 Okay, so basically I'm just going to start by doing just a little bit of some anatomy basic science sort of physiology sort of stuff. Mostly just high yield kinds of things. And basically if you know the answer great if you don't move on and that's no problem don't feel bad and just all for learning for all of us, but mainly I want to kind of get to the end I kind of want to get to some cases and just kind of shoot out some questions and learning about the cases, almost like oral board style. So basically we'll start with PG Y twos and, and then move on to PG Y threes and then PG Y fours and if you know what grade that's okay. So, let's get started here. Okay, so Tyler, what is this little. What is this thing right here. And how many of them are there roughly. Oh, 200 guests. Jordan, you know how many there are. I actually don't know either. Okay, that's okay. Don't worry. Can you shoot to get shoot out a guest. I'd say right at 100. Okay, let's move on Abby. One for I write silly body. How many silly body processes. Sorry, can you hear me. Yeah. Okay. Sorry, I'm just like walking. One for I write because it's like a one thing. So everybody. So there's, there's multiple silly bodies. Right now we have anywhere from 200 100. Let's see, Lydia, what do you think. I think it's to the pigmented and the non pigmented part. But how many processes are there. So there are processes. I have no idea. Tony. Let's go. All right. There's actually. Actually, do any of the seniors now. Is that all 70 is what I thought. Okay. So it's usually about 78. Isn't there 80 or 70. Yeah, it's really about, it's really about 70 to 80. And 80 is really the number you should probably know. So about 20 per quadrant. Okay. So I'm going to get to that question. So there's, there's parts to it. So what is, what is, what's significant about this to us? What does it do? Actually never mind. I just said that it's, it's on here. So you have, so it secretes a quiz, right? So what part of it secretes a quiz. Let's go back to. Let's go back to Jordan. So it's the pars placata. So it's the non pigmented inner epithelium. Okay, good. So what's the rate that a quiz is formed. Let's go with, let's go with Brandon. So it's like two, two and a half microliters per minute. Okay, good. So knowing your anatomy of how big the anterior chamber is. So Brandon, how much. How many microliters makes up the anterior chamber. 250. Okay. So how long does it typically take for the anterior chamber to fill. If say we totally emptied the anterior chamber. Yeah, so you just multiply by a hundred. Cause it's 2.5 microliters per minute. So it'd take a hundred minutes to make 250 microliters. Okay, good. So it takes about roughly about one to two hours to basically fill the anterior chamber. If you completely dump it, right? So say you're doing a pair of synthesis. And, and, and basically for an acute angle, angle closure, any sort of glaucoma, you dump the anterior chamber completely and you drop it down to zero. Which by the way, a pressure of zero doesn't necessarily mean there's nothing in the anterior chamber. A pressure of zero means the, I mean, completely dumping the anterior chamber means the iris is flat up against cornea. So it'll take roughly about two hours to fill up, right? And, and typically that's what's happening when you're in, when you're on call, you dump the anterior chamber, you're waiting around an hour or two hours, it fills up again, right? Now there's some conditions where it can fill up a little faster. But that's when you're hoping that the drops would take effect. And slow things down. Okay, next, let's see. Lydia. This one's a little harder. Aqueous humor has more or less compared to blood plasma. Hydrogen. Well, why don't you go in order for any of these, any of these four? I think it had. I'm sorry. Yeah. I think it's. And you can reason, you can reason it out to you a little bit. Yeah. I think there was one that it had more and then the others that had less. But I forgot what it was. And I think it. Less, yeah. And then less of the others. Okay. So let's start with protein. So you think that it has less or more protein in the aqueous. So I think the aqueous since it's composed mostly mostly of water, I would say it's less protein. Okay. And bicarbonate. Less. I'm not sure. I'm not sure. No problem. Tony. Sorry. So. Where are we at right now? For which one? So we're asking if they're the aqueous humor has more or less compared to plasma. We have hydrogen. Can I do all of them or just one? All four. Okay. So there's more hydrogen. More store base. Less bicarb and less protein. Okay. Is he right? Let's go with a heaven. Marshall. I thought it was like more bicarb and less of everything else. Okay. So by the way, just so you guys know, this is the most annoying part of all the old caps and also the ones going on, I don't know. Teaching will