Check pre-auricular lymph nodes, screen for stds, check upper teeth for cavities
OD-right, OS-left OU-Both
Document visual acuity. If can not see big E (20/400) move them closer. Then use counting fingers, then waving fingers and then light perception only LPO
make people curl their index finger into pinhole to correct absence of glasses
Pupillary Response to Light
Normal is 2.6 to 5 mm in fluorescent lighting. Normal with bright light/pen light is 1.9-3.6 mm (Annals 41:2, 2003)
Swinging Flashlight test
for Afferent Pupillary Defect-swing light from good to bad eye, normally it should constrict, if it dilates, then there is an afferent defect
Measure IOP-normally <21
V-OD above OS c or s correction. Use guiac card with multiple holes punched in it for correction. Need 50% of a line correct to get credit for it
lids, lashes, lacrimals
hordoleum, matting, lacs
Bulbar vs. palpebral conjunctiva
Bulbar conjunctiva on globe of eye, covering sclera
Palpebral conjunctiva on inner part of eyelid; in conjunctivitis
Palpebral conjunctiva red out of proportion to bulbar conjunctiva; with corneal ulcers, iritis, scleritis,
Bulbar conjunctiva red out of proportion to palpebral conjunctiva
Quality of discharge: pus-like in bacterial infection, watery in viral infection; stringy, sticky discharge usually indicates allergy
Papillary vs follicular reaction: papillary reactiondilated leaky blood vessel with localized chemosis; not helpful because present in all infectious and inflammatory conditions; follicleslittle accumulations of lymphoid material in conjunctiva;
Follicles indicate viral or chlamydial infection, also seen in toxic reactions; swollen, tender preauricular node usually present when follicles present; flip upper eyelid to find best area to look for papillary and follicular reactions and foreign bodies
chemosis (edema of conjunctiva), injection, cobblestone, icterus
cloudy, uptake, streaming, FB, abrasion
Look for Seidels sign, streaming or clearing of fluroscein stain from punctured cornea
cells, flare, blood, hypopyon, hyphema
Check for shallow angle-shine flashlight laterally, + if shadow over nasal portion of iris
iritis, size, shape, displaced
curtain dropping=amaurosis fugax
Flashing lights-retinal detachment
Shine a light into the red eye, if it hurts, this is a bad sign (Fam Pract 20(4):425, 2003)
OD=right, OS=left, OU=both
V OD cc or sc
Pressures T (right over left, record time. normal 8-20)
Pupils c mm
LLL (DFE) Fundi
Blue/Yellow Low/High Concentration B-Blockers
Dilation best accomplished c phenylephrine 2.5% for onset of 15 min and 2-4 hr effect
Keterolac ophthalmic 1-2 drops q2-4h prn pain following corneal abrasions (Annals 2003;41:134-140)
Proparacaine 0.5% is probably the best ED anesthetic as it has rapid onset and lasts 15 minutes. Tetracaine 0.5% is slower but lasts longer.
Erythromycin is broad spectrum, but there is resistance
Bacitracin is probably the way to go
Quinolones should be reserved for serious infections
Sulfacetamide is also a good choice
Genta/Tobra for resistant infections
Neomycin containing formulations often cause allergic reactions
Glaucotest $350 tonometer from Heine USA
Traumatic Eye Injuries
Need to know 4 things
- Visual Acuity
- Rupture Globe
- APD? (dim lights, have pt’s focus on a point 15 feet away)
- Zone of Eye
Get CT c thin orbital cuts
Get Plastics or Optho Consult for lid margin, canalicular system, levator or canthal tendons, orbital septum, significant tissue loss, or repair physician does not feel comfortable performing.
If you see fat, it is from orbital penetration as the eyelid has no fat.
Can be from valsalva maneuvers
Differentiate between hemorrhagic chemosis (bulging; indicates open globe) and simple Subconjunctival hemorrhage (flat; reassure patient)
Confined to Subconjunctival space, hold NSAIDS for two days, goes through same stages of color change as a black eye
Rx c abx, pain control, tetanus, and possibly cycloplegics
If from contacts, artificial fingernails or vegetable matter, prescribe drops c pseudomonas coverage. No patching.
