigmentation. This is deeper Deeper pigmentation All right, what do we see in right here? Sneha. Well, I apologize for the color in in clinic. That was almost more pinkish than it was yellowish This is a 14 year old. All right, so you'd be concerned about a nevus here And does this help you any A lot of cysts. What does that mean in this lesion? All right, so as we go to a higher power What you see is you see these cysts and one of these cysts lying by and then what are these guys in here? Goblet cells. So if we go back When you have these nevi In the congenitiva and an adolescent or a child going into puberty eventually They will often grow and the tip off is you'll see cysts in there and you can see these with the slit lineup And and the way I remember it is Where do the melanocytes come from embryologically? The neural crests. So the melanocytes migrate out from the neural crest. They go to the junction Of the epithelium between the epithelium and the substantial propria then they start to grow And then they drop down into the sub epithelial tissue and while they're going they grab epithelial cells and you can come down with them Okay, is that what happens? No, but Don't say that on oral boards, but that's how you remember it So remember they migrate out they grab epithelial cells and so that lets you know this is a long-standing nevus Maybe even congenital And so when you really question the parents they will often say You know something's been there for a while, but it's getting bigger. It's getting darker So as these kids get adolescents these not only grow there's some kind of a hormonal influence to them But they actually get darker And so then they notice them and that's when we end up removing them And so if you look these will have cysts in them and that's a really Reassuring feature that this is not something that you worry about, you know forming a malignancy All right, so when we look at nevi Of the con Sean, how do we subdivide them? And what is this particular one? Junction, so you look at the nest of melanocytes They're here in the junction between the epithelium and the substantial property. There's often some inflammatory cells underlying them So this is what we call a junctional nevus Alley, what kind of nevus is this? Compound so it's got both junctional And sub epithelial and then lastly Sub epithelial, so this is the equivalent of a dermal nevus of the skin again There's no dermis on conjunctiva and I'll know around eyelid skin for that matter But so it's kind of the equivalent of a dermal nevus reason that this is important is When the melanocytes lose touch with the junction, they lose their malignant potential And so you can still technically have a malignant melanoma rising from either junctional or compound nevus Not from a sub epithelial nevus So for some reason once they've matured and dropped down, they've really lost their malignant potential What do we see in here? So an external photograph looks like this brown kind of like dust-like lesion along the limbis So more likely a Pam what does Pam stand for primary acquired melanosis? Exactly. So if you look at this, it's flat It's almost like someone took pigment and just dusted it. It's often at the limbis. So this is my favorite story I tell this every year. This is about a 40-ish year old female On the anxiety scale of 0 to 10 about a 12 And and just looked it up online and he's asking me questions Oh my god, am I going to die? Is this the tumors in a melanoma and asking me other questions? So 40 minutes later I calmed her down and said we're going to photograph this We're going to bring you back in six months However, if it changes between now and then You let me know and I'll see you sooner and if it's really bothering you, we'll remove it And so I'm sitting home at night That night, you know watching the news and I get a call from the resident on call Did you see patient's silence up to the acid? Well, yeah, I did. Well, she just called in it's growing And so she literally called that night It's growing and so to keep from getting phone calls every day for the next six months I said fine come in and we'll remove it for you And the reason that that was good is because we rarely see these lesions Pathologically because we never removed them and so Mike, how do we soak them divide Pam? So you got with, atypia, without So what is this one? This one just looks like it's lining up on the basement Embracing pretty not atypical Exactly so Pam without atypia is benign melanocytes right along the base of the layer of the epithelium And this is even what normal racial pigment looks like so when you see a darker skin person It's not uncommon especially at the limbus that you'll see a little pam like looking stuff So don't worry if you see someone who's darker or pigmented They'll have this at the limbus often And so we can call that just benign racial pigmentation. It's the same thing as Pam Without atypia And you can see on a close-up These melanocytes benign along the base of the layer they do not extend up into the epithelium They don't show any atypical features All right, what are we looking at right here? Yeah, so you look right now. It's kind of elevated. It's irregular. It's splotchy It's in multiple areas And we go ahead and we do a why I see what do we see in here? Yeah, let's pretend for for this picture that the basement membrane is intact. Let's pretend, okay So this would now