come with. So don't feel bad if you, you know, don't get any of these because it's just, it's just facts. Right. It's actually more hydrogen and more a store of it. And less bicarb, less protein. And some of them makes sense. I mean, you want less protein in the aqueous. That you can have like a, I mean, more of that in there. Things get more cloudy. So anyway, so those are just one of those things that's probably going to be one of those OCAP questions. So more hydrogen, more ascorbate, less bicarb, less protein. Okay, so we're going back to the ciliary processes. So what procedure do we use to, do we as glaucoma specialists use to kind of limit aqueous formation? Let's go with Tyler on that. So we can do cyclo-photo coagulation either endoscopically or inside the eye or outside the eye. Sure, and how does it work? So by burning multiple or one or multiple ciliary bodies, then you damage the non-pigmented epithelium, which produces that aqueous and therefore no longer produces aqueous. Okay, and let's see, Abby, you may not know the answer to this and this is not, this is just a certain dependent thing. But how many quadrants do we typically treat when we're doing cyclo-photo coagulation? I actually don't know, but I think two. Okay, so here with most of our providers here, we typically try to do about 180 at a time. So we typically do two quadrants worth. Oftentimes, I'll start with the inferior 180. And then if I'm doing it again, then I'll do another 180 and we'll do, we'll often do it nasally, we'll do inferior and superior aspect nasally the second time around. That's not true for every sort of provider, but we kind of like to do kind of a light sort of treatment initially. This is not an OCAPS thing, but here we tend to like to start with sort of a lighter diode than most places would. And the reason why is because I find that actually has a lot of effect while limiting quite a bit of the information. But other places will be a lot more aggressive about it depending on the situation. Let's see. Oh, okay. There's something else that can happen on the ciliary body. This might be a, this is a PGY4 question, but there's something else that can happen on the ciliary body that can actually make them not function at all. So there's a couple of things, but let's see. So let's go with Mike Murray. So one that I know of is that if you get bad uveitis in the eye super inflamed, the ciliary processes can kind of shut down. Okay. And do you know what's kind of happening in terms of, well, so there's a way, well, there's a distinct way that they can actually shut down. That's actually treatable. Do you know what that is? I guess the idea that I had is like treat the inflammation and they'll kind of, you know, start producing it, but I don't know exactly what you're going for. Okay. Marshall, do you know of a process that can occur on the ciliary bodies that can shut them down, but that's actually treatable? Yeah, the only thing I was thinking also was like inflammation, but we'll shut it down. I'm not thinking of anything else. Do you know what inflammation can be specifically to the ciliary bodies? This is kind of a top level question, so you may or may not know. No, I'm not thinking of anything. Okay, Kathy. No, I don't know. I was going to, I was going to joke in the beginning, SLTing the ciliary body, which I've done a bunch, but you know. Oh, by accident. Yes. Okay. All right. Would it be in that closes the junctions, so if you deatroponize that you could open them? So actually, so since you bring that up, Lydia, by the way, this is how oral boards works. He brings them up. They might ask you, but how does aggregate work in the ciliary body? It closes the tight junctions and therefore would reduce the outflow. Okay. So, and that's, that's a good answer. I think that the truth is we actually are not 100% sure exactly how that works, but that's, that's probably maybe very true. There's something, a process that can occur actually on the ciliary processes. And so actually what I was getting at is a cyclic membrane can actually form on the ciliary processes that can occur due to inflammation, independent of just ciliary body shut down. So that can actually cause the eye to become hypotenuse. And so that this is why you can actually ask Dr. Harry or do a B scan ultrasound to look for a cyclic membrane on the ciliary processes and it can actually be seen. And if they find it, then you can actually remove it and the ciliary processes might actually start working better. So that's just, that's what I was getting at. Hey, Austin, this is Tyler. I just got a question. I think of intraocular inflammation, for example, AC flare as leakage of protein due to more permeable blood vessels. So I've always wondered if there's intraocular inflammation inside the eye and we have leakage of protein and other substances from the