Ofloxacin Ophthalmic 1-2 drops QID x 1 week
Document lid eversion, especially if abrasions are vertical lines (ice-rink sign)
Patching does not help (Annals 38:2)
Sodium azide which is converted to sodium hydroxide from airbags, need copious irrigation
Probably do not need Tetanus shots unless penetrating injury (
Mukherjee P et al:
Tetanus prophylaxis in superficial corneal abrasions. Emerg Med
Document negative Seidel’s
A better way to remove FB, bend the needle (The American Journal of Emergency Medicine Volume 30, Issue 3, March 2012, Pages 489–490)
Punctuate corneal lesions
If acid, coagulative so very little deep damage except for Hydrofluoric Acid which requires irrigation c CaGluc 1% and can cause systemic effects.
Alkali can cause deep burns
C either keep irrigating till neutral pH
Glue in Eye
Use any petroleum based ointment like bacitracin to speed eye opening
50 % Sucrose/50%Fructose dissolved in Milk
Keep Head of bed at 30-45º in case of hyphema
All need consult b/c of possible visual loss
- Grade 0: Small Flecks
- Grade I: <33
- Grade II: <50
- Grade III: >50
- Grade IV: Total
Can cause narrow angle glaucoma
Other risk is rebleeding and permanent staining.
Elevate the head of the bed to 45, No NSAIDS, antiemetics and pain meds
Give atropine drops before narcotics to prevent miosis
no Acetazolamide in sicklers
give amicar for hyphemacochrane
Take steps to reduce IOP as in closed-angle glaucoma
May need lateral canthotomy
Orbital Compartment Syndrome Treatment
visual changes, proptosis (often subtle; look directly at supine patient from head of bed), opthalmoplegia
Risks are recent surgery, fractures, trauma, and anticoagulated patient
Local anesthetic (e.g., 1% or 2% lidocaine with epinephrine); mosquito hemostat; iris scissors; tissue forceps; gauze pads
Lateral canthotomy and cantholysis
- Ensure adequate patient sedation and analgesia.
- Position patient supine and begin irrigating the lateral canthal fold region with sterile irrigating solution.
- Utilizing sterilizing technique, inject 1 cc of local anesthetic subcutaneously along the lateral canthal fold region. Anesthetize the tissue extending laterally from the canthal fold up to the orbital rim. Exercise caution to avoid inadvertent needle puncture to the globe.
- Insert mosquito hemostats at the lateral palpebral fissure, with one blade anterior to and one blade posterior to the lid. Advance the tips of the hemostat laterally, until the orbital rim is encountered; clamp and compress the intervening tissue for at least 30 seconds (to minimize any ensuing bleeding).
- Remove the hemostat and utilize the iris scissors to cut all tissue layers (from the skin down to the bulbar conjunctiva) along the lateral canthal fold, down to the lateral bone orbital rim (lateral canthotomy).
- Retract the lower lid margin outward with a pair of hemostats or tissue forceps. This will facilitate identification of the LCT, which is located just posterior and inferior to the lateral canthal fold.
- Dissection of the conjunctiva and fascial tissues with hemostats or iris scissors will be necessary to identify the LCT. A pocket of adipose tissue (Eislers pocket) will be encountered beneath the superficial fascial planes. The LCT lies just posterior to this adipose tissue collection. Once identified, the LCT must be completely severed (lateral cantholysis).
Shield both eyes
Antiemetics, pain control, sedation, dT
Vanco and Gentamycin
CT scan should include both axial and coronal sections at 3mm intervals
Efferent pupillary defect (EPD) b/c trauma to iris; usually benign.
Must be differentiated from an afferent pupillary defect (APD) which is an emergency secondary to optic nerve injury, retinal detachment, or vitreous bleeding.
Non-traumatic: External/Swollen Eye Problems
White or yellow growth on nasal side of conjunctiva
Triangular extension of conjunctiva over nasal side of cornea
Usually infectious (S. aureus) of eyelid margins.
Infection of tear duct at medial canthus
Oral ABX, Pain Control, Refer to optho
Hordeolum hurt (Acute)
S. Aureus is the usual culprit if infectious
Stye-external hordeolum, infection of Zeis glands
Meibomianitis-internal hordeolum, possibly from infection of meibomian glands or think rosacea (use systemic doxy)
Warm compresses and topical abx (ointments are probably better)
Usually erythromycin resistant, but bacitracin sensitive (Audiodigest)
Nasolacrimal infections respond to first gen. cephalosporins.
