Back to the Cyber Underground. I'm Dave Stevens, your host. This show we dig deep to find out how cybersecurity touches all of us in our everyday lives. Joining us here today, again, is our exceptional co-host, Mr. Andrew Lanning. Andrew, the security guy. Welcome back, man. Thanks. I'm good to be here, brother. And Tom. Findling? Yep. All right. From IntSites. That's correct. IntSites. Don't say Insights. You get the wrong website. Yeah, you got it right. All right. Well, hey, welcome. This is our cybersecurity show where we talk about all kinds of stuff, and you're going to tell us about in-depth security today. You were mentioning, before we got on the air, though, we're going to do Black Hat Def Con here coming up in two weeks. Not even two weeks, right? Yep. Two weeks. Almost two weeks. Black Hat starts on the 26th. Yeah, we've had the training days before. Are you going to the training? Yep. Oh, right now. What are you taking? I haven't decided yet. Oh, you get to pick at the last second? Yeah, I guess so. Your company has a good budget.  I always go in for the briefings afterwards. So this is your first Black Hat, or you've been before? This is actually going to be my first official one. Official? So you've gone unofficially? I was around there when it happened. You jumped the gates? Snuck in? So what's for you? Physical penetration? You're not going to admit anything. I don't tell all my secrets, right? Good for you. So tell us a little bit about yourself. First of all, where you're from? Because I hear the accent. So does everyone else? Yeah. So originally I'm from Israel. Oh, right. And I started... Coastal inland? North? South? Tel Aviv, right there in the middle. Right in the middle, okay. Yeah, right next to the sea shore. Like, you're in Hawaii. That's why I like it so much. Oh, yeah, right. And it feels a little bit at home.  That's like one and a half hours away. It's like for you to go to a different island, right? You're right. Okay. That's cool. From Israel. Now, when did you come over here? Approximately four years ago. So all your schooling pretty much was done in Israel? Yeah. Actually, I kind of skipped school. Skipped school? This is a hacker's story right here. Yeah. Tell us about how you did this. You just didn't need it. Yeah, so I started back in the days. I was a pretty tech-savvy kid. Okay. And then at the age of 18, after I finished high school, you get this letter. And then the letter you have tells you you need to be at this base at this time. And then they take you to the army. Then you have three years of mandatory service. Three years in Israel. I wish I did that in the U.S.  As a matter of fact, I think a lot of Northern European companies does it. Sweden, I think, is two years though. Yeah. So they take your independence and you become a soldier. Did they pick your job or did they actually find a good fit for you? You don't get to pick your job. You run it for some tasks and then you put you on the right position that you will be able to maximize your skills. Wow. Thank you. Where'd you end up? I ended up in intelligence. Awesome. Yeah, some of the units that was dealing with intelligence, back in the days I remember it was almost like 10 years ago. This is all free. So you got into high school and you went right into the army intelligence. Wow. Training. And so there's a lot of training with it I'm sure. It was like, yeah, at the beginning it was basic training.  But after like approximately a month it's starting to get more, you know, civilized. So you get to sit back behind your desk and start doing a lot of interesting things. Wow. Breaking out the basic end map and then working way through Wireshark and getting some cybersecurity under your belt and all sorts of things. Wow. Yeah, it's getting pretty interesting.  I bet you did. Wireshark, yeah. That's, you know, and back in the days it was much more innocent than what it is today. So I remember like 10 years ago nobody was understanding the value of cybersecurity and especially I remember back in the days in the army when we were talking about, hey, you know, the Russians can just get into Hawaiian Electric and turn off the flag on the white. People will look at me and tell me, who is this crazy person? That'll never happen. Come on. Why would they want to do this? Why not? That's a good point. Exactly. You know, in Israel because where we are, we were always under attacks.  That's kind of what it is.  A little bit of both? It was very, very early in the program so we kind of did everything. I see. You know, build a lot of capabilities and this is one of the things that, you know, kind of connected me with 14 sides just today. So after the army? After the army I left to work for a small firm then I moved to VMware. Oh, okay. And I worked for VMware for almost six years. Future of the world, man. We're utilizing everything. Everything is a virtual service. We built micro-segmentation. We did operations for micro-segmentation so see how those things are working and how they work in the real life because it's a great idea. Like, when you look at it and this is where we started back then micro-segmentation was like, wow, I can just go ahead and create those small islands and make sure that, you know, everything doesn't talk. Only the right thing can talk with the right thing. Connect your little sandboxes around here. Yeah, you have like 2,000 fireworks running across your network. All of them are virtual, getting up and down. So it looks like very good in theory but then when you have to put a rubber on the road then you can hit some challenges but I think getting through this process and, you know, being able to run through that and see how organizations maturing into it and all the information stuff off it was very pretty interesting ride. Was that the beginning of, like today you talked about these containers, right? So was micro-segmentation the beginning of that? Or is it not really? I think that we deal a lot with containers these days with Insights because we build a lot of our capabilities based on containers. So I think containers, they have a security aspect as well but I think that from an operational perspective, engineering landscape, they provide a lot of advantages beyond security. Micro-segmentation was mostly focused on security and I think that being able to virtualize it all and being able just to get a load balancer in like 3 seconds and firewall in 5 seconds. So the scalability is then the rapid deployment of devices in this virtual environment. So for our audience, virtualization is when you replicate something in main memory somewhere, there could be a physical device in the real world. Yeah, can you just take a, you know, a Windows box that used to be tied to hardware and just virtualize it and make it being able to run, you know, almost on any hardware anywhere and you can just move it around across the wire. You can take it to the cloud, you can bring it back, you can do almost whatever you want with it and with that, there are a lot of security challenges as well. So again for our audience, the cloud is not really this actual cloud in the air where things exist. It's multiple data centers around the earth where things get stored wherever you need them to and backed up to wherever you need them to. But you can access them through anywhere on the Internet. It depends on your policy. But theoretically if you stood up a server, it could be in Portland, it could be in Virginia, it could be in Canada, it could be in South America. It doesn't really matter. It depends on how fast you want to get to it, where you want to get to it from, where it's going to be, how much you pay for it, what vendor you're using, right? So this cloud virtualization that we're doing now, I think companies are just glomming onto that. They just love this being able to ramp up a whole bunch of servers. Amazon Prime Day today, I would imagine since Amazon Web Services, they virtualize almost everything. I bet they had two-thirds of their services ramped up to maximum capacity and they have backup servers upon backup servers because they're expecting more business. And tomorrow it'll go away because they don't need it. So you don't have to have a standby physical data center.  And then when you don't need them, you put them back. Saving power, processing, CPU time. You can move them between on-prem and off-prem and just play with all those weird configurations. That's what my cyber students love.  And they can go and they can play within this little sandbox and they can't harm any other devices on the network. But they can talk to all the systems that are in that sandbox. So that's what we play with Wireshark and MAP, stuff like that. So they can't harm anybody else. So you've been doing this from the very early days. I've been doing that right after the NYSERA acquisition that we had in VMware. Before that I was doing also cloud management as well. So I have a lot of background with virtualization operations security operations and just how to get it into their real-life, to their biggest customers in the states and just roll it out. You were one of those kids that saw the Matrix and went, oh yeah, that can happen. No surprise here. That can happen. That's totally real. There were a couple of other movies that I was watching back in the days when all those stars were able just to change traffic lights when they rob a bank and they drive on the train. Well, the Italian job. Exactly. That can be done. That's a little scary. You can do it from your room behind your desk.  