[Music] welcome welcome thank you for joining us um i really appreciate it um so we'll just get started straight away because i think that we are on one minute past seven and i'll keep an eye on any participants that are going to join us which is now apple um so thank you for joining us for this ip revision session i am victoria from vision scotland most of you have probably spoken to me before we are joined by mr sanjay mantry tonight and one of the optometrists who has just recently passed her ip exam claire lower who works at um works up in perth um and uh and they're both going to do a bit of a presentation for you sanjay on some of the clinical side and declare more on some hints and tips there's somebody that i need to mute um sorry let me just meet some of these um you can do them no because it'll meet you guys as well um so yeah so claire's going to tell us some of the hints and how to how to pass the exams um or pass the exam um now just to make sure that we've disclaimed this that uh sanjay has been reading up um both in last november and um more recently just just this week on the cmgs to make sure that the talk and the advice that he is giving is in line with them um but this may not always be quite right so we really do encourage people to speak up interact we have got claire who's going to keep him on the straight and narrow as well um but if there is anything that you don't understand or you want to check uh sanjay is more than happy to um to hear that and to go through that um so um without further ado there's a text they're saying from morwen saying there's terrible feedback so i think we need to mute everybody and whoever wants to speak will have to just unmute that actually i think it's probably best to do because otherwise there's a lot of uh sort of sound okay so i'll meet all of us as well and um and i'll just keep doing a recheck to make sure sorry about that more of them but thank you for letting us know um so i will mute myself now and i will pass over to uh mr mantry um just i think sanji is frozen sanjay okay we might need to wait a minute until we've got to get some can you hear me oh yes we can yeah okay i will mute myself can you hear me now okay i'm sorry it's me again it looks like we've lost sanjay again um claire i wonder if we should start off with your presentation to give sanji a chance to am i okay now oh yep you're back again okay sanjay oh here we go all right okay am i sorry you keep cutting out after about about five seconds each time i don't think the reception's too good at sanjay's house okay claire should we start off with your presentation and then see if sanjay's gets better in a little while yeah we could do it might be the way that or something who knows so oh what oh i'm so sorry that's okay right okay um is it okay now it's it's okay now really sorry really sorry so i'm sanjay mantri one of the consultant ophthalmologists i'm going to go through the revision material for anterior eye and i hope this will be useful for you to allow you to think over as you get your questions and differential diagnosis and i'm sorry about the internet so um the first thing first actually the co one of the commonest thing we come across is red eye and uh looking at marginal creditis it's not uncommon to get this in your practice and i think uh i dare i say um we've stopped seeing in the secondary care much of marginal keratitis because you guys sort it out now so why do we get marginal keratitis it's typically a hypersensitivity to um to a staph toxin um and you know you get um immune mediated reaction and usually the commonest reason for it is blepharitis um and uh what you need to do is basically manage uh blepharitis now whether it's mabomitis or it is uh blepharitis you need to manage that but more importantly the ulcer in the cornea you've got to either make sure that you do a concurrent um approach to it ie you take either doxycycline as thromycin if there is mabel mitis but you need to use topical antibiotics to cover um the epithelial defect first followed by topical steroids now you you might argue uh that this uh may or may not um be everybody's approach but typically as a safe option the best thing to do is uh reduce uh or you know get the epithelial defects sorted first and then do the tropical antibiotics steroids afterwards um i'm going to spend a bit of time on herpetic keratitis and the reason being the various presentation herpetic one it's very common second the various presentation it does um is is quite important so um i thought this is a good opportunity to discuss you know significantly why would we treat one in a different way than the other um overall we know um uh herpetic keratitis hsb one and two one is above the waist more lips and face and eyes and his v2 is is more below the waist yesterday causing what may cause keratitis too but i just see one is what we're talking about but primary one usually happens in childhood and um later on this recurrent disease now once you get her particular diet is the problem is um it goes through the nerve endings and it sits back in the trigeminal ganglion so chance of recurrence with herpeticularitis is very very common what does it affect it affects lids it affects conjunctiva it affects the cornea with the coordinate effects all the layers and all the layers are affected in different ways and it's quite important we look at each of them so epithelial disease it affects it causes vesicles it can cause like a what looks like a recurrent coral erosion actually so you can get vesicles you can get uh you can get vesicles on the lids as well but more cornea vesicles but commonest one that you come across where you think oh is this dendritic um ulcer um is is um um is it true ulcer with waste borders now if you stain that with fluorescein you'll always get um a raised border at the edge and that's where you you take the sample from so if i was if i was to prove someone having a a true dendritic ulcer you need to take it from the edge of that ulcer and send it for pcr um we used to see geographic ulcers a lot before because a lot of them got treated as a red eye and with steroids and then you get geographic calcium but look luckily we don't get geographical ulcers as much now um a common presentation an uncommon presentation is marginal ulcers but i think it's more likely vesicles and dendrites the commonest epithelial representation you get from hsp1 um a typical one again is a dendritic culture where you you get the dendrites appearance and again at the bulb is what you're looking for in terms of getting the um and if you have to debride it as well that's what you do you you first debride the bulbs and then along the way so that you you're taking and debridement is slightly more common for geographical rather than dendritic ulcers and a resistant uh treatment um they can actually may or may not be associated with stromal infiltrate but more importantly locally you'll find a diminished coding sensitivity so um dendritic pattern is is quite a classical as you know for an epithelial disease now strobel disease is very different now stomal disease may or may not happen with with an epithelial disease so let me just talk about stromal disease on its own now that is actually an immune mediated reaction so the virus antigen you know um excites an immune entry chamber immune reaction and that causes biscuit form keratitis i.e you get cornell edema you can get necrotizing keratitis or you can get neovascularization long term or lipid ketopathy at a later date you can also get as a secondary effect of that and endothelial almost like a ring uh which which um uh which happens in the back of of of the stroma or or basically the endothelium so stromal disease is very different because it's immune mediated and hence your treatment is different than that and i'll come to that in a minute now zoster keratitis um again um this is something which will come across um a lot where um zoster keratitis will actually affect your ophthalmic division and they come with a flu-like illness now they may or may not come with any eye symptoms so if you know if you get a gpu ring you're saying well somebody's presented with shingles um there's no eye involvement would you like to see them in which case i would say no actually zoster keratitis you treat systematically with cycle over 800 milligram five times a day but if there's no eye involvement you do not need to see them but if there is irritation or eye involvement then you need to check the chronic sensation check their leads their conjunctiva and cornea um including um and doing a stain and checking the corner