Greek for hailstone
Chronic stye (Remember the C is for chronic)
Warm compresses and refer for removal. If for some reason suspect active infection, must use systemic abx, not topical.
eyelids do not close completely; frequent problem after plastic surgery of eyelids; plastic surgeons often do not pay attention to underlying conditions that may complicate outcome; ask patients partner if patient sleeps with eyes open; difficult to elicit history of cosmetic surgery of eyelids
15% to 20% of patients develop hypersensitivity reaction to neomycin (common agent; speaker tends to stay away from this medication); patients can develop reaction to almost any ophthalmic medication, including benzalkonium chloride (most common preservative in ocular medications); can also be caused by tape used after ocular surgery; treat with systemic antihistamines, cold compresses, and, if sure of diagnosis, local topical steroids
Periorbital (Preseptal)/Orbital Cellulitis
Preorbital if pt non-toxic, normal visual acuity, no proptosis, and painless & intact EOM
Treat c augmentin
Otherwise admit for IV ABX (Unasyn) and get CT Minus c Orbital Cuts axial and coronal
Consider mucormycosis in diabetics. Consider aspergilliosis in HIV
kids get orbital cellulitis from spread of ethmoid sinusitis. Even in adults, orbital cellulitis and abscesses are from sinus extension 70% of the time.
Non-traumatic: The Red Eye
will have purulent discharge
Antibiotics shorten duration, but are not really necessary. It will allow a return to work/school in 48-72 hours. If not better, pt should go to a specialist.
Staph, Strep, and Hemaphilius so aminoglycosides are not a good choice. Fluoroquinolones are not necessary. Use Polymixin/Trimephapin. Use drops rather than ointments.
Ask about STD sx
watery discharge, preauricular node, and follicular reaction
no treatment needed, infectious precautions, adenovirus is just like the cold viruses, stays around forever
cold artificial tears. Pt’s are infectious for 7-10 days. Use cold artificial tears and cold compresses. Hand washing and reducing spread is most important.
Itching/rubbing. Atopic/allergy history. Stringing, ropey discharge (like mozarella)
Topical antihistamines and systemic mast cell stabilizer
Copious purulent discharge c preauricular nodes and injected sclera, eye pn
Systemic GC and Chlamydia Rx in addition to topical erythromycin
By email@example.com (Ves Dimov, M.D.) on Ophthalmology
According to the current clinical evidence, 64% of cases of acute bacterial conjunctivitis improve spontaneously and do not require local antibiotic therapy with eye drops.When antibiotic therapy is indicated for bacterial conjunctivitis, the most cost-effective options are the eye drops listed below that are included in the Walmart $4 prescription medication program:
- Sulfacet Sodium 10% op. solution
- Tobramycin 0.3% op. solution
Tobramycin is better tolerated because it causes less local irritation, often described as stinging and burning. This improves the compliance especially in younger children.Sulfacetamide 10% has a better gram-positive than gram-negative coverage. Antibiotic-containing eye medications available in the $4 Prescription Program by Walmart:
- Bacitracin op. ointment
- Erythromycin op. ointment
- Gentamicin 0.3% op. solution
- Neomycin/Polymyxin/Dexamethasone 0.1% op. ointment
- Neomycin/Polymyxin/Dexamethasone 0.1% op. suspension
- Polymyxin Sulfate/TMP op. solution
- Sulfacet Sodium 10% op. solution
- Tobramycin 0.3% op. solution
Gentamicin is used for gram-negative bacterial coverage but tends to be toxic to epithelia and retards healing. Aminoglycoside antibiotics include Gentamicin, Neomycin and Tobramycin. Ciprofloxacin 3% is a broad-spectrum antibiotic with good gram-positive and gram-negative coverage (not included in the $4 program).Gatifloxacin ophthalmic solution 0.3% (Zymar) is fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis.
Anterior segment inflammation, cells flare
Broad Spectrum ABX drops-e.g. Quinolones
Will see dendrites c staining
treat c acyclovir, fam, or val.
