 okay believe me I'm as excited to be lecturing on the 27th as you guys are to be here so I have to have a chat with Elaine and say you know what maybe the you know day after Christmas vacation we should probably not go lecture but in any event let's go to Copenhagen and so the best way to see it is by a tourist boat because the canals run everywhere and so you get a nice kind of an overview of the city and this is one of the old fortresses that the entrance to the harbor that used to protect the city and then they're very much into clean energy in Europe so this is something that like burns trash or something of the very very clean energy this is the mermaid and I don't know if you guys have heard the famous mermaid statue this is the famous mermaid statue in Copenhagen all the tourists sitting around taking pictures of it of course as we were there in the boat you see the Sun is coming right into our eyes and so that's as close as right from the boat so this is as close as we came to the little mermaid statue so this was based on Hans Christian Anderson's you know little mermaid or because you're younger Disney little mermaid you know okay I didn't have Disney when they made this statue but still so this is the famous mermaid okay cornea so Becca cornea anatomy starting from the outside and working to the inside what's the outermost layer epithelium and under that layer and then beneath that stroma decimace and endothelium so let's go ahead and let's start a couple layers at a time so I'm sure I'll tell me a little bit about the epithelium okay how many layers thick is it usually five to seven very good and I want you to know here's the epithelium here's Bowman's layer okay Nico what is Bowman's layer and if you were to injure Bowman's layer does it regrow it does not so key to remember Bowman's layer is not a base membrane we call it Bowman's membrane it's not really a membrane it's a layer so it's condensed a cellular stroma and it does not regenerate so if you damage Bowman's then Bowman's does not regenerate and Tara what kind of stain are we using right here and why would I be showing you this that's kind of staying red the red part now look closer at the epithelium it's a PAS and what does PAS really light up basement membranes so no here is the basement membrane of the epithelium right here here's Bowman's underneath it so the basement membrane of the epithelium picks up PAS stain Bowman's is not the basement membrane that's important people always get that confused and so Bowman's layer does not pick up PAS stain and the basement membrane of the epithelium does so it's above Bowman's all right what layer are we looking at right here Reese okay tell me about PAS staining and decimates it will stay so decimates is indeed a basement membrane in fact if you were to look at decimates with electron microscopy decimates is really two layers there's an anterior banded layer and that's thought to be the congenital banded meeting bands of collagen you have to do em to see them and they're very regular and that's the almost the congenital decimates membrane but remember because decimates is the basement membrane of the endothelium it is continually laid down throughout life so that posterior non-banded layer gets thicker throughout life because the endothelial cells are laying it down so decimates does indeed regenerate to get a break in decimates the endothelial cells can slide over and fill it in and lay out new decimates now okay so back to Becca in terms of the endothelium tell me what are the functions of the corneal endothelium okay so they keep it detergesse they keep the fluid from from going into the corneal because when the endothelium breaks down the corneal becomes a demodus fluid pours in there and whatever a couple of different ways the endothelium can do that okay so because I am I am Greek especially male Greek males are known to not talk quietly and to project and so when you are talking quietly and not quite sure what you're saying you're not projecting an error of confidence that you know the answer so if you don't know it you say I don't know if you're taking a guess say it with conviction you know you know so a couple of ways the endothelium keeps the corneal detergesse it's got tight junctions so the endothelium has very much tight junctions between the cells and if you look at it in three dimensions it's a geodesic dome it's actually hexagonal now if you look at it in cross-section they look cuboidal but in three dimensions they're hexagonal which is kind of nature's way of covering a curved space with a single layer so just like geodesic domes are hexagonal and the corneal endothelium is the same way it's got tight junctions but it also has a pumping mechanism so it'll also actively pump fluid out but nutrients into the corneal so it pumps both ways now can endothelium regenerate I guess I have to be specific in a primate yeah see that's fine you always say I don't know that's better than saying so it does not effectively regenerate now some people have argued well they maybe will have a few endothelium as well but they don't now rabbit you know if you guys are practicing cataract surgery in a rabbit now you know Reese could take out 10,000 easily 10,000 endothelial cells with his fake hotel but rabbits