But understanding what's important what has to be gathered and then analyzing that and then Processing that into a decision for your page. That's really what being a physician is all about right there So that's kind of what we're going to try to do in this format of of a lot of interaction going through cases trying to learn how to maybe Go through that process and make those decisions and then finally to answer your questions and whatever questions you have About glaucoma or the cases we're talking about or more existential than that is just you know future of glaucoma future of Ophthalmology that that would be great to just any question you have feel free to jump right in I think as I Had to make some changes in my career and kind of winding down a little bit of waxing more philosophical than normal So any questions you have just feel free. So let's go ahead and jump in so open-angle glaucoma is our topic for today and Open-angle glaucoma is a pretty big net And there's a lot of page there are a lot of pages a lot of disease that are under that category of open-angle glaucoma So in this category, we would put ocular hypertension We would put of course primary open-angle glaucoma Normal pressure and then there's a whole group of secondary But open-angle glaucoma's what are some of those the secondary? But open-angle glaucoma's Pseudo X so around here that is absolutely the most important by I mean by a long shot There's so much pseudo exfoliation. It'll just dominate your practice Around here because it's it's so common A and B. It can be pretty difficult to deal with so a lot of exfoliation So exfoliation certainly number one. What are some of the others in that secondary open-angle glaucoma category? Pivotary there you go. That's probably the second most important. All right, then there's others traumatic There's inflammatory most inflammatory glaucomas are also open-angle. Okay, and then The lens induced one of the lens induced open-angle glaucoma like fake lytic Excellent as opposed to say fake or morphic, you know, which is more of a closed-angle process. All right, so these are a You know kind of a diffused group a diverse group and there's a you know different pathology Obviously different clinical signs that we'll talk about but for those you know if you're going to practice Comprehensive ophthalmology or certainly if you're going to be a glaucoma specialist This is going to be most of what you do is in this category, especially if you're going to practice the United States Most of it's going to fall within these disease elements here. Okay All right, so let's talk about then Analyzing data. All right, and one of the most important we're talking about open-angle glaucoma. So By definition we have an open angle. All right, we have an open angle. So let me just ask a couple of things Who can who would like to go over these structures with us here in the angle any volunteers to do that again? There's there's bagels in the back help yourself anytime if you'd like to do that Just jump right up How about right here? What is that? Trying to show right there Corneal wedge, what is corneal wedge? Exactly that's exactly right the endothelium there of the cornea. It just stands right there just makes and that is such an important Kind of clinical sign dollar. How do you how do you find the corneal wedge? Like when you're doing corneoscopy, how do you go about finding the corneal wedge? Right exactly. So so that's great You have a thin slit beam and I usually take it like one click off You know on the on the slit lamp, right? Which is the slits of just this genius instrument, right? You can feel the clicks as you move it to the side, right? And so you might talk about one click or two clicks and so when you're talking about different Elements of the examination doing different things you can think of that in your mind You know one click or two clicks so for me the corneal wedge is a thin slit beam and then one click I usually go one click to the side to allow me to get that beam and That is such an important thing to practice and to learn how to do because that is the the one that'll keep you out of trouble So why is it important? When does it really get important to be able to find and and kind of distinguish that corneal wedge? Very good, that's excellent other other examples other instances Like pigmentation shows you where you're at for me the most important time to break out the corneal wedge It's actually when you have potentially kind of a narrow angle and especially If you're getting what's that pigmented line called that's up above? Decimates sample aces line so you actually have a narrow angle I would say for residents and fellows the the single most common will call it air in Gonioscopy is not Recognizing if that angle is actually closed and that's a sample aces line Okay Not a pigmented TM and so that's where that corneal wedge So in that setting what does the corneal wedge do you don't get one? It doesn't meet the two these two lines here that one and that one they never meet right? They just dive down into the angle then you know that angle is actually closed and any pigment that you're seeing in sample aces line So okay very good. So we've got Corneal wedge and then what are the next structures you see here? What's Travecular mesh work, and then you have anteriorly you have the Non-pigmented posteriorly you have the pigmented TM correct Very important. This is kind of your target zone for doing things like laser trabecuoplasty. Okay, and then next structure is Excellent scleral spur to me kind of defines the angle being open if you can see Sleral spur just in a general sense, and we won't talk too much about classifications today But if you can see Sleral spur you got an opening. All right, you can see it 360 degrees. It's open. And then what do you have down here? Seller your body face. Okay, so excellent. So those are the major landmarks of Gonioscopy we're talking about open-angle glaucoma. So by definition we're dealing with open-angle diseases. So What instrument do you all use to? Do Gonioscopy just curious what do most of you have or do you have one? Do you own one? Okay, the bulk so the the one that you hand handhold. Okay excellent any others that would mostly people have and that's an excellent You know bulk is an excellent instrument. So I my favorite is this Zeiss Formier, okay, and there's a couple reasons why I like it I'm not very tall obviously have kind of a short arm And so this allows me to kind of comfortably For me kind of rest my arm on the table and then use this You know lever arm here to kind of get up to the eye and it just kind of helps stabilize things for me If I need a little extra. I've always got my lens box with me I'll just put that lens box on the mail go and just kind of go just like that and Get it done just helps to stabilize and the optics of this are excellent This is unfortunately the most expensive but it I do think it's an excellent But those you know, it's whatever you get used to if you like the ones that you know The one thing that's nice about the the like the volt that you handheld is you can spin it right so you can get kind of a You know kind of a dynamic 360 degrees as you're looking through it. There are other Formiers that are that have a handle like there's a Posner Volk also makes one that's a former and those are all excellent So mostly it's kind of they're all good Get get used to one. Okay. This is the one. I like like the best, but there are others to can't be used But yeah, yeah, if you're gonna do Glock home at all you got to have a gun gonna ask me lens of some sort. Okay, very good So it's just kind of I'm gonna just a virtue a little bit. We talked about the other kind of tools of the trade We're talking about gathering data So we're gonna obviously got slow lamp got a gony omere What kind of lenses do you like to use to look at the optic nerve? 90 okay, excellent most as everyone have a 90 so 90 degree lens is kind of the lens of glaucoma care and there are several reasons for that It gives you I think just the right magnification. Okay It allows you to look through a small pupil And so oftentimes in glaucoma you're dealing with small small pupils, you know And it's nice to not have to dilate somebody every time So I think a 90 is is an essential now. There's I tried for a while Volk makes this wide field lens and Man, it's an amazing view through that thing in terms of wide field But I found that for me the magnification of the optic nerve just wasn't quite enough. Okay, I thought I was Not quite getting the detail that I needed and so that's where the 90 comes in. It gives you more magnification than that Okay, now if you want another lens like like this, this is the super 66 or like a 78 Those are amazing. This is an amazing lens to like really Just hone in on the optic nerve and you get this incredible magnified view The only thing about it is you usually have to dilate the patient So I like this lens a lot and I break it out whenever the patients dilate it Okay, and I find it very useful for just really trying to discern subtle changes in the optic nerve All right, but day to day 90 is the one so, you know a goniomere a 90 doctor lens, okay You're pretty much ready to go 66 is great. And yes, I still have a 20 that I break out and look at peripheral retinas But 90 90 doctor lens, okay any questions about that at all? So gonioscopy so the way you get good at gonioscopy is just goniome a lot of people And just so you know when you're in the clinic and you're looking at people Especially if there's any question Uh about you know block home in any way Break out your goniolensin and just practice goniome people and if you have any questions at all You know ask your your faculty member to take a look and and just kind of uh corroborate what you're looking at, okay All right, great. So that's gonioscopy. Just one of the essential things So let's now talk about some of the the disease categories in this open angle Open angle group. So ocular hypertension by definition Ocular hypertension has an open angle, okay So anything that has a high pressure in a closer narrow angle that moves into a different category So ocular hypertension, uh, there's an open angle There's elevated pressure to what degree when when would you say? That ocular hypertension kind of starts to Kick in you start saying that that pressure is too high. What what kind of number do you have in your mind? Yeah, mid 20s, you know like so if you look at the normal pressure glaucoma treatment trial, which we'll talk about here in a minute Um, they had a cut off of 24. That's kind of arbitrary But you do need to have kind of something in your mind about where you might consider that that cut off So so about up to about 22 24 We consider pretty normal above that we start calling ocular hypertension By definition again, they have a normal visual field They have a normal optic nerve. Okay, that that's part of the definition of ocular hypertension so This it leads us to talk about this ocular hypertensive treatment study. Okay, this oats trial and um, I can't I can't emphasize enough How much we owe A debt of gratitude to the individuals that started and ran these massive Clinical trials that for you all thankfully are just second nature. I mean, they're just part of your You know what you hold on to for glaucoma, but they have all been introduced since I've been practicing glaucoma Okay, so when I was in your shoes These fundamental trials that we're going to talk about today Did not exist. Okay, but the oats trial is just so Genius and it provides so much help to us in the clinic. So Why didn't why was the old trial done? I mean, doesn't everybody know that, uh, you know, preventing ocular hypertension or lowering pressure Helps with prevention of glaucoma or progression. Well, yeah, we know that now But we didn't and so Back in the day that I was just starting residency in the early 90s There was really there was kind of two camps. Okay those that felt like and there's some pretty important names on here Andrews Hile, you know the inventor of the Humphrey visual field Who landed on the side that controlling pressure really didn't have any impact at all In terms of protection from glaucoma and optic nerve disease It you know to you you're you're going. Well, what are you talking about? But that's the way it was and then there's also a very strong list over here Some really well-known doctors That landed on the side of yes, it does. Yes, it does So the one I want to show you particularly here. It's just this michael cas michael cas Great glaucoma doctor a long time at washew st. Louis He then became the