Lecture: Slit Lamp Grand Rounds

DR. FERRIS: Welcome, everyone, to this Cybersight webinar. Our first Digital Grand rebound based in the Bristol Eye Hospital. Thank you to Orbis and cyber sight for giving us this opportunity to present interesting cases to a global audience today. Without further ado, I will pass you over to the corneal team at the Bristol hospital, and presenting interesting cases. And we would like to thank our patients for giving up their time. There will a live feed, and the opportunity for you to pose us questions for some of the cases. We hope you enjoy the next 60 minutes. Omar, over to you. >> Thank you, John. Hello, my name is Omar, one of the corneal consultants. And I’m just gonna get right to it. We have our lovely patient here. Good afternoon, hi, how you? >> Thank you. >> Do you want to put your chin on here, my dear? I’m just going to show the signs here. So, you’ve had cataract surgery with us four weeks now. That was done by one of our registrars here in the hospital. It was an uneventful cataract surgery, wasn’t it? So, in terms of how the eye feels. Everything feels okay, no problem? >> No problem. >> But you’re still not seeing improvement in your vision. >> No. >> Okay. Can you try and look straight ahead for me? That showing okay? >> Yep. That’s good. >> So, this is your right eye. This is the eye that we did not operate on. >> Not that one, yeah. >> Big wide eyes for me. >> Next. >> Big wide eyes as much as you can. Okay. Right. Looking straight ahead here. Just there. Good job. All right. So, these are the signs that we have. >> And you can see — >> Yeah, of course. So, essentially, we’re now looking at the cornea. You can see that she has moderate to severe post-operative corneal edema. Her pupil is nice and round, the IL there is stable. I know she had a bit of zonular dehiscence, and it was put in during surgery. This is residual 4 weeks down the line after cataract surgery. I guess the question is: What to do now? >> The endothelium on the right. >> Sorry. >> No, let’s try that. That’s fine. Big wide eyes. See the endothelium here on the right side. Actually, that has an interesting sign as well. If you want to — what you can see… Can you see that on the endothelium in this eye? >> Can you just describe what — >> So, what you can see on the endothelium, there’s a bronze on the endothelium of this eye, she has underlying dystrophy. That might explain the situation with the left eye after the surgery which has led to the cornea not really clearing up. What we will typically do in this case on the left eye, we will continue to manage conservatively with topical steroid drops and topical drops to try to clear the edema. We typically give it up to 3 months to resolve. If not, we might consider having to do a corneal transplant. Edema. All right? >> Lean back. >> Yeah. >> So, if you were doing — when it comes to the surgery on her right eye — >> Yeah. >> What are your thoughts? >> Yeah, of course, with the right eye, we need to first do a corneal pachymetry and do a specular count to see if we can continue only in the right eye. If it is, do cataract with soft shell. Trying to put — well, the cataract with the soft shell to try to conserve if we can. If we think it’s a high risk, we can offer a combined edema from the start. >> Can you just maybe tell us — do you mind, sorry, what medication are you taking at the moment? >> I think it’s some methasone. >> That one. >> Yeah, dexamethasone. We should add concentrated salt solution, sodium chloride, to manage her corneal edema. Give it time to clear, and if it doesn’t, then we offer her an endothelial transplant. >> New medicine today. >> Right. >> And hopefully clear it up. And you have had your cataract surgery done. Your lens is sitting there nicely. >> Good. >> What we can see is the clouding. You are on the steroids, which is great. If we are going to give you a new medication, that will help with the drying and swelling. >> Definitely, yes. Yeah. >> Have you got any questions? >> No. It all sounds very — a corneal transplant. >> We’re not there yet. We have to give the eye a chance — >> Is that kind of the same thing again? >> Similar process from your point of view. But the recovery is a bit different. And the management in terms of eye drops and things is different. But we’re not there yet. If not, we can offer you something else. >> Thank you. >> Thank you. >> Thank you very much. >> Your drops again. >> Yeah. >> Thank you very much. >> Thank you very much. >> Sorry. >> Thank you. >> See you. >> Come on here. >> So, this is our second patient that I wanted to show today. He’s a 51-year-old gentleman. He has underlying diagnose of atrophy and conjunctivitis. He’s suffered with it for many, many years. I’m just gonna go ahead and show some signs here. Start first with his left eye. Two big