CHAPTER XIII Margate Jetty was dull and deserted that night. I went there when darkness precluded farther rolling, but with the rest of the lounges was driven off by a steady fall of rain. The sky was overcast with dark clouds, and the patching rain formed a dismal accompaniment to the melancholy surging of the sea among the iron columns below. I sought my lodging, therefore, and strove to while away an hour in conversation with the old son of Crispin at whose domicile I had quartered myself. "'This must be a very dull place in the winter,' I remarked. "'Oh, no,' he rejoined. "'You don't see so many people, of course, and it is quieter always—no band, no niggers, and such like about—but, bless you, there is always something exciting going on, a ship coming ashore, or the lifeboat going off, or a disabled vessel being towed into the harbour.' "'Any smuggling done now?' I asked. "'Nothing, or next to nothing,' the old man replied. "'It don't pay now, like it did in the old times, when there was heavy duties on foreign wines and spirits and silks and lace. Fortunes used to be made in them days in what they called the free trade.' But recalling the story of Will Watch, embodied in more than one old ballad and modern romance with which I was acquainted in my boyhood, I could remember hearing much about smugglers and smuggling, which disposed me to be a willing listener to anything the old man might say upon that subject. I had heard my father speak of the smuggled merchandise brought into London in those days by strings of pack-horses, through byways and green lanes. And I knew a mansion in Surrey, within six miles of the Metropolitan Bridges, which was the suburban residence of a wealthy wholesale-mercer, whose father was said to have made a fortune by speculations in smuggled French silks, the said mansion being, when I was a boy, familiarly spoken of in the village, a smuggler's hall. I remembered, too, that being one day, many years ago, at one of the oldest houses in Norwood, then the property of one of my maternal aunts, the old lady who saw the ghost. My relative produced a bottle of Hollands, with the remark, This was smuggled by old Will Fox. It is the last bottle. There must have been some money flying, when the famous Bill Johnson escaped from horse-monger Lane jail. I observed, in response to the old man's last remark, Aye! he returned. It was a golden key that opened the prison doors for him, you may depend upon it. And a sight of money must have been spent to open the way to Beloyne for him. I have heard my father say that relays of post-horses were ready every ten miles of the road to Dover, and that all the turnpike gates were thrown open for him to dash through without a moment's hindrance. The smugglers on this part of the coast used to run their cargos ashore at the gaps, didn't they? Said I. Aye! Many's the cask and bail that's come up the gaps between here and the Forland, he replied. There was always men on the lookout when one of the luggers was expected. And then she dodged off and on until a favourable opportunity offered, such as a dark night, or the preventive men being led away on a false scent, and then a signal was given, such as a flare or a blue light, and the cargo was run and before daylight was carted away in land. Sometimes there was a fight, I suppose. Not so often as might be supposed, or the trade couldn't have been carried on. Still, the preventive men used to come down upon them sometimes, and then shots would be fired, and perhaps there would be some cutlass work. I remember hearing a story when I was a boy of a fray like that, in which a preventive officer was shot dead, and a young man who was said to have been helping to run the cargo disappeared, but whether he had been killed in the fray and secretly buried, or whether he had run away on account of being concerned in it, nobody could say. When several years had passed without anything being heard of him, his father, who was a farmer, and had accumulated some property, as farmers could in them days, died, and the second son stepped into everything, telling everybody that his brother had died in France. In less than a year, however, the elder brother came back, and claimed the property. The other one tried at first to make out that he was an imposter, but finding that wouldn't do, he gave information to the justices, and the young man was taken upon a warrant, and tried at Maidstone for the murder of the officer. "'Was he convicted?' I asked. No, there was not sufficient evidence found when it come to be tried, and so he was acquitted. The rain had by this time ceased, and I went out to look at the sea again, and to ponder the old man's story, the chief incidents of which I recast into the following form, as I leaned over the railing at the back of the houses on the north side of the high street, looking at the somber sea, and listening to the mournful sound made by the tide, as it alternately rolled up the shingle below, and then swept it back again. The King's Press Two hundred years ago no one would have predicted that Margate, or as it was then called Margate, would ever attain its present proportions. It was a village only, consisting of a straggling street of wooden houses occupied chiefly by fishermen with a sprinkling of necessary shops, and the old flint-built church dedicated to St. John the Baptist, which had been erected in the eleventh century sixteen years before William the Norman marched through Kent with his victorious army. Such it had been for centuries, and such it seemed likely to remain, and probably would have remained but for the inventions of Watt and Stevenson. One night at no later hour than the band now plays on the jetty, but at which few lights twinkled in cottage windows and shops were all closed in the days when economy in candle-ends prompted early hours. A band of seamen armed with cutlasses and pistols, and whose leader's uniform showed that he was an officer of a King's ship, came from the little harbour in which the fishermen moored their boats, and tramped along the street in the direction of the village ale-house, before which swung the sign of the six bells. There they paused and listened. Night shone through the faded red curtain at the window, and from within came the sound of merry voices, bursts of laughter, and snatches of song, mingled with the chinking of ale-mugs. "'There must be a dozen star-fellows in there,' whispered the officer to a boson, "'we shall have a rare hall.' Entering the house alone he looked into the room in which the topers were assembled, and saw that most of them were fishermen, with here and there a yeoman or farmer of the neighbourhood. "'What cheer, lads!' he exclaimed, assuming a jovial tone, how many of you will volunteer to serve the King!' The voices ceased, the merriment died away instantly, and mugs on their way to mouths were set down again. "'The press!' cried one, as the figures of the seaman were seen beyond the officer, and then they all sprang to their feet, some rushing to the window, others snatching up ash sticks and fire-ions to defend themselves. The officer and his men rushed into the room, and the former, seeing an athletic young fellow endeavouring to escape by the window, caught him by the arm, and tried to pull him back. A struggle ensued. A knife was snatched from a seaman's belt and plunged into the officer's breast. He staggered back with a gurgling cry which subsided into a groan as he fell upon the floor, and the homicide made his escape by the window. Similar struggles were going on at the same time between the latter's companions and the seaman, both sides using their weapons freely but without any more serious results than cuts and contusions on heads and arms. In the end half a dozen of the villagers were dragged away to serve the King, their companions having escaped by the window, and the corpse of the officer was left to await the coroner's inquest. The affray, resulting as it did in the slaying of a King's officer and the impressement of six fishermen, produced an unwonted excitement in the quiet little village. There was another man missing, the eldest son of a substantial yeoman of the neighbourhood, but as his description corresponded with that given by more than one of the seamen of the young man whom they had seen struggling with the officer, and the boson swore that he was not among the impressed men, it was supposed that he had fled to avoid the consequences of the fatal blow, and a warrant was issued for his apprehension. Ten years passed, and Paul Max did not return. If his relatives received any communication from him they did not make it public, but professed to know no more than their neighbours. His father died a few years after his disappearance, and his younger brother Stephen Max did took possession of the patrimonial estate. One day, as the young yeoman was calculating the probable value of his ungarned corn crop, for he was a man over much concerned with the care of adding guinea to guinea, a footstep on the garden path and a shadow on the porch drew his attention to a stalwart figure in the garb of a mariner, who, as he looked up, stepped forward and extended a large brown hand. "'What chair, Stephen!' said the mariner, with hearty joviality. Stephen Max did stared, changed colour, and neither moved nor spoke. His wife, who was rocking the cradle on the other side of the table at which he was sitting, looked up on hearing the stranger's voice and wondered who he was. "'Don't you know me?' said the mariner, as ten years' wandering so changed him that you don't know your own and only brother. "'My brother!' exclaimed the yeoman, with an air of surprise and incredulity. My brother went away ten years ago and has never been heard of since. Who you are I don't know. Then I must be more changed than I thought I was,' said the mariner, with an expression of disappointment on his sun-brown but not unhandsome countenance. He doffed his cap on perceiving Stephen's wife, and, without waiting to be invited, seated himself near the table and looked around the room.  "'And I should have known you, Stephen, if I had met you on the custom-house key at Rotterdam. That, lady, Mrs. Stephen Max, did I reckon, has changed more than you have, but I think I remember her when she was called Jenny Harnett.' "'I don't remember you,' said the young woman, averting her eyes from the mariner and occupying herself with her baby. "'And I don't believe your Paul Max did any more than I am the Duke of York,' said her husband. "'You don't?' exclaimed the mariner, with even more surprise and incredulity in his tone and look than had been manifested by the yeoman. There was a strong resemblance between the two men, not only in the colour of the hair and the eyes and the general cast of countenance, but even in every feature, their dissimilarity being confined to the expression of character and temperament, in respect of which the balance was in favour of the mariner. "'What will convince you?' the latter asked after a pause. "'It will take a good deal to convince me that your Paul Max did,' Stephen replied coldly. "'It would be uphill work to convince you against your will, Stephen,' said the mariner, with a thoughtful air. "'Have you got a bit of my writing anywhere?' "'Not a scrap,' replied Stephen, with a shrug. "'Not the letters I wrote from Rotterdam,' said the mariner. "'My brother never wrote,' rejoined the yeoman. "'We have for years believed him dead.' "'Try me with questions about the family and about the place,' said the other. "'Not I,' returned Stephen, "'you have got your story up well,' I daresay. "'This is not the sort of welcome I expected,' the mariner observed, as he rose and turned towards the door. "'But I daresay I shall find old mates in the village that will know me, and be glad to see me.' Stephen Max had changed colour again on hearing this remark, but he said, not a word, and the unwelcome visitor departed. "'He has gone towards Margate,' said the yeoman, gazing after him with an air of anxious thought. "'Is he Paul, think you?' inquired his wife. "'He can't be,' he replied. "'He is not a bit like Paul.' "'But what made you say Paul never wrote?' Jenny asked. "'What made me say that?' returned Stephen with a slight degree of confusion. "'Why, I wasn't going to give him a chance of producing a tolerable imitation of Paul's handwriting. Let him make out his claim the best way he can.' He made two or three turns across the room, corrugating his brows, and looking anxious and perplexed in spite of his strong expressions of disbelief of the mariner's claim. In truth, there was in his mind, no doubt whatever, that it was his brother from whom he had just parted so coldly after a separation of ten years, but he was unwilling to acknowledge the conviction to his wife, having long before determined that he would never willingly surrender to Paul the patrimony which circumstances had placed in his possession. "'This fellow must be looked after,' he observed, or he will make mischief. "'There is nothing very particular to be done today, so I think I'll ride over to Canterbury and see a lawyer about it.' So while the mariner walked towards Margate, gradually forgetting his disappointment under the influence of sunshine and his natural lightness of heart, Stephen Maxterd was riding towards the ancient city of Canterbury, pondering the possible means of ridding himself of this awkward claimant. "'Nothing easier, my good sir,' said the lawyer to whom he stated the case, rubbing his hands as he spoke, as if he thought the suggestion a good joke. If he is Paul Maxterd, there is a warrant out for him, and I would go bail he would be glad, if he saw it, in company with a constable staff, to prove that he is not Paul Maxterd, though after claiming to be your brother he might find that as difficult as proving that he is Paul Maxterd. Stephen Maxterd had thought of this while riding, and he was not sorry to have it suggested to him by a lawyer. It made it so much easier for him to satisfy his conscience as to the shortest way of dealing with the claimant. So he rode to the residence of the magistrate who, ten years before, had issued the warrant for his brother's apprehension, and gave information that a man claiming to be Paul Maxterd was in Margate. Mind, he was careful to say, I don't say that he is Paul Maxterd, I don't believe that he is, but he says he is, and if he isn't, why then your information is worth nothing, and if he is Paul Maxterd you will have hanged your brother, rejoined the magistrate, with a look of emphatic condemnation of the informer. But I don't believe he is Paul, said Stephen, colouring to the roots of his hair, and casting down his eyes. Then what have you come here for? the magistrate asked. I must do my duty, Master Stephen Maxterd, and that is to put a constable on the track of this man, but mark me, whether he is your brother or not, your name will stink in the nostrils of Kentish men as long as you live. Stephen Maxterd left the magistrate's presence, looking very red and very glum, and remounting his horse rode slowly home. He said nothing to his wife about his visit to the magistrate, limiting his communication of the result of his journey to Canterbury, to a statement that the lawyer's advice was that the mariner should be left to his own devices, as if he was not Paul Maxterd he was not likely to risk a halter for Paul Maxterd's crime. The mariner was, in the meantime, consoling himself for his reception by Stephen Maxterd, with a carouse at the six bells, with various old acquaintances of Paul Maxterd, who had flocked to the house on the rumour spreading through the village that the missing man had returned. Some had recognised him at sight, others, without doing so, shook his proffered hand heartily, and asked for no proof of his identity when assured by him that he was Paul Maxterd. But aren't it a bit risky, Paul? whispered Will Hogburn, the Wheelwright. What, after ten years? returned the mariner. I reckon that is pretty well blown over by this time, Will, and who is there that would inform against a neighbour for what he did in defence of his liberty. If there is one that would, Margate Manners must have changed while I have been across the herring pond. And so you have been sailing to the Indies with the Dutchman, said Sam Mockett, who kept a general store in the village, and had just run in to see whether it was really true that Paul Maxterd was at the six bells. I warrant you saw many things to be talked about in them outlandish parts. Is it true that the Emperor of Java has a palace covered with plates of gold? Before the mariner could answer the question, the village constable stepped into the room, staffed in hand, and approached the table at which he was sitting. I arrest you, Paul Maxterd, for the murder of Hugh Cleavering, said he. Here is the warrant, and I call upon all to aid and assist in the king's name. No one moved except the mariner, who cleared the table at a bound, overthrew the constable, and rushed for the door. There, stumbling at the threshold over a dog, he was detained by a wagoner, who did not know him, and who, thinking he looked like a foreigner, deemed that circumstance and his flight sufficient to warrant his detention. His endeavours to extricate himself caused the wagoner to hold him with a more determined grip, and the constable, having picked himself up, closed the handcuffs upon his wrists with a savage click. An hour afterwards, one of the fishermen of the village boarded a small Dutch vessel, which had come into harbour that morning, and asked to see the skipper's wife. A fair young woman, with a glory of golden hair waving about one of the loveliest faces the fisherman had ever seen, came from the cabin, and looked inquiringly upon his weather-beaten countenance. "'I wish somebody else had to tell it you,' said he, regarding her with an expression of compassion as he doffed his cap, but it had better be told you at once, and "'What is it? Has anything happened to my husband?' she asked, turning pale at the thought. "'He is well, my good lady,' returned the fisherman, but he has got into a bit of trouble along of a fray there was in the village ten years ago, when a king's officer was killed while pressing men for the navy, and it was sworn as to as Master Paul maxed his hand as struck the blow that killed him. "'Is he in prison?' the poor wife asked, pressing her hand upon her heart. "'Oh, take me to him!' "'Don't get stericky, there's a good lady,' said the fisherman. "'He has gone up to the justice's house to hear the charge, and it may be that they'll be able to make out nothing against him. But while we hope for the best, we must be prepared for the worst.' "'Where is he?' she asked, all the anguish of her mind finding expression in her lovely countenance. "'Take me to him, I must see him.'" Poor lass! murmured the fisherman, as she hurriedly attired herself for the shore, and came forth from the cabin, leading by the hand a beautiful girl of three or four years old. They had not advanced far along the village street when they were met by a brown-faced fisher-lad, who was hurrying towards the harbour with an expression upon his countenance that indicated the possession of news and a burning desire to impart it. "'What cheer, Master Kebel?' he cried, scarcely pausing, but turning round and walking backward, speaking as he went. "'Heard the news? Paul Max did his committed, and they say he'll be hung.'" "'Never, sure!' exclaimed Kebel, dilating his eyes widely. "'Harder, life! But there!  It may not be true, after all.' For a moment the mariner's lovely wife looked as if she would faint. But she leaned against a wall, and a mug of water brought by a fisherman's wife arrested the receding life. As she put back the golden tresses from her forehead her blue eyes discerned a well-known figure on the opposite side of the street. It was her husband, handcuffed, and in the custody of the Constable. In a moment she had bounded to his side and clasped him in her arms while the little girl clung weeping to her father's coat. At that moment the joyous clang of bells rang out from the old church tower, and the clatter of horses' feet upon the hard road, causing the Fisher children, who had gathered about the prisoner and his grief-stricken wife and child, to turn their gaze eastward. A cry was raised of, "'Here they come!' and the sorrowing group was immediately deserted for the new attraction. "'Huzzah!' shouted the villagers, running from their shops and their cottages and from the six bells, as a troupe of velvet-coated and sordid cavaliers trotted into the village. "'Huzzah!' for the king and the noble duke!' The king exclaimed the prisoner's wife, catching at the word as if it had been a reprieve from the scaffold. And then she rushed into the road, and throwing herself upon her knees in the dust, raised her clasped hands and tearful countenance, lovely even in grief, crying, "'Pardon, most gracious king, pardon!' "'For whom do you implore pardon, my good woman?' asked the king, who with his royal brother had just before landed at Bartholomew's gate, thenceforward to be known as the king's gate. "'For yonder good-looking rascal with the bracelets on his wrists, come hither, fellow!' "'Surely I have seen him before,' he added, as if speaking to himself, as the prisoner and the constable stepped into the road, the latter taking off both his own hat and the prisoner's. "'Of what is he accused?' "'He has just been committed, may it please your Majesty, on the charge of murdering Hugh Clavering, an officer of the fleet, ten years ago,' replied the constable. "'Ten years ago!' repeated the king, stroking his moustache with an air of thought, as he contemplated the sad yet bold face of the prisoner. "'What do you say to the charge, fellow?' "'It was a hasty blow, your Majesty, struck by a desperate man in defence of his liberty,' replied Paul Maxstead. "'Resisting the press, may it please your Majesty,' said the constable. "'Or to be hanged,' observed the Duke of York with a frown. "'How is the fleet to be manned?' "'The certificate, Paul,' cried the kneeling beauty, raising her blue eyes anxiously to her husband's countenance. "'Where is it?' "'In my breast pocket,' replied the prisoner, a ray of hope shining into his heart as he remembered it. In an instant she had sprung to his side, and took from his pocket a little leather case from which she drew a folded paper. "'Ah!' ejaculated the king, as he extended his hand for it. "'I thought I had seen him before.' The paper was in his own handwriting, and set forth that Paul Maxstead had on a certain day saved the life of Charles Stewart. "'The boon-new crave is granted, good woman,' said the king, returning the paper. "'By my faith