sensitivity and that can be affected in various way you can actually have um of thermoplagia i.e you can have muscle uh deficiency you can have episteritis you can have scleritis you can have uveitis but the worst case i've seen is is called on it's called acute retinal necrosis very uncommon but can happen and some people can be left with post therapeutic neurology as you know with the shingles but um again uh the common signs are again similar as an epithelial stromal keratitis which is same as hsv how would you treat a zoster is more likely a sacrifice if then there is an epithelial keratitis then you've got to treat with the topically saturated but if there is no um epithelial disease it's only stromal then you treat with or acyclovir and steroids and you've got to do pain relief that's very very important actually and postherpetic neuralgia can be a long-standing disease so some people need um some people need antidepressants for that um antivirals um i think um i wanted to spend a bit of time on this antivirus is quite important because if you've got an epithelial disease so there is three percent ointment and a five percent ornament five percent ornament is used for skin condition but five three percent ointment is used for any corneal involvement and that's two to three times a day oh sorry five times a day and typically i would i would say after about 10 days you don't need to use it but a general overall guideline is for two to three weeks the minute the dendritic ulcer heals actually acid liver if anything causes epithelial toxicity rather than um you know helps the disease so if the epithelial defect is totally healed do not carry on a sacrament there is no specific reason that it has to be carried on or tapered like steroids it doesn't actually you can stop um if the epithelium is totally healed you know just even for reassurance you can do it for a day or two but start lubrication and get them seen back in a and a couple of weeks to make sure and and unwant them but do not they don't need to carry on for two to three weeks or taper it down if a cyclops is not available against cyclover is useful again five you know five times a day for a week and then three times in three times a day um trifluorometer is more common in america because they don't have access to a secular and gun sacrifice but it stinks like hell tri-fluid thymidine stings like hell but you know if you've got dendritic ulcer and if you you're you're you know if you though that's the only thing you've got available you just got to use it but we had to there was a time in captain naval we actually were ran out of acyclover and mufild um pharmacy ran out of gan cyclover and honestly i think it was hard work with trifloru the thymidine with the compliance but we had to do that for for just a couple of months um antivirals again acyclovir valve cycle where fam cycle were a similar uh pathway and you know um you use it for stromal disease and topical use for epithelial disease um there was a major study which is a prospective study called herpetic eye disease society had run this called head study and because the stromal disease is immune mediated that's why you use steroids that's where people get confused oh somebody's got steroid somebody's got stromal disease and it's herpetic and i think well hepatic eye disease i thought we never use steroids actually you do use steroids in immune mediated stromal disease but you do not use in when there is coexistent epithelial disease so somebody who came to me with a stromal disease and an epithelial defect or dendritic ulcer i'll first get the epithelial health and then i would get uh topical steroids afterwards but if there's no epithelial disease topical steroids with acyclovir 400 milligram twice a day is the typical treatment for um for stromal keratitis sanjay i've just got a question here for you um i have a patient with post hepatic neuralgia one year later she has had pre-gabbling but not working what antidepressant is recommended uh i'm not um don't [Music] say that i'm i'm actually the specialist for that i actually think we have to involve gabapentin with the neurologist actually so i i normally get these uh to be the pain relief um with gabapentin and um the others but i i do think the common ones are pro gablin and and gabapentin is what they use and if that doesn't work it does need to be neurologists and psychiatrists together but it is out of my agreement as well actually in terms of what uh what i would give them um for because it's chronic and nagging which actually affects their life so they they need to be managed that way actually so that's quite unusual actually but government is the communist one they would use um so coming back to um oral acyclovir i think is quite important and there's a lot of people who'll ask me this question why does this patient needs oral acyclic versus topical the minute you think of hepatic eye infection you think about acyclovir ointment which is not the case acyclovir ointment is only only only needed for epithelial disease for stromal endothelial disease recurrent disease you need oral acyclovir cover um and if if i was doing a graft and somebody who's had a hepatic scar then i i use prophylactic post keratoplasty activate tablets for up to 18 months sometimes sometimes lifelong actually and so again going back to the thing it's quite important that um we manage this um carefully and you you know if if possible you've got access to photos you manage you know but the important thing is what is an epithelial disease what is a coexisting epithelial disease and you you you manage or use treatment according to that um i know i've probably gone on a few slides on this but it's very important to just reiterate that um this treatment is quite important and i think stromal stromostromal you've got to think about immune mediated and you've got to use oral acyclovir with with steroids and topical uh or epithelial disease you just use no steroids but you use um cancer cycleware or acyclovir ointment five times a day um another common one you probably come across is fortunately not as common but you need to keep an eye on because you get allergic eye disease but if you actually get somebody who's young and uh has got unilateral unexplained you first see anything well maybe it's it's just hay fever you know why don't we just give anti-allergic eye drops but actually the patient keeps on complaining it's mainly unilateral only in the right eye or only on the left eye and it's persistent with the nuclear protein discharge then you need to send them for referral for a swab um and get a pcr done uh and actually uh you know once once it's positive obviously you've got to tell the patient you've got to inform the geo clinic you use topical erythromycin but more importantly and more important for female where it can lead to a pid a pelvic inflammatory disease and further infertility you've got to give a course of azithromycin but typically this is in conjunction with geoclinic but unilateral papillary conjunctivitis is the giveaway for chlamydia um allergic connectivity is again it's it's hypersensitive this is what you'll see a lot of seasonal or perennial and you know they will they could be transient a conjunctive edema now the one you're seeing in the at the bottom that's actually like a you would you would almost say this is a typical swollen palpable conjunctiva which can be nothing else except for uh an immunitated allergic conjunctivitis it's a bit like it's got anaphylaxis of the eye and you know it will swell up it is called chemosis and it will settle down with with um anti-allergic or or steroid drops the worst one is viral keratoconus arthritis and you know there are two types of it fortunately we don't come up with limbal variety much here but limbal variety is really bad uh palpable vernal keratoconus vitis is again recurrent bilateral a bit more common in young people i've got a series of young young patients unfortunately who are on long term medications and they actually look like you know typically when you get sick severe reaction to your contact lens you know gpc that you get giant paprika and antivirus and they get much discharged now these are the ones which you need to manage because again it's a long-term game it's not that they'll they'll get it once and you treat it once and it's gone it doesn't unfortunately um there is something called tranteus dot which you get in the at the other variety uh the liberal variety which fortunately is not that common it's more common in afro-caribbeans but when it happens it almost causes a peripheral corneal melt and and much