I'm kind of wondering since you ultimately came out to California what do you tech technology and tech savvy amongst the kids there versus the kids where you grew up? They're starting to teach at a younger age in the schools in the mainland now but it sounds like you guys started very early. Everyone had access to advanced education as much as they could handle? I think that just growing up in Israel, your sense for security is much higher than what you will get in other parts of the country. I don't think that a lot of people in California feel that on a daily basis something could happen to the state but in Israel that's a much more complex situation. So I think growing up in this environment and this is what we saw before cybersecurity became such a big thing around here. It was a big thing in Israel because Israel was under attack from day one. So I think that when you grow up with this mentality it allows you to just be more focused and aware about the tech and about the challenges about what you would like to achieve. And I think just by the culture of growing up out there you get a lot of it to be part of your DNA. Sure. I've seen this with a lot of smaller countries. The people that I know are from smaller countries and especially Europe. I have a lot of European friends. They grew up with multiple countries very nearby. So they have a very international view on multiculturalism, other languages, other ways of thinking. Where's the United States? Especially California. They think they are the country. Exactly right. Well that's so after you finished all that you came out to the United States. Did you come straight to Hawaii? No. I came straight to California. Which city that's a big state? I used to live in San Francisco. Good for you. I lived in Palo Alto. So it's a lot of commute everyday. Palo Alto. That's a nice year of been out. Palo Alto is a beautiful place. So I used to live in Oakland way back when I lived there. I'm old. Our main worries were not security. It was raccoon and deer. It's a different city now. You can take care of that pretty easily. Yeah, now you can. So Palo Alto you worked in Silicon Valley. Yeah, absolutely.  No. Were you there with Insights or VMware? No, I was there with VMware. So VMware located out of Palo Alto. So I spent some time over there. And then I moved to Southern California for a job opportunity. Small startup. I'm the guy, the founder of the company that I'm currently working for. Which is a good friend of mine since high school. And offered me the job. And I decided to leave my previous place and move to Insights since it's just getting back to my roots. Security, cyber, all the interesting stuff. And I think that kind of what we do is like this is what's going on these days and getting into the heart of it and understanding it and being able to help companies to protect themselves and proactively take some steps against those bad people out there. That's a big advantage that we can provide. I like to be on that side of the equation. How many offices do you have? Is it just the one and you remote to every place else or do you have actual physical locations? We actually have physical locations. Where are you guys at? So our R&D center is based out of Israel, obviously. Okay. We have a bunch of engineers there and we have the major of our security analyst based out of there. We have our New York office, heart of Manhattan. On the island. Yeah, pretty interesting what's going on there. That's a successful business when you got an office on the island. It's a good zip code. Not as good as this zip code. Not as good as this. I mean it's good for business zip code. And we have another office in Dallas. Oh, awesome. No representation in California. But I kind of think that after this visit here in Hawaii, I might recommend that instead of a California office, we should go straight to Hawaii. I think that's a great idea and I support that. Do you serve clientele in Asia? Absolutely. So this is the gateway. So this is the gateway. So this will make sense for you guys and it gets you on the beach more often. Absolutely. To do business. Well, you can't help it. It's just work here on the beach and the water's right there. You can't help it. That's right. It's a board meeting. Board meeting. I love that. Okay, we're going to take a little break. I'm going to pay some bills and when we come back, we'll continue with what your company does. And I want to hear the gritty details. Okay, we'll be right back. Aloha. My name is Raya Salter and I'm a host of Power Up Hawaii which you can see live from 1 to 130 every Tuesday at thinktechhawaii.com and then later on YouTube. I am an energy attorney, clean energy advocate and community outreach specialist and on Power Up Hawaii we come together to talk about how can Hawaii walk towards a clean, renewable and just energy future. To do that, we talk to stakeholders all over the spectrum from clean energy technology folks to community groups to politicians to regulators to the utility. So please join us Tuesdays at one o'clock for Power Up Hawaii. We all play a role in keeping our community safe. Every day we move in and out of each other's busy lives. It's easy to take for granted all the little moments that make up our everyday. Some are good, others not so much. But that's life. It's when something doesn't seem quite right that it's time to pay attention. Because only you know what's not supposed to be in your everyday. So protect your everyday. If you see something suspicious say something to local authorities. Well back here we are at the Cyber Underground. I'm your host Dave Stevens. Thanks for joining us today. Again we have Mr. Andrew Landy and with the security guy with us. And Mr. Tom Findling. Thanks for having me. We ramped up with your history, how you got here some cultural differences in your education in your three years in Army Intelligence in Israel and now we're talking about maybe you're open a location out here. I hope so. Let's find out what you do and get into the nitty gritty details. Why is in depth intelligence so important and why do you guys do it? Yeah, so if you look at a lot of companies out there, they're putting a lot of money towards protecting their internal network. So they put like great fireworks together endpoint protection tools, next gen endpoint protection tools. You know all this great devices that you put within your network. But without understanding what's going on on the outside world, you kind of live in the dark. So the idea of insight is I get you the visibility to what's going on in the half of the cap. So you know you can see the what's going on within your network. You track the bandwidth, you block some IPs but the firewall will block what you will tell him to block. But what you don't know about it's very hard to deal with. So being able and we go to the entire internet. We go to the clear deep and dark web, bring you threats and risks that are described. So for our audience again, we assume non-technical memory that they're telling what the difference between those internets are. Absolutely. So it's all start of the clear web and the clear web is basically what all of us familiar with. Everything Google indexes. Exactly the definition. So if you look at social media pages, if you look at paste sites, if you look at application stores, search engines, everything basically that can be indexed by Google, this is the clear web, which is by the way a small function of what's going on out there. It has window shopping walking down the street. Then you have the deep web and the deep web is getting a little bit more interesting. It still can be accessed through normal protocols like usually like web, but those are closed forums and closed communities that you can get in without using them or talking or whatever it is or pay yourself in, but it can be indexed by Google. And there is a lot of stuff going out there as well. Just so we take a little bit, that is usually, I think if I'm not mistaken that the websites hosts will put up like no robots text files or something like that telling the search engines don't index us. And it's also behind closed doors. So you need to get a username and passwords to get in so Google can get to those places just by nature and they don't want to be on Google as well. This could also be accidental, right? Somebody puts up some of this stuff and thinks they put a username password page up there but behind the scenes it's still open. If they did it wrong. If they did it wrong, right? That's a mistake. That appears in what we call the deep web. Not so much. That's a deep web. If it's behind closed doors and you can't access it, we need to use the username and password to get in. That's a deep web. So a lot of people and a lot of companies can access to those forums and those close communities that people just exchanging bad stuff in there. Usually tutorials about how to hack your organization. The dark web is actually going one level down. A level down. This is the bottom of the iceberg. Usually what you need, you need a special gear to get in there. Usually the full browser to browse some onion sites and the good thing about that is to provide you anonymity that you would not get through a normal web browser. So let's stop again right there. The onion networks that you're talking about instead of .com, .net, . whatever, we have .onion which is a domain that's not recognized by browsers natively. Browsers won't know what to do with .onion. So you have to use a browser like Tor, TOR. The onion router. And that's what it stands for, right? And that will recognize onion networks. But it's not like we have Google for the onion networks. It's kind of chaotic. It's kind of chaotic. So there is some search engines there but I would not trust them. But you guys search it. We search it. But you need to know. It's not like you go to google.com and say, hi, I want to find those five things and that will bring you results and probably the first one will find you what you're looking for. You need to know what you're looking for. You need to know the website's address. So just think about the internet that you know and aware of the clear web without search engines. How do you get to certain locations? And they're not nice website names, right? .net knows 1234XYZX. Imagine that people don't want you to find it. The dark web doesn't have click advertising going on. No. They don't have Google ads. But that's what evil stuff can happen, right? Weapon sales, human trafficking. No pornography. They're really bad stuff. Advertise for what you want and advertise for what you've got. Most of my life I think is probably on for sale. I don't think you died in the first day. How sad is that? So you guys will search this place in our universe. The whole internet. Do you have any responses for threat intelligence for a certain company? Yeah. So the idea was take some of the capabilities that we did for the military and just bring that into the commercial market. So we know that a lot of organizations today would not have the tools that we had back in the days just to start building all those capabilities and also maintain them up to date because those sources that we are dealing with they're changing on the go. Like, you know. You need to stay on top of it. You need to maintain your access. Sometimes you need to pay your bills because sometimes you need to pay your way in. So when you need to maintain your avatars and your reputation. So it's not an easy job to do. Just being able to go out there, search for your company name, come back and just see what is out there for you. So being able to maintain all this network and the way we do it is actually pretty interesting because we don't want to go and take your domain and just go and search it on some dark web forums, right? That would not be a smart thing to do. So we develop some capabilities that allow us to bring all the information into our servers in the cloud. And you search it there. And then provide, like, then look for the matches over there.  