regenerator primates do not and so when you're in humans doing cataract surgery you knock out 10,000 endothelial cells with your fake hotel they don't effectively regenerate one of the issues now is to get them to regenerate and and there's a lab Dr. Kinshura in Japan is really trying to regenerate endothelial cells which would be great because then you wouldn't have to do corneal transplants or desex or surgeries like that all right so we'll look at some diseases here that affect the corneal what are we seeing right here then look at the pattern you said it's actually kind of between where the palpebrofisher is between where the lid sit so you've got this this dark area right here what do you think that could be that's one thought although I don't usually doesn't get that diffuse what else can be deposited in a corneal calcium exactly and this is one of those descriptive terms you see it forms that broad area that band so thus the name band caretopathy and so it is indeed a deposition of calcium it starts at the limbus between the eyelids and the palpebrofisher and eventually will march all the way across the corneal now band caretopathy is pretty non-specific it's just a sign of inflammation in general and so you can have it from external inflammation you can have it from internal inflammation but you get deposition of calcium and here is a close-up of a corneal with band caretopathy now extra bonus points these kind of blank spaces in the middle here where the calcium is not being taken up and I'm not sure is a legitimate answer that's okay well believe it or not these are where the little nerves penetrate through and so when the nerves to the epithelium they penetrate Bowman's layer and where they do it leaves a little circle there in the calcium so that's where the nerves penetrate now if you ever had a corneal abrasion if you have you know that that cornea is exquisitely innervated because it really hurts and so these are just the nerves poking through the calcium so when we look at the pathology I'm sorry I shouldn't flip this around it sideways but here's the epithelium here's a bunch of connective tissue here is Bowman's layer and what stain is this well this stains the calcium red so this is alizarin red and it stains calcium and so you see the calcium is predominantly along Bowman's layer and that's where you've got the calcium now Niko what's going on right here layer hard to say I'm not sure if it's intact especially to the right you know what Bowman's is intact it's still there so there's a lot of proliferative and above the Bowman's layer so what do we call that if it's growing from the limbus between Bowman's and epithelium it's a panacea and so panacea can often run along with band care top then if you look right here here's the epithelium here's Bowman's with calcium and here's connective tissue and so panacea is one of those things that again is kind of a non specific sign of a chronic inflammation and so panacea and band care top they often run together they're homies they hang together so if you look right here you can see panaceas can be vascularized but also panaceas can be fibrous and here again here's a fibrous panacea this is calcium along Bowman's and calcium here so panacea and band care top they often run together Tara what are we seeing right here yeah that's kind of a weird picture with some heterochromia but I was trying to show the Arcus here they used to call it Arcus senelus senelus is a bad word now because you know we're not allowed to say senelus it's bad so maybe President Trump will allow us to say senelus now he's gonna take away political correctness he's gonna say like it is say senelus but if you look right here it's interesting when you see this arc of this shadowing around the periphery note the clear zone and so whenever you see a clear zone and then the limb is here in a clear zone it usually means that this is kind of a diffusion gradient of some kind or people have speculated that this may be diffusion and what is the material in Arcus senelus it's actually lipid so it's a lipid deposition and so if this is indeed lipid and I'm showing you this slide what stain would this be oil red oh so this is an easy one to remember because it stains those little o's red and they've got a oil in them so oil red oh what do we have to do to the tissue in order to get this stain to work has to be fresh because if we process it through the oil gets dissolved and so this is a stain on actually a fresh corn and I had a copy this from Dave Apple I mean you know we don't get fresh corny as said to us and so this is an Arcus senelus and you see that the deposition of lipid is more anterior and more posterior here and people say it's shaped like an hourglass you know how an hourglass comes into the middle and then goes out above and below so it's shaped like an hourglass here so the lipid is more posterior and anterior here and again it diffuses in a little bit from the limits and we see this you know at the VA you know everybody's got a pigwekula dry eye and an Arcus so you see this very very commonly it doesn't really portend disease nor necessarily mean that they've got high cholesterol or high lipid all right Reese what do we see in here okay so what do you think is causing this okay so this is