a sweet face, James. "'The pardon shall be sent down as soon as I reach Whitehall.' "'A bird in the hand is worth two in the bush, your Majesty,' said Paul Maxstead. "'A bold fellow?' murmured Charles, glancing at him under his bushy brows, as ready with his tongue as with his cudgel. "'But I have a sad habit of forgetting things that I ought to remember, I must confess. "'Draw me up a pardon in as clerkly a form as you can,' he added, addressing one of his attendants, who instantly dismounted and disappeared within the doors of the six bells. "'Heaven, bless your Majesty,' cried the prisoner's wife, as with tearful eyes she leaned upon her husband's shoulder. "'You should have seen how the fellow laid about him,' said the king, turning to his royal brother. "'He saved my life, I verily believe, when I was sorely beset by the rufflers of Alsatia during a night frolic with Rochester and Sedley.' "'The pardon, being brought him for signature,' he scrawled Carolus Rex at the foot without leaving the saddle, gave it to Maxstead's wife, who availed herself of the opportunity to kiss his hand, and rode on amidst cries of, "'God bless your Majesty, as are for the king and the noble Duke.' The constable, being unable to read, would feign have taken his prisoner back to the residence of the magistrate by whom he had been committed. But the villagers insisted upon Maxstead's instant liberation, and he was awed by their vociferations and threats into unlocking the handcuffs and setting him free. They would then have carried him off to the six bells, but Paul, shaking hands with the nearest, hurried towards the harbour with his wife and child. Stephen Maxstead left the neighbourhood a few days afterwards, and took up his abode in an adjoining county under a change of name. Paul Maxstead abandoned his roving life on the ocean, renounced taverns and roistering companions, and lived quietly and happily during the remainder of his life on his patrimony, remitting to his brother on every quarter-day a sum of money sufficient for his support for the next three months, thus returning good for evil, though Stephen could never be brought to see the matter in that light. End of Chapter 13 Chapter 14 of In Kent with Charles Dickens This LibriVox recording is in the public domain. Recording by Ruth Golding In Kent with Charles Dickens by Thomas Frost Chapter 14 On the following morning, as soon as I had breakfasted, I started on a ramble westward, leaving the high road and following a footpath, or rather a track, worn by the feet of preceding ramblers, along the edge of the cliff. Arable land, across which the view was extremely limited, was on my left, and on the right, below the tall white cliff, stretched the sea, which, for a short time after I started, was shrouded in mist. Presently the fog lifted and quickly dispersed, the sun shone out upon land and sea, and beyond the broken masses of brown and green rock below me, over which the white-tipped waves were breaking, an illimitable expanse of water changed by imperceptible gradations from green to silver. Returning to the high road near the village of Birchington, I left it again by the lane which passes the railway station and terminates at a farmhouse at the western extremity of the village. From this point there is a footpath through the marshes between Cliff End and Reculver, and which extend inland as far as Starmouth. It is a narrow causeway between the green pastures, which stretch away on the left as far as the villages between Nicholas and Sarr, and the strip of waste which the seawall separates from the beach and protects from the encroachments of the waves. The yellow-flowering poppy of the coast and other plants which grow only in marshes bordering the sea may be found in this waste, in traversing which the rambler will probably meet only a brown-faced fisher-boy, and here only the bleating of sheep on the one hand and the horse murmur of the sea on the other. This part of the coast abounds with evidences of the physical changes which have been going on for ages and are still visibly in progress. The greater part of the parish of Reculver has been washed away. A yeoman whom I once met and conversed with while resting and refreshing myself with a glass of ale at the red lion at St. Peter's and whose patrimony is bounded northward by the edge of the cliff, assured me that his farm was several acres less in extent than when he inherited it. The church is a ruin perched on the edge of the clay cliff which extends from that point to Whitstable and has been saved from the fate which more than half a century ago overtook the greater part of the burial-ground only by the construction of the seawall by the corporation of the Trinity House, by whom also the two towers of the church on account of their utility to passing vessels as landmarks. Before the cliff was faced with stone human bones were frequently picked up on the beach and the broken ends of coffins might be seen protruding from the crumbling face of the cliff. The name of this place is derived from the military station called Regulbium which the Roman governors of the island established to guard the channel which in those days divided the Isle of Thanet from the mainland, but of which the only existing traces are two or three ditches through the marshes. The site was near the Coast Guard Station in which direction there appears to have been a considerable town, many vaults, cisterns and foundations of buildings having been discovered at various times by the falling of the cliff, together with large numbers of Roman and British coins, utensils and articles of pottery. Some of the old chroniclers state that a palace was built here by Ethelbut I, King of Kent, and this may have been the castle mentioned by later writers within the walls of which the church formerly stood and some shattered portions of which still remain on the eastern and southern sides overgrown with ivy and briny and half concealed in some part by elder trees. These fragments show the walls were twelve feet thick and built of flints, pebbles and septaria unmingled as at Richborough with Roman bricks. There are no traces of towers. Of the monastery which existed here in the Anglo-Saxon period and in the church of which the Kentish kings Ethelbut I and Ethelbut II are said to have been buried, the latter in 760, not a stone remains. To look for Roman remains here at the present day would be useless the sight of Regulbium having long been under water. Batterley, writing towards the end of the seventeenth century, says he remembered that, quote, when part of the cliff being undermined by the waves fell down some years ago, some brick foundations of great bulk were discovered, in which were some small vaults arched over. And while I was examining them with my hand I saw some fragments of a tessellated pavement and of other Roman works. But I only saw them for very soon after, either broken by the waves or swallowed by the sand, even these ruins were destroyed. End quote. Hastid says that, quote, from the present shore, as far as a place called the Black Rock seen at Low Watermark, have been found great quantities of tiles, bricks, fragments of walls, tessellated pavements and other marks of a ruinated town. And remains of household furniture, dress and equipage of the horses belonging to the inhabitants are continually met with among the sands, for after the fall of the cliffs the earthen part of them being washed away, these metaline substances remained behind. End quote. In the old church nothing now remains but the two towers, known for ages as the two sisters, and a portion of the walls. The former vicarage house, very near these remains, has been converted into a public house and is much frequented during the summer by visitors from Margate and Herne Bay. The present village and church are about a mile and a half distant in a south-westerly direction. The towers of the ancient church, which are conspicuous objects at a great distance, whether on land or sea, are often pointed out to each other by cockney voyagers as the reculvers, which is as absurd as it would be to designate the towers of Westminster Abbey as the Westminster's. The spot is even marked by this ridiculous appellation on Bacon's map of Kent. Their traditional name originated in the circumstances of their reparation by an abyss of the Benedictine convent at Davington near Favisham, as related by a Dominican friar of Canterbury who quitted England at the time of the Reformation and died at Louverne, bequeathing his manuscripts to the university of that city. According to this narrative, the abyss, France's St Clair, during a dangerous illness, vowed that in the event of her recovery she would visit the shrine of the Holy Virgin at Bradstow, as Broadstairs was then called, and their offer a costly present as a grateful acknowledgement of the saint's intercession in her behalf. Having recovered, she, in fulfilment of her vow, embarked aboard a small vessel, accompanied by her sister Isabel, to whom she was devotedly attached. But they had been scarcely two hours at sea when a storm arose which drove the vessel on a sand-bank near a culvert. The abyss, with some of the passengers and crew, succeeded in reaching the shore in a boat, and Isabel, who remained on board the disabled vessel for some hours after her sister, was, with the remainder of those on board, rescued from it by a boat sent off to their relief, but died on the following day from the effects of cold and exhaustion. In pious remembrance of the peril from which she had been delivered, and to perpetuate the memory of her sister, as well as to warn mariners from the dangerous proximity of the shoal, she caused the towers of the church, which had fallen into decay, to be repaired and raised higher, directing that they should thereafter be called the two sisters. Leaving the ancient churchyard, in which many moss-grown gravestones of considerable antiquity may be found, many of them so deeply sunk into the earth as to be overtopped by the tall nettles, I dined and rested at the neighbouring public house, called, if I remember rightly, the King Ethelbutt, which is probably unique among signs. I was the only guest that day. On a former visit, when I walked from Herne Bay on a Sunday afternoon in summer, the parlor was crowded with visitors and filled it with a blue haze of tobacco smoke. All bona fide travellers, as defined by the statute, for they had all come from London by rail or steamboat and walked from Herne Bay or Margate. The following day, being the last of my pilgrimage, I devoted to an inland stroll through the most pleasant spots of which Thanet can boast. Having followed the high road westward as far as Birchington, I there turned into a secluded lane on the left, which leads at a little distance to a footpath across the fields to the Hamlet of Acle, and thence to Mount Pleasant, the highest spot in the island, and in the midst of scenes made interesting by their historical and legendary associations. From the summit of this hill I looked over the most extensive prospect which the eye can command anywhere between the star and the sea. To the right, looking across the green pastures between St. Nicholas and Reculver, was the sea, its emerald waves glittering in the sunlight as if tipped with silver, and the towers of the ruined church of Reculver distinctly defined against the