eyes, please. Okay. I’m just gonna try to help you open your eyes. As you can see, there’s a lot of light sensitivity. Big, wide eyes. He has his contact lens on. And if we look here on to the cornea, underneath the corneal — you notice he has some superficial corneal scarring. This is due to him having also keratoconus, which we know is a common association with atrophy because of the corneal — and now look at the right nigh aye. Try to get the right eye as much as possible. There is a lot of light sensitivity. Can you look down for me? That’s really good. So, I’m not sure if you can see here. But he’s had surgery only yesterday. And this is his eye on day one after the surgery. Try to look down for me, please. So, what you can see here is a full thickness transplant. As well as a sect under the full thickness transplant with about a 40% filled chamber with air. The reason why we had to do this is — sit back. Is because he had a full corneal transplant after developing corneal eye drops, about 11 or 12 years. Of course with the significant ocular, we had to use the suppression. It was the high risk corneal transplant. He’s done well for a number of years. His vision was 6/9 corrected with glasses with the PK up until last year, he had a rejection episode and the transplant ended up failing. He ended up with significant edema and movement. The options was to either do another full-thickness transplant in the midst of the significant interior surface — ocular surface, and which would have been suppressive medications for at least two years then manage the stitches and the new refractive state of the eye. Or the other option would be to only try and replace the endothelium. And we ended up doing that by doing a dissect on the back of his PK. So, that’s where he is. In terms of the management of eye drops now, he’s just gonna be on topical achievement with antibiotics and intensive steroid eye drops. And we typically see him in week one. If it’s attached then, then it will continue to be attached and we will get back to the 6/9 vision. Yeah, that’s a very good question. Actually, it was a surgery under general anesthetic. What was the experience for you? >> The first dissect was general anesthetic. That was okay. I don’t need mind the drowsiness. After they realized the endothelium didn’t stick, I had to quickly go in for — to try to un-scroll or unravel. >> Sorry, I’m just gonna — so, essentially what happened is, I forgot to mention that a bit. We initially tried to do a DMEK for the failed PK. In the week one, it didn’t stick and we tried to do a re-bubble. That’s what you were describing there. >> When it didn’t stick, it rolled up and scrolled up. And Lee, one of the surgeons said we’ll get you in next morning quickly. And try to roll it out and fix it. He had a good attempt at it. He said it was difficult because of the foggy surface. He kept putting dye in which helps him to see. But apparently the endothelium clears it away very quickly. Because that’s its job to clear away fluids and things. He had a challenge with doing that. We bubbled it with air. But it didn’t work. That procedure was done under local anesthetic and I didn’t like it. >> Fair enough. >> Very uncomfortable. So, the going rule, drops and I think this is, it’s okay. But then you feel the needle when it goes in. That deep injection. >> Yeah. >> You feel like your eye is gonna explode. >> Okay. >> But, you know, but you get over the anxiety and you start to settle down after a while. I mean, it’s kind of interesting as they talk, while we’re doing it. That’s the interesting part of it. But pain-wise, it’s not great. >> And then the last one yesterday? >> Last one was yesterday. Perfectly good general anesthetic. Put you to sleep. I was okay afterwards. >> Good. Yeah. >> Thanks very much for your time. >> Thank you. >> Straight after your operation. >> Right. We’ll put that back on. >> Okay. Is that all right? Yeah. Let me introduce — yeah, I’m slightly off screen. But that’s okay. Hello, so, my name is Dimitri, I’m one of the consultants here at the Bristol Eye Hospital. This is Piper who is 19. She went for an eye test last year. Which was her first eye test in several years because of COVID. And was found — now — >> Yes. >> But you weren’t really aware of any eye problems. You thought you were getting migraines because you needed focus. And found to have pressures of around 45 in both eyes. She was sent straight to the eye emergency department here and we started on some drops. And shortly afterwards, went — we went ahead with surgery in one eye and then in the other eye. So, I’m just gonna show you the signs around that. Okay. Sit yourself forwards on that. A bit higher for you. >> Thank you. >> Let me put my glasses on to try to get it in focus. Now, look down for me. Okay. And then gonna have a look at the other eye. Look