what I call a classic dendrite you see the little bulb shaped out pouchings and that it stains in the middle and you've got the little bulb shape so this is classic herpes what kind simplex now zoster dendrites aren't quite this classic you can also get dendrites in in zoster but herpes most common so you guys are going to learn something today that's going to help you for the rest of your career if ever an attending shows you a picture of the cornean says what is the differential diagnosis you say off-handed well of course herpes and you say that off-handed well of course herpes and then they say well which one you say well most likely simplex but could be zoster so remember that no matter what they show you because herpes is in the differential diagnosis of everything and so you say it off handle of course herpes while you're thinking of what the real differential diagnosis is and so that they'll help you get through boards so when you look at a cornea here you can see that what's happened to the epithelium here yeah it's gone and so remember what does fluorescein stain exactly so that area that's the bright green staining is where the epithelium is denuded and so if you were going to try to do a culture you don't want to scrape right in the middle here because the epithelium is not in there's no active viruses there you want to scrape at the edges here where the active viruses and so the fluorescein dye is taken up where the epithelium has been denuded or broken out so you can see that and then you see there is a chronic kind of mononuclear inflammatory reaction mostly lymphocytes which you can also get a deeper herpes what we call a stromal herpes or you know deeper herpes and what this is characterized by is you get inflammation way down deep near decimates membrane and sometimes you can even see giant cells along decimates membrane really deep and so these are more difficult the epithelial herpes are easy to treat you treat topical antivirals you can even just scrape them and denude them and that will help but once the herpes gets into the stroma then you start to get the chronic herpes and the recurrent herpes when you guys do your corneal lectures you're going to know all about prophylaxis and ways to keep it from coming back and things but remember when you get these deeper herpes you can even get giant cells down here by decimates membrane and this is trying to show you inclusions because this is a scraping so I apologize it's not a very good picture but you can see that there are inclusions here in the nucleus of the cells so herpes and a lot of viruses will give you little intra-nuclear inclusions now we don't even have to worry about that because now we've got PCR and other ways of diagnosing this and so it's a lot easier to diagnose than it used to be in the olden days when I was a resident. All right back to what do we see in here now all this white is in the cornea and you see it's angry it's very injected all the way around so what would you be concerned about here in the cornea? Exactly so bacteria ulcer so this guy was actually contact lens wearer and as you can see by his fingers as he was holding this lid out he's not very hygienic and so this was a corneal ulcer and it turned out this was a pseudomonas and for some reason pseudomonas loves living in contact lens cases you know they're wet they're moist they're warm and so all it takes is you just over wear your contact a little bit just to get some microtrauma to the epithelium and as a result then the bacteria can start taking hold and so you get a corneal ulcer and corneal ulcers are truly an ophthalmic emergency because if you don't treat them properly and soon what can happen? Exactly so here's the corneal look the epithelium is almost gone remember we showed you that nice pink stroma well the stroma here is all white because it's necrotic and sure enough there's a perforation so it's a double it's a double whammy because the bacteria themselves will often elute proteases and collagenases to melt the tissue but then what do the PMNs that come in to fight them elute they elute all kinds of materials in their granules that can melt corneas and so you have to stop the ulceration immediately and so these are people when you get them you scrape them to culture and then you start you get a bottle of something right away and you start putting them in every five minutes and every 15 minutes and these guys have to be on antibiotics hourly I mean they literally have to set their alarm and get up hourly because if you don't kill those bacteria not only will they melt the cornea but then these PMNs will come in here and they will dump all of their granules in there and here's all the PMNs here and they will dump all their granules in there and they could melt the cornea in 24 to 48 hours and so bacterial corneal ulcers are truly an emergency especially if it's an aggressive bacteria like a pseudomonas all right so what are we seeing here a lot of chemosis here and you see here's this lesion and then look at this halo kind of he's around so this here's a Idaho farmer his potato farmer and you said you have you know did you you know remember getting anything you know I don't know why yeah maybe something got in my eye doc I've been hurting me lately you know how long