In diabetics or immunocompromised
Need ampho, debridement, possibly hyperbaric O2
Contact lens-related problems
contact lens users are contact lens abusers; overwear and abuse most common problem; overnight wear increases chances of corneal ulcer by 15- to 20-fold; lens abuse can lead to abrasions, infections, allergic and toxic reactions; sensitive-eye formulas proliferate because people develop allergies and toxic reactions to contact lens solutions; get them out of the lens, get them out of the solutions, and that in and of itself will take care of most of these problems; every contact lens wearer needs pair of glasses as backup
bulbar conjunctiva red out of proportion to palpebral conjunctiva; history of trauma or contact lens wear; signs and symptoms include pain, redness, light sensitivity, white spot on cornea; need immediate culture and treatment; if you know its going to take them several hours or more to see somebody whos going to do a culture on a plate (not in media) or start treatment, go ahead and start treatment yourself; start fluoroquinolone drops immediately (two drops every 15 min for first 8 hr [throughout night], two drops every 30 min for next 16 hr); ophthalmologists often inject special fortified antibiotics; perforated cornea possible if left untreated (this is why you want to start them right away)
distinct, dramatic appearance; patients panic; symptoms include blood-red eye, no pain, no decreased vision; patients demand to be seen, need reassurance; no treatment; resolves on own in 1 to 2 weeks
Miosis of affected pupil, can be irregularly shaped with limbic blush
Consensual Photophobia-pain in affected eye when light shined in opposite
Pain c Accommodation-look far then at your finger
Will have cells (sparkles) and flare (smoke) on slit lamp exam
Cycloplegics give relief
Visual loss until resolution is frequent
usually presents acutely; self-limited disease lasting 7 to 10 days (sometimes longer); not usually associated with pain or systemic disease
Sign of systemic disease
bulbar conjunctiva red out of proportion to palpebral conjunctiva; usually develops over days to weeks; insidious; deep boring pain and tender eye; diagnosis made by history and palpation; look for deep violaceous hue (putting phenylephrine in eye will shrink superficial vessels but not deep vessels); usually associated with systemic diseases; patient needs workup by ophthalmologist; can be associated with rheumatoid arthritis, Wegners granulomatosis, polyarteritis nodosa, syphilis
Sclera may look blue or purple b/c you can see through to vessels
Infection of deep eye structures, usually post-operative.
Horrible risk for poor outcome
Acute Angle Closure Glaucoma
Assoc. c family history of same
Sudden decreased vision c haloes and lights in field
N/V, emesis, possibly presents only c red eye and abd pain
IOP usually 50-70, can usually be palpated
Painful, rock hard eye=diagnosis
· A beta-blocker such as timolol 0.5% (Timoptic), 1-2 drops every 10-15 minutes times three, then one drop BID.
· A parasympathomimetic such as pilocarpine 0.2%, one drop every 30 minutes until the pupil constricts, and then q6h.
· Prednisolone 1% (Pred-Forte), one drop every 30-60 minutes to reduce inflammation.
· Apraclonidine 0.5%, two drops, once; an alpha-2-agonist that reduces aqueous humor production and acts additively with the beta-blocker.
· Acetazolamide (Diamox) 500 mg IV q12h or PO q6h. Because of the possibility of metabolic and respiratory acidosis, this medication should probably be avoided in patients with serious respiratory disease.
Also avoid in sicklers as it can induce crisis.
· Mannitol 20% 1-2 g/kg IV over 30-60 minutes. Mannitol is a hyperosmotic agent that should be used with caution (if at all) in patients with congestive heart or renal failure. It may cause mental status changes, worsening headache, and dehydration.