force behind The oats trial the ocular hypertension treatment trial and The reason these trials are so amazing Is the number of patients that they recruit? And then the rigor of the follow-up. Okay So this is just some a few little characteristics patients were between 40 and 80 again by definition They had normal fields. They had normal nerves Okay, and their untreated. IOP was between 24 and 32. Why why 32 a cut off? Above that it's just too dangerous, right? I mean, you're not it's just a little too dangerous to randomize somebody with a pressure that high Into a study where you're going to watch and potentially untreated For a length of time so 24 to 32 and so that's all these patients now If I ask you About the oats trial, what are some of the kind of Bottom line findings of the oats trial? What do you when you think of it? What do you take from the oats trial? There was less glaucoma that developed in the treated patients, but People didn't progress immediately Okay, that's all very true. That's excellent. So there was less glaucoma in the treated group by how much roughly? It's a half. It's roughly half. Okay, so here is just just like our understanding here is the Kind of the bottom line that in the treated group those that got medication and were treated The rate of progression to end point glaucoma was about half Okay, but it wasn't zero, you know, they still progressed obviously, but it was reduced by about half Okay, and that's just kind of the bottom line and yes, the progression was delayed You know it came came down the road, but that's really the major finding and that's why you know when it came out 2002 I don't know why I keep saying 2002. I promise I worked on this talk more recently But this study came out in 2002. All right And um, that's that's really the important finding. What's another this is a clue right here What's another just major major finding of the oats trial? Central critical and and what did it tell us about The effect or the impact of central corneal things independent It's an independent risk factor from IOP Yeah Which is amazing. Which is amazing. So there's a great history there. So when the oats trial was started It was designed and you know the recruitment criteria and everything is a beautiful study But actually they were into the study into the recruitment quite a ways when a smaller group of ophthalmologists Mostly kind of credited with like Jamie Brandt out of Davis Said hey, listen, we have got to measure Central corneal thickness in these patients. Okay, we've just got to do it and and so actually They went back to you know, there was some you know, kind of future date one of the visits They went back and got central corneal thickness on all of these patients. Okay And so it was kind of added to but thank goodness because it actually amazingly came out as the number one predictor Of advancing glaucoma of all the parameters that were looked at even more than intraocular pressure That's it's amazing and and so Measuring central corneal thickness is absolutely essential To managing glaucoma these days and all of that came out of the oats trial All right, so just from a practical standpoint, what do you have in your minds as far as Numbers and impact of central corneal thickness. What's what's a thick cornea to you? Yeah, 600 definitely that's great 600 I kind of mind about 580 I'll show you a slide here in a minute. Maybe argues that about 580 and above that's thick. Okay And what does that mean in terms of pressure? Right higher because you know in the goldman equation Um That you know the Which we have goldman tonometry a thicker cornea Overestimates the pressure right so you have a thicker cornea You know actually the the true pressure is a little lower than that and I don't try to convert I don't think there's no formula really that works very well. I just have in my mind 580 and above I'm you know, I'm overestimating their pressure. Okay, then what do you have is kind of a low What's a thin cornea? 500 certainly I kind of think in my mind maybe 520 520 and lower so 520 and lower Um, you are underestimating their pressure, right and then everything else in the middle You're probably pretty accurate, but it's it's amazing You know to have this number so I would say to you that's wherever you go and you're practicing and you're managing glaucoma No matter what kind of chart or you know, I'm sure you're gonna have an emr somewhere that you have Visible to you at all times that you're seeing that patient what their Corneal thickness is, you know something that's easy to look at like when we built the MRI we designed that I don't know if y'all use that snapshot. I use that all the time I have it up on half my screen all the time for my patients and one of the Parameters that's on there is the central corneal thickness so that you know when I'm trying to determine Is it getting worse or not or what's the pressure and I can look at that central corneal thickness And I'm looking at that all the time almost every visit on the patient Not only am I looking at what their pressure is, but I'm looking at what their central corneal thickness is. All right So it's just it's just amazing and it's so powerful. So let me just show you a couple of things here This is a graph that came out in the original publication And it basically shows The impact of central corneal thickness Let's see if I'm not getting a point here Central corneal thickness is what it does basically what it allows us to do is stratify risk For a patient it provides another variable. So look at this graph right here. Basically, this is stratifying risk Based on intraocular pressure on the left So imagine if that graph were collapsed because without the central corneal thickness all you've got is one variable All right, so without central corneal thickness you would collapse that graph into just one column Okay, and if you were to do that and I've done this before let's say for people that have pressures of Who measures 25 75? I don't know it's 26 and above So at 26 and above if that graph were collapsed and you looked at all those numbers and I've done this You would get a risk factor of about 18 percent if all you had was pressure Okay But if you then stratify it with corneal thickness what you're allowed to do Is realize that in that group that when you're just measuring pressure is about 18 percent at risk for advancing to glaucoma Some of them are twice that actually The ones with thin corneas and then some of them are a third of that If their cornea is actually thick, okay So The power of that is really extraordinary. Okay So any any questions about that right there? That's just such an important thing Yes So I'm saying if you thin the cornea like if did lacyk or something like that That is a great question that I don't think we know the answer to okay. I don't know My gestalti is that it if you do it with lacyk it doesn't have quite the same impact As if that is their natural Corneal thickness does that make sense? So but I there is not really good data out there I mean that would be a really important question to answer But it does seem that you know as we said that The central corneal thickness the the statisticians that worked on this data they tried as hard as they could To to show that the only reason it really matters is because of its impact on measuring the pressure. All right, but Again and again and again it kept coming out that it seems to have an independent role in predicting about Glaucoma damage So whether or not that means that there's something Also wrong with their optic nerve or who knows what that means It seems to have some independent effect other than just its effect on pressure measurement Does that make sense? So this is just an incredibly powerful thing and why you can start to stratify risk and we'll we'll look at something here in a minute I want to make sure and i'll take too long here Now if you do the same thing based on optic nerve, so if you're looking at larger optic nerves Okay, and their risk of moving on to glaucoma. It's the same thing That if you move everything to the left because you don't have central corneal thickness You know on that top category you'd get a number there of about 14 percent But you'd have no way of knowing that some of those in that same group. It's only eight percent So in my mind when i'm seeing patients in the clinic I kind of think about Up into the left and down into the right because I have these tables in my mind So or these graphs I should say so up and left means they've got higher pressure They've got increased cup to disc ratio and they've got thinner corneas Okay, so if you get up in that upper left higher pressure higher cup to disc ratio thinner cornea Their risk of progressing to glaucoma over five years Starts to get into the 20s and 30s percent Okay, as opposed to just down and right down and right means they've got a thicker cornea They've got lower pressure, you know, I mean it's still a little high, but it's 24 rather than 29 Okay, and they've got smaller cup to disc ratios those folks their risk of progression is Two to four percent, you know, so so much difference and it helps you so much in determining So let's look at some kind of real-world examples about how this changes things. Okay So we're going to keep the pressure the same But we're going to just vary some of the other variables namely in this case the cup to disc ratio is point one Vic cornea, right? So there's there is down and right, right? They got a Vic cornea. They got a small They got a small cup to disc ratio and the pressure is kind of in the middle Their risk of five years of progression glaucoma is just about one percent Let's change it a little bit pressure is the same Little bit higher cup to disc ratio and a kind of a normal corneal thickness Okay, so you're kind of in the middle of that graph sure you're at seven percent risk over five years Change it further. This is where you really start to get up and left The cornea is thin the cup to disc ratio is kind of marginally high 20 percent I mean think of the difference of that and the power that gives you When you're trying to cancel patient about do we start treatment or not now Right, their their cornea is 620 their cup to disc ratios point two and their pressure is 27 Everything else normal on testing That is a patient you could probably say, you know, it's probably only about a 1% risk The development glaucoma and maybe we could just watch for a while. All right, does that make sense survey and then I want to go back here one thing. So what's one other thing that came out in the second oats report That is so important in terms of about deciding Are we going to treat or not? What did the second oats report have to say about the impact of a delay in treatment? You know that I mean to play read my mind, but it actually is a really really really important finding Yes, it did not impact the final outcome So the idea then is if you're going to take one of these one percenters or two percenters and you're just going to watch them But let's say that in five years, they're like the one or two percent that starts to show glaucoma and then you start treatment There was no negative effect of that Looking long term as opposed to if you started that patient right from the beginning And treated them versus starting them five years later when they actually showed glaucoma It did not have any negative impact on treatments. That's really important So it gives you the power to kind of observe in some of these low risk patients as long as the patients come Really really good If we kick up the pressure a little bit even with the pressure of 28 with those parameters again, we're up and left Um, you know really lower to see me down and right mostly we're mostly low. It's like two percent. Okay All right, any question about ocular hypertension? Yes So that's that's a great question and that's one of the points that I really want to emphasize today and hear a little bit We're going to talk about it either more and and that is about in glaucoma in glaucoma you Want to form this kind of partnership with the patient, okay And those are some of the decisions that are going to make not just entirely based on what you might think But what the patient feels comfortable with you're going to find patients who In that in the exact same setting you're going to tell them, you know, you're about one or two percent Over the next five years of developing glaucoma. Some patients are going to say well, I still want to treat Okay, I just I just you know drive me crazy I can't I can't go with this pressure of 26 or 27 and not treat it and you're going to have others