blood vessels. Why does the pressure often go down? And is that because just the ciliary body shut down or I guess I just don't understand that mechanism? Why the pressure goes down with inflammation if you're having leakage of protein and other substances from the blood vessels due to the inflammation. So if you're having leakage of protein, so actually do any of the seniors want to take that one? The way that I've understood it is that the ciliary processes have to have a really active pump mechanism in order to actively get the fluid out. And so basically when they get inflamed, then those cells aren't processing metabolically as well. So smart. Yeah, that's a better answer than I actually would have said. Basically, I would have just said there's increase through the uveal square alfo. So okay, good. Okay. Next. Easy question. Tyler, what is this? The angle. Okay. And what was I going to say about it? Okay. So what's the angle composed of? And some of these are kind of on here, but kind of describe this picture a little bit. Like for instance, what is, what is this area here? Yeah, so that looks like, so I think, I guess thinking about it inside the out, you have the trabecular mesh work, which is divided into, I believe it's uveal scleral, corneal scleral, and juxtacanalicular followed next by Schlem's canal, and then fall load next by collector channels. Okay, good. And then why don't we have Brandon kind of tell us the pathway of where the fluid flows, or is Brandon on? You hear me? Yep. Okay, you're kind of, you're kind of breaking up, but I think I heard pathway where the fluid flows like starting from the auxiliary epithelium or just like outside what Tyler said? Just the outflow. So you go through the corneal scleral, uveal, juxtacanalicular, to Schlem's canal, and then to the collector channels, which I believe are like the aqueous strains. And then I forgot. Hello. Actual aqueous is flowing out of or two. He kind of broke up. So I'm going to move on. So Tony, after Schlem's canal, what where, and so he mentioned collector channels, and where else does the fluid pathway go after that? Yes. All right, so after Schlem's canal goes to collector channels, and to aqueous veins, then these scleral conge veins, and then you go back into the anterior sclerary superior ophthalmic veins, and then Catherine Sinus. Yeah, good. So what gives you a superior, what gives you a dilated superior ophthalmic vein sign? What's classic to watch out for? So that's when the flow is, I think, backed up. And so the vein is dilated. The thing that you watch for, I forget, but I wonder if there's like hemorrhage in the, or kind of some kind of trauma in the triangular mesh work. Jordan, what does the superior ophthalmic vein go to drain to? Does that, I'm actually not entirely sure what the first range point is. Okay, Abby, where is the superior ophthalmic vein drain to? It's kind of a big structure. Well, in terms of the brain. Okay, that's okay. Marshall, what are you worried about? So drain to the cavernous sinus. So, Abby, you're worried about some kind of like, dural, cavernous fistula, maybe a cc fistula. Yeah, something like that. Thrombosis of some kind. Okay, good. So yes, superior ophthalmic vein drain to the cavernous sinus. Anytime you have, you can have increased episcleral venous pressure from a lot of different diseases, but you see, you hear the words dilated superior ophthalmic vein, you see that on imaging. That's a board's kind of thing. First thing you think about is cavernous sinus, some sort of cavernous sinus syndrome or blockage. And one thing that you should definitely think about is a cc fistula. And so if you get that on the boards, they'll show you that on boards, they'll show you a dilated superior ophthalmic vein and one of the top differentials of the cc fistula. So what happens to this pathway as with age, with time? What happens to the actual trabecular mesh work? Does it get more or does it get less resistant? And we should kind of hurry this up because this is getting really, want to get to the cases. So Jordan, does it get more or less resistant with age? You have a 50-50 chance. More. Okay. And what about, who is that, Kathy? No. Okay, I was a senior that answered that. And then what about aqueous production with age? Does that get more or less? Tony? Less. Okay. Yeah. So the TM gets more resistant with age and that's typically why glaucoma can get worse with age. But as you get really old, aqueous production actually tends to decrease with age. And so patients sometimes in their 80s or 90s all of a sudden their pressure will go down with time. Okay. What types of procedures do we do in this area? So the minimally invasive glaucoma procedures are all in this area, right? Like Marshall, give us a really quick overview of three or four types of things that we can do in the angle. So you