· Pilocarpine 2% for light eyes 4% for dark, 1 drop Q15 min x 8 doses
Non-traumatic: Acute Visual Loss
New floaters or shadows in visual fields
Consider Tersons syndrome-SAH c vitreous hemorrhage
Will see floaters and dark shadow over vision. Yellow spots on retina
Consult for tacking
Central Retinal Artery Occlusion (CRAO)
Sudden loss of vision c afferent defect
Cherry Red fovea c pale optic nerve
Firm ocular massage 15 sec, repeat multiple times
Lower intraocular pressure c same rx as glaucoma
Carbogen (5% CO2, 95%O2)
Central Retinal Venous Occlusion
Blood and Thunder on fundoscopy
Cavernous Sinus Thrombosis
30% treated mortality
Usually from sinusitis or mid face furuncle that was squeezed, also
HA, N/V, vision loss, possible 6th nerve palsy. Periorbital cellulitis, meningeal signs
Contrast CT for DX
Possible Surgical intervention
Usually bilat, if single eye usually presents with hemianopia (loss of half of visual field)
Ipsilateral eye slow to adduct, contra has nystagmus c abduction
Associated c MS
Gradual monocular visual loss
Pain c eye movement
20-40 year olds
assoc c MS
Temporal (Giant Cell) Arteritis
Unilateral vision loss
Afferent papillary defect
HA, Jaw claudication, tender temporal area
Get ESR, treat high dose steroids
Normal variant in 20% of the population
To differentiate Adies tonic pupil from 3rd nerve palsy, instill pilocarpine 0.1%, If large pupil constricts and normal doesnt then it is Adies. If both fail to constrict, then 3rd nerve palsy or med usage. Then instill pilocarpine 1%, if both constrict then 3rd nerve palsy, if affected one doesnt then med usage
Place mirror in front of eye, should get no reaction in true blindness. Also there should be afferent defect.
Decision-making: does not rely on use of slit lamp Refer to ophthalmologist: eye getting progressively redder and more inflamed after ocular surgery (indicates infection); rock-hard globe (indicates acute angle-closure glaucoma); white spot on cornea (indicates corneal ulcer) Contact lens wearers: redness caused from contact lens or contact lens solution until proven otherwise; stop contact lens use in both eyes Bulbar conjunctival redness greater than palpebral conjunctival redness: indicates serious problem, eg, iritis, corneal ulcer, scleritis; if globe tender, refer; if globe not tender may be episcleritis or subconjunctival hemorrhage Palpebral conjunctival redness greater than bulbar conjunctival redness: dealing with conjunctivitis; can be managed in emergency department (ED); do not need to check for follicles; if preauricular node tender, patient has viral conjunctivitis or Chlamydia (Chlamydia if exudate pus-like, viral if watery); if preauricular node not tender, patient has either allergic conjunctivitis or bacterial conjunctivitis Conjunctivitis: patients with bacterial conjunctivitis have crusted lids that stick together; patients with allergic form usually have history of allergy and complain of itchy eyes (allergy patients tend to downplay how much they rub their eyes, so ask patients partner)
Seattle, Washington Page 7
October 6-9, 2002
Unforgettable Eye Facts
Borrowed from Drs. Roland, Clark, and Hamilton
(previous ACEP Presenters)
1. Never give topical anesthetics as an outpatient treatment. (Overuse delays healing
of the cornea)
2. 1% Paredine is the drug of choice for emergency dilation of the pupils. It is easily
reversible with 1% Pilocarpine.
3. Neosporin is the most sensitizing topical antibiotic to the eye.
4. Use the cheaper and older drops when treating routine conjunctivitis, such as sulfa
5. Have patient wear glasses when taking visual acuity. Use a pinhole if glasses not
6. For severe trauma, immediate treatment consists of placing the patient supine, with
eye shield over the affected eye.
7. Do not use steroids unless you have consulted and are referring the patient to an
ophthalmologist within 36 hours.
8. A topical anesthetic will differentiate superficial (corneal) from deep eye pain.
9. Arc Welders flash: use topical anesthetics, antibiotic ointment, and cycloplegic.
10. Sub-conjunctival hemorrhage: be sure to rule out foreign body.
11. A semi -diagnostic test for iritis is 1 drop of 1% Midriacyl, which should relieve
about 50% of the pain within 10 minutes. Also, light shined in the unaffected eye
will cause pain in the other eye.
12. When at a loss about what to do with a potentially severe eye injury, place the
patient supine, put patches over both eyes, and let them rest.
13. A retinal tear or dislocated intra-ocular lens should be treated as in #12.
14. A lid laceration through the lid margin or the canaliculus should be repaired by an
15. With any black eye, dont forget to consider a blow-out fracture.
16. If you even think about an intra-ocular foreign body, get a soft tissue radiograph of
the eyes (or CT)
17. There are only two true emergencies of the eye: acute central retinal artery
occlusion and chemical burn.
18. Optic neuritis looks very similar to papilledema, but the former is
2. Associated with moderate to marked decrease in vision
3. Has a large central scotoma
4. Has minimal retinal hemorrhages or venous congestion
19. If the visual acuity with corrections is 20/25 or better, and the pupils are equal and
react to light and accommodation, and the funds looks OK, there is probably
nothing serious going on.