it's been hurting you know I don't know weak and then the wife goes no no it's even longer than that you know the wife always tells the truth because Idaho farmers they're like oh no that's fine I got this thing in my eye you know he's like hand motion vision with with this what do you think this could be yeah and so this is a little bit more indolent than the bacterial ulcer so this is more a fungal ulcer and the key with fungal ulcers is there's some vegetative exposure and so people will say oh yeah I was trimming my bushes last week or I was out digging up potatoes who knows but they'll have some kind of exposure it's more indolent it doesn't happen overnight but slowly over the course of a couple of weeks you'll get this you'll get this lesion and then when you look you can see here are the little fungi what I call the yeasty-beasties so what kind of stain do we do for fungi GMS so Gamori methenamine silver and the reason I say that is here's the silver and so the actual fungi will stain this silvery black color so GMS will stain for fungi now you can sometimes see these even on H&E or PIS but the GMS will specifically stain them and then this is treated differently the bacterial ulcers you've got to use the antifungals which can be pretty nasty by the way to the surface of the eye so these are pretty tough to treat okay Niko what do we see in here so this is an external photograph the quality on looks off-center maybe have the defect okay so big epideffect here and then it's a whitish rake-built type of hazy borders so what do you think this could be exactly and the history with these is again kind of indolent these are often misdiagnosed as a herpes so they'll be treated with herpes for a while then they don't get better and they hurt so people will just say God this thing hurts and you look there's this chronic non-healing epithelial ulcer and there's this ring infiltrate and so when we do a special stain why bonus points I don't think I showed you this what's the stain we do for Acanthamoeba? Gridley stain exactly so the gridley stain is a stain that stains the Acanthamoeba cysts and again it stains them kind of a silvery almost like the yeast they're stained and so it'll stain the stroma green but here's the Acanthamoebas here's the cysts here's the trophazolites and they get the mixtures are very difficult to treat because if you do an EM they are a triple line cyst so they've got this hard wall around it and getting medicine into that cyst is very difficult to do and so you know at the moment you know we were talking grand rounds a couple weeks ago you know Boopy was mentioning how they had to get medicine from England you know we used to treat these with a propymidine it's called Brolin you had to order it from England but now what works pretty well is actually swimming pool disinfectant and so we literally put swimming pool disinfectant in the eyes and you can imagine how good that feels and so you can do that even Neosporin will sometimes work a little bit but these are tough because when they insist you can't treat them and if they start going into the nerves they like to go perineural that's why they hurt and they get out of the cornea into the sclera these are very difficult as Boopy would say they're real buggers bugbearers you know bugbearers to treat so very difficult to treat so the key when they get to me but you want to be very suspicious early and so you can get these from contact lens cases you get them from hot tubs you know so if you're in a hot tub don't put your face in it you know you can sit in up to your neck and enjoy it but then the bubbles and all but don't put your face in it because you can get them they love warm moist environments so obviously there's not a lot of a catamiba outside now but you know if you're in a hot tub up at Deer Valley or something you know be wary don't put your face in it all right we see in here Tara you know it's always hard to see when they put the slip beam on there because you can't see depth and that's what's hard when they do boards to you look at this and you say man is that epithelium is it endothelium who knows where that is but I'll give you a hint it's more superficial just under the epithelium so what are you starting to think about here as you start to think of some of the different dystrophies is a better word and so we're going to spend quite a bit of time here on dystrophies and so some of the anterior dystrophies you know map dot fingerprint is one of them what we call epithelial basement membrane dystrophies it's got a good name you see the little mapping that's going on there and then this one up we're trying to show with a slit lap here the fingerprints and see here's kind of the fingerprint lines and then against retro illumination you can see that there's some dots there's some fingerprints there's edges of maps but they're very superficial they're right under the epithelium now this is I wanted to take I took this out of a textbook this pretty bad picture because it's blurry but you can see that there's multiple areas here of this thickened epithelial basement membrane on PAS stain but this is a good one we just had this in the lab two weeks ago this was a superficial scraping to try to do this and this is epithelium that's been scraped off