We do a lot of things. So there's a lot of analytics done on the data you gather, I would imagine. Oh yeah, billions of webpages on a daily basis getting for algorithms and the idea is just to provide the best protection that we can for our clients. And this is what caught my eye. So that's why I seem to come on. Because I don't know if people understand that there are clues and ways to find out that people are building tools to attack you with. And those tools may be similar to the domain that you own, just for example. And these guys may come across that. And then you get the idea of what kind of threat is actually being built to perhaps attack you with. And this is super valuable to business. Yeah, absolutely. And I think ahead of time that, for example, you're going to suffer from a phishing attack or a dittus attack can get you a competitive advantage, right? On the attacker. Being able to know that you will have five or ten employees that are going to be attacked on a certain phishing attack, that's even better. So now we don't just know that you have a phishing attack being launched on your organization. You might know where the individuals that already gave their password in the past that are on some kind of list that probably people would try to phish them again. And those people could also be high profile in your company. So they can do name searches and things like that. And people are also trading these fees. I can ask like in the University of Hawaii who are the top people that already gave their password in the past and they have access to certain information. So this is interesting. We've gone from the phishing attack from emails to spear phishing, identifying individuals with a high profile target spear phishing, wailing. That's really interesting. So you identify this up front. You can come to people and say, look, based on what we have you're probably a target. This is probably coming down the pike very soon. That's why we're very strong with the gaming community. I can tell you that. That's great. The tools even went further. In some instances they were able to show us some of the folks that they knew they recognized like the work that they do. So they kind of maybe know where this work's being done. It's just an identity, a virtual identity that you have to maintain. So sometimes in order to get your way into somewhere, you need to just have a reputation. You know, you don't just show up at the door and say, hey, I want to get in. So there are a few ways to get to those places that we try to get into. One of them is to get a recommendation from somebody. So you know me and I need to maintain our relationship for a while. So do you know me and I need to maintain our relationship for a while? So therefore you recommend me to get in and then this is how I get my way. Sounds like high school. Yeah. It happens in a little darker place. This is a college frat party. He's cool. Sometimes you have to pay your way in.  Your monthly, weekly fee, daily fee, whatever it is. And you know, sometimes there are some other ways you need to prove yourself or do certain things in order to get into those sources. But the idea is that we maintain all of them up to date and whenever there are new ones we always get behind them and be able to provide the information. What can you tell us about this sample client and some of the successes you've had and some of the things you might have prevented? Can you share any of that? Yeah, we can take and give you some good stories that we've seen. Yeah, generalize it so we can minimize the data. I talked earlier about gaming. So the amount of money that's going on the dark web or to those like gaming programs that big casinos have in the world, it's crazy. People take stolen credit cards and move money into those accounts, game belong them and sometimes what they would do, let's say that I will use a credit card and move some of the stolen credit card and move some of it into my gaming account and I will get into a poker room with you and with you that you guys are my friends and I will lose the money and you guys will win. Oh nice. Yeah, you just lauded the money. Yeah, so that's cool, right? Brilliant. See what you learned on the show. That's awesome, right? Okay, we're almost out of time. Anything you want to tell us before we leave the show today? Audience, how to be safe? Just try to be safe, never give your password to anybody and if somebody write you an email, hey it's to help us send me my password, send me your password, never do that. Never do that. Well, thanks for being on the show, Andrew. Absolutely. Thank you for being here. I think we'll get him at Black Hat maybe. That's right, Black Hat at Defcon. We'll be at Defcon ground floor, I believe at Cesar's Palace for Defcon on the 28th, about 4 p.m. Nevada time, 1 p.m. here and we'll have somebody in the studio to Skype with us and hopefully you can stop by. Absolutely. You promised me some shots, so I'll definitely be there. We'll do some shots. Thanks everybody for joining us on the Cyber Underground. Stay safe.


Okay, crappy picture. Okay, so conjunctivitis. So you have kind of two main types of conjunctivitis that you're having to figure out. So which one do you think this is? So look at the size of the bumps is kind of the idea, which again, it's always hard to tell. So right here if you look at this slip beam, and you can kind of see these like slump areas here, so it's a fullicular conjunctivitis. So anytime you see a fullicular conjunctivitis, there's almost always... I turned it on.  So if you want to know what a follicle looks like, just pull any patient's conjunctiva, their lower lid, just pull it down really, really far, and you'll always see a few follicles in the forehead. So you can kind of get an idea of what one type of conjunctivitis is. Okay, so patient presents with chronic fullicular conjunctivitis. All the following could be the cause except. So HSV, definitely, right? Holoscope? Definitely. Stevens-Johnson syndrome. Chronic ocular environmental allergies? What do you think? Probably Stevens-Johnson, right? Stevens-Johnson is just gonna kind of cause it's like an irritation, like kind of a like papillary conjunctivitis, and you'll usually see membranes, right? With Stevens-Johnson syndrome. So the term chronic in kind of a follicular reaction is technically over four weeks, and somebody came up with this BAPMAP lap, kind of tried to try to remember them all. I never was very good at remembering these lists of things, but these are kind of all the ones that the main ones are gonna be viral, and then you've got like things like trachoma, like chlamydia, moluscum.  Okay, another question. So patients after hyphema, so they've had a trauma, they've got an intracular hyphema, are more likely to develop corneal blood staining due to all the following except. So what can cause corneal blood staining? Imagine like sickle cell trait, are they getting that? Because if the re-bleeds, it just kind of leads to maybe a prolonged course. So the idea is if the blood doesn't clear quickly, then you'll get it, or if they have high pressure they'll get it, or if they have some other endothelial condition, they can get it as well like these. And the method of injury has no bearing on it, right? Okay, alright, CIN. So you've got a patient that comes in with CIN, how do you treat it? What is CIN? So we're thinking this is some sort of lesion growing on the congenitiva that's in the spectrum of a squamous cell carcinoma, right? So you can have all the way from benign growths on the congenitiva, which are like a pinguecular atorrhagium all the way to squamous cell cancer, right? So that spectrum sort of in between those is a CIN. And you can have any variation of this. A lot of vets have this, so you'll see a lot of these at the VA. And you have to kind of decide, okay, how am I going to manage this? So you've got to the point on this patient where you probably want to do something. Does mitomycin C work for this? Not very well. You'd usually actually do what for it? What topical treatment might you do? So interferon alpha works for it. Mitomycin is actually not the treatment of choice for CIN. Mitomycin might be a treatment of choice for what other ocular kind of growth on the eye. PAM. So it works well for PAM, that melanoma kind of spectrum of pigmentation, okay? So you either have simple excision, which is the least good option up here. Mitomycin C, not a great option. So you've got wide local excision with topical steroids. It's going to help prevent what if you do topical steroids after this? Scarring, right? So it's going to be helpful a little bit. But what you really need to do is wide local excision with cryotherapy. And what's the term that they like to use for the cryotherapy technique that you use when you're doing cancer killing? So no touch for sure. But the cryo part, double freeze thaw. So what that means is that you freeze the edge of the conjunctiva where you excise this and you let it thaw. So you kind of just move all the way around it and then you repeat it. So you do it twice. And what that essentially does is it kills any cells that you didn't excise. And you're trying to excise everything that you can see. We haven't gotten to the point where we're doing mows for this on the surface of the eye. So we usually just, you can't really take, you know, like the classic for even four millimeter margins are kind of big on on some of these. And so you usually try to take a couple of millimeter margins on. Okay, another really crappy picture.  And this is what they all seem to look like. They were all grainy and crappy. Okay, so somebody help me describe what you see just to kind of get an idea of what's going on. There's a classification at the limbis with a lot of vessels. Okay, so we got congenjection, maybe some whitening here, hallucinate that it's a little elevated to. So just right at the limits. No contact lens wear, no trauma. What's your diagnosis?  