can do like a trabecular bypass that would be like ice stents or hydras just to get you through the TM. You can also do like canal capacity where you dilate the glimpse canal as well as the collector channels and things distal to it. You could you could do like a trabecuilla me or agoniatomy where you remove the trabecular mesh work and part of the angle to also bypass trabecular mesh work or if you do like a filtering surgery, like that basically connects the AC to the subcontractival space. Or there's some with a super caroidal space also. That's correct. We don't currently have any super caroidal space that used to be side pass for all those who were familiar with that and that got removed from the market. And everyone knows yeah anyway you gave that lecture about that. But there are others that were working in that space but currently none that have come to market yet. And I don't know that they will actually. Okay and just so you know the canal is roughly about 200 to 300 microns in diameter. Okay classes of drugs. Tony what are the main classes of drugs to lower eye pressure? Yeah beta blockers, alpha agonists, carbonic anhydrase inhibitors. You have parasympathome and medics. Then I need help on some of the other ones here. Let me see. You got most of them. And then I think lastly there's like epinephrine. Okay Jordan do you know how these work typically? Um so like the carbonic anhydrase inhibitors decrease aqueous production. I think the. So let's go one by one. Here let's go one by one. So carbonic anhydrase inhibitors decrease aqueous suppression good. What do beta blockers do? I think beta blockers also inhibit a little bit of aqueous production right? Or is that all outflow? Okay so that's good. No that's correct. What do the alpha agonists do? Alpha agonists decrease or sorry increase out outflow. Okay and what about the prostaglandins? I'm actually not entirely sure how the prostaglandins are working. Okay Brandon? Prostaglandin increases uoscular outflow. Yeah so at prostaglandins increase uoscular outflow. It's not that the alpha agonists actually both decrease aqueous production and increase outflow as well. But the other two are predominantly aqueous suppressants. So how does pylocarpene work? Very simply Tony. Pylocarpene works by contracting the or basically pulling on the scleral spur and then opening the mesh work. Yeah so the one class that you forgot about that I didn't expect it's not I don't even know if it's in your OCAP or BCS book is the rokinus inhibitors. So let's see. I know Marshall knows the answer to this. Mike do you know how the rokinus inhibitors work for glaucoma? So those are ones that actually work on the TM correct? Yeah you know the little more details on kind of how they work in TM? We don't exactly know but I think that they relax the mesh work. They get more compliant. Yeah so that's pretty much it actin myosin right it basically relaxes the TM there. So okay good I don't know why I have somebody's on there again. That's also actually don't rokinus inhibitors also decrease EVP? Yes that is true that is also the thought of how they work is they were how direct effect on the trabecular mesh work and they can also work downstream as well which is why as a separate therapy it can actually work completely differently from any of the others when none of the others are working the rokinus inhibitors can all a sudden work because it's actually even more of a downstream effect and that's why you can actually get pressures below 10 with the rokinus inhibitors right is because EVP is thought to be roughly around 10 ish and so that's why it's very difficult to get below 10 with just the other drops but rokinus inhibitors almost work and in that sense almost like a trap because it can almost bypass that or at least works downstream. Yeah I was very convinced at the rep dinner so oh yeah that's right you went to that too. Did the reps talk about how well they're tolerated? Yes they talked a lot about that. Yeah a lot of lies. Anyway uh all right okay um what's going on here Jordan? Sorry I'm dealing with something over at the VA that's crashing and burning um so you have gonio um and then it looks like you're doing um a little bit of um is this like um trabeculate to me like kind of disrupting the trabecular mesh work a little bit? Yeah well we'll talk about what's going on well actually yeah we'll talk about what's going on there but um I don't I don't know if you've seen any of these so what's the difference between the view here on the top versus the view on the bottom? Oh it's like is it a direct view versus an indirect view? So this is a direct surgical view whereas the other ones are indirect um more of an indirect view right uh so um in terms of OCAPS they might ask you what type of lens that they use for the direct versus the indirect um oh Ali so I haven't called on