down for me, okay? Down and to your left, if you will. Now, when will it get back. Turn that brightness down a bit. [ Away from microphone ] That shining — a little tricky to do this on this. It’s being reversed. One more eye. Go on. Have a rest back for me. Thank you very much. >> We have the first questions for case 1, please, for the audience. Most think it’s a limbal based trabeculectomy on the left, and on the right. Pass it to over Dimitri to tell us what was actually done. Well, it’s — well, I suppose it depends what you prefer to as a limbal-based or a fornix based. Typically, it’s the conjunctival flap, not the scleral flap. Conjunctival are — and sclerales are fornix-based and also often limbal based. This is a fornix based trabeculectomy because it’s in the fornix. You’re right, there’s a present flow in the other eye. Actually, so, Piper is one who has juvenile open-angle glaucoma. And because the glaucoma is relate significant and the pressure didn’t come down enough with surgery. We knew that we wanted to do surgery. But there is evidence now to suggest that because the majority of outflow resistance in all glaucoma, really, but particularly in open angle juvenile glaucoma is at the level of the — doing that, means you don’t have to do trabeculectomy and drainage in so many people. At the time we aren’t doing ab interno here. We’re doing the omni system here. We asked at another center whether they were interested in doing that. But the feeling was to go for the most significant operation for the more significant glaucoma. Because there was more visual field loss in the left eye, we went straight for trabeculectomy in the left eye. >> We asked the question too about drainage surgery in younger patients. And why there’s a risk of excessive drainage. We popped that question up, and then Dimitri, carry on with the discussion. It says single choice. But actually, my fault in writing the questions, one or all of these may be correct. What makes it difficult from the technical side. So, all of you are correct in that all four answers, hypotony and wound leak due to more elastic tissues. There’s a greater risk of rapid healing. You may require more suturing than you would traditionally do. And you may require stronger concentrations of anti-metabolites. So, these are all the things that with glaucoma we need to consider in a younger patient. I will pass it over to Dimitri. Thank you for the question. >> Yes. So, trabeculectomy in younger people is the same operation as in older people, it’s just a lot less forgiving, generally. You have to be more careful about every step of the operation. And because the tissues are generally more elastic, more stretchy, you’re certainly more prone to over-drainage and wound leak as well. Now in Piper’s case, we did the trabeculectomy in the left eye first. And the pressure afterwards was around 3 or 4 for a week or two afterwards. And that was affecting her vision. So, because when we went on to do the — because the — there’s less visual field loss in her right eye, we decided to do a Preserflo operation in the right eye. At the same time as doing the Preserflo in the right eye under general anesthetic, we reopened the conjunctival Peritomy and redid the sutures. We realized that was a risk before doing the surgery. I did do more releasable sutures of the flap than I would normally do. Typically. And I made sure that it appeared that there was minimal flow at the end of the operation and yet still afterwards, there was more flow than I was anticipating. So, I then went back when we did the right eye, I opened up the left conjunctiva as well. Put more sutures in. And for the next week or two, unfortunately,s the pressure was up around 30 or 40. it worked, but too well. We were required to go back in and release some of the sutures. Because the pressure was so low, in order to really be very secure and look at the amount of flow on the table — sorry, another thing you can do is use an AC maintainer because that makes it easier to titrate the amount of flow through the flap and you can simulate with physiological pressure with the height of the infusion and work out what the flow would be at that pressure. That’s what we were trying to do. But that required quite a few sutures to achieve that. Extra sutures at that second operation, and then the pressure went high. Not all were releasable or adjustable sutures. We had to remove the conjunctiva to remove the sutures. And re-dissected under the conjunctival flap because there was quite a lot of healing. And unfortunately the pressure went the other way, the nature of these things in operating on younger people. And the pressure was then low again. And for the next couple of weeks, the pressure was low. So, in the right eye, the Preserflo, which is specifically designed to only allow a certain flow rate