And this usually the question will kind of help you sort of get an idea of what they're maybe leaning toward. So a little inflammatory lesion of the congenitiva, what type of hypersensitivity reaction is happening?   Yeah, good. So flictenual is what kind of hypersensitivity reaction? Type one, type two, type three, type four, type seven, I don't know. So it happens to be a type four hypersensitivity reaction. So this is a little bit of a better picture of what they'll look like. It almost looked like a, like a necrotizing scleritis is what you're kind of like worried about initially. But it's going to be just almost like a little ulcerative lesion on the congenitiva. It reminds me of what like an ulcer of kinker would look like in the in the mouth. So we don't have great information about these because they can sort of just be anything that can cause this, but they can be infectious. So you have staff is probably the most common cause of them. And obviously, you're you're always worried about tuberculosis when you see somebody with this, you're asking about exposure and travel and all that kind of stuff. It's a, it's a lymphocytic sort of collection of inflammation. And so really, the treatment is topical steroids. And usually you do like it tobermicein or something with it. So like a toberidexerum, acetrol would usually get these to melt away pretty nicely. So if it doesn't seem to respond to this treatment, you'd want to culture it and kind of go from there and see if it's something else. But they're trying to get you to test for tuberculosis when you have a flictinule. Okay. All right, another funky picture. It's kind of blurry, but it helps you understand sort of what's going on. You can describe what's happening. What is this? The lower lid. Okay, lower lid. And we have what appears to be a large corneal abrasion. Okay, so we've got missing skin, right? Yeah, rolled up edges. It's a rolled up edges. What's this? Okay, so we've got the upper limbus here, right? Okay, so where is this going to be? Superior. So superior up underneath the eyelid, right? Okay. Shield ulcer. Okay, so good. So you kind of have to sort of take a step back and say, okay, where am I? What's the most likely thing that they're trying to give me to think of here? So if you have, if you take a step back and say, so what causes abrasions on the upper corneal or what causes the skin to break down in the upper corneal? So you talked about a shield ulcer, but a foreign body is a big one that they'll want you to think of too. Okay, so they're kind of the two made ones. So you'd always want to flip that upper lid and see what's going on up there. Okay, so this patient presents with the following finding after years of battling allergies, what is the cause of this finding? So which one of these is kind of an allergy type appearance, right? So if you look at these other ones, you could have any of these, right, recurrent erosions, it could be herpes simplex, it could be a traumatic epithelial defect, it could be a foreign body in the upper eyelid. But it's kind of that location of it being up underneath the lid in somebody with kind of an allergy type appearance or look. Okay. Shield ulcer. So vernal keratoconjunctivitis is a type one and a type four hypersensitivity reaction. They're usually young people. And we don't have a lot of them here in Utah, but we do get a fair amount of them. They usually present with just this really nasty, beefy, tarsal conjunctival sort of inflammation. Typically, it's better on its own. This is kind of your link to it. So somebody who has like a really bad sort of atopic dermatitis, they're going to kind of go down that path of trying to get you to think about more systemic issues. There's kind of two types. There's some that are just right at the limbo sort of involvement and then some that are more on the lids. So it's kind of this cobble stone papillae is kind of the big one. And they have these huge septic kind of in between them that separate those papillae out. Okay. So that's a vernal conjunctivitis. All right, Marshall. What's wrong with this guy? Major things are very floppy eyelids syndrome, potentially very large with acidity. Okay. So don't do this to yourself too much. But if you try this, you can't do it to your eyelids because your eyelids are normal, right? I try to tell patients like I can't like flip my eyelid over just by doing this. Whereas in somebody who has really bad floppy eyelid syndrome, you can. Right? Okay. So they're always going to think about what's the scariest thing with floppy eyelid syndrome. This patient has the font chronic medical condition, sleep apnea, right? So that's going to kill him because it causes pulmonary hypertension and heart disease and chronic oxygen deprivation. And they're tired at work all the time and they might fall asleep while they're driving to work.  And so that's what they're going to get you to think of. So how do you treat floppy eyelid syndrome, Marshall? I'm a steroid ointment like Mastrol, especially if they're having crusting of their eyes. And if they feel like the antibiotic ointment is helpful, but then they get crusting back and they can do eyelid surgery to tie them up, tie up the lids. I'm also a treat sleep apnea, okay, so what's the mechanism of their sort of ocular inflammation? What happens? At least what do we think is happening? Are you just getting under the lids because the lids aren't tightly opposed to the globe? And sometimes these guys, they'll actually like flip their lids will actually flip over, they'll get like tarsal plate inversion while they're sleeping.  For some reason, a lot of people with sleep apnea actually sleep on their faces. It's like the strangest thing. I can't breathe, and I'm going to suffocate myself at the same time. So okay, there's a ton of sort of other issues with this. So what, what's a cornea problem with floppy eyelid syndrome? Anybody know the cornea connection to floppy eyelid syndrome?  Yeah, you've got you've got all that kind of chronic irritation stuff, right? There's something different structurally with the cornea. So I don't know that we know the exact mechanism, but I mean, I tell my care to come this patients to stop sleeping on their faces to try to get keep their it's crazy like if you talk to young kids or like teenagers or 25 year olds with the care to come as they sleep on their face. It's like the strangest thing. I don't get it. Just like face down. Yeah.   That would be a good approach. Okay, so this is a papillary conjunctivitis. There's typically no follicles. And you're not seeing like a filamentary caretitis with it. So it's kind of easily averted upper eyelids. So you have to touch your patient sometimes to kind of figure this out. And the underlying problem seems to be this decrease in elastin in the tarsal plate. So you've got obesity, sleep apnea, eyelid, rubbing, careticonis. So the treatment really is to protect that eye. So either wear a shield at night, take the eyelid closed at night, obviously do some sort of a lubrication on it. If you can just lubricate the inflammation will go away. Sometimes it does need a steroid to kind of calm it down like Marshall was talking about. Like chronic erythromycin ointment is not that big of a deal in a patient like this to try to keep some of that crusting away. And then you have this, what is the surgical lid tightening procedure where they call it? Wedger section. You guys ever seen one? Kind of weird. They seem like so, I don't know, invasive, but it seemed to work. Okay, it'll come back if they continue to leave things untreated. Alright, I give you a little better picture because I just have a really good picture of this. I thought it was a good picture. So this is a patient that I actually saw when I was fourth year, they showed up in my community clinic. And they had, they had lost vision over the last week. What was their claim? True or false? Completely false, right? No chance. No chance that you could have lost vision over the last week.  Okay, so what's happening here? What is this called? You have blood vessels on the surface of the cornea, you got blood vessels in the stroma of the cornea. It's kind of deeper, you can't really appreciate the depth of it. Some of these are superficial, but it's kind of full thickness in the cornea. So blood vessels in the deep cornea, I think I heard it. Inner, somebody say it? No, it's in the Okay, it could be that. But this is interstitial keratitis is what they're trying to get at, just kind of deeper, deeper blood vessels kind of growing in the cornea. You'll also get them up on the surface too, even if you have that deep vessel kind of growing. Okay, so patient presents with the following condition. What is not a cause of this condition? Good. So thyroid eye disease can cause chronic eye irritation, right? It's usually just going to cause kind of a kind of like a marginal neobascularization that's right at the edge of the cornea. But interstitial keratitis can be caused by so you're thinking something that causes infection or really bad inflammation of the ocular surface. So a chemical burn can do it. I actually have a patient that's like, it's one of the most challenging cases that I've ever had to deal with, who drank, fell asleep, was like passed out on a heating pad.  