become Pam with atypia. Why is Pam with atypia important? Exactly. So so Pam without atypia does not become melanoma Pam with atypia does So if you take 100 conjugal melanomas And you look and try to see where they came from Probably 80 percent of them will arise from pre-existing Pam with atypia Now it's not the flip. It's not that 80 percent of Pam with atypia goes to melanoma not necessarily But if you have melanoma about 80 percent of them arise from pre-existing Pam Maybe 10 to 15 percent arise from pre-existing nevine That went bad and the others sometimes we just don't find it but by far and away the most common is The melanomas arise from pre-existing Pam with atypia. So pearl here. I shouldn't be giving you away these pearls So you only have to remember three percentages for your career to answer questions 15 45 and 80 Okay, why are those important because if you think something is not that common you say 15 That way you're covered anywhere from gosh five to 25 If you say 45, then that's you're kind of covered in the middle if you say 50, they know you're guessing So if attending says what's the percentage of this? Oh 50 they know you're guessing And so but if you say 15 45 or 80 then You know if you think it's rare or intermediate or common then if you have no clue what it is That's what you're saying. You say it with confidence 80 percent And they say oh, okay. Yeah, very good. Very good. So you get credit for that. Okay That's only if you have no clue These are pearls now as you remember these and so I shouldn't be giving you these pearls All right, so now we've got something a little bit worse here Catherine. Why is this worse? Yeah, so you still see the All right, so one thing you got to remember Pigment in the fornix is melanoma until proven otherwise So you can't just say well, that's probably just Pam. No That's melanoma until you prove to me that it's not and you can tell that this patient's had previous surgeries before to remove pigment lesions because look at the simblethora on the scarring between the Bulbar conjunctive in the palpivore conjunctive across the fornix So this patient is at multiple pigment lesions. They've been removing them. They keep coming back Now unfortunately, they've got this pigment lesion in the fornix and that is very poor prognostic feature So now we're looking at this and I want you to this is low power. So it's kind of hard to tell low power If you look right here Here are some melanocytes in the epithelium in the epithelium in the epithelium. Oops They've now invaded. So this is superficially invasive Malignant melanoma question You can see either one Yeah, either one. There's no predilection. I mean, it's uncommon for it to go into the fornix most commonly this will occur On the actual bulbar conjunctiva, but you can get it to spread anywhere So right here, this is Primary acquired melanosis with a tippy giving rise to malignant melanoma the conjunctiva And as we go to a high power these melanoma cells can look very bizarre So if you look right here big nucleus clumped chromatin all over big cell Big cell small cell so pleomorphic You know many different sizes many different shapes And so this is malignant melanoma and again these can be bad actors because They can go into the orbit. It can even metastasize And this is just a special stain for melanocytes So you can do a stain. It's called hmb45. You can do a melan A stain all kinds of stains Unfortunately the Stains that stand for melanocytes don't tell you by nine from malignant They just tell you melanocyte from other nasty-looking cell So we'll sometimes do these if we have a you know, kind of a big malignant looking cell Sometimes they all look alike and so we do these stains to tell for sure it's a malignant site And this is what can happen if you don't Take care of these And so this was a pam And this was an old, you know vet, you know old vets They don't come into the hospital until the eye is literally coming out of their head. And so by now You know, this is this is an regeneration. So you don't want to let it get to this point And we say goodbye to the Eiffel Tower All right, so you guys get a christmas vacation here. We're obviously not going to lecture christmas eve or new year's eve So have a good holiday and we will be back to a little january 7 Um lymphoma amyloid is much much less common. So if you see a salmon patch you think lymphoma Other questions we still got a couple minutes Any pigmented lesion in the fornich you have to at least biopsy it And boopy will go flat out. He'll say it's melanoma until proven otherwise. He says you just remove it period The problem with these pams with echipias like that one picture we show They don't show up in one place. It's like there's five different places They'll be there and then you take a picture of Ronald flair and you remove it and another flair and you're removing the problem Is is you're constantly putting on fires with these guys, but you can't just you know eviscerate everybody. I mean Exenerate everybody that's got this PAM. And so you just try to treat it as you can initially Some of the pams are now responding to topical anometabolites And so people are looking at those to the treat PAM or you can treat them You know by just removing them serial times But in any event if you see pigment going into the fornich you really got to be careful with that other questions All right. Have a good holidays