that say Matt, I don't want to I don't want to do that. I don't want to start drops now Okay, and what you can then say is that either one of those options based on the data this incredibly powerful data You can say either one of those options is okay Right Either one is okay because you know that delaying the treatment even if they turn to glaucoma. It's going to be okay All right And uh to not treat them as fine, but to go ahead and treat them is also fine All right, so it's that collaborative partnership, which I think is so important In treating glaucoma so that's a great question Yeah, yeah That's right in that in that true That's such a that's such a key point. That's really astute. Um, I had a I had a patient the other day Not the other day like yesterday who asked me that Basically that same question, you know, they said well, what do you think my risk of going blind is If I don't treat and and then that's that's really the crux of the matter, right? That's what we're trying to do trying to have you die with vision and that sounds terrible But you know, I have I have patients all the time that you know, we get their obituaries I do a lot of patients are really old. I've been here a long time So a lot of our patients pass away and and I immediately just think what you know, were they seeing? Yes, they were seeing okay, you know victory. We'll take that But the two things, you know, if you could So I told this patient, okay, so I need two Variables here if I knew exactly what your life expectancy was how long you're going to live and if I knew exactly The rate of progression of your disease and if those two were ever going to cross I could I could counsel you Perfectly on whether or not we need to start treatment right now, but I don't know either one of those So we just make our best kind of judgment based on but life expectancy absolutely I have I have several You know 95 year old people who if they were 65, we'd be doing surgery on but they're 95 And we've we've together they and I we have together decided We're just going to take the drops and and take our chances here that My vision is going to outlive me. Okay, so that's really a great point Okay, so normal pressure glaucoma, what do you what kind of thoughts do you have? normal pressure glaucoma What are the just some of the connotations that you get when you uh, think about that diagnosis It's frustrating Man, it's like these are the patients that will just keep you up at night. Okay Their pressures are 12 and they are getting worse, you know It's just it is just something else. So that's really really true. They're frustrating You there's got to be something else, right? I mean These patients that are their pressures are so low and they're just getting every time they come in their their visual feels worse And they're worse and their pressure is nine There's got to be something else other than pressure But we're going to talk about we know pressure plays a role but perfusion genetics acceptability Some type of abnormality and their optic nerve or something there's got to be something else, but There's not many of those variables we can control All right, but that does a great point any other thoughts about normal pressure glaucoma. Yeah Yeah, that is a super exciting research that they're doing there And that's really one of the fundamental questions that they might hopefully can maybe answer for us. Okay So again by definition, there's an open angle Pressure is you know, it's a little bit arbitrary, but let's say it's not greater than 22. Okay. That's in the untreated state. All right And they have again, we've got glaucoma here. So they have a visual field defect So let's talk about some of those important things. Really. I I know I emphasize these studies a lot You're probably sick of hearing them, but They're very exciting to me because they have come out since I've been in practice and they have absolutely just reshaped Glaucoma practice, okay So the Baltimore eye study is one that we're going to talk about and then this normal tension glaucoma treatment trial So the Baltimore eye study here is the bottom line slide right here the um The Baltimore eye study was published in the very early 90s I was just starting my residency and again, I mean, you just have to admire the effort like 7 000 patients That got full exams. Okay, including visual fields So just think of that effort and what they were wanting to know is the prevalence data Of glaucoma in a Baltimore population. Okay, this is all this done at Wilmer. So it's kind of surrounding Wilmer And just looking at the the incidence and prevalence of glaucoma and these two slides The one on the left represents treat patients who were untreated meaning they they didn't know they had glaucoma. Okay, the The the one on the right is people who were Already treated. So I already knew that they had glaucoma. So they're still comparing the pressure and you've got the The upper graph represents african-american patients The lower line represents caucasian patients. So let's just look at this for a minute. What they found again Remember we're early 1990s. We are still trying to establish whether or not pressure even played a role In glaucoma something that seems so obvious to you. But what they found is that As pressure increased the prevalence of glaucoma clearly increased Okay, without a doubt and look what happens when you start getting up to around 25 But especially if you get to you know, say a pressure of 30 or so, okay The incidence just really shoots up and notice how it shoots up so drastically in african-american patients Okay And so this main findings of the baltimore eye study are number one Prevalence of glaucoma increases as pressure goes up. And again, this is 30 years ago. That was very important information number one number two that that those curves are Exaggerated in african-american patients. Okay, and if you can look if you look at african-american patients that have a pressure of 26 or above and look what happens to that prevalence. You're up to one in 10 even one in eight Have glaucoma, okay Now the other really important finding of this study Is subtle, but it's right there. What happens to these graphs as you go down towards the lower pressure end? But yeah, it's just kind of a smooth curve going down there. Okay, there's not like another spike Suggestive of this separate disease down there. That's normal pressure glaucoma Does that make sense? I mean if normal pressure glaucoma over this kind of independent thing One might expect that as you go down those curves, you would see another kind of blip Of prevalence, but you don't it's just a smooth curve down. Okay So that kind of came to argue that maybe normal tension glaucoma Was just part of open-angle glaucoma in general and it's just You know, they they had the glaucoma, but the pressure was never high So a lot of that information led to this study now. I really want to put this up here 1998 so 1998 This was the first study of these major You know NIH funded trials That were conducted in a very rigorous way to be published 1998. I started I did my fellowship here with allen 95. I started here faculty 96 So this is two years into my practice. This was published And it really was the very first large trial that showed without a doubt that pressure Intrumpular pressure was part of the pathologic process of glaucoma even in Patients that we classified as called normal pressure glaucoma patients. Okay So the randomization this is a little bit tricky. They took 140 eyes of 140 patients They were randomized, but they didn't get randomized until after they showed progression or The glaucoma split fixation right at the start. So these are these are naive patients These are patients that are just getting diagnosed with glaucoma. They are not treated patients, right? these are naive patients and They are diagnosed with glaucoma and then they are Consented to the study and then they are put in the study and then they are followed until they progress Documented progression so they watch them until they got worse So these are kind of the worst of the worst in terms of their glaucoma because the pressure is low And they are getting worse and we've documented and then we're going to randomize them We're going to randomize them either to no treatment Or a 30% lowering of pressure. Okay The 30% number is a little bit arbitrary, but it was picked To say that most of these patients were going to get surgery. So It's interesting We don't think of it that way but the normal tension glaucoma treatment trial is actually It's kind of a surgical treatment study as well. All right So they get randomized after they've worsened 30% lowering or not most of these patients Got surgery to achieve that 30% lowering going back to the Otis trial. What was the amount of pressure lowering in the Otis trial? With medicine those that were treated 22% 20. Yeah 22% excellent So this is more than that. Okay, we're going to lower it by more than that Bottom line right here of the control eyes the ones that were untreated 35% of them progressed again. Okay during the after randomization only 12% Of eyes that had pressure lowering of 30% progressed highly significant the conclusion was that Pressure is absolutely part of the pathogenic process even in normal pressure glaucoma, but generally speaking It just gave us data that lowering the pressure in a patient with glaucoma worked Okay, it protected them from advancing even in this group now if you go back and this is just an important point If you go back and use the original baseline But you know before they were actually randomized, but their original baseline before they got surgery And if you use that baseline the effect of IOP was only found after cataract impact was taken out Why well the way they used to do surgery back then A lot of these patients got cataract after getting trabeculectomy Okay, and and that would obviously affect their visual field So they had to kind of factor that out either by taking the cataract out Or by using the you know the algorithm that kind of accounts for cataract effect. Okay But the bottom line is that lowering pressure protected these patients so conclusions From normal pressure glaucoma treatment trial lowering pressure works 1998 first time We actually held that in our hand without a doubt lowering pressure works Another kind of conclusion is kind of what we've been talked about already What about this thought paradigm again, this is kind of whole but I think it still holds true That in glaucoma patient, there are two forces that are at play all the time And there are these pressure dependent factors And there are pressure independent factors and as indicated on these slides The graph here the higher the pressure goes the more these pressure Dependent factors, whatever they might be, you know direct trauma on the optic nerve Restriction of circulation of the optic nerve whatever that pressure causes The role of the pressure dependent forces goes way up, right? You've got a pressure of 30 It's all about getting the pressure down. All right now when you're down below There are still these pressure dependent forces at play even when the pressure is 12 And that's why lowering the pressure even further still helps these patients But likely there are these pressure independent forces that are dominant when the pressure is 12 And those are things like the genetic susceptibility of these channels who talked about you know those kind of things So I like to think of normal pressure glaucoma in that way That there's some pressure independent forces that I can't control very much That are probably working here, but I can still lower the pressure Still good data that it's helpful Okay Yes, um going back to the Baltimore eye study Were the patients that are treated and not African-American? Do they ever comment about why there seems to be a decrease in that? Yeah, uh, no, I don't have an answer for that. That's just that's probably I don't know if this Kind of a fluke of observation or something and in the treated group, right? And we know they're treated. They can have variable pressure But I don't know of any particular, you know kind of reason or explanation for that. That's a good observation Okay Very good So let's take this patient right here. We'll just talk to this patient So a 57 year old man. He said lacyk in each eye. So this is one, you know, uh, I don't have their Uh, according to fitness data from before but they have had lacyk So this patient noticed their own visual field defect, which you never Like to have happened, but this patient noticed their own visual field defect Went in got diagnosed was