I don't know why he had it on his face. But he burned his eye. So it was like a thermal keratitis and it caused interstitial keratitis, the deep vascularity of the cornea. Syphilis can also do it. So thyroid eye disease is the one that does not do this. Okay, so interstitial keratitis, the one that they love to get at is this syphilis congenital is most likely bilateral. If it's unilateral, then it's more of an acquired syphilis later in life. You have this Hutchinson's triad with congenital syphilis where you get the teeth abnormalities and deafness as well. Tuberculosis, HSV, Lyme, these things are always something that you should have in your differential when you've got theobascularization of the cornea. And then you have this Kogan's sort of triad as well, maybe quad, what do they call it? We have vertigo today just hearing loss, so it's involving the eighth cranial nerve. Other less common causes, you have to kind of think about all these things, but it's usually something that you don't really come up with a diagnosis on and you treat them for a viral keratitis just to cover them and then how are you going to treat that? How are you going to get rid of that? So they might present this to you and say what are the treatment options for this? Steroids to start off just to see if you can kind of calm down that inflammation scarring, but I think it eventually requires a PK. Yeah, so you have different options before that that you could try. So steroids is kind of the mainstay is to try to just calm down any active inflammation. Active inflammation is what drives new blood vessels to grow and so you can probably get some of this stuff to regress that's kind of on the edges. These big vessels are probably not going to regress with topical steroids, so what could you do to these big vessels? So you can burn them, so what are the methods of burning a vessel? There's a couple of different ones. So you can do pottery, right? Is there anything else? You could do some in clinic. I do that in the OR, but you could do it in clinic. You can do some with a laser, so you can use an argon laser to actually ablate them and that again may not work on a big vessel but it would probably work on knees. You could ablate those vessels. Okay, what else could you do in clinic? Are there medicines that you could use? Maybe. What did you say? Well, that's a temporary thing. Like maybe you put them on lumefi, alfagan, some to kind of close them off. What about what causes, how do we treat neobascularization in other parts of the eye? Anti-veget, right? So you could do, so a vasin is actually kind of approved for this. You could do subconju vasin kind of in this area, which is what I ended up doing on my thermal burn guy and it worked okay. It didn't work perfectly but it regressed the vessels pretty well. So you might do a series of three over the course of three months and see if you can get it to regress. They typically come back. It's not like, I don't feel like it's like the retina issues where you can actually get it to go quiescent over time but maybe you can't eventually. So you've brought up an interesting one, is mitomycin C, which you could potentially do that topically to kind of help it. But there was a guy just recently who actually took a cannula or a needle and injected mitomycin C into the vessels. Like he actually cannulated the vessels and injected it and it actually made it pretty much completely go away on a case that looked pretty similar to this. Not published yet, not really widely agreed upon it, that's okay. Because if you inject mitomycin to the stroma the cornea probably melted but he claims he got right into the vessel. So kind of an interesting one. There's other sort of vascular surgeons that will actually go in and sclerose vessels by injecting like a soap or something. So you could put like a, I think it's called like saponification of vessels. So you could potentially do that. But these are tricky because you may end up needing a PK. What's the problem with a PK in this setting though? So the vessels are going to be right at the edge of the graft. So it's probably going to regrow but rejection right? Super high risk of rejection in that setting. So you'd want to try to calm these down, get them to be as ghost vessels as you can before you go in and do a surgery. All right, what do you got? This right here. We put a picture on OCAPS for this. It's really bad. Looks like a white iris too. So really light iris. Should the limbis ever look like this? You should never have pigment on the cornea, right? Yes. That's a reflection. Okay good. Okay so the patient has the following finding. That's what I think that's the exact picture from OCAPS. That's crazy. You went and found it. I remember having a picture that looked pretty much like that. Okay so the patient has the following finding. So the PSC cataracts, they have hypertension, they have splutter hemorrhages, they have decreased the riloplasma. Increase the riloplasma. So what's the disease? Wilson's. Okay so Wilson's disease. I want you to come to the bedside and see if they have the Kaiser flight. I've tried. So they actually do have decreased the riloplasma, increased copper. So it was that one. And they have this sunflower cataract. So it's copper deposition in. That's a maze memory. Okay that's kind of the key. And then the treatments they'll sometimes get into and it actually does go away with adequate treatment. That's another item that might show up on the test. If you have a Kaiser flight sharing it's not just in Wilson's disease. There's actually some other really weird things that can cause it to. But it all has to do with that suruloplasma that kind of binds to copper. Okay uh I forgot my picture. But I don't think you need to know. You're not going to remove any else, right? So patient at this lesion removal kind of line would be present on the corning exam. Okay so fly string is in what? We said this fly string, like the Kaiser fly string. So this one's different. So the keratoconus. So that's a that's a round iron deposition in just kind of around the apex of the cornea, right? So it's going to be displaced a little inferior with keratoconus. Okay a stocker line is a teridium, right? I have a really good picture of this and maybe that's I might have fallen asleep trying to find it. But and then what's a ferry line? That's the bleb. So I always think of a ferry being water and in blebs we're kind of dealing with water trying to move it around. And then the Hudson stolly line is just like I just think of like a Russian with like this straight line or something I don't know that just like it's just just above the lid. It's where the tear film kind of just deposits a little bit of iron. So it's like a a millimeter or two above that lower lid margin. Okay did everybody have good breakfast? Maybe. I almost did when I saw this. Seen this before. Disaster. It's one of our own patients at the Moran. Okay so V1's Oster. So what makes you think this is Oster not something else? Like because what are you gonna use on this to kind of determine I mean I'm just a test to say this looks like Zoster compared to other issues with it. It doesn't cross midline.  Okay and then the other thing is that if you take it and you kind of say okay V1 is typically sort of out here at the lateral canthus and goes up this way sometimes you'll be a little bit crossover in that lower lid but you're typically not getting much lower lid involvement right. So lower lid actually looks reasonable and it's mostly just this upper lid right on the forehead. I had a patient one time that came in for she had supposedly been splashed by a chemical at work and she was trying to get disability from her work because she was suing them and she said that somebody had like sprayed a chemical on her and she developed a rash and the rash was on one side of her face like you look up at her she's like I got stuff in my scalp all over it it was literally just like inner hair one side face one side nothing over here nothing up here so you have Zoster this is not a chemical injury it's Zoster because it's that dermatomal thing okay so that's the key to it. I had a patient yesterday presented with V2 Zoster just like right here. So what are you worried about with Zoster? There's a lot of things but can you give me the rundown of what they're going to test you on what things they're going to be worried about on an exam? So clearly the cornea is involved here right? I don't know if it's involved because the lid sucks or if it's actually infected but the cornea is hammered. So intracular involvement too right so you could potentially get a UBI this or R in the retina so you're having to dilate them and try to get a look back there. So you're going to deal with all the eye issues okay so what else?  So is this a disseminated thing? Are they altered in your clinic or are they having a hard time like understanding what's going on? Do they seem like they're they've got it going on and centrally like CNS involvement right? Okay you're going to check their pressure for sure what if they're saying things just sound muffled to me? Yeah so you can get the Ramsey Hunt syndrome where they've actually got cramps or eight involvement which my patient yesterday I was she was like I'm having like I feel like it's muffled. I said to her how's your hearing those muffled. Have they done anything about that? What are you going to do for that? So they'll actually test hearing so they'll actually do hearing tests to kind of see what the frequency of their hearing is doing and they can kind of follow that over time but you're going to treat it with what the thing is steroids for that part of it. So she was on Valtrex on an appropriate dose of Valtrex. She'd just been diagnosed like two days before I saw her. She had a prodrome of symptoms which is sometimes really challenging to figure out. So I've actually missed it. I had a patient that came in that was like complaining of swelling in her cheek and it just felt like tight. She didn't have any lymph nodes that were positive. I wasn't sure what's going on. So when I was a fellow she came in the next week with just raging disaster and this patient presented the same thing. She went to insta care. She had a swollen cheek kind of around her ear just felt funny and then like two days later broke out in a disaster. So you've got to watch out for the hearing part of it along with it. So okay so what's the optimal treatment for this patient? They only have eye involvement or something else. Nothing right just watch them see how it goes. Surgery of the bereavement maybe this is like a necrotizing fasciitis again that midline idea right? Try to try to look for that midline to get that out. So obviously we're doing oral maltreks and then kind of a little threshold to use oral steroids or something like this probably with how bad it is once they've kind of got appropriate coverage of the antivirals. So maybe like three four days into it. Other considerations long term with the disaster? Neurotrophic. Yep so neurotrophic pain is probably or neuropathic pain whatever you want to call it. It's probably the it's probably the biggest long-term consequence of having zoster no matter where it is and and how do you prevent it or what's the idea if you do something you might be able to minimize the risk of it or I mean GABA I know. It's really getting an antiviral started in the first five days