more difficult to manage and they need not topical steroids they need systemic steroids actually um so you have to manage it with the physician this one um but then they they can cause just punctuated epitheliopathy or it can cause macro erosions and massive scars and i've done at least a few graphs the lamellar grafts because of this because they when the recurrent comes and only when later in their life when the the immune reaction of viral keratoconjunctivitis is settled down you've got poor vision as a result of the scars you then then do a graft not not when they're in the acute phase so a treatment of allergic conjunctivitis how would you treat them typically avoid allergens now that's always with the dermatologist or or or allergy clinic um lubrication now to maintain something you've got to use a muscle cell stabilizer but not in the acute phase acute phase you've got to use all of you know paternal or um you need to have inhibitors rather than stabilizers so for me practical advice is if somebody has got um you know it's got seasonal logic conjunctivitis to maintain you could write to the gp and say the patient needs an optic rom or sodium chromoglycan but actually whenever there's a flare up you need um androsoline or xylometrosalone or all epitome which is which is trade names of paternal is what you have to use to bring it down the problem is when um this doesn't just affect uh palpable conjunctivite um it also involves cornea then you have to think about topical steroids because if you get peripheral corneal infiltrates along with the allergic connectivities then you need to make sure it's not getting into a melting disease earlier rather than later so then then they need uh some steroids but i think that would probably need a hospital referral as well um moving on to acute varieties again i'm trying to cover uh the common things that you'll see in anterior eye and again um anterior is more common we all have to examine if you get an anterioritis make sure you've dilated the fundus and look for intermediate tvitus you've looked we are lucky with that we've all got all most of us have got oct so you you actually do there's no macroedema there's no posterior vitritis but fortunately acute uveitis is usually a bit more anterior so they're restricted in front of the lens plane so that that's that's a bit easier to treat um most of them are idiopathic autoimmune but if you get bilateral or if you get recurrent and a young person young male angst bond is um hlb 27 uh or cerro negative arthritis is very common with it so common conditions which comes with his ankylosing spondylitis or sarcoidosis or psoriatic arthropathy and now these these are fortunately not that common the commonest one is unilateral acute idiopathic anterior so typically they'll present with a lot of sort of red eye symptoms like pain photophobia watering uh you can get certain corneal injection typically you'll see flare and cells in entry chamber you know if i i think the keratic precipitate um fortunately now because you see a lot more of them you probably start seeing um you know whenever they come on board initially kp's is one to watch and remember uh because what's happening in the entry chamber the there's more protein secreted so it becomes thick and viscous so what you see is a lot of flare then enter chamber reaction and the flare wants to settle down and it settles down and deposits in the lower part of the cornea in the in the lower part and it's it's causing keratic respirate and then if you don't treat it it'll go as a hypopian hypopian not infective this is a inflammatory hypoprint which needs to be so typically if you're getting inflammatory hypo hypopen you want to actually give them a subconjunctival steroid uh so that there is a constant leak of steroid going in and they need a huge huge amount of um almost half hourly topical steroids in regular review and they also sometimes get because the iris has become so hyper it almost eyes looks like there's rubiosis and it's not true reverses it is just a reaction of the iris blood vessels in reaction to the inflammation um typically you need to have a dilated examination of these so tip a treatment how would you treat them you want to present you want to prevent cyanicia like this because otherwise the pupils don't dilate they can get people block glaucoma so it's quite important you try and avoid that and how would you do that you would um give them cyclopently uh three times a day initially too because again because the protein because everything is sticky in inside the entry chamber the iris wants to stick to the lens and you want to keep it dilated so you use that for pain relief and to prevent sanikia but using um very strong steroid topical steroids like bread forte or prednisone acetate um sometimes if the preservative allergy then use uh dropper decks or dexamethasone mediums hourly to bring the inflammation down you'll probably typically see them if they're very inflamed to see them back in five days time and then if they're if they're responding the right way your your dilated people your antichambers reaction is is then you can taper that gradually down and bring them back in few few weeks but and typically if they're recurrent you know that they follow a pattern but if it's a acute entry uveitis which is presenting to you and at the first time you're gonna you've got to see them a bit more quicker within a week um believe it or not i think recurrent conorusion is a bit more common than what we think um you know any patient who's got a very very subtle epithelial corneal dystrophy where it is very difficult to sometimes see you've got to be very highly magnified and look out for it saying so if i get any signs of recurrent conversion i'll always always always look for the other eye and very much peripherally under the lead uh superiorly just to make sure that there's no epithelial microcystic or mapped or dystrophy um the other reason recurrent colonization is common is traumatic collaboration so you basically can get uh if if there's trauma this is the history of corn abrasion and the patient then recurrent so that's that those are the two common causes of frequent conversion and typically the patient will say i wake up in the morning with with sore eye and you um how would you um etiology is as say traumatic or or secondary in case of coronal dystrophys or diabetes because uh the base membrane is is defective and it it it causes motor current corrosion but dystrophy coral dystrophy and traumatic abrasion is the most common ones how would you treat them typically you would um lubricate during the day gel at night and once that is done still not helping but helping but not enough then you trial a bandage contact lens all it does with the bandage contact lens it breaks the cycle and you give them a trial of bandwidth contact lens and then control lubrication if that helps then that's great you don't need to do anything else the reason we don't go to any surgical treatment is there's no cure for it what you do is you reduce the chances of recurrence you still need to continue lubrication afterwards too so there used to be previous treatment when you if you've got this microcystic spot which is in the lower cornea you could use anti-stromal puncture we don't use that anymore not much at all alcohol delamination is not not uncommon we use 20 alcohol take the epithelium off because the epithelium off isn't taken as a sheet rather than debridement on the split lamp they behave much better and the epithelium grows nicer but the the best treatment that's available surgically is you take the epithelium off and then use excimer laser to smoothen that and that's called phototherapeutic keratectomy now um i think the success rate with this is 85 so for me if you've tried lubrication if you have tried bandage contact lens and actually the patient still is symptomatic as an affecting the lifestyle the next jump should be straight to ptk otherwise nothing there's no point in humming and hiring about what what approach to go for but most of the mainstay of the therapy should be conservative um and just to finish it off in terms of you know folks endothelial dystrophy again um is more common than you think um you know coral gata peripheral quantum gata what is the inheritance of it all corneal dystrophies are dominantly inherited except for um macular dystrophy so macular corneal dystrophy which is recessively inherited all other are dominantly inherited it's very common in female in 40s or you know some people ask me you know how come i've got it 48 and i've not had it before and it's something