started on by zoltan in the right eye And then came to us for a kind of a second opinion consult. Okay So when we first saw them the vision was 2025 2020 pressures were 20 and 19 Oh, we couldn't find any documented pressure about 21 in any old records I had I have a normal angle. So there's no secondary identifiable secondary cause Come to this ratio is about 0.8 and 0.5 Right left eye the right eye is the one where this patient notices the problem. Okay So we're gonna work them up of course and we're gonna get Uh visual fields that look like this. Okay, so what do you what do you think what goes to your mind? When you see this this scenario for this patient visual fields that look like that any thoughts on What you might do next what your your thoughts what your next steps would be It feels very asymmetric, but the right eye does look glaucoma. It looks like there's superior arc Q and an imperie nasal snap Perfect. I think that's great great analysis. So very asymmetric. So I you know that kind of Sets off a few bells, you know, um, but it does look like glaucoma I mean that looks like a glaucoma field rather than a neuro field um, and so We you know we felt the same way and then I want to show this thing right here this oct. So what do you think of this oct? Very asymmetric As noted before and correlates with the field. I would say just with the level of thinning. Yeah, excellent So tell me about this right eye. What do you think about that right eye? That just looking at that scan What's that I'm sorry Yeah So Yes, absolutely. Absolutely. So I would say Uh, I put this up for example that right oct to me is uninterpretable Okay, you know, whenever you see those octs just dipping down to zero You know that is That's just I just inadequate right as there's there's an inadequate box on the readout and I just put inadequate The reason I bring that up because it is this is so important in glaucoma You know, there's an old saying that the only only thing worse than making a decision based on no data is making one based on bad data And in glaucoma management, you can get bad data This is bad data. You just can't make any clinical decision Based on that oct and you just have to be willing to Ignore it. All right Now thankfully as has already been pointed out this person does really reliable visual fields And so this a person that you know in that specialty comment section of epic, you know, it's right there I'm going to write in that note Don't get any more octs on the right eye You know, just don't get it because they're not going to help you or or something like visual fields It's going to be what we what we use in this patient. All right So very good got a normal oct on the left and the trochanal on the right But we do have a very reliable visual field which is great At least for the first oct, can't you say that you can interpret that it's like certainly a thin nerve fiber layer? You you can But even that I just I almost just put it into this. I can't I can't use this category Would you be able to at least like I don't know at our level in my level Like just be able to say well at least this thinning correlates with the visual field changes making a certain that it is glaucoma versus something like this I mean like I said like I say you can try to do that, but I would be a little bit Careful about that. I mean that that particular oct is so Not good that it's almost better to just throw it out now Going back that was a while ago. Now we have a little better technology of our oct You know we can section those things out and hopefully get a better reading But at least that one that I had right there We wouldn't uh Wouldn't spend much time on that one that that's my opinion That's that patient have peripapillary atrophy because he has a history of lacing And it looks like the oct was just through that area that's why it's all flat and unreliable That's probably the most common cause of that type of oct Is when you have a kind of a big tilted myopic nerve peripapillary atrophy, which this person does So that's usually the reason for an oct. That's just not very useful When you have an oct like that, is it worth Repeating one the next time they come? Absolutely. Yeah. Yeah, absolutely. I think you bet repeated the same thing then for sure But but and that's true of visual any any of these tests Repeating them is a really important part of of managing and and try not to again try not to make decisions on bad data um, would you also repeat uh r and f l as if you're following, um Fields consistently, would you also repeat one like every one or two years just to make sure the left eye is not thinning? Sure, again, so when I say don't get any more oct, I'm I'm saying right Left eye you bet super super important for this super important oct So I'm glad you brought that up because for this patient um oct for the left eye takes on even a greater significance because Of the history in the right eye. I mean and so you want to just be all over that left eye And making sure you keep protected and so serial oct will definitely help you with that for sure for sure So what do you think in this patient? What would yeah, you got the they're sitting there and you got that data You got that history You're just trying to put that You know process this into making a clinical decision for this patient so I feel like I still want to be entirely convinced this glaucoma and not another process like an orbital mass or something like that I I totally agree. I totally agree. So let me just say this boom and where I was normal, okay? um, I mean I I do I absolutely agree that that looks and smells like glaucoma, okay The one thing about and I I'm sorry on picture But the one thing about it is it was already pointed out that this nerve was a little funky looking. Okay, so um, you know, I couldn't really feel Like super confident that this was a glaucoma nerve and we'll talk here a little bit about some of the things that help us differentiate that So, yeah, we we scan this person. Why? That asymmetry Okay, and the fact that the patient had noticed that visual field defect, you know, I mean there was There's worrisome. So so we did scan and the MRI was normal. Okay. So now you got that in your hand What what might you do next? You bet absolutely Absolutely and no evidence of secondary glaucoma in this patient So let me just just to refresh your memory. So we got that visual field. Okay, that visual field right there And we've got pressure of 20 normal MRI So Any thoughts about ramping up treatment in this patient? Yeah, I I agree, you know, this is a patient that even just sitting right there in my chair Even though I don't have a lot of a lot of history of working visual fields in my mind That history that visual field and a pressure of 20 is just not compatible. Okay, not compatible We got a normal MRI. So yeah, we decided to ramp up the treatment So we added the result of my timelall comes back with a pressure of 14 pretty good. That's pretty good You know, there's our 30 right? So feeling pretty good about that Comes back in four months later pressures 12 and 14 Excellent except Vision is now 20 40 There was 20 25 So Any thoughts on on that medications? What's that? I'm sorry. I talked about ask about other medications. Yeah, absolutely. I mean you're really starting to so You know The vision dropping with the visual field that's right at fixation that is that that really starts to get you know You're worried about that, right? So yeah, looking at things any chance they have sleep apnea any chance they have some other contributing factor Couldn't really find anything so We decided let's repeat a visual field So there's this repeat visual field The first one is the one on the right The subsequent one is the one on the left any thoughts on that Good. Yeah, could be Let's see the one on the left is the new one. The one on the left is may of 2020 and this one is december Of 2019 so it's about five months apart. This is the most recent Pretty similar Yeah That's a good observation. I mean all that's good. They do look pretty something. They're pretty similar right there. I mean if you're You'd be you'd be really Splitten hairs, which probably is You know beyond what these visual fields can do just call it worse. I think but that mean deviation is the worst They do have a little bit more fixation losses that could be due to again decrease visual duty. Yeah So that's true. This is a 20 40. I that's you know, say my 20 40 20 25 Well, so yeah field looked about the same Um, I put really not changed. I mean a little bit of mean deviation changed. I may have not changed the vision 20 40 Okay, what do you want to do? Let's let's uh, we decided yeah, let's just watch this four months later vision's 2050 So What do you think now you're gonna start really looking at stuff? Let me say this. We had them Go through neuro op. I mean it's decreasing vision We've already got an MRI But okay, let's let's make sure we've covered all the bases went to neuro op Not their you know, they're opting Optic neuropathy work up they we'd already had the MRI but they did all the blood work and everything like that And that all came back pretty normal. So the idea was we were sending neuro op If they didn't come up with anything then we were Watching that vision decrease Not liking it very much. What might we do? So let's say this patient did come back from there off without any other fine, so we're talking about glaucoma and Vision getting worse, but visual field kind of staying about the same What any thoughts on that and he does have some cataract that's there. It's not anything drastic But there's a There's a little cataract I didn't on him, I don't think that's a very good thought It's all IOP measurements throughout the day that a very good thought. Yeah, very good thought What's that? Is it in? Yeah So With that in mind or what is our main concern? My main concern is this vision is going down, right? This vision is going down even though the visual field looks about the same. He's got a cataract We talked together and and I told him that I think it's possible that your cataract is causing your vision to decrease But I'm not 100 percent certain but I think there's a there's a reasonable chance that your cataract is getting worse. So Let's say that we're making the decision together that we're going to do cataract surgery All right. Should we do something else in this patient? I've given a couple of options there Should we do a fecotrab in this patient? Should we do maybe something less invasive? As far as a glaucoma procedure in this patient There's not a perfect answer But what what what are some of your thoughts as you're sitting there with this person? You're trying to help them and you're trying to make it to help them to make a decision How old are they again? Uh 50, 70. About my age. Yeah That's pretty old I think we're at pressure 12. I don't think makes is going to get us much lower an acupuncture So a trap maybe has a good chance. Okay. I totally agree. There's no doubt That the best chance of getting the pressure lower than 12 Is a trap. No doubt whatsoever. And if it's a younger patient, then maybe healthier conch Like surgically and then just longer longer Benefits of actually doing this intervention. Okay Excellent. That's very true What would be the argument for maybe doing feco niggsy thing? I think it's better with the cataract that you didn't have to Really I guess intervene that much as as drastically and that could be first step And you always have the conch to go back later if it's not going down. So All of these answers are fantastic And they're all really really excellent I will say that that is what we went with that argument right there. Okay That my main concern in this patient was decreasing vision And I had a stable visual field and a pressure of 12 Okay, so together He and I We basically adopted that philosophy right there. Let's take your cataract out And let's do you know a mig's procedure and let's see What we get Back in terms of vision We could always do it. You're back to me later. Okay Now what would have changed my mind? Well change my mind if the pressure was still 25 Or especially if I had documented visual field progression, but what I what we have is vision decrease. Okay So we went with that we did a feco and we did an eye stent And We got lucky Okay Got vision to 2025 and I remember this fellow because I you know, I remember watching him and we were Some of it was during the pandemic and man, we're just having You know hard time getting follow-up and stuff like that had to get you know got a surgery done And I remember the first time he came back after cataract