through it, and therefore hypotony shouldn’t be a major problem, was also over-draining. So, in the right eye, in the Preserflo we inserted a — I’m just trying to remember what the next questions are. >> The next questions, please, Lars. >> Just read that quickly. Okay. So, I’ve given away some that have already. >> Again, not a single choice. It could be multiple answers that are correct. >> I’ll give you a minute to answer that and then we’ll talk about what we actually did. Okay. So, most people saying compression sutures. I think — oh, and the re-suturing of the flap. No prizes for because I talked about doing that twice. Compression sutures some of you may have spotted those on the examination. And stenting of Preserflo. Injection of autologous blood is not popular these days. You’re trying to induce an inflammatory reaction to the blood which causes fibrosis. You don’t want too much fibrosis and how much effect you have. I would personally rather have something that’s a bit more in control of what I was doing. So, yes. We did re-suture and then we in the right eye, we stented the Preserflo. You can use a 9-0 stent, it will only go in by a millimeter or two. And you can essentially stop flow with that. You have to be quite careful about how far in it goes. And you can stent the entire tube with a 10-0. And some people do that routinely, particularly in people who are at high risk of hypotony because they have no aqueous production like elderly people. And some people are routinely considering the Preserflo at the time. I’m going to show quickly again what we did in the left eye. Back on. Move a little bit for me. So, we can see. There’s a couple of sutures. Brilliant. Sit back. There. Lights back on. So, then in the — so, what we did the next time when the pressure has been — it’s been low, high, and low-low again. Is I — having opened the conjunctiva three times now, and with Piper being young there was quite a lot of fibrosis of the Tenon’s each time. It’s not something you want to be doing a huge number of times if you can avoid it. So, for this reducing the amount of flow, what we did, we put compression sutures, both over the flap. But one at the ostium level, and one at the back near the posterior edge of the flap. And they pressed down over the flap. They do two things, they physically compress it, and they also induce a bit of inflammation which causes fibrosis and reduces the amount of flow and presses up near the high single digits now which is where we want it to be. And her visioning improved in that eye. So, that is why we are in the left eye. The only thing — other thing I would say is when you put in stent suture in the Preserflo, it’s quite helpful to actually put the end of it into the cornea which I haven’t done in the right eye. A bit like a releasable suture. Because then if it does work too much, or you get more fibrosis over time, you can then remove it in the same way that you can remove a releasable suture and then induce a bit more — a bit more flow. That’s where we are now. >> You have been through a lot of surgery. How has it been — how did you feel when the diagnosis was made? As a young person being told that you have this condition. >> I didn’t know what it was. So, I was a bit confused about it. All I knew is my eyes kind of felt like they were — they were obviously quite inflated. And then I’ve never had surgery before as well. So, a lot of surgery in a short amount of time. And my vision got worse from it as well, which is understandable. But it’s nice to know how what the code is, what is being done to me. And I’m quite glad I’m stabilized so I don’t have to go back into surgery. >> How did you learn more about glaucoma? What sources of information did you find helpful? >> So, when I was gonna go for my first surgery, I read about it and I watched a surgery on it so I knew what was gonna happen to me. And I got more interested like that. And I couldn’t really go into the university, it was quite unreliable with my surgeries and appointments. I decided to work at Specsavers. And I learned about what’s going on at the job, me sitting behind the machine. I can ask questions and everything. It’s quite handy because if I’m unsure about something, I can get more information. But I’ve always explained here what’s happening. Which is nice. >> Emotionally, a lot to deal with the pressures going high. How has that been? >> It’s been okay. It’s nice not to feel like my eye is gonna explode. That’s the main thing. But it was quite noticeable from the pressures went high and low. Because the eyes are actually — one eye will feel a bit more solid, and the other feels a bit more like jelly. I always one of them was weird and I could tell what eye it was just by that. >> And what have you been told by any restrictions to everyday life and activities? What advice have