which because there is the endothelial cell drop out with age is it shows up a bit more um after 40s and and 50s basically and as you know corner thickness is important specular count is important because you start getting these drop out of endothelium uh it causes polymegasm as in the cells become larger and there are there are dropouts of cells and that's that's where the water pump doesn't work and then corn is starts swelling up this corner thickness will increase and so those are the way to monitor yourself that chronograph is increasing corner thickness is increasing patient is then getting diagonal fluctuation and hence what's the treatment for that so if i see a data and patient's got early cataract i would jump in early i'll protect you in that endothelium take the cataract out early rather than leave cataract to be for much more um mature where i'm going to use a lot more ultrasound power that will cause endothelial cell loss so that but if it's gone beyond where you've got coronal edema sometimes uh hypertonic saline helps but again it's stingy some people don't like it so there are some um i think there is one um sodium hyaluronate with um i'm pretty sure it's spectrum or one of the companies do it it's uh sodium chloride with sodium hyaluronate and that that actually is is a bit more so some some patients who do not want an intervention and is managing very well and getting some dynamic fluctuation that that's not a bad treatment but fortunately now we do selective endothelial transplant so worst case scenario if the cornea does decompensate the the dsec which is the um slightly thicker form or dmacc are the two treatment for endothelial transplant and the results are very very good it's technically very challenging but the results are very good so that's the end scenario if the cornea compensates so with all the internet disturbance and me running through it um i'm hoping it's my turn to see what you've listened or are you ready for the exam so i'm going to just put some scenarios up and uh our lovely victoria is going to get some pulling done and we will see you know we just walk through some scenarios and i think it'll be finished off with the icing on kick with claire's experience coming on soon after that right so scenario one just before you start on that there's just a question there of what is the typical cost of private photo therapeutic keratectomy um let me think about it now i know it it's two and a half thousand pounds okay thank you so so yeah i think um you know i i had a good system going actually to be fair we had an amazing system in nhs as well so at gut naval or a5 or anywhere actually um nhs offered them lubrication bandage contact lens they'll try everything they'll try alcohol delamination and if that's not suitable they would get that management to even refer to me at ross hall or or edinburgh and actually get exam release a ptk through the nhs so there was a payment that the hospital took the private hospital took but privately on its own it's two and a half thousand pounds but there are some pathways to be fair i have treated few ptk patients from gartneville over the last few years that's what we've done if they've tried everything else any other questions uh i have a yeah okay that's fine so i'm sorry i think i so 52 year old male presents to your community practice but the one week history of red sore photophobia right eye the vision is normal but the symptoms have been slowly getting worse um the patient works as a taxi driver and symptoms is now starting to interfere with his work on the basis of these symptoms alone what do you think is the differential diagnosis so we're going a huge range here marginal keratitis what what can cause uh redness for the phobias or eye margin keratitis hepa synthetic thyroiditis contact lens related infective keratitis allergic conjunctivitis um world character conjunctivitis bacterial conjunctivitis acute uveitis acute decreases status now what four would you look for so let's start the polling please a2h so um i'll read up yeah because that's that's good eighty-two percent have um uh answered so marginalities i i think yeah uh 24 or 20 85 percent of respondents that's good oh that's so everybody's answered okay so the top four we think here is marginal ketus which is i think is absolutely right herpes simplex keratitis again keratitis is more likely to cause red and photophobia contact lens in filtrative keratitis again i think and acute anterior varieties so i think those four which is the most um now d which is allergic and i think most of the conjunctivitis in keratoconuctivitis i think um off of those four if you had to choose i think uveitis um uh hope is similar keratitis margin keratitis and contact lens keratitis which most of you have answered i think are the best i will we'll check it out the next one uh what what we think but more likely dacrosses statistics and conjunctivitis may not cause as much photophobia they might cause redness and discharge rather than photophobia and blood vision so uh let's take that pole away so um so yes we thought um marginal credit is simply so yes we were on the right track all the four were right so now you examine and there's a linear corner epithelial defect which stains with fluorescein now the defect is three millimeters parallel along the limbus with a 1.5 millimeter clear strip between the two android chambers totally quiet uh there is significantly lit margin debris and multiple blocked membermen glands the patient does not wear a contact lens denies and any recurrent um i think it's coming away one minute uh recent uh trauma and um has no history of cold sores or ocular problem which you think is um the most likely of of these so i think we'll just do a poll again if that's okay of these four abcd it's like i think basically the answer says it's a no-brainer okay great i like that it's great so yes all of you thought it was a marginal keratitis so i think you diagnose it and um let me just take that away so you diagnose multiple keratitis now how would you treat them sorry it keeps on coming back so you diagnose marginal keratitis how would you appropriately treat and and plan this um so again we'll have a to d so you have fml current financial review in um in five days fml chlorine funny call review in 30 days um prednisone acetate four times a day uh chlorine final call and review in 30 days and britain's loan um and reviewing five days two hours i'm gonna wait a minute before i put the before i put the poll up because um it's gonna block people's screens so i'll just give them a couple of minutes just to read through that and decide which one they want and then when we put it up they can just okay fair enough right is everybody ready okay off you go um it's kind of um conclusive okay i'll end that i'm gonna mute this because my husband's yelling at our children so lovely i think so it's again as very conclusive isn't it so that's pretty good let me just um yeah i think you you do want to because you want to actually make sure um so i think you know if if you are in doubt um i would i would i would say uh current financial you know for a bit and then fml but i think if it's typically the way it's presented um yes fml and chlorine financial review five days is probably the most appropriate um and so you you've done that so i think that that's what everybody's on absolutely right track you prescribe fml chloramphenicol and review after five days the symptoms have actually worst and visual acuity is reduced by four lines and you see branching epithelial lesion stromal infiltrate edema ac one plus and the pressure is 32 right what do you think is the most likely diagnosis um the amended diagnosis should be zoster of thalmecus or herpes simplex skeletal uveitis bacterial keratitis or a can thermopicariditis so again let them have a look at the question so that then we can have the choices right let's so i think most of you've answered and i think i would totally agree with 96 percent of you so why do i think uh hopefully simplex kennedy vitis is more common so zoster of thalmicros um ophthalmicus would have caused it could cause it's slightly less likely to cause raised iop um now i think because of keratouveitis you've got keratitis and uveitis which can sometimes cause trabeculitis and raise pressure so hope is simplex keratovitus in this situation bacterial genetics probably wouldn't have a dendritic ulcer like a picture canthamum keratitis can have a pseudo a picture actually so can't be ruled out but there's no contact lens history so it's unlikely uh zoster of thermicus is probably the closest