Ali at all so Ali do you know the name this is a little harder but do you know the name of the types of lens that they might use for a direct versus an indirect? I think Kepi is direct uh huh like a Zeiss or like the Formir would be indirect yeah good job excellent and what principle is um does the indirect work uh does gonioscopy kind of work on what explain the sort of principle that's uh that allows us to see the angle where we can't normally see it? Oh no I think it has something to do with like internal reflectance or something that's past correct yeah so um uh let's see Lydia what's what's going on with internal well what's going on with what Ali said? Well I was I'm just wondering if it's uh just the mirror that we're having the view by looking kind of by having the mirror angle so we can see the structure but the big important thing with gonioscopy um with the contact is that we can see if if there is any senike or if there's any angle closure to see if this is oppositional or not by just pressing on the angle and seeing if it opens um aka is there senike or is it just apposition? Uh so that's all correct but um there's a principle that this is working on so Catherine what am I going up for here? The tear air interface at 46 degrees okay good job we're turtles sorry thanks Brandon I think okay yeah so we're overcoming total internal reflection right so that normally the light is being reflected inwards um at the tear film uh air-tier interface and that's why we can't see it when we're looking in but by putting on this um the um the lens directly contacted on on the eye um we're overcoming that and that's how you're able to see the angle um so overcoming total internal reflection that's that's key um okay I want to get to the cases getting super boring um so okay so uh we know what's going on oh well actually okay so this is really important um so what's the number I'm going for what diameter of the cornea is being flattened uh why don't we go with um let's go with Allie again there's a number that's like really important it's okay if you don't know three point three three point three six okay and is that correct Abby um yeah I think so I know I remember three I think it's three point zero six three point zero six good this three point zero six so three point zero six millimeters is the answer um for some reason you got to know that number um so that's the diameter of the cornea being flattened for uh affirmation tonometry and this based on the invert thick principle um where basically um the corneus flattened for a fixed diameter um and uh anyway so that's you got to know that for both boards and written boards and ocaps um okay let's just skip all this stuff for now this is really boring all right so um okay Jordan what is going on in this picture or what is this um I'm I'm actually not entirely sure okay no problem uh let's move on to um Tyler so it looks like pseudo exfoliated material that's deposited uh a little bit on the peoplery margin as well as the interior lens capsule I think this is uh there's like two different lines that you can have one starts with the z like a zent Meyers line or something like that um and the gene l2 I don't know I made that up okay um let's skip the gene for right now what to be associated what's what are the main things clinically to look out for with this syndrome okay so you can have uh zonular instability so definitely wanted to know if somebody has pseudo exfoliation syndrome prior to cataract surgery you can also have pseudo exfoliation or pseudo x glaucoma as well um and then this exfoliated material can deposit in other structures throughout the body so making sure that they have the ccp follow-up to screen for any of that like specifically the lungs and liver okay very good Catherine give me um some specific details as if you're teaching some of these residents about um what are some clinical uh pearls about dealing with the things that um Tyler's mentioning yeah so you mean like during surgery or yeah leaving that very general for you yeah like I know that um a couple times when we looked at like you and I when we looked at patients with pseudo exfoliation you can even kind of like definitely look how the lens is they can have some fake odenesis or rid odenesis just because of zonular weakness or dehiscence and then when you actually like pound your fist on the slit lamp while they're at there while they're there you can actually see some movement of the lens or instability um and then just being I guess um and then just being really careful during surgery with what their um what bag lens complex so usually putting in like CTRs and things like that okay what about glaucoma associated anything specific about that that's unique about Pseudo X um it can be really unilateral uh like very very strikingly asymmetric um and then also I think uh like SLT is a