surgery and that vision had improved from like 2050 2060 to 2025 That was a really satisfying happy day. Okay Because the other alternative is that it was his glaucoma That had worsened that was taken away his central fixation So to get this and we even got a little pressure lowering maybe just from taking taking his cataract out But but anyway, that's I think that's a just a good example of trying to Right analyzes data and synthesize it process it into trying to help a decision for you make it help Your page making decision. Yes, I'd rather that decrease ocular Refusion pressure is a risk factor for progression and normal touch glaucoma And I'll make a beta blockers kid and do that as well. So would you have considered? I think he was on timbalall. Yeah, sir switching that out. It's that's something that you've seen Work or not working that that's that's a great question. And and that comes up all the time I will I will just say this that In practice, that's not something that I've noticed That much But what I have noticed is the benefits of lowering the pressure and So, you know on somebody like this so if their pressure was like 10 or 11 and their field kept getting worse, you know, that's something that I might consider but But usually I think the pressure lowering in most patients because timbalall is a great pressure lowering drug Kind of outweighs maybe any effects on blood flow, you know The problem with that and it's such a great question The problem with that is that it's just so hard to measure, you know Their their perfusion pressure or get any kind of measure of that. So it becomes kind of theoretic, you know So that that's a great thought All right, very good. So let's talk about a different patient. Okay Uh, this is a 69 year old native american woman She had outside she had cataract surgery on the outside about six weeks ago and she had no improvement in vision So this is the opposite of our guy You know, you think she's got cataract or vision's going down Um, okay, let's take that cataract out. Whoa, it did not get better at all. Okay So she came to us for another pain and after the after the vision didn't improve after cataract surgery then The other doctor, you know, I mean not not criticized and just got some Fields and that doesn't look very good started on medication And then the patient came in for an evaluation And when we saw the patient, this is what we had and let me just make another point about managing glaucoma patients I believe that somewhere in your chart You need to have easily accessible Kind of their baseline characteristics like the first time they came to see you What was their vision? What was their pressure? You know, kind of what was maybe their visual field? So For me I again in that specialty comment section I almost always put in their first visit with us vision was this pressure was this Um, you know their field was this so that I can always refer back to it. It's been shown in studies That when you're reviewing visual fields If you only go back Like two or three years in your visual fields that you can let like this creep occur Without really noticing it But what you really have to just go back to the beginning, you know and go back to the very early field So I always have this information, you know the baseline information. So this is the baseline information We get on this patient 20 60 on the right 23 on the left pressures of tan. She's on some medications open angle She's had cataract surgery on the right. I don't see any secondary signs of guacamole. No exfoliation No, no problem like that that I can see cup to disc is this maculotok What do you do next? maculotok here Again oct What do you think of that oct? Yeah, you can see that up there So difficult I would say I totally agree with you difficult I would say this one that is opposed to the other one. I would say not impossible I think there's some usable absolutely some usable data here Right eyes, you know thinned out relative to the left There's our field any comments on that field It's not the most reliable field, you're right. It's it's not it's not perfectly reliable Very good any other thoughts about that field? Yeah, that's the vertical midnight almost yeah, it kind of smacks of that doesn't it but it's looking a little Little potentially neurologic, right? Okay, so There you go So, you know again, you're just trying to do your best to To make these decisions and know when to you need to scan somebody and when not but in that patient What were the clues there? If you know, what what are the clinical clues that you might have just even if you just look at that right there You know the history that a cataract was taken out And the vision didn't get any better And you're just looking at that right there What what's something that maybe or some things maybe stand out to you? Absolutely, absolutely, it's just not that just doesn't fit does it you know central? That's a great point central vision loss due to glaucoma is Yeah, almost never you never say always it almost always associated with a really bad nerve. I mean just really bad This nerve looked less cut than the other eye actually, okay So that's a great clue central vision loss that's disproportionate to optic nerve findings Not a lot not a lot Now one of the things I will say this That you know how when you got a pseudo fakie guy and a fakie guy and you're comparing a pseudo fakie guy to a fakie guy The optic nerve on the pseudo fakie side like always looks like it's got power relative to the optic nerve And so or relative to the optic nerve on the fakie side You know you get those the effect of the cataract and so maybe we were just noticing that but power didn't really Didn't really stand out to it. So, you know this patient big tumor Referred on the surgery and um, so let's just think of this normal pressure glaucoma when you when you've got Normal pressures you got optic nerve disease What are the what are some of the things that you would look for clinically? That might lead you to scan or to work them up scan a patient Rather than just initiating treatment maybe for glaucoma. What would be some of the clinical findings that would Lean towards Asymmetry is huge. Yep Well neuro field to have that one asymmetry is one of the ones I have up here What are some of the others? We saw a field, right? They did that didn't quite look like glaucoma, right? It just didn't quite look like it So that's going to tip you over uh, asymmetry absolutely that's one of the biggest in Utah, what's the number one cause of really asymmetric glaucoma? Exfoliation absolutely So one of the things that I think is really important Is that when you got a patient there see so often the patient's going to come to you And they're very asymmetric And if they've got exfoliation and they're already on three drops, you know um One of the most important things I think is to go back in their records All right, and it just takes a little time to get those records and if you and you can find that well five years ago When they first came in to that doctor they came in and their pressure in this left pseudo faking guy Exfoliation I was 42 Okay You're done. You're done looking you don't have to go look for another cause of optic neuropathy Because their pressure used to be 42, but when you look back and they've never had a very high pressure That asymmetry and in the in the presence of not having a documented high pressure absolutely worrisome a neuro field Central vision loss like in this lady right here Central vision loss that is disproportionate to optic nerve cupping Is that's a that's definitely a red flag. Okay Yeah, unilateral or asymmetric and no history of old trauma or Uh elderly and trucker pressure. So sometimes you have to dig through some records to get to What about on this side what what would be findings against imaging? A notch a notch excellent So In studies that have been done where they look at really experienced glaucoma observers and they're analyzing optic nerves And they're trying to determine You know, is it glaucoma or not a the presence of a focal notch It's like like darn near pathic mnemonic of glaucoma Okay, so if I look back there and there's this focal notch and everything seems to correspond And their vision is still like, you know, 2025 or something like that That really makes me think mostly glaucoma along with The discount bridge. That's another thing that is really common in normal tension glaucoma and really there's not anything else that does that Okay And then again, if you've got a previous, you know, you look back in the records and the pressure was 42 when they first saw their their doctor, okay for any questions about that Those are good cases to You kind of think about managing normal pressure glaucoma and then of course classic visual field. All right, so Or normal tension glaucoma they they classically have like central visual field defects compared to like primary open angle glaucoma Classically speaking. Yes. I mean, that's the classic teaching that normal pressure glaucoma patients tend to have like more Paracentral defects closer to fixation than high pressure glaucoma But they're still not usually associated with vision loss Like like acuity loss Until until quite late. Okay So I wanted to talk about Some things with this patient right here So this is a patient Came in nice fellow and he's been, you know, managed, uh, you know by On the outside and he came to us and we'll we'll look at when when this patient came to us but so this is a patient that has had pressures in this range And their vision was 2050 and they had a two plus cataract and this was before they came to us And so They were on drops already and they had slt And they had the visual field going from the first one to the second one So the first one of the second one is on the outside And pressure was too too high the vision is 2050 had a cataract And this patient had a mixed procedure. I think, you know, I think that's very very appropriate. Give that a try I had a mixed procedure but They had some elevated intraclopressure afterwards wondering if maybe it was a steroid effect. Okay But the bottom line is that They progressed from the second field to the third field after Their fake oi stand. Okay, so I think you could everyone can look at that and You look at that and you say that that's getting worse That's getting worse So then they came to us this patient came to us And We had a long talk and We decided to go ahead with a my demise intraclopressure to me. Okay In this right eye Now the reason I want to bring this up is and this is something that I think is just so important when you're going to manage glaucoma patients and Here's the thing Even with that much visual field loss that patient other than the 2050 now, they do have better vision now Okay, but they're still progressing You know that patient is amazingly asymptomatic with even that much visual field loss and so one of the most challenging things about managing glaucoma Is that you are to a large degree Dealing with an asymptomatic disease Okay, and you're trying to help them understand. I know it's asymptomatic But it's getting worse And if you don't do something different, it's going to keep getting worse All right, and I like I say I've become very philosophical about this relationship Uh not to get too personal, but as I've dealt with my own cancer diagnosis It's it's very similar. I have pretty much a to my knowledge I have not had a single symptom From my cancer, but I've had tons of symptoms from the treatment of my cancer And glaucoma is very similar. Okay, you can these patients They many of them feel like they just see fine. Okay, and yet you're telling me you need to have surgery And that sometimes can be a hard thing and that's really where That's the art of medicine right there and the art of being a a doctor in just the fullest sense of the word Is helping that patient understand You know the nature of their disease and I know it's not I know you're not having symptoms.  