but because the pressure as well um i think um more likely herpes simplest characteristics would be the right answer here so so we've we've treated we've now recognized that this is what um you know we've got uh what is the most appropriate management plan emergency referred to an ophthalmologist routine referral to an ophthalmologist prescribe 400 milligrams of acyclovir tablets five times a day timolol um five times a day gun cycle over gel or prescribed five times a day 800 milligrams uh tablet timolol um and gan cyclovir what would be your most appropriate that's the most important thing actually is most imp appropriate management plan for this patient i'll just wait a couple of minutes until because it's going to obscure the whole screen the poll i'm not sure if this is one to answer just now sanjay but when doing a bandage cl do you advise moxifloxic and eye drops are you as well to help prevent infection or do you advise just for cl for rces so i think i would say moxifloxacin will be a bit of an overkill i would i would i would say if there is a significant epithelial defect to prevent i would use chromophonical minims with a bcl but to be honest if you're just using for rce to prevent it i i don't think routine antibiotic needs to be used but if you're worried about on the borderline about hygiene and things i would use phenocorp just as a preventative democracy floxacin is really to treat um a an active keratitis so you want to reserve it for that so i hope that answers the question thank you and you can you can vote okay yep i think you know this is this is an interesting one because i think you know the the difference is more of more and more of you are managing a lot of cases particularly with this pandemic actually where um getting access to um a secondary care has been a bit of a nightmare um i do think in the exam situation i do agree that a is the right answer emergency referred to ophthalmologists and i think i would say c is the probably if you were confident enough or if it was a current one or you had um sort of you know um good access to um you know that it's not a not a problem to treat it but i think in exam situation i think exac emergency referred to ophthalmologist property is the best here the downside is you've got that and you've also got raised pressure so i think maybe that's probably the safest option to be is a but i can i can understand why people have 800 five times a day i think i i you know again um is if for the first time and if it's true my keratitis then 805 times a day is okay but 405 times a day is is good enough um in terms of the cover so that's why c is more likely um an answer compared to d for me but emergency referred to ophthalmologist is is probably the most obvious answer because of the scenario yes angie i'm just going to jump on there just to reassure people that this is far more of an advanced situation than what you'll face in the exam so the exam is not going to try and trick you and make you deal with things that you think this is so beyond my scope of practice so in this situation the correct answer would be a um they might however um ask you what kind of treatment would you expect to happen at ophthalmology in which case then you would have to know c but don't think this is the kind of question that will come up in the exam it will be much more straightforward good that's useful that's useful claire um and i think um that's true actually but um you know uh it's a similar situation when i used to do interviews um for trainees and they'll say oh i would refer this to uh or i'll ask my consultant and you know the next question would be what do you think your consultant is expected to do what will be his treatment so i think you're right and that's the next question by the way oh i thought there was a next question actually but no it is not so yeah i think the treatment would be in this scenario uh what what we were saying at sea i think the only thing is um maybe if the pressure is quite high you might have to use diamox as well um and and treat it that way but i think uh otherwise um you know systemic uh asexual cover with anti-antivirals is quite important so yeah but here emergency referred to ophthalmologist is probably the right answer claire this is probably a question for you um in the exam would it have said that the patient was a contact lens wearer in the question yes uh and for that reason because in the cmgs it tells you what to do after a console ends where and if they're not so one thing to remember and i think it's in my talk as well that if there's any ambiguity in a question then it might well be a pilot question because these exam questions are from a bank that are you know they're checked constantly all the time and it's covered by the standard setting panel so if you ever do get a question where you think there's not a bit of important information i'm not quite sure if it's a or c or whatever it's probably a pilot so if it's relevant they'll say it's there if not then just ignore it that's great lovely um so i'll rapidly move on to scenario two so this is um a patient let me just see i'm covering a bit of a 45 year old male attends coming into practice with two week history of red photophobic and slightly blurred left eye there is a very orbital pain and a brow ache patient has history of severe asthma and causing spondylitis um visual acuity six nine um um the pressures okay slit lamp examination shows grade two injection one plus cells in the entry chamber with a normal iris at the moment right so um you diagnose left acute anterior vitis what's the most appropriate treatment plan i'm not going to read out the whole thing it's probably um it it probably wants to test you making sure how frequently you use your steroids how frequently you cyclopentlate and when would you review so um have a look at that for me i'll just wait a couple of minutes and then i'll put up the poll okay all right let's stop there there you go okay so most of you thought i mean the treatment is obviously steroids but most of you thought cyclopently for a week pregnancy loan one hourly and tapering over six weeks in review i have to say in this scenario for me um it is the first time the patients come to you my first thought would be if it's a recurrent anti-uveitis and you know the patient then i think that's that's a very good treatment i think otherwise because you can have pressurize you can have different other factors i think personally the treatment would be the same but i would like to see them back in a week and then if it's everything is okay and going the right way then i i don't remember exactly but i'll just double check actually i have a feeling this review is what i was going to say i think the treatment is right and normally if it's a recurrent one or the patient is known to you six weeks review is good but otherwise i would prefer to see the patient in a week particularly because of you don't know whether this how patients could respond so let's check that um so you prescribe this and uh review in five days just a bit like what we're saying but actually the inflammation is improved but iop is now at 38 millimeters of mercury um so so patient is a steroid responder um maybe steroid responder may be other things going on but what are you going to do here so again similar exam scenario prescribe uh pilocarpine routine referral to ophthalmologist emergency referred ophthalmologist stop redness throne acetate um now that's a tricky question i think stop prednisone acetate normally you would want to um because steroid response but there's still um inflammation going on at the moment so that's the that's the bit to consider when you're answering this question so abcd what's the most likely revised management plan somebody has asked here um prescribe cossopped in conjunction with pred prednisone acetate yep yep no i think um i i don't disagree if there's no asthma core soft is is is a is a good option um and that's what probably what they will do um if the pressure is near 30 i think you'd also consider acetazolamide um as well actually so um i think we are on to 24 answered so i think most of you would probably agree to refer to um ophthalmologists and i think in this in this scenario i think i would agree uh that's what we would do and again it doesn't need to be exact reflection of your practice it should be uh what what overall um is expected of thailand community in terms of saying where are we um are we going to be referred in uh or or managed in the in the hospitalized service or not so i think um an emergency referred to ophthalmologists will be probably so you do