good option for these patients because the thought is that the pseudo exfoliative material is clogging up the drainage angle okay um Marshall any additional pearls right in regards to the glaucoma part of it oh and um makes this also a production sorry go ahead Marshall oh yeah uh no I think that's all good I was just gonna say um like captain said it can be like really asymmetrical and it can be quite dramatic so you often have closer follow-up for these patients because even when they have normal pressure they can kind of have a sudden spike which can cause a lot of progression quickly um they I think also with note as that um oftentimes the degree of pseudo exfoliative material either on Goniasky or on like other SLAMP exam is not necessarily associated with the uh the degree of glaucoma that they'll have um and also um related to SLT SLT has shown that it has shown to be potentially more effective in this and pigmentary glaucoma but it could be potentially more pro inflammatory so I think at least here they recommend just treating 180 degrees that most at a time um yeah okay perfect so yes so that hit most of the clinical pros I actually wanted to talk about is when it comes to pseudo x glaucoma um SLT can be very highly effective if there's actually a ranking of how effective they are with the different types of glaucoma and pseudo x and pds are at the top um and and poag being in the middle um but you have to be very careful when you do so because um and typically we kind of set it at lower settings especially with pds which is going to be my next which is going to be another thing but anyway um the other thing about pseudo x is that the reason why you want closer follow-up is because these patients can be fine for a while and then all of a sudden come with a pressure of 40 and so if a lot of these acute glaucoma patients that are coming in where their angles are open um look really closely because you may actually see pseudo x material on the lens or where else can you see it Marshall um like in the angle as a sample you see mine okay that or or where else um Mike can it build up on the zonules yeah but it's that's hard to see Catherine do you see it just like the pupillary rough like the like basically the pupillary margin yes so um so just a heads up for everybody here pseudo x is highly prevalent here and you are hearing this these parts um you don't have as many pigment to patients do it but you see a lot of pseudo x uh and and there's a lot of patients that don't actually have pseudo x on the capsule but if you look really closely at the pupillary margin you'll see little little bits of it and so um these patients patients can get really high pressure spikes it can be unilateral very high suspicion for that if you get an acute glaucoma um they also tend to have downstream effects too so it's not just at the angle so if you do angle surgery on these patients it may not be enough uh because they for whatever reason have some downstream um either in the collector channels or what have some effects uh and that's a clinical pearl um okay let's talk about surgery for it real quick and then we'll move on um so uh i want to go back to you Catherine so you so you talked about zonulary instability okay um so what part of the surgery um do you have to look out for this um starting from the beginning which is the part that really is i mean all of them are important but kind of like you're instructing a resident yeah i think the biggest telltale sign of that zonular instability is for us when we make the capsule rexis at the marine we don't use a cystotome we usually use we try to forceps close and then you kind of just use the tips to dip into the lens and then puncture the capsule um and if it's moving around a lot or if you're not just like puncturing right away and it's almost like the lens is bouncing or you just like your tips don't go in right away that can be the first clue of um zonular and capsular bag complex instability okay and um say you have some uh dehiscence um so uh tell us what types of things you can use um to help you when the bag's unstable yeah so the biggest thing is if you have uh i believe like less than six o'clock hours of zonular dehiscence um typically more like three you'll you can use a capsar tension ring so or CTR and you basically inject that into the bag most typically after the entire lens is removed and you're like and um and after you removed all cortex and you can put that into the bag you can also use like Ahmed rings uh segments which are um like fixation structures that you actually have to suture and fixate to the sclera um and then there's also um those are the oh and also sorry and then also with other structures you can also use capsar tension hooks which kind of look like iris hooks but they're a little bit more broad base and they have actually like two little