clear blue sky in the distance. Westward the delighted eye wanders over a wide tract of intermingled pasture, arable and woodland, pleasantly undulating, with the towers and spires of village churches rising among the distant woods, the white spire which surmounts the tower of Ash Church and serves as a landmark being especially conspicuous towards the south, and the venerable towers of Canterbury Cathedral backed by Harboldon and the woods beyond closing the view up the valley of the star. On the left is Pegwell Bay with the star meandering through the once-submerged flats and guiding the eye onward to where the towers of the sandwich churches rise against the bright blue sky and thence to the downs. The early history of our island seems to unfold itself before the mind's eye as we stand on this hill and look around. It was here, according to tradition, that the Kentish king Ethelbut I met the Roman monk Augustine and held the first conference on the prospect of converting to Christianity our pagan ancestors. Away to the right where the towers of the ancient church of Reculver cut the sky stood the palace or castle which was built by Ethelbut and the monastery to which he is said to have retired after his conversion. Close at hand are the low green ridge which marks the course taken by Dom Nifers-Dier and the chasm which engulfed the base assassin, Thunnell. To the left is sandwich where the galleys of Imperial Rome have anchored and whence fleets have so often sailed to prosecute the interminable Anglo-French wars of the Middle Ages. And then what memories crowd upon us as we look towards Canterbury or gaze southward upon the shipping in the Danes? The remarkable events embodied in the legend of Dom Nifers-Dier and Thunnell's Leap are said by Thorn, a native of Thanet and a monk of the monastery of St. Augustine at Canterbury to have occurred in the latter part of the seventh century. The manor of Thanet was held at that time by Egbert, king of Kent whose nephews, Ethelred and Ethelbright were left to his guardianship under a solemn promise that they should succeed him in the sovereignty. Thunnell, a base and sycophantic minister, advised Egbert to have these princes murdered lest they should disturb him in the possession of the throne which execrable deed he undertook to perform and actually perpetrate it. On the crime being discovered Egbert was advised by the Archbishop of Canterbury and the Abbot of St. Augustine's to make such atonement for it as would satisfy Dom Nifers-Dier the sister of the murdered princes who was a nun. The princess demanded of the king that he should give her as much land of his manor of Thanet as would build and endow a convent wherein she and her nuns might continually pray for his absolution in the repose of her brother's souls. Egbert granted her prayer and asked how much land she required when she replied as much as a deer could run over in one course. The king agreeing to this singular stipulation a stag was taken to Westgate and liberated on the beach in presence of all the court and a large concourse of people. Among the spectators was the assassin Thunnell who ridiculing the monarch for his lavish gift and the mode of determining the extent of land to be given sought every means of obstructing the course of the deer by crossing its path and encountering it until, says the monkish chronicler, quote, heaven in wrath at his impiety while Thunnell was in the height of his career caused the earth to open and engulf him, end quote. The deer, after making a small curve eastward, directed its course south-westward nearly in a straight line running over forty-eight plowed lands comprising about ten thousand acres of the best land in Kent. Egbert thereupon surrendered to his niece the tract which the animal had traversed and granted her a charter which concluded with a singular curse upon anyone who should infringe its provisions. With this land Domnevere endowed the abbey which she erected at Minster according to some accounts upon the spot where the church now stands though others represent the ancient and handsome mansion now known as the abbey as occupying the site of Domnevere's foundation. An embankment was raised across the island to mark the boundary of the land surrendered by the king and some traces of it are still discernible in a ridge near the prospect inn on the summit of Mount Pleasant. The spot where Thunnell is said to have been swallowed by the earth and which was long known as Thunnell's Leap is not far from the prospect and has very much the appearance of a long-abandoned chalk-pit. Its depth is considerable and the brink overhung with brambles. It is now called the Smuggler's Leap from a tradition that a famous free trader endeavouring to evade the pursuit of an active officer of the preventive service was precipitated with his horse into the hollow which is said to have been haunted ever since by the ghost of the pursuer who met with the fate which might have been anticipated but which the Smuggler seems to have escaped. The remarkable incidents of this story sensational enough for an Adelphi drama of the Flying Dutchman and Three-Fingered Jack period are said to have occurred in the early part of the last century. Antony Gill, an active and intrepid officer of the preventive service, had long been endeavouring to compass the apprehension of a Smuggler as bold and as active as himself but whose name has not been preserved. One night, when a cargo of spirits landed under the lee of the Reculver Cliffs and was on its way into the interior the convoy was intercepted by Gill and his men at the turn of the road leading to Hearn. The Smugglers fled in all directions but Gill, who had recognised by the moonlight the man whom he was so anxious to secure singled him out for pursuit resolving to continue the chase until he had run him down. Both were well mounted outside the chapter of accidents success was likely to attend the man who rode the best horse unless indeed the Smuggler could find a refuge to which he could not be tracked. Such a place there was at that time a cave near the hamlet of Manston about a mile northward from the road from Sandwich to Ramsgate and to gain this retreat the Smuggler directed all his endeavours galloping down Chislet Lane then turning off sharp to the left thundering over Sar Bridge and rousing the sleepers of Moncton and Minster. Too closely pressed by Gill to reach the cave he turned his horse's head northward and urged the reeking and panting animal towards Acle with what purpose can never be known probably he had no other than to out-ride his pertinacious pursuer. The closing incidents of that ride for life can only be surmised. Gill and his horse, both dead, were found next morning at the bottom of the old chalk pit near Acle. Beneath them was the crushed and lifeless form of the Smuggler's horse but the desperate rider was never seen afterwards. The manner of his escape must have been a terribly perplexing mystery unless, as seems very probable, the Thanate folks solved it by ascribing it to the agency of the devil. From Mount Pleasant I strolled on to the straggling village of Moncton pleasantly situated on the southern slope of the island. The little church which looks ancient but is in good substantial condition is built of flints and bricks some of the latter having the appearance of Roman. A very agreeable exception to the want of shade which characterises most of the roads in Thanate I believe the only other is a portion of the road between St. Lawrence and Pegwell and that is shaded on one side only is presented by the road from Moncton to Minster and thence to the junction with the road from Ramsgate to Sandwich near the Sportsman Inn where the cliffs subside into the shell-strewn flats which stretch away to the star. The latter portion of the road is shaded by trees on both sides and the road being narrow there branches meet overhead forming an arch of verdure very refreshing to the eye after a long walk in the glare of the sun. From the church at Moncton to the village of Minster is about two miles. The church at the latter place is ancient but the mixture of styles in the architecture seems to indicate partial reconstruction at different periods. The carved oak seats are undoubtedly antique and with the handsome roof give a good appearance to the interior. After refreshing myself with a glass of ale at the bell I strolled down the shaded road before mentioned and looked once more upon the shining waters of Pegwell Bay from the pleasant garden of the Bellevue Hotel. There I dined that day and there on that bright September afternoon I saw the shallow waters of the bay dotted with shrimpers with their hand nets and baskets pursuing the staple industry of the village. Pegwell is the chief seat of the potted shrimps trade many men and boys being employed in the capture of the tiny crustaceans and a considerable number of hands chiefly women and girls in preparing and potting them. Early in the evening I strolled back to Minster and in a few minutes was seated in the train which was to bear me back to London. In concluding this record of a delightful ramble I have only to recommend those in quest of a week's recreation to go over the same ground in the same manner and the admirers of the works of Charles Dickens in particular to at least visit Cobham and Strewd and Rochester and Canterbury with the most portable addition of those works of the great novelist which have associated those places with his genius. May they enjoy the ramble as much as I did. End of Chapter 14 and end of In Kent with Charles Dickens by Thomas Frost Recording by Ruth Golding


All right, so we're gonna get started over here. Hi everyone, my name is Tony, I'm a third year OpFM resident and I will be introducing our students today who will be presenting. First up, we have Vivian Han and fun fact about her is that she trained with the Olympic ping-pong team in elementary school, yes. And she'll be presenting today first, go ahead. Thank you, Tony, for the introduction. Good morning, everyone. I'm so grateful for the opportunity to be here. And this morning, I will talk about adjustment pains, specifically, explanation of a light adjustable lens. This is how our Manless Warner Lab is set up and I wanna first take a moment to thank Dr. Warner and Dr. Manless for their incredible support and mentorship throughout our past five months here. And also a huge shout out to Mary who's been a lifesaver in the lab. These are the grants that support the analyses of Explanted IOLs in her lab. As you know, we have a problem which is refractive surprise after cataract surgery. This is the third most common reason for explanting an IOL and the possible causes are interpatient differences in wound healing, postoperative shift of the lens and prior refractive surgery. Unfortunately, in eyes with previous refractive surgery, the best formulas reach within a half diopter of the target only 69 to 79% of the time. And the incidence of refractive surprise is only increasing with time as more patients who've had refractive surgery grow older. The technology of LALs has great potential for addressing refractive surprise. The RX site light adjustable lens is the first and only FDA approved LAL back in 2017. And FDA study of 600 subjects showed that eyes with LALs were twice as likely to attain 2020 uncorrected vision as compared to those