I got you. All right. It's it's a very visual Thing that helps the patient understand, you know what they've got going on and Getting that buy-in from the patient especially if you're going to talk about doing Some of the more invasive glaucoma surgeries Getting that buy-in You just you just have to have it even I will say this Even if you have to delay a little bit To get them to to buy in to what needs to get done It's worth it. Believe me. It's worth it To have the patient, you know kind of you and the patient be in agreement that we need to do this so Information like this, especially if you're going to do a trabeculectomy or valve or something like that That will help you sleep at night because let's say something doesn't go well. Okay. Let's say there's a problem Well, you can look back at that Visual field chart right there and you can say well this this patient was going blind. I mean we had to do something Okay And the patient can do that as well and one of the things that I always tell the patient and I believe it I mean it's it's I absolutely believe it. I never recommend surgery to somebody, especially if it's like a trabera too I never recommend surgery to them unless I fully believe that The risk of doing the procedure is less than now the risk of not doing it Okay, and things like the age of the patient really weigh into that, right? I mean This visual field that that sequence right there are going to have a very different conversation with someone who's 95 versus someone who's 65 Okay, but getting that That rapport and getting that relationship and getting that buy-in from the patient is so important and visual fields Help you do that. Okay, and and so use them in that way So this patient had a trap And they did well But about 10 months later their pressure crept up a little bit Up into the kind of the upper teens again And so we needed to do we did a revision of that trabeculectomy And now we're sitting good pressure seven And vision's 2030 And you know, we're feeling feeling good about things. Okay Now This same patient. This is their left eye. Okay, this is their left eye Pressures again between 19 and 22 vision was 2025. They just had a small little cataract on that side uh on drops SLT was done And this is the visual field sequence that we're watching here. Okay um Any thoughts on that? So, uh, this is actually not that long. This is just uh January of 2020 at the top and september of 2020 down at the bottom. So that's not a very long interval That's a very good question. It's less than a year The rapid progression of this eye and also the other eye I think I don't know it might be better to be aggressive since this is a good seeing eye Okay, so Yeah, I couldn't couldn't agree more and the reason I wanted to bring this up is This person had a trabeculectomy the patient asked for it. Okay now I would say yeah, we had we got a good result on the other side and that's that's that helps but I would just argue that that is kind of about you know getting building this relationship with your patient that They can then you know just Know that you are their advocate and you're going to do their very best and they're going to yeah, let's do this So basically the patient adopted exactly the philosophy That that you express there and that's what that's what we want. Okay. We want that kind of relationship and um That's really when I like I know I'll just tell you this so You know when I was talking to my doctor about you know, what are we going to do here? and And they said to me a very important phrase and and it kind of goes along with This idea that I have that I don't recommend surgery unless I feel the risk of doing the surgery is less than not doing it My doctor said to me. Hey Norm said you need to start thinking about this In terms of surviving this thing and not worrying about side effects And that's you know, I needed to be told that and so, you know, that's just part of that Relationship that partnering that you they have with the doctor and so if you're going to treat glaucoma Just encourage you to really work on developing that kind of relationship. It's a it's a partnership and to Make sure that the patient is on board with what you're asking them to do and a big part of that Is because you're dealing with this asymptomatic because I'll guarantee you that that fella's got no symptoms from that He's got zero symptoms from that visual field Okay, so again, not trying to be too existential But I just uh, it's just such an important thing when you're going to take care of these patients and want to do it Just the very best you can yes How low would you like the IOP to be because I didn't really find numbers on kind of the lower end And seven on the other eye It's probably what we want, but what would be the lowest number to prevent hypotony? Because if they come back with an IOP of two Yeah, no good. Yeah So that's a great question. And I boy, I'd love to be able to just dial that in You know, I'll take a nine on this person, you know And I'd love to do that and you can't can't do that. But let me just um I'm gonna bring up another patient here in the context of that question Okay, so I had a gentleman that I met for the first time just yesterday and 14 years ago. He had a traveculectomy and um Just meeting yesterday and he had a terrible experience with it and and his pressure went super low he had a ton of vision loss and he Again, I'm not not criticizing anybody, but you know, the trap didn't look very good um, and he'd had vision loss and He said to me said that is the worst decision I've ever made in my life Was to have this surgery And then he said another thing he said, you know, I think the only reason they wanted to do it Was to get me off some of my drops So I would say and I mean it breaks my heart to hear to hear that You know from somebody because I'm sure somebody had good intentions, but but I would say There's two things to learn from that number one Again, let me criticize, but I would say that that's There was not enough understanding between patient and doctor there about what they were trying to accomplish.  That's a different story But um to do a trap just because someone doesn't like their drops or something like that I don't know that I've ever done that But but to you just have to build that relationship You have to get the patient to buy in and and the patient to understand. Okay. I know I've got to do this Okay, but the second thing to learn from from that is that in traveculectomy surgery Valve surgery too, but traveculectomy is especially Avoiding the low pressure Is a super big goal and so, you know, I'm not doing surgery anymore But you know for 25 years of doing surgery and 25 years doing traveculectomy So much of it was to just try to Refine the technique so that we avoided the hypoteny because that's where the disasters come from most of the time Pressure goes too low and you get maculopathy you get coroials and all that kind of stuff and you know things You're never going to be the same So if you're going to do traveculectomy And if you're going to do glaucoma, you're going to have to at least for right now We still got to do traveculectomy um Having a way to avoid the hypoteny and to titrate the pressure from the top down so When I do surgery The ideal for me is like on day one or something the pressure was like 18 or 20 or something like that And then we're going to titrate it down by cutting stitches and we're going to take it down easy That's the way we like to do it now As far as what kind of pressure I would like to have for this person Well, I would say this is that even though the pressure Based on visual field we need lower pressure on that side Based on the history of the left eye I would say we're at least aiming like low teens if not, you know 10 or something because we know their other eye Went really bad with pressures kind of in the mid teens Okay And the other thing is that just because the pressure is low doesn't mean they have hypoteny I know that sounds defensive from the glaucoma guy, but just because the pressure is low doesn't mean it's a bad thing In fact, I will tell people that they come in under pressures for And they have good vision And no coroitals and no maculopathy as like this is the best thing that could ever happen to you To have a very low pressure and have your eye be able to tolerate it. Okay Love that certainly some do get hypoteny change and you have to be dealt with but Avoiding hypoteny I think is the key to glaucoma to do what you'd like to like to me I had a colleague as as we talked about this talking about with a colleague I had he said to me he said So you would rather have a trapezoid like to me fail Then deal with hypoteny and yes, I would I mean hypoteny is that bad of a thing. Okay, I'd rather hover around the too high end Rather than go real hypoteness. I would okay great any other questions about about any of that Okay, very good. Now. He's got pressure six Ouch, but 20 25 love it Fantastic, you know Fantastic, so he's he's doing well. Okay exfoliation syndrome So the normal pressure glaucoma patients that are pressures are 10 or 11 and they're going down the drain They're going to keep you up at night. Sorry But this the other set that's going to do that because Exfoliation can just misbehave so badly and you know it from cataract surgery, right? I mean that's a that's a real thing. You know exfoliation cataracts are they're a different beast than Regular cataract surgery. Well exfoliation glaucoma Is it is a different beast than a regular glaucoma and I'll show you some examples So what do you think of as the clinical features the main clinical features of exfoliation disease? Is that you see on exam? The most obvious is Yeah on the lens capsule, so that's that's number one And so yeah, you always look for that So what are some of the other clinical findings though? Because oftentimes a patient is going to come to you And they might be treated for glaucoma or maybe just have high pressure and they're super faking Right, so what are some of the other clinical signs you can look for to make the diagnosis of exfoliation disease? Tids Absolutely tides. That's a very good and where are those tides? So I think people are margin people are margin. I think of them people are margin mid peripheral ones the pigment area, okay? Yeah, so any other thoughts? Yeah, excellent That's a really important one. They have a very Characteristic angle on gonioscopy. Okay, they very commonly have a sample aces line But they also it almost looks like kind of an inflammatory angle. It's not but it's it looks kind of junky I just kind of describe it at that. I mean is the team is not like really smooth and You know, it just looks like it's kind of funky and so they have the you know, it's kind of one of those gestalti ophthalmology As you know ophthalmology exam a lot of it's just kind of gestalt is well, that's it. That's exfoliation I've seen that a thousand times. I know I know what it looks like That's kind of the angle of exfoliation patients Kind of looks it just looks like an exfoliation patient. There's one other thing that So tids They can have they can have pigment on the endothelium. They can't make with any Absolutely That's a that's a really big one the only one other one I'd say that I actually think for me is the most important and that is the appearance of the iris margin the pupillary margin It has kind of that again. It's a kind of that gestalti look. It's that kind of scruffy It's not real smooth and you just look at it and you go wow, that's an exfoliation iris, you know And so the appearance of the pupillary margin just right off of that the tids Kind of a junky angle. I know these words are ridiculous But that's just kind of how I describe it and of course if you see it on the lens, then you got it made But oftentimes we'll be pseudo faking. Okay, so those clinical features because it's really important to know If your patient has exfoliation It's really important because you just got to be careful with it So let's take this patient right here a 79 year old White man vision 235 2020 pressures 24 and 20 Exfoliation on the right and we we've made that diagnosis, you know based on he's pseudo faking But we can look at our other findings that we just talked about we can make that diagnosis of that exfoliation He's on three drops in the right eye one drop on the left eye left. I does not have exfoliation by the way Is Just in the right eye cup to disc 1.7 and 0.4 All right These are his fields. Okay, and I know that There's a there's a fair amount of distance between the middle one and the lower in terms of time You know, there's like three four years there and I realize that's quite a bit And I'm sorry that the bottom I got kind of cut off there But what I wanted to emphasize is that exfoliation eyes can't just go bad in a real hurry And I We don't understand everything about exfoliation, but I just based on your clinical experience These nerves just seem really susceptible to damage And to to do it poorly and it can happen really fast. It can happen frighteningly fast You know, I've seen easily I've seen that much change in an exfoliation patient in six months And uh, it's it's really kind of a scary thing to see and I The reason I bring it up is because I think in a in a in a