curves so you can also use that also if you're worried about that while you're actually doing the surgery okay very good um Mike there is a certain number of clock hours that are um that are the minimum or I'm sorry maximum there's certain number of clock hours that are appropriate for each device uh can you run that down for us real quick yeah CTR I think is three and then Ahmed will be more like six one thing I was going to add is when you're rotating the lens if you know that there's a zonular instability you usually won't and you'll also do a lot more friendly maneuvers for nuclear disassembly meeting you won't do like a direct chop where you could be pushing posterior at all okay that's excellent um so just to add to all those things so um capsar tension ring typically you're looking at yes about two to three or less okay um if you're looking at four to six you're look talking about a segment and if you're looking at more than six clock hours you're talking about two segments one on each side um and uh capsar tension segments can be held various different ways but usually they are fasted to the sclera okay either by sutures or we do a couple of different techniques you don't have to mention that during the board session but they will ask you how many clock hours is appropriate for each device um in terms of rotation yes you try to avoid rotation as much as possible um the pre chopper is actually very good at limiting uh stress in the zonules though and we know that from the miaki apple view uh and and you'll see videos of that at different ask if you guys are up at the park say I don't know which one of you guys are it's totally fine I don't care but um I may or may not be there okay good I think that's that's I mean it's better to be there than when listening to this okay good um okay we're spending a lot of time on this but those are some clinical pearls um lock so one is the gene associated um so okay so Jordan what is this looking funny looking awesome sorry super fast can I ask you a question do you personally feel like it's worth it to save the bag with two omette segments or just like bag it and go to yamani since you're fixating two devices basically anyway I have uh changed my thoughts about that multiple times and currently I would say that I do not have a um straightforward answer for you it kind of just depends on the situation so um what he's talking about is whether or not it's worthwhile to put all the hardware in there because the bag can still dislocate and then you got to take out all the hardware and just fasten with um a scleral fixation technique like yamani and I have gone back and forth and I haven't decided yet you tell me what they say at park city okay um that's sorry thank you yeah Jordan uh sorry going back to you if you're still on no I guess you're not that's okay Jordan had to go to the VA okay Brandon what is this funny looking thing on the corner it's a curve convert spindle for pds okay um and what are some other things to look out for in pds yeah so you can have mid peripheral TIDs you can have a sample as these line angonio you can have chic or zen mires line um those are the main things I would think about okay what else would you be worried about so what would you be worried about besides this in terms of clinically like reduced pupillary block high iop um I'm not sure what you're looking for here yeah you know what was one other thing that's really important Lydia um I think patients can have lettuce degeneration and retinal detachments and yeah exactly very good very good so this tends to happen and so this is a board's thing because they're going to ask you what else do you have to worry about in high myopia um retinal detachments um so we already talked about slt um and how these patients especially I've had one where they get really high iop spikes if you go a little bit too high on the slt uh okay let's see tody what is this stuff on the cornea I'm just looking at it I'm thinking real quick I know it's not the best picture but uh realized for boards they will give you crappy pictures you know honestly I'm not too sure what that is okay um Ali do you know what this is can you see it yeah I don't I don't know what it's trying to show me okay Marshall do you know I think Marshall went to the OR okay this is like well are they mid-dialated or no okay chathen since this is coming up for you pretend that this is a board's picture oh god okay so we go systematically right yeah so this is a silt lamp photograph of it looks like both eyes yes it looks like both eyes and my attention is drawn to the um the anterior chamber it looks like there's some fibrinic substance in both in both uh in both eyes and it's difficult to tell from the photo but it looks like that the pupil is mid-dialated and there may be um either a bombay or some kind of anterior iris bowing of