you been given? >> Well, I can start learning — I started to learn to drive. Obviously, I couldn’t for a while. So, that was something. So, for a teen, it is quite — that’s what you want to do at that age. That put a stop on it. That was quite sad. I did want to have that independence. And going to the gym. Because I normally do weights. But I can’t do heavy weights now because of my eyes. So, again, that stopped something I enjoyed. I work around it. Instead of doing heavy weights, low weights. So, worked around it. It’s just taken time to get used to and kind of accept. Yeah. >> Thank you so much for giving up your time this afternoon. Dimitri, thank you very much. That’s it. >> Thanks very much. >> I’m just gonna clean. And I’m just gonna be washing my hands before the next patient as well. Because that’s always extremely important. So, let’s just get the next in, then. Do this, the first thing we would like to do is put a microphone on you. Is that okay? Just so we can hear what you’re saying. Okay with you? My name is Dr. Mamtora. We spoke outside. Thank you very much for agreeing to talk to us this afternoon. Could you just tell us in your own words about what your experience of your eye problems have been. >> This one? >> Well, yeah, let’s focus on the right eye. >> This one that I had the cataract. >> Yeah. >> And there was a split. And the lens has moved. >> Okay. >> I have had some laser treatment. >> Yeah. >> But it’s still a bit wobbly, my eye. And I think they said they would see me in a couple months time. I don’t think they want to operate again. But I don’t quite understand what we’re gonna do about it. It — this is my bad eye. And this is my good eye. >> Okay. >> So, I thought they would have done my bad eye first. But they didn’t. So, I was very disappointed, actually. And I’m frightened to have this one done. >> Well, you’re actually having your left eye done today, aren’t you? >> Yes. >> I can assure you you’re in very good hands this afternoon. And we’re obviously going to be taking into account what’s happened in the right eye and maybe change our technique for the left eye to make sure — >> Would it be the same problem with that eye as that? >> Sometimes when people have problems during surgery, particularly cataract surgery, the reason for having that problem is due to many different reasons. But sometimes the way the eye or the way that things are, it’s more likely that the second eye can have a similar problem. So, we can do is we can learn from what has happened in the first eye. And maybe apply slightly different surgical techniques to your second eye surgery to do our best to make sure that will happen in the first eye that it doesn’t happen again. Can I ask another question, you mentioned that the right eye is wobbling slightly. >> It’s moved. >> As a patient, what do you see? >> Sometimes I see sort of spots sometimes. >> Okay. Yeah. >> It’s not — it’s a bit muzzy sometimes. I thought, when I had it done, it would be perfect. >> Okay. >> There is still a bit of a cloud around that. >> Sure. >> Sometimes. >> Okay. You were telling me about your experiences of having macular degeneration as well. Tell us more about that. >> I have the injections — now I’m on every 3 months. I started on a month. But on this eye, they didn’t do it last time. >> Okay. >> Because I think they were waiting for the outcome. >> Of course. >> But I don’t — I have to go again in two weeks time. Do I have to go ahead or postpone it? >> Well, I suppose we’ll have to have a look after the surgery. And hopefully see how it’s going. But I think your consultant who is looking after you will have to make a decision about that one. >> All right. Okay. >> Will it be okay to have a look at your eyes? >> Yes. >> Gonna turn the lights off. I’m gonna lower the table for you as well. Just so that you’re hopefully nice and comfortable there. And not on your legs at all. Can you just lean into there and maybe bring your — is that comfortable for you? That’s okay. >> Sorry. >> Yep. Lovely. >> I can’t put my feet on the floor. >> Yeah, that’s okay. Okay. If you want to, just bring your chin on to the rest there. That’s perfect. Backside. Just there you go. And forehead all the way forwards now. That’s it. Can yep. And hopefully that’s coming through now. Okay. Let’s have a look inside and see what we see. Okay. So, just looking generally at your eye there, I think we can see that there is the lens which is moved upwards slightly actually there. As wide open as you can. Is that too bright, or is that okay? Okay. Hopefully that’s clear for everyone on the screen. That here we can see that the intraocular lens that’s been implanted is there,s and covering the central visual axis. But on the dilated examination, we can see that it is moved upwards slightly. >> Can you talk about the — >> Yeah. So, we can see