refer the patient as an emergency what do you think will be the immediate management by the ophthalmologist will it be paracorpin perform a ct scan or let's take that away um perform a ct scan use a timolol use dorazolamine use oral acyclovir uh sorry cycloid um diamox acid is all in mind that's a trick question 800 milligrams of augmenting or co-max circular stop steroids or prescribed uh guttate uh brimonidine so this is a to h um um and what do you think three of them that you would use this question may have been answered but this patient has severe asthma would not be contraindicated that's what i i think when i said initially if if uh timolol or any beta blockers if there's no asthma then you give tumor otherwise coresoft is not a good option you only use dorazolamide and possibly other things but if if the patient's got severe asthma then you don't use timor this is a tricky one um so let's let's go for the top ones uh 21 or 21 have answered um so i would say the top two here is d and e uh dorsal white so that's true soft um uh or laser um acidosolomide which is right um there's a bit of a difference at twenty nine percent think palo carp in 24 thing uh is premoniting and actually to be honest um i would say pyrocarbon is a bit more um less available and i think palo carpen is used more for and closer so i think um bremont is probably more likely but you know i don't think you'll get it wrong if you've said palo carpen the other thing is if you got higher pressure let's say for argument's sake it was 38 i don't know what what the pressure was was it 38 um i it was in the question if it is 30 palo carbon will still work but more than 32 palo carpen there's so much iris is kedemia that apollo carbon will not work so i think a safer option would be um timolol if there's no asthma in in this case there's asthma so no um dorazolamide bremonide and diamox um i don't think there'll be a huge issue with palo carp but follow carpenter would be slightly down the order for me so yeah i think that's that that's where that one ends but i think um um you know i say follow carpent will slightly be lower down the line the reason being uh this ischemia and not readily available so i think typically people will go for bremonadine terozolamide and diamox another scenario and i just don't want to carry on a lot because i think claire has got to and i'm sure is getting later at night so 80 year old boy attends um let me just bring this down a minute so eight-year-old boy attends his community practice with his mom he's got a one-month history of itchy and red eye there's a history of asthma eczema he presents at the end of june um as a as a hint which used to species neurological and arthritis which is the best clinical presentation of seasonal logical enthusiasm uh is it grade four ballpark engine tiber or grade two uh grade four with severe chemosis or a clear cornea or totally pacified cornea so have a look at that and think what is a typical seasonal allergic connectivity you've got to remember a typical one okay great i think i think you're absolutely right i think um you know i i i wouldn't say grade four a great deal is a good option because a opaque cornea you know i think uh would be would be totally i mean i i think that's that's a very extreme scenario i would say great to bulbar uh conjunctival hyperemia with my chemosis and clear cornea normal va is what you would typically accept in in this scenario um so um examination reveals that and vision is six six given that the patient has has four weeks left at school which of the following is more appropriate in addition to cold compress whether you go for ketoti fan you go to sodium chromoglycate you go for four methalone or you go for dex methameniums or or for a methodology so there are two steroids uh one mast cell inhibitor or stabilizer and mast cell inhibitor um which one do you think is the most appropriate um on top of cold compress so that's a2d sorry somebody pointed out the the pressure was 38 which which i think going back to that palo carpen um because iris becomes ischemic palo carpet will not work as much as as other um so timolol will work very well but timolol is not contraindicated because of the asthma so the answer should have been terozolamide um acetozolamide and and brimonity so i think uh i i went one one ahead so basically as as agreed uh you'd probably want to use a mast cell inhibitor rather than a stabilizer and not use steroids at this point because uh patient young child and it's manageable at the moment so you'll actually use but whenever there's a flare-up you would want to use a muscle inhibitor rather than mast cell step stabilizer so i think that's the right answer so patient returns to return six months later read in hgis eyelids thickened vision is now getting affected large popular stringing discharge now you've got to remember more um the corneal affected and large papilla is is probably what they're trying to point out on this so likely is atopic or vornal or perennial or um viral keratoconus dividers and interests of time i think you'll probably just go for it for the next four okay quick round there you go yep great great i think uh typically uh uh you know uh papillary connectivity or or thick papillas and stringy discharge with with possible corneal involvement born will continue to conjunctivitis most likely here and that needs to be i'll go through this basically um because i just think are we are we okay for time i'm just aware of everybody's timing and i think seven to half past eight so um okay so uh what do you think now it's one look at you've got to remember here we've discussed about large scapular you think it's vernal corrective kind of fitness but the vision is affected so most appropriate plan in this scenario particularly for exam um so emergency refer routine referral dexamethasone or sodium chromoglycan um which is the d option so let's go for a to d i'm sorry [Music] okay we'll stop there yep okay okay that's good i think i think you know as i say i think routine not because things are getting worse and the vision has effective so emergency referrals is probably more called for and i know you probably would think well why can't i start steroids i think it's probably best um it's a eight-year-old boy it's a long-term management and there's a lifelong residue so it's probably best to prefer to um to an ophthalmologist for hospital eye care here so the last um uh you know a 40 year old woman presents your practice after she after a six-month-old baby poked in her eye with the with his finger and she was struggling to open the eye when for you to examine due to pain and photophobia right so what would you do to aid assessment would you drop would you put a drop of chloramphenicol 0.5 percent or one percent or oxybuccane and a drop of fluorescein which would be the most likely in this scenario which one of them okay absolute right i think there's a bit of a confusion because the way i've put it but basically first of all you've got to open their eye and the only way you can open their eye is basically having a topical anaesthetic so it will be oxidative again i do agree that after that you need to stain it so sodium fluorescein will definitely come so you drop you instill a drop of topical anesthetic patient is now able to open the eye then you put sodium for uh you know fluorescein dye and you see a linear corneal epithelial defect what's your pharmacological management for this patient so um is it preservative free um actually um oh you know i think i've i've given a very wrong choices here but anyway preservative free lubrication clarification chronophanical ointment four times a day for a week painkiller um a cyclopently if the abrasion is too big either the answer is all of the above or none of the above so there's no i think oh do you know what let's make it a b c d e f so a to h is what you you do if that's okay a to f yeah yep so i think at least a will be the preservative free um then chronophonical painkiller d is cyclopently all of the above is um e and then f will be none of the above sanjay there's a question from michael in the comments if you could just check i'm not sure if it's about this one or the previous one so i'm not sure when you want to answer it but if you could just check that that would be great okay okay i think we'll b c d e says all of the above yep that is true that is true so i think uh michael that's true why did i go for one you know a typical so large popular and cornell involvement is a lot more common in moral character conjunctivitis than atopic character conjunctivitis but i think you're