 see how to move through through this slide deck. These are things that kind of become inherent once you start doing cataract surgery and things like that where you're kind of looking at, okay, how big is the eye? When you look at the white to white measurement on the cornea, there's usually you know 11, 11 to 12 millimeters is kind of average. At birth, the cornea is a little smaller, so you'll notice that if you're doing like a PK or something that you don't have as much room to sort of treffinate or sorry punch a cornea tissue to put onto your graft. The power of the cornea, so when you look at kind of the power of the cornea, the anterior cornea is actually a little bit steeper than you would expect. The posterior surface has some negative power and so the average ends up being right around 43 to 44 on the power of the cornea. There's a bunch of corneal nerves that come in. They love to test that they're from the long posterior ciliary nerves. Epithelium, when you're doing PRK, you'll kind of realize it's between 50 and 60 microns thick. We do a pachymetry right before we start the surgery and then once the epithelium is off, we do another pachymetry measurement and that helps you kind of understand the thickness of the cornea and all the different layers. Most of the cornea is stroma and so a majority of what you're dealing with in the cornea is that connective tissue, the collagen fibers of the cornea. They love to test that the basement membrane of the epithelium is type 4 collagen that is not Bowman's layer. So that's type 4 collagen for all basement membranes. Bowman's layer is actually type 1 collagen so the key factor there is that it's not going to stain with that PAS stain that you get with type 4 collagen. Stroma again it's mostly water actually by weight. It's about 480 microns thick so it's a majority of what you're dealing with on the cornea. Decimates membrane is one of those PAS positive membranes. It's type 4 collagen so you think of it as a basement membrane for kind of endothelial cells. You have this banded kind of anterior layer and non-banded posterior layer so those are kind of different types or parts of the decimates membrane. Most of it is pretty standard where it doesn't change with age with that banded layer but then the adult kind of increases with age in thickness. Endothelium is a mono layer. Initially it starts out with 3,500 to 4,000 cells. Most of our transplant tissue ends up being about 22 to 2,600 cells. If you get a younger corneal, sometimes hit that 3,000 cell mark but it's essentially a mono layer of cells that does not regenerate so there's no stem cells on the cornea as far as the endothelium goes and so once you kill off endothelium it continues to go down. So once a cell count kind of gets below about 1,000 is when you start worrying about endothelial failure from any intraocular surgery things like cataract surgery and things like that. All right let's see. What can you guys actually see on my screen? I'm trying to can you guys see all these boxes over here too? Yeah it's just like your like your desktop. There's my desktop. I can't get this to go to full screen mode. All right. May I ask a quick question? You said that it's under 1,000 when there's failure with surgery and then if there's no surgery it would be under 500 when there's failure. Is that correct? Yes exactly. Yep. Yes you'll start to see the the swelling start to pick up once you get in this range but yeah below 500 is kind of the cut-off they use. But on surgery you expect to kill off a couple hundred cells so that's where that kind of comes from. That makes sense thanks. So the sclera they love to test on the thinnest area it's right underneath the rectus muscles that becomes important when you're kind of dealing with an open-glo blunt trauma injury that's why you have to kind of look underneath those muscles is because that area is kind of the most likely to rupture. It's made of type 1 collagen and it's pretty regular as far as its orientation and that's why it ends up being pretty white in color. So again just kind of reviewing the types of collagen, type 1 collagen, Bowman's membrane kind of falls in there so don't get that confused that it's not a basement membrane. True basement membranes will always be type 4 collagen. All right so this is a highly tested topic sorry these are super small I tried to put too much on this slide. You have follicles versus papillae and where they show up in different disease processes. So in follicles I kind of think of those kind of chronic follicular reactions that they come up in. So you can get them just with chronic just plain old inflammation. So if an eye is just inflamed for a long time you'll tend to see follicles show up but you want to think about things like meluscombe and HSB as viral causes and then chlamydia is kind of a common cause of chronic conjunctivitis as well. When you look at papillae I think of more just kind of generic inflammation with bacterial infections. Allergies tend to get papillae but sometimes you can get kind of a mixed reaction with allergy but you think of that giant papillary conjunctivitis is kind of the papillae that form