and look at the basement membrane and that's almost as thick as the epithelium so that is a classic sign of map dot fingerprint dystrophy it is a dystrophy of the epithelial basement membrane and so sometimes in order to treat it you have to just scrape the epithelium off now what's the problem with this dystrophy what does it cause in terms of patient symptoms and findings exactly so because the epithelium doesn't stick down properly the Bowman's layer you get recurrent erosion those people have recurrent erosions sometimes you have to scrape it off and hope it comes back fine you can use a laser you can use an eczema laser re kind of marbleize the surface of the cornea what we used to have to do before we had that is do micro puncture and so you can literally take a 25 gauge needle and bend it almost like a sister torment and you do micro puncture and that helps to anchor down the epithelium kind of scar down into Bowman's layer so you don't get the recurrent erosions so that's epithelial basement membranes map dot fingerprint there's a close-up look at the thickness of that epithelial basement membrane I mean that's massive Reese do we see him here yeah so again hard to see with the beam really difficult but they're more superficial and they're forming little discreet dots with this trophy gives you these discreet dots how about more superficial yet in the stroma we're still in kind of Bowman's epithelial starts with an M Eastman's okay now I just gotta tell you there are a thousand corneal dystrophies when you guys do cornea you'll read in this every yeah so they find some village in Italy and they find a dish okay so they name it after the village of corneal dystrophies every verse we'll try to just cover the common ones the reason I wanted to cover this one Miesman's is because the path is really cool and so you get this PIS positive like stuff under the epithelium between epithelium and Bowman's and they form these little discreet dots here and it's interesting some clever pathologist called this peculiar substance that's the name of this stuff it's really called peculiar substance and so I just thought that sounded cool so that that shows you distinct dots it's a little bit different than map dot fingerprints these more distinct dots in its Miesman's dystrophy now there's another superficial dystrophy that you guys may hear about Beck I won't make you do this because you know I don't even understand it anyway but but this is this is Reese's dystrophy Reese Buchler and there's a type one there's a type two there's all kinds of types but in any case you get this kind of a honeycomb pattern but again it's superficial it's under the epithelium when you do the path you'll actually see areas where Bowman's is just completely gone so we kind of start with dystrophies use the epithelium sub epithelium Bowman's layer and then we go deeper and so now we have the stromal dystrophy so for the interns there is a mnemonic that you have to remember so get your pens out and write this down and so the mnemonic is and the easiest way to write it down is write it from top to bottom because then you can fill in next to it what it is so the first line on the top is Marilyn second line is Monroe third one is really always gets her California or LA County you can do either one so Maryland M that's the first corneal stromal dystrophy so what what is this one called okay that's all right so this is macular so macular these are corneal stromal dystrophy so if you look at macular you can see that there are these opacities but if you look carefully you'll see that even in between the opacities it is hazy and so it's very hazy even in between so macular Marilyn Monroe mucopolysaccharide so it's a deposition of mucopolysaccharide always a ocean blue Marilyn Monroe I'm sorry really always so really are recessive I even have to think about this I don't know who made this up this has been around since the ancient times you know since even the 80s so it's recessive you know that's all you have to memorize because the rest are all dominant so macular mucopolysaccharide recessive always a ocean blue so a ocean blue is the stain so this tells you the dystrophy the material and the stain so that's why this mnemonic is not so a ocean blue mucopolysaccharide and there's a oh man that's a fellow's picture I have to take that out it's blurry okay gets granular and the difference between granular and macular is if you look you see these individual granules it's well named now here's macular up here here's granular down here look it's like cookie crumbs but notice the clear spaces in between it's like there's little crumbs little breadcrumbs in there but there's clear spaces in between and here you see on retroillumination granular herb h what does that stand for it's highland it's a highland man mason's trichrome so mason's trichrome stains for the highland niko what do we see in here this is a lattice deterioration lattice and you see the name it looks like a irregular lattice work so think of a you know lattice work that you know you have rose bushes grow on that you know it's gotten old and the nails have fallen out it's gotten all crooked and so you see all these little lattice lines so l a amyloid california or county that's congo red congo red so the