not wrong in saying atopic to conjunctivitis can present the same way as well so it's a bit sometimes it is a bit more um sort of you know on balance you kind of think well you know either could have been right but maybe uh you know you get a bit of a bias and i think in my head i've always been thinking world character might as well have been preparing this question but i don't think it's um atopic character conjunctivitis would be wrong but i think one character conjuring practice does present with a is slightly more common i in in my opinion but when it when it comes to corneal involvement i feel it's a bit more common with one category names but i don't disagree that atopic can present the same way as well thank you so yes i think we we are all on track for this one so this is good and so the patient returns with pain and waking up in the morning you do a fluorescent stain and you see erosion in the area of previous separation now what will be your top differential diagnosis here is it hepatic carditis is it a recurrent conrosin is it exposure keratopathy or is it contact lens related epithelial erosion um and that's last one which is a to d so a is the herpetic keratitis exposure and contact lens related epithelium okay okay here you go since you're getting all of them right i think you're totally right there's a history of trauma there is history of um uh uncalled for pain and waking up in the morning this is very common typical of rce so you think it's rc now how would you um manage this um ocular lubricant dn and gel at night or doxycycline bcl uh refer to for ptk if above fails all of the above or none of the above the last for you i'm sorry uh victoria i've kept you really busy uh one a b c d e e is all of the above f is um uh none of the above and a b c d um so let's do the a to j or you know uh whatever option we had oh gee please finish this now and let us go and have our dinner there's no g's yet sanjay it's all good so yeah okay everybody's almost answered i think you're right you know i think all of the above is right actually octa lubrication doxycycline so sometimes they're associated with there is an anti-mmp effect of doxycycline which helps the tear film and helps stabilizes um so there are there are publications of recurrent colorism helping with doxycycline balance contact lenses we discuss and refer for ptk so all of them above uh is right so e is probably the right answer here and sanjay is it fair to say vkc more likely than a topic in an eight-year-old also yep yep yep i yeah it is fair to say i agree age is another factor actually see the thing is because i've been reading out sometimes uh i've forgotten the age and things so i think you've well picked up on that so yeah it is it is um more likely that it will be a vkc rather so i think that's my last slide yes you'll be pleased to know that you are ready for your dinner before but claire will finish it off by making sure that um you know you're absolutely ready for the exam so just one second somebody's just going to take a couple of minutes there to switch between presentations so if anybody would like to either speak out and ask any questions that they have or type them quickly and then i will ask them then this is a good chance to do so you can throw any scenarios at him you want he knows the answer to everything oh thank you the how do i share this so i think i should have saved this wait a minute um still do you want me to just share on my screen um oh i i think you should because i i've tried to save it and it's changed all the background okay right okay can everybody see that yep just magnify it a bit yeah okay let's try for that and claire over to you hello and thank you so much everyone that has stayed behind for my talk i'll hopefully be nice and quick to be honest this is just like uh basically what i wish that i knew before going into the exam because it's a completely different way of doing any exam you've ever done before and for me there was a lot of anxiety around that you know i was so busy worried about the content of the exam that i never actually thought about how it was going to go what was going to do blah blah blah so yeah this is just going to give you the put my little dip tip down the bottom i'm using that very proudly signed all my christmas cards with it was great fun so yeah let me go so basic um structure so don't shoot me if this is slightly different for the march exam i don't think it should be but this is what the november exam was so you've got 85 questions in total 75 will be graded and like i said briefly before 10 will be pilot questions meaning that you will not be assessed on them so if something does seem weird and wonderful it's probably a pilot so you've got 102 minutes to do the exam um it is worthwhile thinking about breaking that down per question but i think i've got that on the next slide if we can move along victoria um i must have put out a later one but anyway i'll go through this here so this was quite important for me because i like to have things set up organized good to go i feel at peace before i can even think about answering questions so most important thing that you will have to go through before you actually set the exam you will get the test reach um information emailed out to you so you have to download that um software to your computer and make sure that it can run properly on your computer so it'll go through like a little checklist for you which is quite easy and straightforward as well so for the exam itself make sure that you've got a paper copy of the bnf they will not accept anything on a kindle or a tablet or anything like that you can have sticky notes in your bnf as long as they don't have anything written on them so you're absolutely fine to have little markers if you think okay i'll tab off the glaucoma section i'll tab off the antibiotics um but just be aware that the person um watching you they will ask you to show your bnf to the camera if you've got them and also make sure that you've got your id must be photographic and you'll have to hold that up to the webcam as well you are also allowed an a4 sheet of blank paper for notes and which is quite useful as you're going along if you want to jot things down and you will also have to show that at the end if you have used that another little point is remember your comfort i was freezing sitting my exam so have a blanket over your legs or something just something to make you more comfortable so i'm going to ask victoria to change the slide she's got a little helper there two little helpers thank you um so this is something that caught me off guard so i was doing my exam on my laptop you will be asked to show a 360 degree view of the room that you're in so make sure it's tidy if it's your bedroom like me make sure the bed's made things like that what was really strange was that the assessor asked me to hold a mirror up to the screen and they were just making sure that you've not stuck anything on your screen like notes or anything like that so you actually have to hold a mirror up to your computer or your webcam whatever you're using just so you can see that they also asked me to open my desk drawer they also checked underneath my desk and they asked if i had any notes in the room i had notes beside me but like away from me kind of hidden away and they asked me to remove that so physically out the room they were gone um so yeah it was quite it was quite intense i think kind of even setting up the exam before even getting anywhere and the other thing that put the bottom there obviously you have to roll up your sleeves you're not allowed smart watches like this you're better to tie long hair back before the exam i know it sounds silly but they will ask you for a little look behind your ears to make sure you're not wearing anything like any kind of you know bluetooth speakers headphones whatever so yeah just i think little things like this to be prepared for because you're that worried about the actual questions coming up and then this can freak you out and give you a bit of anxiety anyway so if you know what to expect i thought that'd be pretty good so next slide if you could play please oh yeah so there's my little breakdown so yeah you've got 102 minutes um 85 questions so roughly 1 minute 12 seconds per question you will have a little timer on the screen which is handy so you don't have to worry about wearing a watch or having a clock in the room um i can't remember if the timer counts down or counts up but do pay attention to that so that you can make sure that you've got enough time but i would say to be honest don't worry about