on the upper eyelid. And then floppy eyelid syndrome is another common one where you get these large papillae happening. You think of that as being when kind of an eyelid is almost getting rotated over and rubbing on a pillow at night and so you sort of get that inflammatory reaction there. So if it gets beyond four weeks you start thinking about some of these things. Again I'm mostly thinking about chlamydia. I mean this is like some sort of mnemonic that I never could remember but viral causes like HSB, keratitis and chlamydia. And then meluscombe I've had a couple of cases of meluscombe causing chronic follicular conjunctivitis and to me the meluscombe that I always saw were just like just tons of lesions in kids and I didn't really ever see them in adults but I've actually had a couple of adults and I had one that was just like this little tiny probably about a millimeter and a half lesion on the upper lid and I noticed it and asked the patient and she said yeah I've never seen that before now but I can you show it to me I can see I can tell it's there and Dr. Marks actually went and excised it and it was meluscombe. So that comes up occasionally when you're when you're sort of examining the lids looking for causes of chronic follicles. But tenials are kind of weird things they tend to have kind of this white-raised center with a lot of vascularity around them and they are most commonly bacterial causes are staff. You have to think about tuberculosis in endemic areas. They typically respond well to just kind of topical steroids so most of these patients we treat them with like a maxotrol or Tobromycin sometimes you'd separate out and get them a good antibiotic like just even like poly trim or o-floxacin or something like that then do a topical steroid a few days later once you kind of get any bacterial stuff under control. Just make sure you're watching out for tuberculosis. So it's one of those things where it's like there's this systemic really bad disease that you have to watch out for and so they love to show a picture of that and test you know what's a positive PPD and how much elevation you have to have or what if somebody's been vaccinated whether what kind of reaction are they going to get from a PPD test? All right so we do a whole lecture on degenerations of the cornea so these are essentially really common ones I don't they don't really test a whole lot on these conch palaces comes up occasionally teridium maybe here and there but not not like a highly testable topic here. Hypersensitivity reactions these are things you just have to know cold you know what type falls in in which area. Stevens Johnson is a common one they test on with type three kind of an antibody antigen complex flictenol which we just talked about is a type four any granulomatous disease is typically a type four so like syphilis tuberculosis can kind of lead to that. Stains will come up occasionally looking at you know do they stain devitalized cells or do they stain actual disruptions in the intercellular junctions between fluorescein and these other two. So atopic keratoconjunctivitis really common thing that we see in Utah there's a couple of different reactions you see with this you'll see a type one and a type four sometimes in combination a lot of these patients will have symptoms year-round but when you have really bad atopic disease it'll kind of flare up in the spring and fall with kind of the with the seasonal changes it's raining in California how is that possible all right i gotta go under a deck or something i'm gonna move over send that water this way i know i should should be coming right let's see if this is any better it's like a 40 chance of rain today i'm like that's better than any chance of moisture we've had in utah for a month all right let's try this spot okay so let's since i switched seats we're gonna switch gears a little bit we'll move over to uh we're gonna do some test questions i'm gonna get you guys involved a little bit here all right now we're better at full screen right yeah okay lydia i'm gonna have you take this one on so i want you to describe the picture for me and this is a classic o-cap picture where it's super crappy and you can't tell exactly what's going on okay um so this is a external photograph of the lower eyelid the lower eyelid is inverted and what i see when i look at this photograph is that instead of the regular smooth surface there is an irregularity um that looks like there could be like some elevations that are looking kind of around what i'm trying to look out for is if there are vascular tufts in the center or not um to be quite frank it's very tough to tell on this photo i saw it next to your folliculitis so i suspect that the tufts are just on the like that they're no tufts but that it's just around the base but i would have a hard time telling it from that photograph um it's just kind of pearly right they just look kind of pearly and elevated is the way i think of a follicular conjunctivitis so i agree with you okay well as we mentioned before chronic inflammation um would be what i would would be thinking of and then rolling out all the causes we talked about previously