stain for amyloid is congo red now yeah i i don't like you guys is that red to you looks kind of more i don't know red orange to me so i never really bought red it's kind of red orange and so this is a congo red stain and the cool thing about congo red is if you put two polarized filters on and cross them you get by refrigerants and so here you can see we've actually cross polarized them and where the congo red is it lights up and so by our fringes so macular ukeopolysaccharide recessive all shin blue hyaline i'm sorry granular hyaline the sun's trichrome lattice amyloid congo red so if you know that mnemonic you know the corneas normal dystrophies and this just shows you that not all amyloid is in the lattice dystrophy so this actually amyloid of the cornea it's a pretty nasty deposition there and when you look at it again this is now cross polarization so that is not yellow that that is the red stain lighting up when you cross polarities you can actually get amyloid deposition without lattice both primary and secondary you know systemic amyloid and local amyloid to the eye all right what do we see in here karen real carefully when the light hits look at that irregularity people call this a beaten metal look it looks like someone took part of the eye and just hammered it with a round hammer so what dystrophy gives you this kind of beaten metal look exactly so now we've moved through the stroma now we're posteriorly and there's a bunch of decimates and pre-decimates dystrophies and again i don't have time to do them you guys can decide whether you want to memorize all those or not um but kind of skipping over them a little bit if you look at you know fuchs endothelial dystrophy then a fuchs dystrophy is more people will call it a decimates or an endothelial dystrophy and when you look at these you've got this little you know as i said it looks like a beaten metal appearance but it's deep when you put this thumb up in a true fuchs you'll actually be able to see that it's very deep and here's retro illumination and you've got all these little dots it looks like someone just pounded a sheet metal with that so you know in the olden days boys took shop in seventh grade and girls took homep grade huh and so as part of the shop you had to work with metal and so we had a really sadistic shop instructor so guys to get back at him would like take the sheet metal and just hammer the hell out of it just to be passive-aggressive as 13-year-old boys can be and so it looks like this and so you just looks like you took a ball peen hammer and just hammered a little piece of sheet metal so you know girls did important things like learn to bake cakes and you know make doilies and things and so you know thank goodness you guys are in a different era you know did it come out okay so hopefully you know and and i remember there was one guy who wanted to take homep grade and he did for that heck about being ostracized i mean he really took it so we didn't have any girls who wanted to take shop but you know nowadays i don't think they do it that way yeah that's what kind of split like you guys do do a little bit of yeah well good that's how it should be because guys should know how to cook and stuff like that too or we start to death so so what does it look like what is this path terracing okay and othelial cells are almost all gone here exactly so look at decimage right here now this is the most you know you know plain example i could violently take a picture of this if you look at decimage membrane that's probably four times normal thickness so markedly thickened decimage membrane what do we call these little deposits butata so you get these little butata and that's what you see on the thumbnail that gives you the bulky hemorrhage so these are butata they're little deposits and unfortunately the endothelial cells in between die off and so eventually you get enough endothelial cells die off they get corneal edema so these butata these little flat top but shaped little deposits here and then you see the endothelial cells are being between and they eventually will die off and you get corneal edema so bux dystrophy is the most common you know endothelial dystrophy posterior dystrophy reese what do we see in here months in sign and what is this showing here at a conus look at this kid we've got him looking down i mean look at the indentation on the lid there i mean his corneas are cone shaped now this is end stage i mean you hopefully won't see this nowadays because we have superficial topography where you can see the problem with the steepening and the inferior central cornea but this is a severe example it's called months in sign of keratoconus and what's the pathology usually that we see exactly so you see this little discontinuity or break in bowman's layer so some people have argued that this is actually bowman's dystrophy i don't know we're still looking at that but the idea is is that you get focal discontinuities or breaks in bowman's layer you get progressive thinning of the stroma especially inferior centrally where it starts to outpouch like a cone and what do you think happened to this guy this is a long history of keratoconus so what is hydrons exactly so if you think about it you know think about you know decimates is pretty elastic that cone