configuration of both irises irises okay so I'm just gonna tell you so this is in the corner oh crap okay is that ppmd uh no ppmd doesn't look like this ppmd has snail tracks yes but it doesn't look like this okay anyone else have an idea are those are they hop street uh nope not hop street good guess so that's not at all in the ac it's all in the corner it is all in the corner it doesn't maze so just describe it in terms of what it looks like right now so sometimes this happens just so you all know sometimes this happens on boards you don't know what the heck you're looking at okay and you may not even know what part of the eye it is so you can you saying fibrin and whatever that's totally fine if you think that's what it is but they and they may just let you go off on a track like that but um when it comes but but they may kind of direct you back on track to hey this is in the corner which it is one thing that I was wondering when when I looked at it but I think that makes me less suspicious for it is that it's bilateral um my first thought was that it looks like a pseudo-hypropion and I was thinking of ghost cell glaucoma form of itchers hemorrhage like weeks later but I guess that would not be in the corner so I think that's just my question if the pseudo-hypropion would look like this on what way it would look different yeah so that that would be in the anterior chamber you're right Lydia that's something that can happen and sometimes you can look like this but this is in the cornea so okay so this is a older patient and they're on certain medications and um this developed all of a sudden oh is this a verticillata yeah that's correct oh this verticillata okay um but sometimes if you don't know what it is just describe it and then you're not sure it I'll just describe exactly what it looks like hey this looks like brownish deposits on the if it's in the cornea you know it looks like brownish deposits that are in a world-like fashion whatever and sometimes when you describe me you all of a sudden figure out what it is so uh this is verticillata this is actually a patient that I had so um what can cause this uh Tony sorry I couldn't hear your question what can cause this if it's verticillata so can you guys buy amiodarone other medications but also other things like um give me two of these um multiple uh self-taste efficiency um ganglossidosis those are the classic ones reports that I know okay very good so um amiodarone for rezero is the top ones I think you can just call them corneal deposits um but uh there's also a medication that can cause this as well um topically and uh that would be real presa and this was actually a real presa induced patient that I have um so um are these visually significant abbey how we go these typically aren't noticed by patients okay so that's the board's answers typically they're not um in truth uh I 100 feel that if they get bad enough um it can actually decrease their vision this patient had great vision started on repress so these developed and all of a sudden she said my vision declined um so uh I stopped the repress and we'll see if she gets better but I have had a couple patients where I stopped it and the verticillata went away and it gets better um so answers stopped the offending agent uh okay um so Katherine give me a differential of three things that can cause this I know we're we're we're done so this last one uh yeah you can have um you can have trauma it could be like trauma during surgery or yeah any kind of traumatic urodiolysis you could have a central iris atrophy like as part of an eye syndrome um and you can also have uh congenital like mole congenital anodinitis doesn't quite look like this but you can have congenital iris anomalies okay good so um that's a good differential um Aksenville Riger uh any of the other any of the developmental abnormalities um and the main thing to know is that anytime you see an iris like this you pretty much got to be worried about glaucoma because you have to be worried about the angle just not being sufficiently developed um okay I have a bunch more but I know that we're at time so um anyway um sorry we didn't get to the cases earlier I know the anatomy stuff is really boring and we probably shouldn't have spent as much time on that um but uh good job everybody and hopefully you all learned a few things um in association with glaucoma whether or not it's for OCAPs or oral boards thank you thank you thank you ask could you send out your slides to us yeah sure the slides are not the greatest and they don't all have answers to them and stuff um a lot of it was just to kind of drive the questions and discussions okay yeah I think whatever you have I think that it'd be helpful and then when we record we recorded this if that's okay so that we can at least recap for people who missed it sure okay okay cool thanks everyone thank you