with standard monofocal IOLs. And this is the light delivery device called LVD. It's a modified slit lamp that provides noninvasive UV treatment to adjust the LAL. And each adjustment consumes 10 to 20% of the macromers and can provide up to two diopters of correction. And these studies to test the safety of the LAL were done in our lab. And you can see Dr. Werner here treating a stuffed animal. And this video demonstrates how the LAL is adjusted and locked in. If I can play it, can you go back? Okay, it froze, we're good. It is based on photochemistry and diffusion of the silicone photoreactive macromers distributed throughout the LAL. And when UV light is directed to a specific area of the lens, the macromers in the path of the light polymerize. And then each treatment takes about 90 seconds and can last up to two minutes. After polymerization, the remaining unreacted macromers diffuse over the next 12 to 18 hours into the space. And that causes a change in the shape and refractive power of the lens. And so the light treatments can add or subtract sphere and sill. And then further treatments can be performed as long as there are untreated macromers left. And then when the adjustments are to the satisfaction of the patient and doctor, the entire lens is treated with higher intensity UV to lock the rest of the macromers in place, which you see right here. And it's mandatory for the patients to wear UV glasses from surgery up until after 24 hours after lock-in to prevent uncontrolled polymerization. Recently, an explanted LAL was sent to our lab for analyses, which we will delve into today. The patient was a 61-year-old man with no prior ocular history, including no refractive surgery. He presented to an outside ophthalmologist with increasingly blurrier vision in both eyes. His ophthalmic exam was normal, aside from 2050 uncorrected distance vision. He batted to 2050 minus one in both eyes and he had a two-plus NS in each eye. They planned for cataract extraction and LAL implantation in each eye one day apart, and both surgeries were uneventful. This was the examination on post-op day two for the right eye and post-op day one for the left eye. Litlampic exam was remarkable for three to four plus stromal edema in both eyes, three plus defaults in the right eye and one plus in the left. Both eyes also had two-plus cell. The next day, the patient reported that his vision in the right eye decreased in surgery and that he could only make out light at this point. Of note, his vision in the right eye went from 2,300 from the previous day to unable to be tested. And his litlampic exam was the same as the previous day and he was started on combination drops. At post-op week one, he reported distorted vision and photophobia in that right eye. His visual acuity was hand motion and the corneal edema NEC cell had not improved since the first post-op exam in the right eye. Meanwhile, his left eye was healing nicely and at this appointment, the blurry vision in the right eye was attributed to the persisting corneal edema and then he was continued on the combination drops. Unfortunately, at post-op week two, he presented with right eye pain. Examination of this eye revealed that IOP was 28 at this point and the cornea exam had slightly improved from the edema and defaults but now he had microcystic edema. His right pupil was also dilated and this clinical picture was attributed to a congested or narrow trabecular mesh work due to the corneal edema and then the pain was attributed to the elevated IOP. He was given 500 milligrams of acetazolamide at this appointment and serial eye drops of Cymbronza and Timbalol. And then at the end of this appointment, his IOP was 11 and he reported that the pain had ceased. And then the patient was given Cymbronza to take home and then he was referred to Dr. Mifflin for a DSEC. Dr. Mifflin saw him around post-op month one and the patient reported only light perception in the mornings at this point with improvement throughout the day to be able to make out shapes in the evening. The slit lamp exam showed worsened corneal edema as well as diffuse endopigment and then the pupil was tonic and dilated to six millimeters. So the exact ideology of this significant corneal edema and this patient was not clear. However, whenever we see acute early inflammation and persistent corneal edema, especially without surgical complications, we highly suspect toxic anterior segment syndrome or TAS. And it was presumed in this patient's case to be TAS as there were no other likely etiologies. Dr. Mifflin performed a DSEC with iris synechialysis and the histopathology of the specimen revealed pseudophagic boluscaretopathy as expected. Unfortunately, at post-op month six, the patient was dissatisfied with the vision and his best corrected vision was 2060. The optometrist went ahead and attempted the first light adjustment, targeted at Plano, but noted that there was poor dilation. As you can see, a week later, the refraction didn't improve much and testing revealed a large, just noticeable difference in refraction of 1.25 diopters. And then they noticed that the patient adherence with the protective glasses were questionable. So given this uncontrollable adjustment, the patient was referred back to Dr. Mifflin for IOL exclamation exchange. Dr. Mifflin had heard that Dr. Manlis described difficulty in exclanting LALs, so he decided to extend the DSEC wound to remove it in one piece. And he noticed intraoperative zonulurgia hitzens, so he implanted the new lens in the sulcus. Pupil's reclage was performed to create a 4.5 millimeter pupil. And then after the IOL exchange, the patient healed well. At the most recent examination, which was seven months after IOL exchange, the patient still had blurry vision with glare, irregular astigmatism, and irregular pupil. And he was referred for a colored contact lens to address the refractive error and to provide light blocking and improved cosmesis. Incidentally, the patient's left eye, light adjustments and lock-in were successful with satisfactory visual outcomes. Once the LAL was submitted to our lab, we and Dr. Ruth Saylor performed a series of analyses. Gross examination showed that the anterior surface had greater convexity at the blue arrow and concavity at the green arrow. And there are subtle distortions on the posterior surface as well. And then the microscopic examination showed a distinct round bump, approximately four millimeters in diameter. And you can see that it's de-centered towards the right highlighted by the white arrows. And the surface deposits just correspond to dried OVD and DSS. The scanning electron microscope confirmed the de-centration, showing the elevated position is more towards the right. And then light transmittance curves from mass spec show that the transmittance curve shape of the x-planted LAL, which is on the right, matches that of a normal LAL on the left. OCT evaluation showed that the shapes of both the anterior and posterior surfaces were very distorted. The anterior surface had greater convexity and greater concavity in different areas. And the posterior surface was convex and very irregular. This is the Air Force target image. And the right image shows the target image obtained through the x-planted LAL. As you can clearly see, the focus and contrast is significantly decreased. These are the results from Nemo testing, which is away from analyzer and maps the power of the IOL. The top left clearly shows that the changes in power are badly centered and shifted towards the right. And then the bottom right graph, you can see there's tremendous irregularity in the radial power of the IOL. So let's talk about x-planted LALs. There has only been one reported case of an x-planted IOL in the literature and it was in the left eye of a 57-year-old female. Her preoperative best corrective vision was 2025 and her exam was normal, except for cataracts in both eyes. Surgery was uneventful. Post-op day one and week one were normal. At post-op week two, the patient reported decreased vision in halos and her best corrective vision was 2040 at this point. And then the first UV adjustment was performed. However, at post-op week three, the best corrective vision decreased to 2125. The slit lamp exam showed distinct paracentral elevation in the LAL, which you can see in the photos. And they somewhat correspond to the decentration in our case. The patient at this point admitted that she had not been using the UV glasses routinely. And they ended up performing an IOL exchange, which resulted in a best corrective vision of 2025 and the patient was very happy with that outcome. Overall, this case emphasizes the importance of patient adherence to wearing the UV protective glasses. So LALs perhaps should be avoided in certain conditions because the macromers may polymerize in an uncontrolled manner. So as advised in the prior report, as well as by the company recommendations, patient adherence to the UV glasses are very important. Since our patient had uneventful light adjustments and lock-in in the left eye, it's likely that this wasn't the sole culprit in the right eye. And additionally, our patient had a mid-dilated pupil and the optometrist reported inadequate dilation before the light adjustment. So that might have promoted issues with the light adjustment. And then our patient also underwent a desec and as we know, different surgical microscopes have varying degrees of UV exposure. Our patient also had significant corneal edema, which precluded the first light adjustment and because of the easy view. And so, however, even once he got the desec and had a clear cornea, we know that corneas that have had a corneal transplant may influence and distort the light adjustment. And of course, if a patient can't hold steady for two minutes at the slit lamp, an LAL would not be appropriate. So although the exact reason for the LAL distortion in our case is not clear cut, it's most likely due to a combination of these first four factors. This photo shows how incredibly easy it is to explant an LAL. And this was from another patient and it was explanted by Dr. Manlis, who will gladly tell you how fun this was. Even with the lightest pressure, forceps would break off little pieces of the LAL whenever you tried to hold it because it's so hard and brittle. And then this was the LAL that Dr. Manlis explanted in the other eye and he switched to using a mini scleral corneal frown incision to remove the LAL in one piece. And the technique had less risk of astigmatism and also didn't require sutures. And Dr. Nicole Fram, who's worked a lot with LALs, described that while the LALs after light adjustment are hard and brittle, before adjustment they're soft and gummy. So anyone preparing to explant an LAL should be aware of these nuances. And Dr. Fram developed a new technique to remove these brittle LALs and she will publish them soon and is allowing me to present them here today. She creates a 3.5 millimeter wound because the lens is made of silicone and is very thick and may be difficult to remove from a sub-3 millimeter incision. As you can see, she injects plenty of OVD and then she dials the LAL to be perpendicular to the main wound, which is right here. And then she goes in with serrated scissors and she does in bisection in one cut and then uses a since the hook to provide counter traction. Then she dials at 180 to finish the