perfect world We would follow exfoliation patients like every Like every three to four months. I mean things can change so fast But the practical reality is we can't really do that But if you have an exfoliation patient just having your mind this just things can go bad here pretty quickly And I need to be need to be careful about it Yeah I don't quite still understand why so do exfoliation is often so Isometric because it's like theoretically systemic. I know I don't know I don't know the answer now now certainly, you know a certain percentage do go on to become bilateral But there's a huge number that just stay unilateral and I do not have a good answer for that Um, you know why why that's the case, but it's certainly clinically true So yeah, I actually read something about uh, the side of the bed you sleep on may have a correlation with uh The deposition of I I've heard that too. I've heard that too And you know, there's there's there's things that they're brought up that explain like, um, uh, kind of your um Your latitude, you know, like further away from the equator They think that there's some environmental factors and you know It kind of see if you just look at the the demographics of exfoliation and where it's found most commonly And it is in these kind of populations that Kind of live away from the poles or oh, sorry away from the equator So there's some actually pretty darn good studies about Showing people that always sleep on one side and especially if they sleep with like their hand up That they can get asymmetric glaucoma in that eye that they're always on Now not necessarily exfoliation, but just glaucoma in general So isn't isn't like the degree of exfoliation not correlated to the degree of glaucoma. Not at all. Yeah Not at all. I I agree Yeah You can you can see horrible ones that just seem to have the most subtle Exfoliation and others that are just like throwing that stuff all over their anterior chamber and They're doing just fine. So UV exposure, you say, yeah, like out of car window on one side. Yeah Patients with pseudo exfoliation syndrome have greater diurnal fluctuations in Europe Yeah, would this be something that would even be considered in the united states for patient with pseudox Would it like as that's just something that we don't do or would that be a helpful Tool to see do we need to do laser to get their pressure lower? Yeah, so, you know diurnal fluctuation would be great to get on everybody and And exfoliation patients perhaps especially and I know that in in the united states. So when I was a resident Yeah, I'm sure you hate to have phrases start with that when I was a resident But when I was a resident I was in Iowa I can't even begin to you know, so hunt. Hey Ray had us doing diurnal curves on everybody And so it was like anytime your own call It was just they would just line up these patients and they would keep them in the clinical study center there And you would just be checking pressures all night long So, um The ability to so here's here's just the reality of that In no no American insurance covers that at all anymore and so it just kind of doesn't happen that much quite frankly But but we used to do that tons tons of those patients So it would be good now One of these days I can show you I have I have this patient That um, I call my most instructive patient ever That I've ever had that I've learned more from this patient than any other single patient I've ever had And what made it possible is that he bought a home tenometer And he basically did diurnals all he was he was super compulsive, but in a really In a really nice way a really helpful way, you know, it's just a great guy. I love him and he's uh, He's taught me so much, but he has like done a few hundred diurnals on himself, you know And uh, but then watching what happened to those curves after we did a trabeculectomy and et cetera. It's just it's absolutely Fascinating, okay, so it would be great And I think uh the ability to measure pressure at home once that becomes really widely available And and very reproducible that's going to be maybe one of the single biggest changes that that you all experience I think in your lives of managing glaucoma patients Is the ability to get lots of pressure readings at home from from patients and then analyze the data Okay, good. So what are we gonna do for this for this patient? Let me just remind you here pressure of 24 Is up three drops And it's got this going on What do you think? What's that? Is he faking? He is let me see. Um, he's faking I believe SLT reasonable Seems beyond it I agree. What about what about slt in exfoliation disease? Looks like sure. Well, uh-huh short lasting Yeah, yeah, what it what is one thing that I think and and we actually published paper on this That I think you have to be really careful with especially in exfoliation and doing slt Yes, and what makes them more common? I don't mean to pimp you better just okay. What about the technique? You're right about that. But what about the technique might make it more common? All at once doing 360 doing 360 and I also had high power But 360 so exfoliation patients. I'm doing slt. I only do 180 degrees At a time and that's pretty much I always do that. We had a series here several years ago One of the patients was was mine six of them were referred into me They all had exfoliation and they all had 360 degree slt And they all did horrible with pressure spikes three of them Lost their corneas as part of it and multiple of them had to have surgery. So That was that was real, you know Eye-opener and so I only do 180 degrees and I might recommend that to you all that slt and exfoliation Probably pigmentary as well Just do 180 degrees at the time, but you're right. It does tend to work better in pigment and angles Certainly that was true of ALT, but it's true of slt as well Okay, what about surgery as patient and if so, what kind of surgery? What about what about fake omigs in this? this population What's that the mix can get clogged again You can you can So when you think of exfoliation and and you we heard dr. Ahmed, you know give us a great talk about mix and and dr. Ahmed brought out a really important point that I think is really really been fascinating about the whole mix experience is that one of the most important things mix has taught us is about the importance of what we might call downstream resistance, okay That you can bypass, you know the tm But if you've got bad downstream resistance, like if you think of the goldman equation, right, there's that Just that tagged-on term of epi sclerobina's pressure Epi sclerobina's pressure and because of mix we've learned that is so complicated It's more than just epi sclerobina's pressure It's I think we'll probably even somebody change that term to downstream resistance meaning Everything that resists aqueous outflow beyond the tm and schlem's canal, okay So exfoliation I think of as a tm disease kind of like pigment area. I mean you've got this Memberness junk that's kind of clogging up the tm. And so if you can bypass that You can get some genuine benefit. So I actually think mix Works really quite well in exfoliation and in pigment area And especially well in like steroid glaucoma because steroid glaucoma is a tm glaucoma And that's why it doesn't I don't think mix work that well In good old poag, right? Because I think what we're finding is that so much of poag Is a downstream disease, okay from Does that make sense? So I like mix exfoliation So I think that's absolutely something to consider In this patient though Again for the same reason that slt might not be the best thing That that that's a pretty bad field And mix might not be enough, but I don't think it would be out of the question Especially if your patient felt I do not want to do what you like to be. Okay. I'm not I'm not there yet And so I think mix is reasonable and I think a good good chance reasonable chance expectation That you'd have some good benefit from this, okay Traveculectomy anything special about traveculectomy in isolation Any thoughts come to your mind? As well, but it closes early What's that it closes quicker than in the general population, but it works well generally initially I think that's exactly right. I I think that So if I think of Some of the hardest patients that I have this is just again just kind of a anecdotal bit, you know, I've been doing this a lot Some of the hardest group of patients that I have to get a traveculectomy to work are elderly Women that have exfoliation. I don't know why but I can almost count on it being difficult. Okay They did just tend to scar down Now I still do a lot of traveculectomy and exfoliation disease But I will say Man, we have to work it quite a few of them and there's quite a few of them that end up needing a valve Okay and So traveculectomy, I just don't think it's quite as successful in exfoliation disease as it is in poag Okay Now I I a lot of exfoliation patients that are doing poorly End up with valves some of them after a failed traveculectomy some of them get a valve as primary treatment but A lot of valves going into exfoliation patients Let me just go back one more time. So let me I I know this is not a cataract surgery talk But y'all like cataract surgery. So cataract surgery in exfoliation disease What are what are some of the things you might think of that you might do differently? If you're doing an exfoliation patient Capsule Uh-huh. Absolutely. So you're gonna be really careful with capsular axis You know, some people argue of maybe doing flax or something like that because of that, but you know Capsular axis you can do it, but you just need to be careful. I am a you know, we're all careful surgeons I am kind of a crazy careful surgeon and And I try to really teach, you know fellows and residents about You know staying safe and exfoliation. I I always think about I never I never Want a resident or a fellow to ever use the word fast. I never want to hear the word fast as it relates to cataract surgery Okay, um, that should never be a goal Speed and you can say efficiency. I love that word But fast or quick or whatever. How fast did you do that? I never want to hear that word Efficiency comes with experience it's never In my opinion, never something to try to achieve. Does that make sense? I'm going to do this really fast It's efficiency comes with experience And so I tend to work with very kind of slowish meticulous movements But in exfoliation, it's like even exaggerated. Okay, we're just going to turn the clock off on this case We're going to be efficient and we're going to be smooth But we're not going to do anything fast or quick. Okay Another thing is I think That there is a very definite correlation between The laxity of the zonules in exfoliation and the pupillary dilation Not always, but if you have an exfoliation patient, but you still get this great big old pupil I bet you're going to be pretty good. Okay, but if it's exfoliation and that pupil is going nowhere Just ding ding ding. I'm going to be really really careful here. Okay Anything else you might do in exfoliation cataract? Yeah, like Aaron I said just being very careful with like back stability and zonular weakness Like I know with Dr. Chai, he does not hesitate to at least put in capsular tension hooks hooks. Yeah Just for stability and then if anything looks fishy, he'll put it in a ring or amen ring segments Yeah Yeah, absolutely We have a lot of things to that we can use at our disposal, you know that we we didn't used to have So that's great That's great to use that another thing is If you're gonna So in my experience if you're going to have problems With doing a exfoliation cataract, when is it most likely to occur? I think it's during the ia Because you've kind of you know, you've been working on the cataract and you've got it out and you're nice But then you're you're going to start tugging directly on those zonules and and the cortical material Exfoliation could be kind of sticky. You all know that right? I mean It can be sticky and a problem. I mean, it seems unfair that when you really need it to come right out, it doesn't right? but So to make sure that when you're grabbing cortex That you just don't grab the bag and because it's easy to do both But but you like to just make sure you get underneath And just get cortex and then you know kind of peel it off in that kind of circular motion to Diminish effects on the zonules But those are just some of the things that I think of but if you're going to do glaucoma You're just going to end up doing a lot of cataract surgery on exfoliation patients Yeah, don't hesitate to use the tools that we have but just kind of