is kind of what they think. So and then you may treat it with like a GABA pen. Let's keep out the detection for zoster attention. What do you do? I don't know if it does it for eyes. Oh I don't know. Could be. I'm not sure on that one. Okay so this is kind of a weird one where they'll have they'll come in with the a dendrite antiviral pain. It's kind of a weird thing. HSV usually causes pain compared to zoster. So zoster has asymptomatic dendrites. It's kind of the way to think of it. So they don't even know they have them. Their vision might be slightly blurry. But the the treatment for zoster keratitis is essentially on the steroids. Okay we're trying to figure out if if chronic antivirals help but we don't know because we don't have a good enough study on it yet. I tend to keep my patients on it for a little bit longer than the two or three week course that's kind of recommended. And then you've got all these other things that you have to think about here. Is it random there's seven or facial paralysis Ramsey, huh? Well confused now. Which ones that I thought that was the hearing one? Occidental one. I think. Eight's the vestibular nerve, right? Yeah. Sorry, the vestibular. Seven is facial. I forgot that. Seven is facial paralysis. And I think that is Ramsey, huh? So you got to watch out for eight involvement too. Okay, so this is kind of the treatment that you have to come up with. So it's either you're kind of going high doses here. So 800 milligrams, five times a day. Fambier 500, three times a day or Valtrex one gram TID. It's kind of full treatment dose. And if you can get that started within the first three to five days, then you lower the risk of their chronic pain afterwards. Which can be really debilitating that. Okay, so trying to figure out dendrites and appearances between that dendrite versus pseudo dendrite. So this is trying to say, okay, is this HSV versus VZV. So the dendrites and HSV just look clean. That's kind of the way that I would think of them. It just looks like a perfect branching lesion, like this one up here. You get the base that stains well, forcing the edges with Rose Van Gaal. That's what this is trying to get out here. Whereas a pseudo dendrite is just like blunt ends. So it just doesn't look, it just kind of looks fuzzy on the edges. And you tend to get a little bit more of the geographic ulcerations on this too. So it may not be a perfect pseudo dendrite. And then not really great stain on them. And then steroids here, you're not going to treat it. Here you are going to treat it with steroids. So, and I'm usually pretty chicken about this. So I don't start the steroid initially on first presentation. So I might wait a week to get it going. All right, another blurry picture. But I think this is actually a pretty good photo picture. I think you can tell what's going on here. So somebody describe this to me. It's a ring infiltrate, hypopion, the eye is very injected. Okay, good. So lots of conjection, hypopion. You got that flat whitening that's a hypopion layer out of things inside the eye. And then a ring. So it's dense around the edges, a little clearer in the center. Okay. So what do you think? 26 year old contact lens wear, 10 out of 10 pain. What treatment is most likely to lead to success? So we're going to get the pool cleaner going. Core hexadine. So corneal scraping. Maybe. Is corneal scraping a treatment for Akanthamoeba? Absolutely. Yeah. If it's epithelial. So you can actually cure somebody of Akanthamoeba if they present with epithelial Akanthamoeba only by scraping them. But it can be, it's really challenging to diagnose someone there at that point because there's nothing that's kind of leading you to say that's what it is outside of what can you get to kind of help you know. It's confocal, right? That's the only thing that's going to really help you know this is epithelial Akanthamoeba this deeper stuff. There's no way you're going to get that out by scraping. Okay. You're not going to be able to debulk it. So don't even, don't even try. You do have to try to scrape it maybe to get a diagnosis. Kind of get deep in there and see if you can scrape it. What about this? What's wrong with the PK? They actively have it probably recur. Yeah. So if you look at this, like where is there Akanthamoeba? Who knows, right? It could be anywhere. But what, what if, what if it's out in the sclera? What if you've actually got infiltrated into the sclera? It's across the limbis. Then what are you dealing with? You're probably dealing with the death of the eye. It's pretty much impossible to treat. You may have to go on to like radiation or cross-linking of it with collagen to try to, try to kill it. Like it's just, once it gets into the sclera you're pretty much, pretty much host. So here you could argue that you could do a PK to debulk it, but you're kind of huge risk of it reoccurring in the PK, which isn't the end of the world because sometimes that gets you a little bit ahead of the game because you're probably going to have to do a PK anyway. But these can be really challenging cases. But yeah, it's going to be chlorhexidine. It's kind of your main treatment. And then you've got other, other medications like PHMB, Roline. There's oral medications. Sometimes you put them on like IV medications as well to kind of help with it. So if you look at all the different sort of issues with Akanthamoeba it's really, it's a trophozoite. It has these epithelial cysts, which this is where you can actually cure it if you can get this, if you can get, get it out at that point. As soon as it gets into the deeper kind of ring-shaped infiltrate, then you're probably ending up with a PK because it's hard to get it to completely clear. Convocals are really your best treatment. You can get it to grow on this fancy line here that's always on OCAPS, this non-nutrien agar with E. coli overlay. They're double-walled cysts, which is what you're looking for on the Akanthamoeba foal. So if it's superficial, theoretically, you can de-bride it and it will go away. Again, it's rare because you have to have a really low suspicion for it. High suspicion. High suspicion for it, but you probably have a low suspicion for it. Again, you're usually using chlorhexidine and HMV. Rolling is something that you can technically get from outside the U.S.  If you look at the bottle on rolling, it just says for minor eye infections, which is fantastic because we use it for the worst eye infection that we get in the U.S. And then there's all these other treatments that you can use as well that seem to have some sort of benefit. So this is a patient that I saw at the Marin with a really tricky clinical course. I thought she had, she actually presented with an endothelial plaque on her cornea, high-risk contact lens wear, but it just looked like an endothelitis. So I treated her like it was a viral keratitis, kind of got a little better and then a week later presented with this really dense hypovion. And I was like, that shouldn't happen. So I kind of took a step back and was like, what could be causing this?  So I started her on broad-spectrum antibiotics and she came back and she was worse and her pain was always like 10 out of 10. And she didn't really have a lot of epidefacts. So it was like just really confusing. Did this confocal on her and then so it kind of sealed it. It presented like a viral keratitis and then ended up being a canthamoeba. So these are the cysts that you'll see in the cornea. What's this? What is this linear thing in the cornea? And there, yeah. So this did, this should be actually pretty clear. This is actually a good picture, but it's not very clear because it has pareneritis. So that nerve will kind of look like it's just not crisp. Have you ever seen pictures of corneal nerves? They just look really thin and crisp. So this one's got pareneritis. And for whatever reason these a canthamoeba cysts will tend to like line up. So you'll kind of get a marching out kind of lining up on the confocal. So amoeba cysts there. You can get these subbomans cysts which is what these are. And then pareneritis. Okay. So I've probably managed like four patients with a canthamoeba in four years. So it's not terribly common, but they're awful. So she ended up patient that presented for me ended up with a PK and then a repeat PK. And she showed up as a nurse in the OR one day at Marin and was doing fantastic. Love and life. But okay. Does she have a good reason to have an eye infection? So she was kind of an interesting one. She did wear contacts, but she was actually pretty good at her contacts. She was she wasn't really sleeping in them. She was a nurse of the Huntsman, I think at the time. But she took a trip to Mexico and she was swimming in them some and she was showering with them in. And so I think we think it was just the water source in Mexico. There she go. So that was the other hard thing is it was like you don't have a great reason to have a contact lens keratitis. All right. What do we think here? Keratoconus. Good. So that's kind of what you have to jump to. It's like I see a picture it's keratoconus. Okay. So then you take a step back and you say they can ask me a trillion different things about keratoconus. Keratoconus is a disease that you just have to know front to back, back to front, up and down. You've got to know everything about it. Okay.  So 28 year old with increasing caretometry readings. What's the recommended treatment? So what are where they trying to get out here? Stabilize it. It's progressing, right? Progressive, unstable keratoconus. There's an FDA approved treatment for that now and is it intact? Is it a PK? No, it's collagen cross linking. So they want you to cross link these patients with unstable keratoconus. So all of these are treatments for it and even this in some cases if they've got that floppy eyelid problem. What if they're not progressing? So if they're not progressing you can cross link them at least currently because you have to prove progression for it to be FDA approved. But some people argue that you should cross link anybody who presents with keratoconus. But yeah, they're not progressing you just follow them closely until they do. You can do in tax for non-progressive keratoconus. You can do PKs for non-progressive keratoconus. There's kind of two different ways that I manage keratoconus. One is vision. Okay. You got the vision pathway.  