your time i i actually finished with half an hour to spare and that worried me because i thought have i gone through this too quickly have i made some mistakes but i ended up getting a text from one of my friends who said that she was the exact same she finished half an hour early as well so you will bank time because you will get easy questions that you know the answer to you can be like boom quarantine call blah blah the ones that you have to think about like for example glaucoma questions they're the ones that you're actually going to have to use more time for but honestly i really would not stress nobody that i spoke to struggles for time um even if you're the kind of person an exam does get extra time i would expect you to be absolutely fine so yeah uh next slide if we still got one uh yeah this is another thing so pay attention to some of the questions that will ask you for a set number so one of the common ones would be like differential diagnosis so it'll give you like pretty much what we've just done there actually with sanji it will be like a to g give your top three or top four differential diagnosis you cannot go back so it's quite frustrating that if using you know because you're worried about time you click one and then you go forward and you see in the next slide oh you should have done three or four you can't go back but the main thing is if you do do that don't panic if you go into the next slide and you see that you some don't you've done something wrong just move on you know just treat that as a brand new question there's no negative marking so if you know like i've i did that myself a couple of times an exam moved on to the next part and thought oh i should have answered it this way it's fine don't get yourself in a tis because it's very easy to freak out when that happens but just you know reset your mind just think okay that's a loss or even think in your head that could be a pilot i might not have lost any marks at all and just move on um but yeah the thing about pilot questions i had a couple in mind i thought this is just strange like there's more than one answer i'm not daft i know there's more than one answer to this and that did turn out to be a pilot question so yeah just trust yourself you guys are smart enough by now so yeah and yeah so this is the after the exam you've done all the hard work this is now the next part of your anxiety you're freaking out about your results so the results come out about two weeks after the exam is sat now the past mark is going to be different so my past mark i think was 72 for my exam the one before that might have been 80 odds so there's a standard setting panel so it's optometrists very much like ourselves they set the exam at the same time so they make sure that the questions are fine they're basically making sure that a just competent optometrist can answer them correctly so again we're not looking for anyone to be ip geniuses at this point it's just be safe you know is this person to be safe can we trust them going forward so yeah um one thing as well the exam results don't be surprised if they come out early so i was expecting my exam results to come out at two they came out at 10 o'clock when i was in the middle of a clinic i then chucked my patient out the room and went running to my colleague like yeah i passed patient overheard me which was great she was like oh okay that was good um but yeah so just look forward to your results and be proud of your hard work when they come out and yeah so things to study just know your cmgs inside out the frustrating thing is that this will not always be what you would do in practice so you have to kind of switch off your opt-on brain temporarily for that um just memorize the cmgs as they are and then you can brain dump them after the exam and follow more practical advice and the other thing as well as for the glaucoma questions what i found most useful was just to memorize the tables and the nice guidelines so you can almost guarantee that you're going to get a question and it will ask you what is the recommended recall so it will give you the presenting pressures it'll tell you if you've got the pressures under control it'll tell you if there's a field defect are you getting the patient back in one to four months six to 12 months whatever whereas if you just memorize them it just makes it so much easier and the same guidelines to be fair i just kind of knew there's like a little section of you know if the pressures are over 25 but the cct is within this limit this is what we're going to do x y and z that's pretty much all that i memorized about the sign guidelines but the exam will be made up for everyone so not just for the scottish candidates so the nice guidelines are probably the best ones to do um this the next couple of bits are just basically what i did so i made up some example exam questions just going through the cmgs which kind of got me into the mindset of how the questions were going to present i used flash cards for the drugs so drug names on one side kind of the effects side effects etc on the other um but our good thing as well is just to test each other you know get a support group going i think there's a couple of whatsapp groups going and speak to people in your practice like myself and my colleague will do that all the time we'll say like i've got this case what would you do or we've been like testing each other for the exam questions as well so yeah find some buddies it does make a difference and that's me there we go and yeah honestly you have got this do not worry about this at all if you have been practicing optometry for you know however many years you have been now you're going to be absolutely fine like it's a no-brainer um just relax and just do your best thank you very much claire um obviously i need to apologize for my freaking children who were supposed to be being looked after by their dad but he had gone off to look at his iphone in the bedroom i know i know and yeah not surprising so anyway back to the questions um if anybody's got any final questions then um feel free to shout out or type them here but i'll just there's was one here that um had been asked so um either of you whoever's best for this one in the cmg it says akc can cause retinal detachment how that's a sanji question i think ectopic character conjunctivitis can affect from front to the back of the eye i don't think akc will typically cause a detachment it it it causes um anterior capsular cataract it does cause sometimes a a puk type of picture i think it's an indirect effect rather than a direct effect so i think that'll be it's a bit like oh zoster can cause acute little necrosis it's a very very remote side effect which i don't think will be will be something i have not seen akc causing a retro attachment but i've read it in books so it'd probably be an indirect effect rather than direct effect actually anybody else want to to speak up um claire there's a few people there that just thanked you for that really helpful advice and um didn't realize how strict the procedures would be beforehand so um if anybody wants to unmute themselves and speak then they can otherwise i think maybe everybody's done shell shocked for the evening we'll update to the sea guidelines published on the will updates to the sea guidelines published on the cop see of oh websites yeah so actually i emailed the college about this um on you guys behalf so adam shank or shank got back from me i'm just looking at my phone just now he said yes so there will be a frozen cmg pack that will be sent out to all of the march applicants as soon as the deadline closes early next week so this is something that me my colleague were talking about which is slightly unfair to you guys sitting the march exam that you don't actually have a long time with your proper cmgs so yes sorry so short answer is yes you will get an updated pack sent out to you when the deadline closes is glaucoma 10 or 30 of the questions so yeah no this this is an annoying thing about the college website it reverted back to the old style when it was 30 so no when i did my november exam it was 10 and as far as i'm aware it should still be 10 for you guys as well oh thank you brenda i get a thanks too okay um i think that is that's everything so thank you very much to all attendees we all wish you the very best of luck we would genuinely like to hear how you how you do in your exams um i think they're slightly delayed aren't they from when they were going to be but um yeah best of luck enjoy the recipe good luck everyone you'll be absolutely fine great have a good night thank you guys [Music] you