all right so here's a question for you yeah um oh i highlighted it what the heck what happened to my other slide oh man i'm failing you guys my other slide got deleted somehow all right it's not would be more slaughtering and uh less a folliculitis correct yeah so stevens johnson um when you think about that you kind of expect to see kind of a membranous conjunctivitis in some cases and then also um symblephron right so those are kind of the two things that we worry about with stevens johnson once you start to see the membranes form they'll start to stick together and cause those symblephron so that's why you guys go after these with the glass rod or or i used to use a scleral depressor where i would just kind of break up any adhesions that were in the in the fournesses of the eye um in those stevens johnson patients all right good let's see so again chronic follicles those are kind of the big ones you're thinking of all right let's see col you want to take this one on uh probably four all right yeah good method of injury i'm sorry i don't like to have test questions that are all of the following except does that sound like a typical co or a ocab format but but yeah so talk me through this a little bit um so basically do you have any sort of high pressure in the eye or issue with the red blood cell or the endothelium so kind of those first three pressure pushing blood cells up against the endo or sickled cells more likely to stain and then if the endothelium sick okay perfect all right so method of injury doesn't matter you just get blood in there right so it could be post-surgical um could be um any kind of trauma all right tony one second just reading it uh in between let's see two and three um maybe maybe three mydomycin C therapy alone all right so what is c i n congenitival um um uh intra epithelial neoplasia okay perfect so we've got some sort of a a lesion that's on the spectrum of cancer right it could it could be all the way from just mild atypia all the way to this is the spamous cell carcinoma potentially right um so the best way to really treat this is probably to get the tissue off of the eye and send it to pathology that's probably ideal that's kind of textbook okay we got to figure out what this is um that's not necessarily true um in today's world and most commonly what we would like to do is actually treat these they they respond best to interfere on um topically or sometimes injected so that would be kind of the treatment of choice probably today so the second option would be um wide local excision with cryotherapy so when you do mydomycin C doesn't work quite as well for c i n you'll sometimes use mydomycin C topically after removing like a pigment at lesion like even in melanoma therapy so you kind of remove a melanoma then sometimes use topical mydomycin C um wide local excision I think is the correct answer here um cryotherapy is kind of the key part to essentially say okay I'm going to remove everything that I can see surgically and I'm going to give myself some margins um and then with cryo you essentially are going to kill off any cells around the edges of your um surgical bed where you essentially freeze the tissue and then let it thaw and you go all the way around and then you do it a second time so that's that double freeze thaw technique on on cryotherapy I asked this question as well could these are true except for oh no no no you're good you're good so yeah the key is if you do simple excision with this that's the wrong answer and you'll have ophthalmologists that do that because they don't have a cryo um and then the better sort of topical chemotherapy is interferon so those are kind of the keys to this one all right good okay I showed you a picture of this Sean softball unless you were head got on later tenual all right you like that identification of a flik tenual okay so what type of hypersensitive reaction is a flik tenual oh this is going to be embarrassing what didn't didn't we say it was a type four hypersensitivity you got it yeah all right type four it is yeah all right Sean you win what's the systemic disease you have to watch out for tb yeah tuberculosis what if a patient been vaccinated against tuberculosis how would you test them uh I don't know quantity does quantifier not work anymore I think the bcg will will still will be reactive but yeah I was thinking quantifier on gold because I think the ppb you'll do weird stuff I can't remember the details of it though somebody might have to get it might have to just okay so type four you got this kind of ulcerated apex which is why it's kind of white in the center and then the redness around the side really commonly seen in kids for whatever reason so kids get these a lot and it's most likely that staff sort of bacteria that's causing it these usually like kind of spill over onto the cornea from the limits are they usually more just straight on the conch like that they're more like the bottom picture than the top picture but you can see them where they're just right up against the cornea and usually the corneal sort of findings are more likely to be like a delin type thing so the question is pulling is it a hard to