bisection. And then she actually removes each piece using these serrated scissors. And this way, the LAL is very unlikely to break into pieces. From our patient, we know that unfortunately in complicated cases, the LAL adjustments can't be controlled well and may need to be explanted. There are quite a few explanation options that we've seen. So if we want to remove the IOL hole, we can do a 6.5 millimeter clear corneal incision like Dr. Miflindid or a scleral corneal frown incision like Dr. Mimilis. And then Dr. Fram's technique provides a smaller 3.5 millimeter incision, but requires bisecting the IOL. And RX site has recently improved the technology with the active shield UV layer. And it protects the LAL from unwanted UV exposure, which would help in some of these cases. And then Dr. Fram says that with this new technology, she's noticed that the LAL is less brittle after adjustments and that explanation has also been there. And this is just one adjustable lens on the market and there are several others coming down the pike as Dr. Mimilis alluded to on Translational Research Day. I want to acknowledge and thank each of these individuals and their expertise and hard work have made all of this possible. Are there any questions from the audience? Yes, Dr. Mimilis. And as tasks, you know, there's limits to limits to be in the first day. There's a dilated fixed pupil that doesn't do well. There's a ventral glaucoma later on as the information settles down. But I think the critical points you made are that if you're going to adjust the LAL have to have ideal conditions, you have to have clear media. And so do not try to adjust these to an edematous cornea, cornea that's had a de-sec, anything that's going to disturb the light coming through. Secondly, you need a dilated pupil. And you can see the de-centration of the treatment. You saw how irregular that treatment is. And so it's really clear in the company directions, don't do this in this setting. And so this should not have been done at all. But beyond that, once you go ahead to try to take these out, my first try at this, it's just brittle and it fractured into a dozen pieces. So I ended up taking out whole, which is fine. I think Dr. Fram's technique is ingenious with the serrated scissors because you just can't grab these things without them breaking off. And then you can't slide a normal scissors across because it just slides away. So I think the serrated scissors are ingenious in a way to bring this out, but we don't have those. And if you don't have them, a simple brown incision, which is the way we did cataract surgery in 1988, it's six millimeter, it's a little corneal splaral, mini corneal splaral frown, no stitches, no stigmatism. And so that's a nice way to get these out safely once you have to remove them. So is it clear for you what is the active shoe? And is it clear if the patient is going to have to change the wear of the protective eyeglasses before looking? What exactly is that? What the active shield is, is they put some, normally the way the lens was set up, the UV blocker is along a posterior surface because it really is a UV laser that induces the cross-linking. And so they didn't want us to disturb that. But when it was clear that some people were not wearing their UV blocking glasses at the time of lock in, they put a little layer of some small UV block in the anterior part of the polymer that will make it such that if they're not wearing their UV blocking glasses, the effect will not be as much. But they still have to wear it. Well, they stopped to wear it, it's just the effect is not as pronounced. All right, just one more thing, the Redmond stand-up lens for decades trying to get rid of the silicone lenses. This is back, I've already had one referred to me from the Montana or silicone one over here. Which I could not do, I would destroy the lens. And so if they have reds and polygons, they also fog, I don't know if they're as bad as other silicone lenses, but they fog when we're doing redness or something like that. So we need to silicone them. Dr. Mifflin just had a comment. Dr. Mifflin says, I am watching remotely and my microphone does not work on the chair mat. I'm 100% certain that the patient from this case who did not use the blocking glasses and had significant line exposure between the original surgery and the attempted adjustment. The lens was very bulky and difficult to remove from the capsule. I've removed one or two others earlier in the course of treatment and those two came out easier, but I elected to take them out both and block from a limo incision, cutting the lens in half similar to the office. Thank you so much Vivian for a great presentation. Also, thanks everyone for our similar session. To next up, we have Norma Doji. Just like Vivian, she's also a Pat fellow here this year and her fun fact is that she is an aspiring professional skydiver who's skydived in three out of seven continents and a couple of them in Dubai. So, welcome Norma Doji. Thank you, Johnny, for the kind introduction and good morning everyone for the opportunity to be here. This morning, I'll be presenting on a case that was sent just by Dr. Morgan Michaletti over at the Berkley Eye Institute in Houston, Texas. And so here are our financial disclosures and I just should know as Vivian did that these grants to support you now he would hide well in the cloud. And as Vivian just showed, this is an overview of what our Mamos Warner live structure looks like. Here at the Marin Eye Center and I also want to take a moment to thank Dr. Mamos and Warner for their tremendous mentorship and support. I honestly feel really incredibly lucky to be here. So, thank you so much for everything you've done for me so far. So, let's begin with our case presentation. We have, the chief complaint was, I'm not seeing well in my right eye. This was a 69 year old pseudo-fake Southeast Asian male with a history of technist, multifocal Iowa placement in the right eye about eight years ago in Vietnam who's presenting with symptoms of glare and changes in vision developing over several years. His past medical history was significant for type two diabetes for which he takes metformin for. His past surgical history, significant for cataract surgery in both eyes. As I mentioned, the right eye has a technist, multifocal IOL and the left eye has a monofocal posterior chamber IOL. He denies any significant family history and his social history is significant for tobacco use and is a retired jeweler. His, as far as his examination is visual acuity uncorrected is 2,200. In the right eye and then 2020 in the left his brushes are 15 in both eyes. Manifest refraction in the right eye showed a one diopter hyperopics sphere with a slight cylinder and then in the left eye, Plano with a slight cylinder as well. People's around and reactive in both eyes and there was no afferent people are defect and the exam was otherwise normal. On select examination in the right eye it was notable for brownish haze throughout the technist IOL as well as a nasally de-centered IOL. And then the left eye Dr. Micheletti noticed one plus PCO in a centered IOL. And so here's a video of the Sillimp examination. And so throughout the video you kind of can see this brownish haze throughout the optic. Some capsular like fibrosis of the capsular rexus excuse me and you see those mono or multifocal rings in the IOL as well. But that haze is very appreciable throughout the exam. As far as the posterior segment it was unremarkable and there were no signs of diabetic retinopathy. And so in summary, this patient is presenting with decreased vision and glare in the right eye. Eight years after implantation of a now nasally de-centered IOL with a whitish brown haze throughout. And so operative management was scheduled for an IOL exchange with a three piece IOL placed into the sulcus and Dr. Micheletti used the modified twist and out technique, which he actually published recently in JCRS and I'll be showing a video of that shortly. And so here's a video on a different patient that where Dr. Micheletti used this modified twist and out technique. I'll allow him to present it since it's published and then I'll make some comments at the end. Necessary, but so I think this slide on the patient and use of both hands of course that's vibrate both and you click on the page and it will develop that out in a secondary capsule like you got once a cat is created. I think only dispersive OEM and re-inclined the bag, I attack the habits from each side except in all of them, I need to have a collusion of facile. Once the habits are free, I need to set up the IOL out of the bag. Next, I specialize what happens when I'm in a position to IOL because not normally specialties realize that we all can. Protecting the helium and provide certain control of the IOL is a big amount of information. I took it 25 days from the month they said across the surgery for one site or another, which replaced me for the spatula and for you all. Now both hands can use with the forceps and more versus IOL free time. This says some of our patients fill out the wider top stop it as it replaces the large offer one new location with a two new technique. Yeah, so in addition to the other utilities he mentions about this technique, it also allows for ex-plantation of an IOL in one piece, which is optimal for laboratory analysis and worked out really well for the rest of this case. And so on post-up day one, the patient had a visual acuity of 2100 in the right eye with pressures within the same range that he had before presentation. And then on silt lamp, there was one plus corneal edema with a center three-piece IOL. Post-up week one, there was slightly improved vision at 2060 in the right eye with pressures the same and then improved corneal edema on silt lamp. And so we received the IOL dry in our lab in a plastic container and we were able to do a number of analyses. The first analysis was actually a light microscopy in the dry state of the IOL. And as you can tell, there are really no changes in the overall clarity of the IOL. It's completely clear, no pacification, no discoloration. This large blob you see is just dried OBD, so do not be alarmed. And then this mark over here is actually sustained secondary to maneuvering the IOL during ex-plantation with forceps. But overall, as I mentioned, no pacification, no discoloration and no changes in the clarity of the optic. We then placed the IOL in an immersion of distilled water at body temperature for 24 hours. And now we're able to see in the hydrated state, the IOL has a completely different appearance compared to the dried state. You see this brownish haze throughout the entire IOL extending all the way to the optics, I mean the haptics. And this was only present in the hydrated state compared to the dry state. While the IOL was in the hydrated state, we also did a shine flu photography to assess for backlight scattering. And as you can see, within the bulk of the optic, there is diffuse light scatter suggesting influx of water into the lens which is not supposed to be happening. We also did OCT in the ex meridian of the ex-planted IOL, although you're not able to appreciate as significant of a change as the shine flu photography showing there are some changes within the density of the optic. Next, we looked at light transmittance using spectrophotometry. And in the