some capsular changes. Let’s look at the right. And — can I just ask you to look down? That — sorry about that. Can you look down slightly for me there. That’s it. Now, I don’t know if it’s apparent to everyone watching this. But we can actually see that near the capsule. Maybe around 5:00. It looks slightly discontinuous, there. You can see that it’s run out there. Okay? And that’s perhaps one of the reasons. If that’s quite clear hopefully on the screen, that we can see that that’s one of the reasons. Especially if the capsular Rex is doing around the equator for some zonal instability and how the intraocular is there, and the changes there. What we can see here, we can see on the anterior surface of the lens is some — what looks like — there as well. And we can also see what seems to me like some vitreous in anterior chamber there. Is that apparent on the screen? Yeah? Okay. Can I ask you to look straight ahead for me? And then looking towards my ear. Perfect. Is that comfortable for you? Yeah. Look at the cornea. Now we really have to consider what would those indications be of doing a surgery or doing something for this lady in terms of doing surgery? Because you say that your vision is okay in the right eye? How would you feel if you were told that you would have to have another surgery? >> What would it be a local surgery? >> A local surgery. >> What would you do? Take the — >> That was exactly it. Yeah. Usually we do a surgery in this case if there’s any evidence of that lens coming forward so much to the point where it’s destroying the cornea or perhaps touching the cornea which can cause more serious problems. Or if the lens drops back all the way completely. But in your case, I think it looks relatively stable. You have the benefit of having a corneal expert in the room. Omar, would you agree with that? >>> I agree. It depends on how it looks also without a [inaudible]. It’s important that this pupil is dilated. With the dilated pupil, she will be getting a lot of [inaudible] from the lens as well. Whereas with the un-dilated pupil, it’s shorter and I think it’s reasonable. I think less is more. I think we will do nothing. >> You mentioned to us before, that you had macular degeneration. >> Yeah. >> Can we have a look at your macula? Do a check of that too. Okay. We’re actually gonna put a lens on your eye just to give a nice field. All the time, let us know if it’s too bright at all during that. And we’ll see how we go. Okay. All right. Are you comfortable there? >> Yeah. >> So, if you want to bring your forehead all the way forwards, chin all the way there. Reposition your head slightly there. Look up to the ceiling. We are gonna put a lens on the eye. And all the way forwards there. Looking up. Now looking straight ahead for me. Now looking — looking — forehead all the way forwards. Forehead forwards. Bringing it forwards. That’s it. Perfect. And now I’m just gonna try to bring it such that it’s pushing against the bar if that’s okay. That’s perfect. Is that comfortable for you? And looking towards my ear on this side now. That’s lovely. Just gonna change here. So, nice and steady. You’re doing really well. And nice and still. So, first of all, we’re just gonna have a look at the nerve at the back of the eye. Try to bring your head all the way forward. That’s it. Look at the stable there as well, okay. Is that better? Chin down, that’s it. Straight out — that’s good. Okay. So, hopefully that’s better for you. There we go. You see, we can hopefully have the v a view of the — of the back of the eye there. The optic nerve. Albeit slightly hazy. There’s some issues. And then if we — if we don’t — yeah. That’s a little clearer there, isn’t it? Is that a bit clearer? And just moving on to the macula. We can see a bit of a kind of mottled appearance there. Of the fovea. Is that bright or okay. >> Bright. >> Not subject to you that bright lens too much longer. Thank you. Let me get you a tissue for that. Close your eyes gently there. Okay. Perfect. Okay. Now you’re about to have your cataract surgery on your left eye. Do you mind if we have a look there as well. Bring your forehead all the way forwards. Let’s lower that to get you a bit more comfortable. And bring your chin in the middle. Just back slightly. There we go. And here we go. So, let’s have a look. So, we can clearly see this lady is phasic. She’s got very much a clear cornea. There’s no evidence of any good tartar or endothelial changes there. And we’ve got what I would describe as a very nice two plus nuclear sclerotic cataract there. With… no foveation. Okay. That’s it. Thank you very much for — you can sit back. Thank you very much for agreeing to talk to us today about your experience. >> Right. >> And I hope everything goes perfectly with your left eye cataract surgery. >> So do I. >> Is there anything else you would