just slow motion Be just extra careful. Don't grab the bag with the ia. You know things like that All right, good We're almost there. Sorry. I know it's two hours or longer. I know okay pigmentary glaucoma What are some of the things you Think of with pigmentary glaucoma demographics clinical findings What are what are some of the things on your mind? What's that? I'm sorry Young male. Yeah, young myopic males. That's just boom. That's just who they are I've seen it in women, but it it's just so much less common Especially just in the clinic, you know most pigmentary patients are young myopic males And uh, what kind of symptoms can you have? You know, we talk about being asymptomatic pigmentary is actually a disease that can Be pretty symptomatic What are some of the symptoms that you can can Elicit from patients that pigmentary That's absolutely true So my co-resident bill hains at iowa is one of the guys that published most of the papers and on that Subject and why well god was him. He's a pigmentary patient And he loved to play basketball and he was like in lecture and going wait a minute that happens to me all the time and so Lee albert examined him and gosh, he's like terrible pigmentary So he did a lot of studies on it and wrote a lot of papers about it. So It's kind of really good, but that's a totally real thing Especially after a jarring kind of exercise something like basketball. Okay, they can get these pressure spikes and they can be Super symptomatic anything else about pigmentary. What clinical science that you that you see when you examine Simple yep, definitely almost always. Yeah, and not only sample aces line, but what does the tm look like? It's like a crayon. It is so Yeah, it almost looks thick, you know, it's like wow that is that is some kind of tm And sample aces line. What else do you see? What's that? Yeah mid peripheral tids almost always there Yeah, yeah crew members, so those are all yeah, it's really a it's really an interesting disease I mean those those clinical findings are really really very interesting um Pathogenesis is thought to be what? Yeah, so that's another thing to look for on gonio is that posterior bowing? That's like the the telltale sign of pigmentary rubs against his onioles gives you the ti translimination defects You know liberates the pigment pigment clogs up to tm Very good, so those are the signs that you're going to find what about treatment What are some of the things that you think of when you're going to start thinking about treating a pigmentary patient? Often yeah often especially if it's in that distribution, you know It's just not that very much especially that patients a little older because I think I I believe that this kind of Burned-out pigmentary thing is a real thing and they actually can start kind of You know having less pigment on their cornea less pigment in their angle But they're just an older pigmentary patient, so I think I think that's pretty real Excellent treatment what what medically what works really well in pigmentary patients? Far as a far as a drop So what what is is pigmentary a tm disease? Pigmentary is a tm disease absolutely aqueous suppressants absolutely work. What's even better? Yeah, the prostaglandin so it really does prostaglandins I think have a huge impact in pigmentary they do and almost everybody But a really big impact because you know you open up that That episclerol venous or the secondary outflow pathway, and they tend to really have a positive response to prostaglandin analogs another one is pile of carpene that You all might not even heard of pile of carpene Pile of carpene used to be something we would use a lot The only problem is is that pigmentary patients are also the ones that can't stand pile of carpene Because they're myopic and it makes them even more myopic and it's really difficult, but You know it works like a charm in these patients It also flattens out the iris pretty dramatically and might help with the pathogenesis of it But you know we just don't use very much because of the side effects But prostaglandins are your number one thing slt in these patients Yeah, you know this is the classic You know disease where slt al t Can be very very effective again. I would just treat 180 degrees at one time. Okay Surgery mix a lot of the same things seems Same things we said about exfoliation and migs and stuff apply with pigmentary. It can be super effective. Okay In in patients with pigmentary because you just get them a little bypass by all this tm disease And they can do really well. So I Quick to do that whenever possible Trab and valve I actually I think traps in this in this population work Significantly better than in the exfoliation patient, but what do you have to be careful of what it's already been said What what about these patients makes them More potentially problematic with trabecillectomy They're myopic excellent. They're myopic and so you just have to be really careful with that And how do you tie your sutures tighter? I mean it's That's what you do. You know when I when I'm in the or I'm doing a trap I'm tying my sutures tight I the perfect kind of tension for me Is when I kind of re-inflate the eye in the or to physiologic IOP and I get like zero flow Or maybe just an absolute Trickle anything more than that. I'm going to shut it down But what I love is when I inflate the eye of physiologic pressure I get like no pressure or excuse me No flow, but I just put a teeny little bit of pressure on the posterior lip of the wound And I get a pretty good gush of fluid. So you're just like right at that, you know balance point between Almost no outflow and a lot of outflow. That's where I'd like to leave it right there And and especially in myopic patients Um, I the tidal sutures down in fact if I'm going to air though. I'm going to air on the side of two tight Because I can correct that right Okay, uh vows same I know we're out of time inflammatory glaucoma very common and you know, is it Inflammation or is it steroid you're always asking yourself that question? Which one is it, you know is and and sometimes you don't know exactly But they they tend to kind of respond the same but balancing that can be can be kind of tricky treatment medicines, what kind of medicines you tend to think of with inflammatory glaucoma Like pulling off the shelf first that might not be what you would normally do inventory then usually you Do you want to use steroid like if it's acutely? Absolutely. No question. Yeah. Do you want to use steroid? No question Get it quieted down and you know the the uvix folks will tell you that we get you know I know they're on every two hour steroids and there's your responder But we've got to get the inflammation and I totally agree. So you're going to treat them with steroids if the eyes hot How about pressure lowering? Drops.  That is absolutely right 10 to now If it were my eye and I had inflammatory glaucoma and it was either try this latinoprost or have a trabeculectomy I'm going to try the latinoprost I probably I'm not going to pull that off the shelf first. We're in almost everybody else I'm going to pull the latinoprost off first Usually aqueous suppressants first in inflammatory glaucomas. Okay So that's a couple things about medicine laser What's that you consider avoiding yes I I've never seen ever but I rarely do any laser trabeculoplasty in a inflammatory patient, but yeah, here's here's the thing though Is an slt works great in steroid glaucoma. Okay, so if if you think it's mostly steroid induced all right Laser actually works really really well, but sometimes making that differentiation is tough But in a truly inflammatory glaucoma. I don't do laser. Okay Then what about surgery? mix Mix can be great. I mean this is this is where mix can be absolutely fantastic and by mix. I just mean like Goniotomy Something very simple there's one of the series of papers that I came across that had a Dramatic practice changing impact on me was looking at David Walton's papers on doing goniotomy In younger patients with inflammatory glaucoma. I mean a straight goniotomy just like you do in a baby 23 gauge needle just boom cut the you know cut the TM open It works fantastically well And so if you have a young patient with inflammatory glaucoma, especially if it's like jra And they haven't had a lot of other surgery like they haven't been retracted and all that Boy, think of like a just a straight goniotomy in those patients Beautiful. That's my favorite glaucoma surgery. It's just a straight goniotomy. It's so physiologic. It's just a just a beautiful thing But other mix, you know, be it uh be it gat or abic or something like that You know in the gat studies, this is these are the pages where gat works the best is in the inflammatory glaucoma patients So really think of mix So going on ahead there trabeculectomy, okay Trabeculectomy in inflammatory glaucoma. What are the concerns? Scarring yes, and it also can be the opposite they can have Not they can not scar that much. So hypoteny in general is a real concern in inflammatory glaucoma And so When i'm doing a trabeculectomy in a definite uveatic patient I'm going to tie the sutrus titer because not only do they sometimes have yucky sclera And conch that doesn't form much scar tissue Okay, but they can also very definitely be hyposecretors They just don't secrete as much aqueous because their ciliary body is always inflamed. All right So you have a lot of factors that are kind of pushing towards hypoteny So you want to be really careful now because of that Inflammatory patients get a lot of valves also and what kind of valves are we going to use in inflammatory patient? We're going to use a valved valve Okay, a double valve, but not a what are the what are the unvalved cetons? Bare-velled multinos, okay The new one the new one from a new world medical. So I don't put in Unvalved cetons In uveatic patients, especially if they've had a lot of subtenons catalog Okay, I mean this is this is definitely something to write down Don't do an unvalved valve in a patient that's had a lot of subtenons catalog And why is that they will not form a cap They just won't and as soon as that you know ligature Opens up you're going to have a hypotenus flat eye. It's a it's a mess And uh, that's uh, lee allward Told me that and you know, he's just one of those things. He just said Take it from me. I learned it the hard way. Just don't do it. And so I've never done it So I always use an Ahmed a valved valve in my patients uveitis and even then I flow restrict it Okay And the way I flow restrict a valve is I put a fibroproline in the lumen And then I tie a 7-0 Michael tight around that Fibroproline tight cut it and then I pull that proline out So basically the tube is now like an hourglass And it's it's constricted at that one spot to about the size of a 5-0 proline lumen Okay, and and that's if you're really worried about hypoteny like somebody that's super myopic Or a uveatic patient that's bad inflammatory disease You want to not get hypoteny even with a valve valve doing that flow restriction That can be a lifesaver. So The fact that using vicarol also that that will eventually dissolve it will absolutely But you don't get the big rush like you do in an unvalved valve. It's much more subtle than that But yes, it does eventually open up. That's right. That is it So thanks everybody. I really appreciate your time and You know glaucoma glaucoma is good. It's a tough disease But it's a good thing and just just you know, when you're treating glaucoma you're treating real disease, you know And so that always helps you Take those bagels if you want if you want them up in the resident room or whatever you're free Yeah I'm a computer and I don't necessarily turn into this talk Um I think one day I got to be there Yeah, it feels like a little bit better, but I knew when you had coffee this morning like there's no way that she Delt with the traffic and got coffee and was here before me. No way. She said the hospital Out of the hall room I hate you In that case Yeah Let's go man, did you want to The resident room Do you know where the library is? Yeah, it's right next door. Okay, okay. Are you going to the resident room by chance? Oh But the ciliary body itself Forward but it's mostly kind of the land's design your complex But of course in angle closure The the benefit of pilot corp is to try to pull the iris down try to break that bomb base cycle By you know pulling the iris out of the ego Pull the pupil down Oh, yeah The image between the iris and the lands that leads to angle closure bomb base is classically mid-trivial So that's why you know people give that Um Just kidding, I love it