ex-planted IOL, the only noticeable difference was a progressive decrease, change in the light transmittance at about 500 nanometers. And unfortunately, we did not have a control lens of the same model and diopter to compare it to. However, we did compare it to the directions for use provided by the manufacturer for this model of a lens. And I'm gonna direct your attention to curve number two. And as you can see, although there doesn't have to, there doesn't appear to be a decrease in present transmittance at 500 nanometers compared to our ex-planted IOL, the UV values, which is this downward slope over here are the same in both lenses. We also did a modulation transfer function testing by the help of Dr. Saller, where when compared to our ex-planted lab to the DFU at both near and far distances of various people sizes, we see that there's overall no differences between the two curves. And then next, we looked at US Air Force targets of the ex-planted IOL. And as you can see, compared to what the photo the Vivian showed, both the distorted and the normal image, ours looks just slightly decreased in the contrast. And so for our discussion, I'm just gonna have you guys remember Dr. Werner's presentation last month during translational research day where she walked us through all the different things we've been able to learn from analyzing ex-planted IOLs. And so I'll be referencing various aspects of her presentation, as well as the literature to help guide us through what may have happened in this present case. And so first let's talk about optical clarity changes in hydrophobic acrylic IOLs. One of the things that we can see is during piggyback implantation, enteral and ticular opacification can develop. However, the opacitation that is occurring in this situation is actually centered in the between the two lenses as a substance or material between both lenses. And this substance actually comprises something very similar to what we see in PCO. Here's an image taken six weeks after two rabbit eyes were implanted with piggyback aqueous off implantation. And where you look at the black arrows over here, it's a beginning formation of this inter lenticular opacification. So it's developing between the lenses. I should note that rabbits are much more robust in developing cortical material compared to humans. But nonetheless, we do see this phenomenon when humans are implanted with two hydrophobic acrylic IOLs during piggyback implantation. Another phenomenon we can see is glistenings. I'll go into slightly more detail in the next slide, but I do want to show you what glistenings look like under sit-lamp examination seen here in the left image. And you're able to see these focal points of glistenings throughout the optic. And that's also appreciated over here on the right, which is a gross exam of a hydrophobic acrylic IOL that is demonstrating glistenings. We also can see surface light scattering, secondary to subsurface nanoglistenings. And these are best appreciated under Shine Fluid Photography where we're able to see changes in the anterior and posterior aspect of the IOL as these subsurface nanoglistenings are just concentrated within the surface and not in the optic-like glistenings. And so just briefly, glistenings essentially are fluid-filled micro-vacuoles within the IOL optic and they're usually present in an aqueous environment. They're about one to 20 microns large and they're seeing the hydrophobic acrylic IOLs as well as IOLs of different materials. And here are some sit-lamp examination photos of IOLs exhibiting glistenings. Here's a schematic just comparing the differences between the mechanism of formation of subsurface nanoglistenings compared to glistenings. And as you can clearly see, subsurface nanoglistenings are just within the optic as we saw in the Shine Fluid image here on the left. And then glistenings are contained within the optic itself. And overall, I do wanna note that none of these phenomena described so far can describe what is occurring in our present case. And this slide here will show that quite nicely. So on the left, we have a control lens with the Shine Fluid photography done with no subsurface nanoglistenings. Over here is a lens with subsurface nanoglistenings with its corresponding Shine Fluid photography demonstrating just the densities within the anterior and posterior aspect of the optic compared to our lens where we see this bulk scatter within the bulk of the optic demonstrating there is some hydration phenomenon occurring in our present lens that is not typical of subsurface nanoglistenings glistenings or any of their phenomenons I mentioned right now. However, when you do light transmittance and either subsurface nanoglistenings or in our present case, there is grossly no overt changes in the light transmittance of these lenses. On the other hand, we have optical clarity changes that are only seen in silicone eyewalls or so has been reported so far. And these changes can include surface deposition, secondary to calcium or silicone oil. We can also see opacification as a result of influx of water and Dr. Werner actually highlighted a series of silicone lenses that demonstrated this opacification about seven hours after implantation would be silicone eyewalls. And here's a slit lamp image of what was seen and then here are the light microscopy photos of these eyewalls. And they actually look quite similar to what was seen in our case where you see this diffuse brown discoloration throughout the lens both on slit lamp and light microscopy. And in this scenario, this discoloration was found to be secondary to contamination from exogenous molecules found from fumigants that were used in the storage facility that the silicone eyewalls were in. A similar phenomenon of brown discoloration was seen in early silicone lenses in 1991 published by Malouskas where they were found to be related to a manufacturing process. Interestingly, Wong et al actually reported a series of 16 eyes with brown discoloration of the hydrophobic eyewalls two of which actually were the same exact style as our lens, a Zimbu lens and the rest were still from the same manufacturer. And overall these presented one to 327 days after implantation. So quite different compared to what was seen in the silicone eyewalls I just showed. And the discoloration actually could not be attributed to any clinical cause and none of the eyewalls required explantation. They did do lengthotomy Q testing and although it was abnormal of the patients, none of the patients reported any changes in color perception. And so what happened in the present case that we just discussed to lead to the observed reaction? So considering the lens has a diffractive optic and was de-centered, it is difficult to establish any clinical significance of the discoloration. It is possible that the discoloration is related to light scattering due to water vapor diffusing throughout the lens. So the lens is exhibiting this hydration phenomenon since the brown discoloration only occurred in the hydrated state. And this could be secondary to manufacturing process. So while our current analyses do not allow us to establish the exact etiology of the discolorations, surgeons should be made aware of this possible finding with the ZmBu lens, design and carefully assess signs and symptoms before deciding on explantation. Interestingly, actually right before AIO we did receive this image provided by Dr. Wolsey of a symphony lens. So by the same manufacturer with this central localized discoloration of the IOL observed on Siltlamp examination, although it was not clinically significant for this patient, Dr. Wolsey did decide to explant the lens and she actually sent it to us shortly before AIO. So we haven't done any analyses yet. So don't wanna keep you guys on your toes but I will let you know what we ended up finding. I also wanna take a moment to acknowledge everyone that helped out with this presentation would have been possible without any of you. So thank you so much. Thank you for your time and I open the floor for questions. J&J, now that you may see this aspect but you cannot panic before really checking if it's clinically significant that it's very clinically feasible and there are cases already reported and this one we put in allies because the lens had to be explained because of other problems like especially the de-centration but it's very feasible. But before you decide for explantation check carefully about the clinical significance. Thank you so much for your time. All right, thank you, Nora. Thank you everyone else. And last but not least we have Brian Simon who is a research fellow at Dr. Tien's lab here at Moran Eye Center. All right, so my name is Brian Simon. I did med school at Loyola in Chicago and I'm doing research here with Dr. Tien on the fifth floor, studying retinal ganglion cells. Today I'm gonna talk about a project I did in med school. It's about trends in temporal artery ultrasound and biopsy at a tertiary care center. I have no disclosures. These are my objectives for my talk and I'm gonna start with a case. So this patient presented to the VA emergency room. He was an 80 year old male veteran with the past medical history of hypertension, systolic heart failure, AFib, diabetes, mitral regurgitation, right subdural hematoma in 2020, migraines and tension headaches. And he presented to the ED with four days of sharp left temporal area, 10 out of 10 headaches that felt like the worst headache of his life. He also described them as different from his past headaches. They gradually increased in intensity over several hours and then wax and wane. They radiated to the bifrontal region and over to the right frontal temporal region. They improved some with Tylenol but did improve with sleep, massage or gabapentin baclofen that his primary care provider had given him a few days prior. So he also had associated jaw pain and soreness with chewing. He had soreness with raising his shoulders, fatigue and felt off in the past week. He didn't have any weakness, weight change, light sensitivity, emesis, diplopia, dysarthria, numbness, tingling or gait disturbances. His ocular history, he was followed for a history of diabetes. He had bilateral PVDs and cataracts bilaterally. He wasn't taking any ocular meds and had never had eye surgery or a history of trauma. He was seen actually a few days prior to presenting at the ED at one of our satellite VA clinics just for a four year follow-up. At that exam, his acuity was 20, 30 on the right, 20, 25 on the left, pressures were 10 and 10. He had no APDs. He just had a single blot hemorrhage in the inferior temporal periphery on the left. And so the plan was just to follow up on the diabetes with a dilated exam in one year and presented to the senior resident clinic for the cataracts. So back in the ED, the patient's vitals were unremarkable other than some tachycardia. And his exam was also unremarkable. He had some cervical perispinal muscle tenderness, but his neural exam was otherwise completely normal, cranial nerves intact. They didn't dilate him, but his fundoscopy had no papillodema. His ocular motility was full. They got a CT of his head that showed no acute hemorrhage. And then the labs were grossly normal other than an ESR that was normal high range and a CRP was also normal. So at this point, the differential was still kind of broad given his history