is pooching out pooching out pooching out and finally decimates just breaks and so fluid gushes into the stroma and you get this acute corneal edema now you don't have to urgently do a corneal transplant and if you sit on it eventually this can actually heal up and here you see a cornea with hydrops there's decimates and you see where it broke and decimates is elastic so curls in but if you can just get the patient through this the endothelium will eventually slide over it doesn't my toast but it'll slide and the cells will get bigger and it'll eventually bridge that gap and start laying down do get new decimates membrane and you can actually get the cornea beginning to detour jets but it does cause a scar there so you want to try to treat this before you get to the point where you end up having the hydrops and so you know now finally in the u.s. we've got a plural for cross linking and I think cross linking is going to be what you guys are going to be using to treat decimates membrane earlier the better and so eventually I think we're going to be treating true keratoconus in teenagers with cross linking yeah yes they're right here these are actually endothelial cells right there this little tiny dark dots they don't regenerate they get bigger so when you traumatize endothelium it loosens its grip on decimates and it slides over and fills the gap with whatever you do to injure the endothelium and then the cells get bigger and bigger and bigger and so when you do an endothelial cell count you're counting the cells in a little centimeter of space you know the cell counts going to go way down because the cells are getting bigger and bigger to slide over and fill that gap because there's only so many to do that so eventually your endothelial counts going to go low enough that it's not going to be able to keep keep that pointing it clear there's a close-up here's elastic decimates curl up I said look those are endothelial cells they're still intact in this dystrophy in this keratoconus if you want to call your dystrophy all right now back to Becca so one of the things we wanted to do is we want to talk a little bit about you know other things that can affect the cornea and you could also get deposition of another material beside calcium that commonly occurs in the cornea iron and what's the stain we do for iron so this is an easy one to remember because well easy after I you know pound my history into your head prussian blue guess who are the prussians prussians were the militarists my germany first were united in 1870 that really drove world war one and so prussian you think of prussians what do you think of iron tanks guns you know cannons iron and so prussian blue stains iron and so this is iron deposition in the basilar layer of the epiphyllium it's interesting there's all kinds of iron lines and the bottom line is whenever you get something either a divot or a raised area that allows tears to pool iron can deposit there so you can have an iron line at the base of the keratoconus and the iron line at the head of a thyridium you can even have an iron line right where your lid sits you get a little tiny you know pooling of tears you get an iron line so you have to memorize all of these different iron lines but the bottom line is when you do a prussian blue stain for iron you see that it's in the basilar layer of the epiphyllium iron okay so i'm dropped this is a corneal button it's been cut in half what kind of surgery is this cornea had before yeah you see the stitches that are there and obviously this is a resonant case because they're all irregular so it's maybe the cornea fellas first case now what do you make of that cornea yeah it's thick it's white it's edematous in fact the epithelium here is kind of slothed on and so we look at it right here first of all what kind of stain is this and what am i showing you look closer ah yes so what is this right here yeah so when you get edema the edema doesn't slide under the basal membrane of the epithelium because that epithelium is tightly adhered to bulmansling in fact it sends little tonal filaments little anchors that anchor that in there so what happens is this blue it percolates through the cornea and it goes into the basilar cells and it makes them swell and then eventually they pop and you see the basal membrane stays down here so those cells pop so what do we call this condition bolus carotopathy so boli is a blister and so forms a blister so bolus carotopathy and that's a sign of edema so again it's not under the epithelium basal membrane it's actually percolates through it and then it's above it so the basal membrane stays down here on on bulmanslayer so this is bolus carotopathy and that is kind of an end stage for anything that affects the endothelium so if you look at a cornea button that has failed after pkp bolus carotopathy is kind of the end result and so it can be due to damage to the endothelium it can be due to high pressure it can be due to all kinds of reasons but bolus carotopathy is when you get end stage cornea edema all right and this is the royally yacht you know in the harbor here in Copenhagen nice beautiful old you know 100 year old ship and evidently you can tour that but we didn't have time to do that so next week is i think it's a car collage of legs