tell difference between of like tenual like on the bottom picture and like a nodular scleritis or it can be yeah for sure that would kind of be your differential and if I try to move it around and see which layer it's in usually nodular scleritis is much deeper um yes so that would be one key thing you could try using like a phenyl ephrin drop to see if that changes the the vascularity of it these ones that are kind of really superficially injected sometimes that phenyl ephrin won't get rid of all of it but you could still kind of tell if it's deeper kind of coming from the sclera instead of the congenitiva yeah but it can be hard to tell that's for sure all right tyler haven't seen tyler chime in so he might not be available totally I think tyler's on consult right now I can go oh you're good Brandon go ahead yeah um so external photograph looks like it's a superior ulceration not at the limits but also so I would suspect some type of either trauma or shield ulcer like gpc I don't really see a large infiltrate so it doesn't look too infectious to me or anything like that okay good what kind of trauma would you be thinking of here is there anything like specific um I don't think no upper part of the cornea has like an epidefactor abrasion like uh if you have like intra not intraocular but foreign body within your lid or make sure that yeah absolutely yeah that's a that's a big key thing so if you ever see something on the upper cornea that's kind of abraded that's not commonly going to get hit by somebody right a finger or something hitting their eye because most people will have that upward bells reaction and so the injuries are always to the lower cornea um some people do have a downward bells when they get an injury or something coming at them so you can get that but but most commonly you would think of there's something on the upper lid and that's kind of the pathology here is that there's something on the upper lid all right so what's the cause of this spiny that's a vernal with a shield also yeah yeah so the history is going to help you right so the history of this patient is I've had allergies and so the vernal character conjunctivitis the vkc comes up if the history was different it could be any of these things right so if it's like gosh nothing happened to my eye and I just woke up and it was feeling fine and then as the day went on it started to just hurt more and more you might think oh this could be herpes simplex coming on if it was more of trauma like you said I was out weed lacking and got something in my eye it felt a little bit weird that day but now it really hurts could be that there's something underneath that upper lid with the number four recurrent erosions Brandon how do those usually present so lots of times these patients will have recurrent erosions typically they'll have one I know it's common for those patients to have epmd in regards to how they present typically they'll heal and then overnight their eyelid will kind of stick to their epithelium then they'll resloth off their epithelium and wake up with a ton of pain good so they're just causing abrasions every time that lid kind of sticks to the cornea um anybody know the mechanism of action of that overnight issue why is having your lid closed such a problem isn't it that like suction or hydraulic effect on the cornea on the epithelium yeah so what happens is when you sleep at night with the lid kind of closed over the cornea the cornea actually retains more fluid and so it gets swollen and so the epithelium becomes a little bit more loosely attached um with the stroma swelling and so you end up with kind of a situation where that skin's a little looser yeah and it's just a tug of war every night where the lid and the cornea are kind of fighting and in most cases the cornea wins that tug of war but when somebody has looser skin then um the the lid can sometimes win that so good all right uh vkc so it has a little bit of a type one but mostly type four reaction typically once you get these people into puberty like uh 10 11 12 this starts to go away so it's kind of something that i usually tell them to look forward to is that it usually gets better with a lot of these patients now i try to get them into an allergist pretty early um because i think they've they've come a long ways in treating allergic conjunctivitis and vernal conjunctivitis with with shots like allergy shots they can usually find something that's causing the inflammation and treat it all right should we go back to the news at the top back to lydia yep um so this is an external photograph of uh both eyes and looking uh looking at it the upper eyelid is pulled up and it looks like there is um a mass possibly underneath the upper eyelid and i think i would be concerned for i wonder if this looks like salmon i haven't seen enough of those like i think i'm always thinking of like lymphoid tumors that look like salmon patches or things in the lacromal gland because that's the area where um there could be an effect um of course also like foreign bodies would be possible that's it um but yeah that's kind of all right so that that what you're seeing there in this crappy photo