like to tell to our webinar attendees about your experience of your surgery or anything that you think as a doctor or eye doctors that you would like to know about your experience. >> All I would like know is do I still have to continue with the injections for my macular? >> Sure. >> So, I still have to continue with that. >> I think the reality is that usually in macular degeneration, in the form of macular degeneration which you have, regretfully, it’s usually it’s a long-term condition. And with a condition that you have specifically and what the scans show, you will, unfortunately, need to continue with that. >> Right. Okay. >> But ensure that the treatments that we do give for macular degeneration are effective. They are helping a lot. >> I didn’t want it to affect this eye. I’ll continue to have the injection in this eye? >> Absolutely. >> Next week? Two weeks time? >> I think you have it scheduled for two weeks time. >> So, I can go ahead. >> Thank you so much. Thank you. >> All right. And our final case of the afternoon. Patient Ian is very kind to have been given up some of his afternoon to be with us. There’s a number of interactive questions here. And I want you at the end of the next couple of minutes to be able to get the right answer to the diagnosis based purely on the history. One of the problems with modern ophthalmology and modern medicine in general is people leap straight to the tech rather than taking their time and taking the history. The history, if it doesn’t give you a diagnosis, will give you a differential diagnosis. And your double vision began back in 2017? >> Yes. >> Can you tell me at that time what you started to notice about your vision? >> Really started notice things towards the end of the working day. When I was heading home. I used to cycle a lot. And when I was looking in that upper left-hand quadrant, started to actually have difficulty seeing things up there such as car doors being opened and stuff like that. I would get a bit nervous and things deteriorated a little bit from there. But also noticed when reading presentations or anything like to. Most normally when my eyes were tired. But also, it was particular fields of vision. >> Things slipping horizontally or vertically? Or both? >> Actually a little bit of both. There was a overlap between. That’s — I’m noted it quite significantly during the day. And I was starting to find various ways of correcting my vision. >> So, how did you correct your vision? What did you do to try to correct the can double vision? >> Most of it was subconscious. The head tilt. >> What way did you tilt your head? >> Typically to the left-hand side. A few colleagues in the office started noticing me doing it and commenting. But at that stage, I didn’t know exactly what it was. >> Were you getting much double vision when you looked to the right, or mainly just when you were looking to the left. >> Much more so when I’m looking to the left. >> Yeah. What was it like going down stairs or stairs? >> It depends on how much I’m looking and which given direction. But I have to change the focus and the angle I’m looking at to make it better. But it’s certainly worse nowadays that I’m going down steps. But upstairs now is the worst. >> Okay. So, Laurence, could we have the first question please? So, from that history, you should be able to tell exactly what the problem is. So, this history of a gradual onset of vertical stroked oblique diplopia, worsened left gaze, up and down, little bit in down gaze, fine in right gaze and compensated for with a head tilt to the left. There’s only really one thing that can be. We’ll just give you a moment or two. Let’s just have a look at the score here is. Okay. Good to see that 45% of people have got the correct answer. This is most likely to be a right superior oblique palsy just from the history alone. Because of its gradual onset rather than a sudden onset, the lack of any microvascular risk factors, diabetes, smoking, hypertension. The lack of any history of trauma. Trauma probably being the most common acquired cause of an isolated fourth nerve palsy. And also, Ian has got a large prism — vertical prism fusional range. It’s highly likely this is a long-standing problem that’s decompensated rather than an acute problem. What we’re going to do now is just look at the eye movements to see if we can confirm our clinical suspicious that this is a right superior oblique palsy. And we’ll be doing a little prism cover test for that. But we’ll start off by looking at — going to be the video maestro here. This here. A little sub-conjunct hemorrhage. Better than when I saw you a week ago. Looking right at the tip of the pen, you can see there was a left hypotropia. That left eye came up to take up fixation. And he goes back to preferring to use his right eye. So, he’s got right over left in the