Glasses, contacts kind of in tax potentially. And then the second pathway is how do we keep it for progressing? And some people think that if you put them in hard contact lenses it's kind of like this suspender that you're putting on the cornea to kind of help it. It doesn't work. So the only treatment for progressive keratoconus is cross linking. If it gets too bad that you can't cross link them then you're looking at a PK or a Dalker some sort of a cornea transplant. Okay. If you ever do for someone who has progressed so bad that you need to do a PK do you do a PK and then just like do cross linking? Because you recur in the graph a lot of times. Yeah. I mean it's been looked at. It doesn't work as well as you think it would because you're trying to secure that kind of graph host junction with the cross linking is kind of the idea because that's where it usually recurs is kind of in that lower portion. But it doesn't seem to be that effective so you still can get progression but potentially yeah absolutely that'd be the way you do it. So we try to create a pretty good scar inferiorly with Kariacona scraps. So you try to be long sutures and then you try to really tuck that cornea down so a shallow pass through the donor deep pass through the host to kind of keep it keep it low so you're not getting donor elevation. And then I usually I try to keep those sutures in longer if I can to try to help help a scar down because that's the area where it's going to protrude the most. Okay so Kariaconas is typically bilateral. You have all these systemic things so that's why they're going to they're going to hammer you on these systemic things. Down syndrome patients are really common other connective tissue diseases like aero standalone smart fans. There's tons of ocular associations with it. It's this inferior steepening with abicle thinning. You got the fly shearing the boat straight. You got prominent corneal nerves. I mean there's just tons and tons of stuff to that are testable on this. So that one was this sign here months in sign. And then hydrops is another one that though they'll try to get you to do something risky on. So when somebody presents with hydrops you're not you're not treating them with pk initially and it's not an infection. So that's the hard thing to kind of figure out. So they have an infection as it's hydrops. They have a history of Kariaconas. It's most likely hydrops and then you just kind of watch it. It's mostly just supportive care initially. Some people will put an air bubble in the anterior chamber. Because what is hydrops? Decimates membrane is actually ruptured from the stress of that corneal kind of protruding forward. And so if you can put an air bubble in there you can potentially replace decimates membrane quicker. So it seems to help. I don't like to do it in somebody's faking because you're probably going to push a cataract forward unnecessarily. And I usually just watch them. And they'll usually this is where you'll end up with an apical scar is after they've had hydrops. With Kariaconas. That last one apical or aqueous suppressants. It doesn't show up on that. I don't know why that one. Aqueous suppressants possible to counterlare. Why do you do aqueous suppressants? The idea is just if you have high fluid in the eye pressure in the eye you're going to get more fluid rushing into the corneal all the time. So the idea is if you lower intracutal pressure there's maybe that less of that dry for it to push into the into the stroma. But I usually don't I usually just cycle pleasure for pain. Maybe use a topical steroid muro. That kind of stuff. Okay, so you've got the kind of the different findings here. So that's a bad apical scar. These are hopstriae. No. They're vertical boatstriae. That's Monson's sign and then the Kaiser. Or sorry, the Pleasure Ring is what that's trying to show but that's pretty hard to see. All right. You love cornea for these because they're really easy if you can recognize the picture. Because you've got a memorized. So what is it? So granular stromal dystrophy, right? So you've got these little salt granules, sugar granules wherever you want to look at. They're centrally located. Spare the limbis. There's intervening clear spaces. Okay. Which thing would be positive on pathology of penetrating carotoplasty? Granular gets her man. Granular has what substance? Highland. Stains width. Monson trichrome. Okay, good. So you've got to have this down. There's usually three or four questions related to it on test because it's just so easy to test. So we won't spend a lot of time on it here but. So you've got macular. I just wanted to show you the pictures. So there's another picture of macular dystrophy with the Highland material of Monson trichrome stain. So the difference between macular. Or sorry, I just said that completely wrong. This is macular. So that one is that it extends limbis to limbis. Yeah, it's a little bit broader involvement. And there's not really, there's clouding in between them. So that's kind of the key is that there's clouding between the spots. Whereas with granular, it's super clear between the spots is kind of the idea. So it just kind of looks mushy with macular. Macular is mushy. So macular has what? Sorry. Merlin Monroe. Mutual. Quality sector. Really. Possessive. Possessive. All. Option blue. Always, really always. Right, let's get started. Yeah, option blue. Sorry, confusion though. So there's the granular. And the stain for it. Okay, and then lattice. So lattice you're just thinking linear lines like cracks in the cornea. And there's lots of associated, all right, I hated lattice because they could test you on tons of different stuff with lattice. I felt like, oh, it's lattice. And then it's like, I don't know what you're asking me because it's a little bit of a trickier one because there's all these little like different types here that can be involved. All right, so what does this patient have? So you can see these little dudes, these plateaus here on what membrane? Desiree's membrane. What's kind of missing? Back here. Okay, so there's not a lot of endothelium. There's a few. So the endothelium can't grow over the top of the gutata. So they're kind of stuck in between here. And then this is actually some pigment granules in between. So you can sometimes get a little pigment deposition in Fuchs dystrophy. What do this patient have? What surgery? It's not a path slide. They have some surgery. Yeah, PK, right? There's stroma here. So they've had a PK. Which is not how we treat this anymore, right? How do we treat Fuchs now with the surgery? DSEC or DMEC? DSEC or DMEC. So a DSEC is essentially going to be probably about this thick this on here. So it's about 60 microns thick of some stroma. Whereas a DMEC is what layer? It's only decimase and endothelium. So it's going to be super thin. Okay. So this patient presents with a following complaint. Constant burning. Blurry vision in the morning. Blurry vision with reading. Blurry vision late in the day. Morning, right? That's super high stress on the corneas when the eyes closed. Creates this fluid filled cornea in the mornings. So it takes them a while to kind of wake up and get that fluid pumping out. How can you help it along? What are some things that you can do to treat that? If they're just presenting with morning blurriness. So Muro. So this hypertonic saline on the surface draws fluid out from the front. Okay, how else? You can use a hairdryer. Ouch.  That'll help kind of dehydrate it too. So Fuchs is another one of those that you just have to know everything about it because it's just such a very, it's very common and highly testable. So it does cluster in families. It's probably autosomal dominant but we don't really know. But you definitely see it clustering in families and it seems to have that little kind of I forgot what that's called the lead bias where you like younger people have a worse. What's that called? Anticipation. Doesn't sound right but we'll take it. Trying to put it to repeats. Yeah. So polymegetism can sometimes be the way that it presents where you've got large cells or pleomorphism where the cells are actually different shape. So sometimes you can get what's called guttodalus spooks. In that condition they might see that decimates membranes just a little bit thicker on the path slide. Or endothelial cell counts you might be able to tell that there's there's weird shapes to the cells and stuff. Okay what is this? So anytime you see something white growing on the surface of the cornea what should you think of? You should think of cancer right on that spectrum. Squamous cell all the way to potentially a mild tritium. Right? Tritium to squamous cell. So once you get into an abnormal tritium you call it a CIN. And so this is a picture of a type of CIN. So you can almost get like a little papillomal with it these kind of fine little vessels that are kind of growing around here too. Another appearance, same thing right? White plaque on the cornea leukoplakia. You're thinking CIN to squamous cell. Another one, same thing. CIN to squamous cell. We call it ocular surface neoplasia because we don't know what it is. CIN is technically a pathologic diagnosis. Squamous cell is too so what about this one? It looks like a pretty regular tritium. I probably would send this to the pathologist just because of that spot right there. It looks kind of funny. So I usually don't send tritia to acrimanulus but if they have something funny about them they've got like some gelatinous kind of something going on or the surface seems a little leathery where they've got white spots on it. They don't send it. Another one, same thing right? So typically we might actually try to debulk some of these with the topical interferon especially one that looks like this that's really angry blood vessels around it that's going to bleed like crazy. Those are huge and so I might try topical interferon to see if we can dump this away. Same thing just lots of different pictures of the same thing. Same thing. Yes, no probably not. I think it's probably just a pinguiculate but there's there's a couple little spots here that it's like well maybe that's something I don't know I'm not going to do anything about this other than watch it. It's in the slide deck so somebody took a picture of it but it looks like a pinguiculate to me. What about this one? A little more subtle you might actually gloss over this one because it's not that angry looking but you got this little teeny tiny patch right there again something I'd probably