is that is his lacromal gland okay and it's pretty normal in size so what do you think about as lid the lid is very floppy very floppy right okay good let's um i would suspect sleep apnea yeah all right so what does he have um well he has floppy eyelid syndrome okay perfect yeah if you try to do that to your lid like you can't i can't see my lacromal gland when i do that right i mean that lid is crazy floppy so as ophthalmologists sometimes we um we don't ever touch our patients right so getting the habit of kind of touching your patients in the fact of just lift that upper lid lift that lower lid just kind of get a feel for what their lid position is like and sometimes you'll you'll clue into why their eyes are chronically red or or what's going on with them sleep apnea can kill people it can cause heart problems it can cause um chronic brain injury type issues where they are essentially hypoxic overnight so they love to test you on things that correlate with that and it's interesting to have those conversations with patients too it's like you might have sleep apnea your lids are pretty uh pretty floppy maybe get that checked out um it's kind of a weird appearance that you'll get to be um the palphebroconjunctiva where it becomes like this super smooth red appearance in a lot of cases you'll see like giant papillary conjunctivitis but sometimes it's just this beefy red relatively flat looking inflammation on that lid from rubbing all night um i deal with patients that have keratoconus a lot and keratoconus is a common finding in floppy eyelid syndrome a lot of these people tend to be overweight not always but their heads tend to have a little extra weight to them and they like to sleep on their face for some reason i don't know why that's the most comfortable position but that the weight of their head on their eye can cause changes in the shape of their cornea with keratoconus so essentially the treatment is lubricate like crazy if that doesn't help then sometimes you'll do a wedge resection surgery with the ocular plastics kind of shortening the the lid tends to elongate in the sort of horizontal plane and that's why you get the floppyness of the lid okay so we're going to shift gears again let's see it's 630 let's try something here that i've never tried i'm going to stop sharing so what we're going to do one two three four five so we're only going to have two groups but we're going to i'm going to put you in a breakout rooms just for like five minutes and i want you to come up with a test question um let's see so we're going to do a test question on keratoconus and one on fuchs endothelial dystrophy so those are kind of the two topics um breakout room one will do the keratoconus and breakout room two will do fuchs endothelial dystrophy so you're going to come up together with a test question just a multiple choice question that you can then quiz us on and then teach us a little bit about your question so let's try it it's like we have Cole and Tony in room one and Lydia and Sean in room two questions and and i'm Jordan oh Jordan you're in it too i don't know how to put you in a room i don't think i can put you in a room i might have to just choose oh okay all right so i'm going to open the rooms and let's see what happens let's see brandon how do i put you in a room no i'm not sure i'm going to sign you there you go now you can go into room one yeah Jordan i don't know i don't know if i can get you into a room yeah i think with the with the host privileges i don't i don't know if i can even put myself in a room all right so let's let's come up with one yeah i don't want to put the host in a room because then i think it it might do something weird to the meeting let's see what do you want to learn about you want to do why don't we do one on recurrent erosions let's come up with a test question for that um you know anything about them not particularly than what was just kind of discussed i actually don't even know what the acronym that brandon was referring to like that mdpb yeah so you have ebmd or abmd or those those two refer to anterior basement membrane dystrophy or epithelial basement membrane dystrophy okay gosh um where you essentially have duplication of the epithelium and it causes the skin to it tends to cause the skin to be loose and so you're more prone to recurrent erosions with that disease and then it causes kind of irregular astigmatism and patients wake up with pain um so i guess let's think about this so do you know the treatment for recurrent erosions um i would imagine um that it would start like it was mild would start with kind of like surface lubrication um like topical annoyance and then if that didn't work potentially um like going towards like uh amniotic membrane or um like that like bandage contact lens like some sort of like protective issue or thing or would also like a scrape do you do like an epithelial scrape ever and like with a diamond burr or something and just try to get it to like re-epithelialize on a never like on a rougher surface yep so you essentially lubricate like crazy so drops ointment sometimes a really effective medication is um muro or sodium chloride okay and