primary position. Interesting, and if you tilt your head to the left… It’s still there. Not as much as it was. So, this could be due to, in theory, a weakness of the right superior oblique. It could be due to a weakness of the right inferior rectus. Or it could be due to a weakness of the elevators of the left sigh. The superior rectus or the inferior oblique. So, if we go across into right gaze… is that going to a single pen? >> Yeah. >> Now there’s no diplopia. And no vertical deviation. Small exophoria. We flow it can’t be due to the inferior rectus here or the inferior oblique here. It must be due to either — you can see here. The huge difference in height. Just going to swap my hands. Sorry. So, that height massively different in left gaze with that big inferior oblique over-action. So, it could still in theory a superior oblique weakness. Or much less commonly, a weakness of the superior rectus. If you tilt your head to your right shoulder. And I should be — I measured this in the clinic with prism cover test. And then if you tilt it the other way, the way you like to tilt things. So, the height is much less marked when he tilts his head to the right. So, why is it worse when you tilt your head to the side of the palsy? Can you talk tilt a little bit more. Over. When you tilt your head like this, the right is incyclotort. The incyclotorting muscles are the superior oblique and superior rectus. They normally cancel each other. And it’s going towards the superior rectus. That’s what makes that height even worse. That’s the third part of the Park’s three step test. In an isolated super-oblique palsy, it’s the paretic muscle. But you knew that already. Thank you. We’re now going to talk a little bit about how we’re going to manage this. Because an active man, working, driving is an issue. Recreation, hobbies. You’re not able to ride your bike because of this. So, if we go, please to the third question for case four just to see what the surgical options are for this isolated superior oblique palsy. So, give you all a moment. So, the main problem is primary position and in left gaze and up and to the left. And the answers. I’ll just peek. So, 37% have got the correct answer in my opinion which is a right inferior oblique recession. So, inferior oblique surgery, or exteriorization, either work nicely. I do in the large hypertropia to do anterior of the oblique, it’s more powerful of the recession. That will correct the 15 hypertropia that he has at position. And 16 degrees of cyclotorsion. Not a huge amount, should address that. And address the principal problem of the big upshoot in left gaze. So, primary position. And in left gaze and looking up to the left should be cured by that 10 minute procedure which if done correctly is a very safe and reliable operation. About 20% of people, especially those with a traumatic acquired etiology require further surgery because of persistent problems in down gaze and persistent encyclotorsion. And in those cases, you would re-evaluate, measure nine positions of gaze and look at the degree of torsion. Decide whether superior oblique surgery, be it a tuck if there’s persistent height, and cyclotorsion, or just if there’s only excited torsion would be the second step of the operation. This is something we have discussed in clinic last week. We’re going for the inferior oblique to start with with a slim chance that further surgery might be required. The take home messages from this case, take the history before picking up your occluder and examining the eye movements and then you’ll know the signs you should be looking for. Hopefully that demonstration of Park’s three-step test refreshes your memory for someone with a superior oblique palsy. Thank you very much. Coming to the end of the webinar, just about on time. Hopefully you enjoyed that corneal case. And the posterior capsule rupture and zonular changes. And the very interesting young woman with juvenile onset open angle glaucoma. And the dilemmas faced by the glaucoma team trying to control her fluctuating pressures. And to hear Piper’s thoughts on what it was like to go through all of these procedures. And it sounds like she’s been managed brilliantly. Not only clinically by the team at Bristol, but also on her emotional journey with this condition. I would like to finish by thank Sunil and others for all his technical expertise in setting up the webinar. Hopefully you got a nice clear view of what we were seeing on the stripe silt lamp. Thank you for their sponsorship of this webinar. If you would like to see more webinars of this nature, please contact Cybersight because we’re keen to repeat the webinar if you deemed it to be a success. So, thank you once again for joining us. And thank you very much to Laurence, Allen and the team at Cybersight. And it’s good-bye from us here in Bristol. Thank you.