20. Light sensitivity is a non-specific symptom of virtually any ocular irritation.
21. Most superficial ocular infections, corneal abrasions, and mild trauma will get
better no matter what topical treatment you use.
22. Do not use ointment if there is a chance of penetrating injury (the ointment will get
into the anterior chamber) or when a fundus examination is needed within the next few
hours (ointment will obscure the view).
Abbreviations commonly used by our Ophthalmology Friends
(or how to read other
professional languages and amaze your friends)
ac anterior chamber cc with correction (glasses or
P pupils sc without correction
L/L lids and lashes ph with pinhole
I iris VA visual acuity
L lens LP light perception
K cornea HM hand motion
C conjunctiva CF Counts Fingers (could also be
cells or flare)
OD right eye
OS left eye
EOMI extraocular muscles intact
OU both eyes SLE Slit lamp exam
Common eye disorders and hints to recognition / management:
subconjunctival hemorrhage: painless, no change in vision. Caution: a
circumferential, elevated, dense subconjunctival hemorrhage is suspicious for
corneal abrasion: severe pain, tearing, blepharospasm
contact lens-related abrasion: maintain suspicion of ulcer, always refer.
-foreign bodies: pain or irritation, tearing. Look for rust ring.
globe Penetration: irregular pupil, flaccid globe, flat anterior
chamber, prolapsed iris. Tear drop shape points to the perforation. Place a metal
eye shield and avoid any pressure to the globe.
super-Glue: copious irrigation
traumatic iritis: pain, headache, tearing. Look for cells and flare.
traumatic miosis or midriasis: Treatment not required.
blowout fracture: orbital rim fracture and entrapment of muscle leads to
diplopia, paralysis of upward gaze.
hyphema: microscopic to “eight-ball”. Watch IOP.
intraocular foreign body: ” metal on metal”
corneal / Scleral lacerations: ophtho referral
chemical burns: irrigate, irrigate, irrigate.
UV keratitis: sunburn, welding. Pain, photophobia, diffuse punctate uptake.
conjunctivitis: viral, bacterial, allergic, other. Itching, red, discharge.
keratitis: pain, decreased vision. Bacterial, ulcers, viral, autoimmune, idiopathic.
Rule out herpes.
acute angle closure glaucoma: red eye, steamy cornea, mid- position pupil, pain,
nausea and vomiting.
amaurosis fugax: graying of visual field, associated with TIA.
central retinal artery occlusion: painless, total loss of vision, pale fundus
except for cherry red macula. Immediate ballotment.
central retinal vein occlusion: painless loss of vision of varying severity;
retinal detachment: floaters, flashing lights, painless visual loss.
migraine headaches: scotomas and scintillation followed by headache (usually).
Slit Lamp Exam
they see nothing you and you see nothing (pt can’t see but their eye looks normal)afferent pupillary defectpain, vision loss, colors look weird esp redget mri for multiple sclerosisstart steroids
Vascular: hypertensive crisis, pre-eclampsia, renal failure Inflammatory: Vogt-Koyanagi-Harada syndrome, posterior scleritis, Acute Multifocal Placoid Pigment Epitheliopathy, pseudotumor cerebri Infectious: tuberculosis, toxoplasmosis, syphilis, CMV Trauma: post-surgical detachment Autoimmune: sarcoidosis, polyarteritis nodosa, Goodpastures syndrome, SLE
Metabolic: protein-wasting enteropathy Idopathic: central serous chorioretinopathy, pigment epithelial detachments Neoplastic: choroidal tumors, retinal metastases Congenital: nanophthalmos, uveal effusion syndome, Coats disease, optic pit, morning glory syndrome
is brief (often lasting less than 5 minutes),monocular and consists of “negative” symptoms such as greyingof colours, blurring, fogging or complete loss of vision.
From Orman EM:RAP
allway ketotyphan furamste allergy
ice compresses for allergic chemosis
get sickle cell prep in hyphema if py non whites
epidemic keratoconjuctivitis-can have decreased vision for months
Contact Lens Removal
(PEC 28(7)707) TAKE HOMEMESSGE: Contact lens that don’t come off may benefit from two cotton tipped applicators and using them in a chopstick fashion.