it helps dehydrate the epithelium to sort of try to keep the stroma a little bit tighter um attached to the epithelium and then plugs so punctal plugs so those are kind of the full court press on lubricating and then um if they keep happening then you would do i think a bandage lens sometimes with an amniotic membrane um would be good and then from there you have to go into surgical options so you have superficial keratectomy with diamond burr polishing yep and then another option is uh ptk which is phototherapeutic keratectomy so you do prk essentially on the cornea so remove the epithelium do a small laser and then let it heal back those those two are designed to try to create scars so the skin heals more tightly oh and if it's off center is that if it's like not center involving you can also do like uh can you do like a 25 gauge needle just trying to like puncture Bowman's membrane just try to get like a little reactive scar right there as well yep so they call that stromal micro puncture stromal micro puncture okay yeah perfect all right you come over the test question with all that info um I guess I think like what is a good like surgical management option for center visual axis involving recurrent erosion after you have already after like aggressive lubrication has failed perfect I like it okay what options do you want to give um so I would give them superficial um keratectomy um with diamond burr I would give them also uh the 25 I would give them the needle um stromal micro puncture just stromal micro puncture because you wouldn't want to do that if I was center involving perfect um I can give them give them like a pk okay yeah pk that would be crazy yeah um how about lasik okay all right that works on the right okay yeah all right I told them they could have five more minutes so they've got four left so let's see uh I actually think I could sneak into a room should I sneak into a room see what's going on just drop it says I can join them but yeah I don't even have the option to join which is how's Disney if I don't enjoy Disneyland but that's okay I'm the same way I uh all the the ride heights were always like six nine and I'm like six seven and I just wonder exactly how tight their tolerances are I would imagine there there's probably a fair bit of breathing room but they have a height limit on their rides I never thought about that a lot of them yeah that's interesting I don't know if it's for the head or for the knees I hope it's not for the head but yeah I'm assuming it's for the legs kind of a tight tight squeeze in those things we did get to see the uh Super Bowl parade oh really nice yeah so they had a Aaron Donald and Matthew Stafford and uh Cooper Cup on a little float down Main Street yesterday and it looked like they did like a live something or other so they interviewed them and were shooting something by the castle so it's kind of cool to see them that's awesome I didn't even watch the Super Bowl this year no no just a good one I heard I feel like every game like every playoff game was just really good like the whole playoffs were awesome they were like just tight games anybody could have won them yeah we were just chatting about life so Lydia and Sean might be uh really into this so I have to give them their their three minutes a few minutes what do we got left yeah two minutes we also didn't know we could leave the room so I wonder if they're just waiting I'll go over there and I'll go see what they're doing I'll be back you get if you guys keep writing this weekend look for my phone did you get a new one are you on your laptop so I'm in my laptop it should be in the mail but it hasn't shipped yet it's on the last run of the day I brighten off a snake creek right into the trees on the left it's somewhere and that's the problem it like wasn't a main run yeah I can see it on find my iphone but I can't find it yeah I did I did the same too with I just lost my phone in the snow once and you can never find it again yeah dude there's definitely like a 14 year old park rat in a triple x tall teed chop shopping your phone right now oh I locked it there there was also at Brighton I said there was a DJ who was 11 years old wow that makes a lot of sense DJ Q Jordan I'm thinking about going up tomorrow to Park City after uh in the evening oh yeah I'm gonna get some skinning and Brandon might join too dude I might join that'd be dumb Brandon were you talking with Jacob yesterday because he said he was at that hole in one at the waste management open yeah dude that's insane he said it was like one of his top five sports moments ever yeah yeah he's like I don't really even like golf that much but I'm like that would have been like the highlight of my life yeah that's insane and then they offered all the drinks on the green he said he definitely threw one yeah that's awesome that's crazy I would love to go to that tournament it'd be fun I think you were muted I'm not sure if you were trying to say something oh I bet it's the same temperature here as Utah 55 degrees that's too cold for California I know it's not gonna get out of the 50s today you guys go into the park today yeah yeah kind of perfect because