just watch or potentially treat with topical interferon if you can get insurance coverage. Same thing? No. All right what's this? Dermoid. All right so this one looks kind of scary because it's like right at that pupil margin even though it's a 2D image it probably looks pretty it looks pretty deep to me I don't I don't really like this. How are you going to treat it? First step not the last think of the first step Oh we'll head treat the amblyopia treat the astigmatism amblyopia that's the first step but you're probably in a kid you're probably going to go after this because this one's going to be pretty debilitating there's another one there Dermoid so they love to have these weird associations like with golden hars where they have these pre-illicular skin tabs tags and other stuff go on but it's mainly it's this corneal astigmatism so you're going to excise it but these are usually pretty deep so you're not probably not going to get rid of all of it and you always have to have a graft ready just in case it gets too deep you're trying to just shave it off so that it's sort of playing out with the rest of the cornea but like a shaved dissection is what they call it but sometimes you have to do a little mellar implant by a transplant really crappy picture what do you think they're trying to show you you almost have to guess sometimes what you think they're trying to show you you have this yellow area up here dermalipoma so this is a corastoma you have the hammer tomas corastomas that will sometimes come up on the test you have to kind of remember those but it's mostly just kind of watching something like this or treating it with excision the other thing that can kind of look like this is if you have orbital fat prolapse where you've got fat kind of coming up from behind the septum there and then this one kind of all these kind of dermoid type things this is a dermoid system you remember they're always in a suture frontosalumatic suture is the most common one so these you would either leave them alone or excise them I think if it's causing too much distortion of the lid or if there's some sort of cosmetic reason to remove them so we're out of time 7.59 just ways to think about cornea they just jump a lot is this sort of the format of the op-camp questions? sometimes so I was surprised because I thought I thought it would be more like op-toe questions where you've got this long question stem and then you got a you're kind of logically kind of stepping through this question but I think they're more like this it's more like churn really what? the churn he has ever used churn so they're more questions that are literally like like short stemmed so it's literally like one, two, three lines with a picture okay so they're like kind of a multiple choice or a couple of paragraphs which is really nice the hard thing was is it's like I need in a lot of cases you're like I need more information to be able to decide but you just have to kind of go for your best guess


So please help me welcome Jose Avila from CrowdStar. Hello, everyone. Thank you for having me here. I'm very excited to be here. I hope all of you are having a great time in Barcelona. So I'm the VP of Engineering for CrowdStar. And I'm going to show you a little bit about what we're doing. So CrowdStar, well, we were founded back in 2008 in the good old heydays of the Facebook gaming platforms. Yes, we're responsible for a lot of those requests you guys got. I'm sorry about that. We had published over 25 titles. And we had over 300 million users have been playing our game. In 2011, we decided to make a shift to mobile. And we created the first mobile title for women. It was called Top Girl. And it was a top-grossing game for quite a while. In 2013, we made the shift and decided that we needed to give more for the entertainment for women. And we created a covet fashion. So covet fashion is the first mobile entertainment platform for women that makes use of real brands and real items that you can purchase on any store around the world. It's a competitive platform, so what's that? Well, covet fashion allows women to dress up an avatar or a personality for events that we deliver to them on a daily basis. They create over 150 million looks a month. And then they submit those looks for voting on the platform. Over half a million women play this game around the world. And they vote 50 million times a day on these looks. What are you looking for? Well, everybody wants to have the top look in the game. And the competition is very fierce. Covet Fashion is published in iOS, Android, and Kindle. And it's available around the world in six languages. Now, what you guys really care about is how we get this running. So covet fashion has been deployed across four data centers in the US. We're using a multi-cloud infrastructure. And we have a combination of KBM and Vermetal and some of them. We use about 200 servers. And we process about 100 million API calls a day. Now, we've been developing this over three years. And a lot of challenges have come up. The first one was we were traditionally launched on virtualized instances, which are great for scaling up. But everyone can agree that it gets very expensive once you reach a certain scale. We needed to address that quickly. And we had to also, with the complexity of the stack, as we developed more features and things, our bootstrapping was starting to get very brittle and convoluted. Traditional bootstrapping takes a long time, has a lot of is-else cases and things like that. So it was taking a lot of time and making it very brittle. And since we operate with a very small team, we needed to be able to do more with less. And that's where Vermetal really came to change the game for us. Now, Vermetal, traditionally, everybody knows great performance, very affordable. But you have the issues of long-term contracts and long delays on provisioning all these servers. And that's where OpenStack Ironic really changed the game for us. With OpenStack Ironic, our guys have already been using a lot of the OpenStack APIs. They were able to change a few lines of code in our provisionings and be able to launch bare metal servers within minutes. By doing this, our first deployment, we were able to reduce our cost by about 60% and also reduce our latencies by about 40 milliseconds. So that was great, because our footprint actually got smaller. With OpenStack Ironic, the deployment was a lot faster than the traditional one day to a couple of weeks to get bare metal up and running. The next thing was our ops team was overwhelmed all the time by the developers asking for changes on the servers. Or can I have this library installed? Or oh, I want to use Node with this or this or that. And the bootstrapping, like I mentioned, was getting very complicated, very brittle. Sometimes somebody would change something on one of the servers. And it was just unsustainable for us. And that's where containers really came to really save us on a lot of these things. I mean, there's no silver bullet, but it's very close to getting there. With containers, we were able to give control back to our developers by providing a container to the developer in moving the application into this logic. The developers were able to start changing what they really needed, not depending a lot with the server that it was running on, making sure that libraries were there. They were able to modify the image. And then once they were done, our operations team would just have to check it out and make sure that they didn't do anything they weren't supposed to. Bundle it up and make it available on the repository. By doing this and using orchestration and a lot of other stuff, it allows us to actually create safer and simple deployments. With this, they were able to bundle up the images. Because they were running it locally, they knew that everything that they had coded and the dependencies of libraries were there. Once it was bundled, it gets deployed. And they are able to see that a specific version of the image is already running and that it has everything that they expected. And it's actually working the way we expected as well. Also, for Opsteam, our bootstrapping went down from a few thousand lines to a couple hundred. Just because now all we have to do is launch the bare metal servers, provision a few lines of libraries and code, and then it was up and running and available to run anything on our stack. The other thing is that it allowed them to start mixing different stacks of server that now could run a node implementation together with a lamp stack or a Ruby implementation. So it really created us. It gave us the advantage to reduce the number of servers we ran because before we had incompatibility on the OSs or the libraries. Now, all this wouldn't have been possible if we didn't have a group partner working with us. And that's where internet really helped us out. So internet is a very active member of the community. They were actually a finalist on the Super User Awards yesterday. And they really embraced OpenStack. They're contributing all the time. They have a lot of commits. And for us, they gave us access to over 15,000 bare metal servers that are being provisioned right now with a very broad configuration profiles. So this gave us access to raw power in the bare metal infrastructure to be able to run our things at a very affordable price. They have data centers across the US. And they have a great team that helped us all the time. So coming down for us in the future, we're actually launching our first competitive home design title. If I can explain that, basically, users around the world are going to be able to use real brands and real furniture that exist and you could go to a store made by some of the most exclusive designers out there. Install their rooms for a specific look that they're going for and then compete again the same way that they do with fashion. This is live already in Canada, and we're getting some great feedback. And it will be available mid-November around the world. It'll be published in iOS and Android. And we're very excited about it. It looks beautiful. Make sure you check it out once it's live. Also, if you want to know a little bit more about how we're doing this transition into bare metal using ironic containers and orchestration, we're giving a talk tomorrow at 5.30 on Room 211. I hope you guys will come and check it out. And hopefully, we can learn more from you guys. Thank you very much.