it's not too hot so yeah all right I'm going to put the intern on the spot Jordan's going to give you our question first I helped him because he couldn't get into a breakout room so all right so this question is relating to recurrent epithelial erosions and the surgical management thereof so if you have a center involving recurrent epithelial erosion the appropriate surgical management is either one pk two stromal micropuncture three superficial keratectomy with a diamond burr or four lasik surgery all right Sean why don't you take that one on well I think a pk would be a little bit extreme we don't want to go there quite yet I think that lasik would probably be a poorer option at this point um micropuncture I feel like is something that that maybe could be considered but I think the first line would be a superficial keratectomy uh yeah all right Jordan what what distinguish those two answers in your question uh just the center involving so if it's more peripheral you can do stromal micropuncture yeah your bowman's membrane you have some reactive you'll get scar in there yeah yeah so if it's within the pupil um you don't want to do this stromal micropuncture you know what does that mean is it you know the central three millimeters the central four the central five I'm pretty conservative about it because I think superficial keratectomy works really well and so um I don't do stromal micropuncture all that much unless it's pretty obvious that it's peripheral so and you'll get some of these patients that have kind of chronic um bolus keratopathy kind of on a different topic where um they're getting these recurrent erosions or boli is kind of more of what they're getting and sometimes stromal micropuncture can work for them and if they don't have good vision potential then sometimes I'll do it in the center but for the most part stromal micropuncture is a peripheral corneal treatment if they were okay can you just do prk yes so what do we call it if it's uh prk for recurrent erosions it has a different name photo phototherapeutic yeah exactly so ptk so prk is photorefractive um so we're doing it solely for the refractive outcome and then um ptk is the therapeutic um purpose and insurance will pay for that so kind of a two for for those patients okay let's see breakout room one that was uh colin tony and brennan yep i'm gonna share our screen because we're academics all right let's see who's let's do i have to do lydia since shon just took that one that's a tough one um oh my goodness so i'm wondering if this is a horizontal line um that is kind of in the um so i'm looking for for forked uh lines basically like horizontal lines in the uh in decimates that would break as the cornea keratoconus progresses and then cause uh acute uh high drops and decompensation so i think i'm gonna go with uh voked line all right can you see the question lydia i call we got that we got iron line is seen oh oh my goodness uh the iron line there is an iron line in the on the base of the keratoconus and i believe that is cold i know they i know they're like different iron lines and i'm throwing them all together i think it was very lying that was or was it a flight the flight sharing yep there we go all right now you're now you're on ocaps and you're like crap is it a or c it's one of the f's but i can't remember which one it is uh yeah okay it's a flight sharing we followed up we followed up with this too maybe shan can do that hold on do we just say that this is a flight sharing yep yeah not to be confused with the kaiser flasher that's the same yeah kaiser flight sharing oh kaiser kaiser flasher right right okay all right uh what conditions which conditions are each of the other iron lines seen with now you have to answer four questions and liddy only had to answer one so where do you see a ferry line i don't know the answer to these i don't know any of these answers i can walk us through them yeah go ahead so ferry line i have stupid like little thought processes for these so ferry line i think of like boats and i think of like a blub like sitting on water so ferry lines like right underneath the blub hudson stolly i just think of this as like the hudson stolly river so this is like an older people their tear meniscus line eventually as you age you just get that like horizontal iron line like the inferior one third and then the last one stocker line i don't really have a mnemonic for that or thought process i just remember that's the other one which is associated with trigems at the leading edge if trigems are pretty stocky and they're just marching in yeah i think i'm creeping you know like a trigium is like a slowly creeping growth like a stalker would do yeah and then liddy was going for the boat stria which is kind of these uh b for vertical lines um that are super tiny and small right in the central cornea something to teach us more this this is just from your presentation i screen shot last year so nice i feel like this is pretty high yield yeah so these are the the issue with these kind of diseases is that you have to know everything about them and every association because they're the big ones they're the things that we're seeing on a an everyday basis and so you just have to know them all so my mnemonic for the hudson starling line it's that uh i always think of starlin and think that he's old anyway that's how i remember it yeah yeah very very old right one of the things about high drops i just want to point out um real quick is that a lot of the treatment now could entail probably it could be first line potentially is an anterior chamber gas fill so kind of fill the anterior chamber with air it sort of tries to reattach decimates membrane in the endothelium so that you get a little bit quicker resolution of the high drops so that's something to know is that that answer will come up more commonly now all right lydia and shan all right so our question is about uh fuchs endothelial dystrophy and the question is about cornea gutata do they start peripherally and spread centrally or do they start centrally and spread peripherally do they appear across the entire cornea or do they only appear after endothelial decompensation uh tony um i have a feeling they might start peripherally and move centrally but i'm not too sure okay you're kind of between two maybe one of the good test taking strategies is if two questions look the same but there's one thing that's different about them right that's probably your answer one of those two because they're trying to trying to fool you what do you think lydia um it's natural it starts centrally and then spreads peripherally yep so there's another type of gutata that we see that we don't really associate with books and what are those those ones that you guys also commonly yeah hassle henley they call them warts i'm trying to remember now hassle henley bodies yes bodies i can't remember what this term is but those are you'll see them most old people have gutata kind of in their peripheral cornea so that's one way to kind of distinguish it and and fuchs really is a visually significant problem and so if it's in the center of your view um that's that's when it's a problem and so just think of fuchs is causing vision problems and that will kind of help you remember that um let's see trying to get to this i guess i didn't realize i could share my screen a little different let's try this that more full screen okay so fuchs dystrophy it's typically starting to show up after age 50 um that's when they're going to start to have problems with it it's more commonly affecting women than men and so you'll you'll have a lot of i actually have a fair number of middle-aged females that have a strong family history of fuchs that have had problems with it so i've done endothelial keratoplasty i've done it on three now patients in their 40s and i actually met a patient who has transferred to me that had it in her late 20s that it was bad enough so it's these gutata they're they're part of decimates membrane so it's kind of this thickened collagen on decimates membrane that pops out and structurally you can imagine how that would sort of affect the endothelial cells which is this mono layer of cells so these little bumps are now kind of pushing on those and creating disruption in them and so you end up with a loss of endothelial cells and so as the endothelial cell count gets lower and lower the cells kind of enlarge and they try to fill it in so you get these really weird shapes and large endothelial cells that you'll see and eventually they start to lose their function and you get swelling in the cornea because they only have one slide on oh well he's gone California time starting kind of go to disney well yeah he seemed to realize it right before it happened his computer probably died he went oh is this just an hour long lecture yeah it is and they were probably pretty much done oh me he's coming back oh my god you're oh here he is i think my computer just died so we thought you were leaving to go to disney land that was a good time though i think i was done yeah but yeah i think the way that i sort of studied for ocaps is i would look at pretty much every disease and just try to think in my mind okay if i was writing a question about this what would i ask what would i ask it and i think that that when you get into sort of this test question writing mode you start to learn a little bit more about you know how hard it is sometimes to write good questions and and how you have to have to sort of stick to the basics in most cases and so writing questions is a helpful way to actually study for ocaps because you can start to learn what the test writers are actually thinking about i know dr lin actually writes for ocaps or maybe for boards one of the two and so her lectures would be good at court of sort of understanding her thought process on how to write questions too but corny is a fun one i actually didn't ever do very well on corny on the ocaps which might be the reason that i went into it is because i thought this is a really challenging field and so i think it's going to keep me interested in trying to come up with all the all the weird things that patients come in with any last thoughts or questions before i let you go on with your day if not i will leave you to utah have a good day everybody thank you thank you