of the headaches. We included the migraines and tension headaches, but also he had that stroke in the past. So there could be some other intracranial process going on. Other systemic things could be rheumatoid, lupus, malignancy, systemic infection. He had that jaw pain. So you have to include dental disease. And then of course, vasculitis such as giant cell arthritis. So neurology was consulted. They recommended a migraine cocktail, continuing his home migraine prophylaxis. And they thought it was likely a tension type headache, but they wanted to consider giant cell arthritis and they can consult the rheumatology. He was admitted to neurology and his repeat ESR was elevated to the borderline for his age, which was 40 for an 80 year old man. Rheumatology then thought it was likely GCA with polymallid rheumatica symptoms. And they started him on IV, cellumendrol and they ordered the temporal artery ultrasound. So I'll talk a bit about temporal arthritis. It's the most common primary systemic vasculitis in adults affects medium to large vessels, median age at presentation is 75 years. It's more common in females and white northern European patients. There's a possible genetic predisposition, but there could also be an infectious or endogenous trigger such as calcification in the arteries. And it involves both a systemic inflammatory reaction and a local antigen specific immune response. So the pathology involves inflammatory cell recruitment to the vessel wall, which destroys and remodels the intima. There's hyperplasia and then progressive occlusion of the vessel lumen. And that's what causes the ischemic symptoms of giants of arthritis. On gross pathology, you'll see nodular granulomidus inflammation with the characteristic skip lesions and then on microscopic, you'll see a cellular infiltrate that extends transmurally and possibly multinucleated giant cells. Most common vessels affected are superficial temporal artery, ophthalmic artery, posterior ciliary arteries and the vertebral arteries. So this is just an example of the microscopic path with pointing out a multinucleated giant cell and you can see the vessel lumen is being occluded or being decreased in size. And then here's an example of palpable palpable temporal artery that was very prominent on physical exam. So the ocular manifestations of this disease are usually acute unilateral visual loss. That's secondary to most commonly the arteritic anterior ischemic optic neuropathy. So that is from ischemia from the short posterior ciliary arteries, also commonly seen as central retinal artery occlusion. But it's important to note that GCA can affect anywhere along the optic pathway. So many patients present with again, acute unilateral visual loss. They could also have dythlopia or eye pain, ptosis and anisechorrhea. And then systemically, they could have temporal headache in up to 90% of cases. They might have scalp tenderness. They could have constitutional symptoms, jaw tongue, jaw and tongue claudication, proximal muscle myelogias and then symptoms of PMR, which our patient had in our case. On exam, you might see a tender or pulseless temporal artery. The ocular exam, you could have visual acuity of 2200 or worse, or APDs, dythlopia, and again, cranial neuropathies or other ischemic changes along the optic pathway. In labs, you'll see elevated ESR, CRP or thrombocytosis. So this is diagnosed in a clinical setting. The criteria include five main points and age over 50 years, localized pain in the head, a temporal artery abnormality, ESR greater than 50 and an abnormal biopsy. So as you all know, the gold standard for diagnosis is the temporal artery biopsy, but the negative biopsy doesn't rule out the diagnosis and we often see false negatives. There's been many different imaging modalities tested in giant cell arthritis, including FAC, CT, MRI, PET CT, but in 1997, they first proposed using color duplex sonography to help diagnose GCA. It's proposed to be more safe and well tolerated than a biopsy. It's obviously a quick exam, not as costly as taking a patient back to the OR. You can repeat the exam if you wanna take another look at something. And then I think the most important one is you can examine the full length of the vessel and possibly avoid the problem of the skip lesions. So a quick review of the anatomy. The temporal artery rises from the external carotid and the main branches you're looking at in the disease are the parietal and frontal branches. The technique for a temporal artery ultrasound, you start at the level of the tragus with the ultrasound probe and you can sweep the entire length of the vessel in the transverse or longitudinal plane. Then you flip the probe 90 degrees and scan it in the other plane. On a normal ultrasound, you'll see pulsating and compressible artery. The lumen should be anechoic and the surrounding tissue should be mid to hyperechoic. That's an example of a normal ultrasound. Abnormal findings would be a halo, which is hypoechoic tissue surrounding the vessel lumen and a compression sign, which is an artery that doesn't compress with depression of the probe. You can also see stenosis or full occlusion of the vessel. So that's an example of a halo sign. You can see the hypoechoic tissue surrounding the vessel lumen and the lumen getting compressed. This is an example of a normal compression sign on the top with the vessel disappearing upon compression. And then with the halo sign on the bottom, with the wall swelling, the vessel does not disappear on compression. So back to our case, patient got ultrasound the next day. This is right temporal artery in the transverse view. You can see clear intimal swelling and this is a view with the Doppler flow. So you can see there's still some flow. It's not completely occluded, but there's clear intimal swelling. This is the same vessel in the longitudinal view and this is the artery upon compression. So the compression sign was positive as well. So this patient was on the IV steroids. They had improvement of their headache, jaw pain and scalp tenderness. Their transition to P.O. steroids and they actually deferred a temporal biopsy given that they had already kind of cinched the diagnosis with ultrasound and then follow up labs for normal. So the last few minutes I'm just gonna talk about our project. We looked at the usage and utility of ultrasound at our VA facility and it had four main components. The first part was a literature review to see how useful the ultrasound has been at other centers. The first study we found, this is just a brief overview of our review but in 2004 meta analysis of all the studies available to that date showed the ultrasound had a sensitivity of 69% and specificity of 82% compared with biopsy and then another meta analysis in 2010 showed that the sensitivity was 75% and specificity was 83% compared with the biopsy. So they actually recommend at that time using ultrasound for first line investigation. There's a few more studies. I'm skipped to this part. The study in 2016 also looked at reduction in permanent visual loss in their patients. We looked at 135 patients that they had scanned in clinic as opposed to using the conventional referral model and they had a reduction in permanent visual loss from 37 to 9%. And the same study also estimated the cost per patient for using an ultrasound compared to a biopsy could be reduced by over $600. Summarizing all the evidence we found with a reliable technician for the ultrasound the procedure can be as specific as a biopsy. It may be more sensitive than a biopsy and it may be more efficacious and cost effective. But again, it depends on a reliable technician and inter user reliability is a concern. The next part of our project, we implemented a new protocol with our vascular lab using this data we had reviewed from the literature. So this is just a snippet from that showing how we scan the ultrasound or scan the artery in our vascular lab at the VA. We implemented a new order in our CPS, CPRS system to make it easier to diagnose this. And then lastly, I'll talk about some of our data. So we looked at all the patients who had a ultrasound or a biopsy in an 18 month, 18 month period. We had 18 patients during that time. They were all male, mean age was 72 years. Their chief concern at presentation, half of them had visual change as their chief concern. Five out of the 18 had temporal headaches and then a few of them had other systemic concerns. So out of the eight ultrasounds we did, five of them also underwent biopsy. These ultrasounds were ordered by medicine department, a few of them were ordered by ophthalmology. And then seven of them were negative and one of the ultrasounds was positive. That was the case we talked about today. We did 15 biopsies during that period. Seven of them were done by ophthalmology but vascular surgery and neurosurgery also did. So then five of them ended up being bilateral taking both temporal arteries and the other 10 were unilateral. And we only had one positive during this whole time. That case unfortunately didn't undergo an ultrasound so we couldn't correlate it with the other procedure. From all the cases, two patients were able to defer a biopsy after a negative ultrasound. So maybe using that screening ability of the ultrasound to kind of rule out the diagnosis. We did see concordance between the five negative ultrasounds and biopsies. And then we had the one confirmed positive. Finally, in the treatment of the disease, 11 of the patients were started on IV steroids and switched to PO. Five of them were actually just started on PO steroids. And two of them had no treatment. Those were the patients who had negative ultrasounds. An important point is that steroids were continued even after a negative biopsy in 10 out of the 14 patients who had biopsies. And that's because it's a systemic inflammatory response. So it's important to even continue the steroids if the temporary is not affected, other vessels could be. So limitations, small sample size, and we don't know if our sensitivity and specificity are the same as reported values. So we got to keep looking at it. I was able to talk with Dr. Roger Harry for a few minutes last week about how you use ultrasound here at Moran. So I've just accumulated a few things I learned from him. So try to get the scan before you start steroids because the wall edema will respond quickly to those steroids and the ultrasound becomes less useful at that point. Again, a negative ultrasound doesn't rule out the diagnosis of giant cell. You could still have inflammatory cells present in the vessel and positive biopsy, even if the intima edema has gone away and the ultrasound's negative. And finally, order both ESR and CRP. One of these lab values could be normal, but the other one could be highly elevated and Dr. Harry has seen that in the past. So basically in the future, we're gonna continue collecting more data and then a few interesting things for ultrasound in the field in general. You're already doing this here at Moran, but point-of-care ultrasound in the clinic could help identify a lot of these patients and hopefully avoid biopsies. And in the future of time, we'll just end here. Thank you for everyone for having me to speak today. And I'd like to acknowledge my team at Loyola and the people at Moran who did this possible. Thank you. All right. If there aren't any other questions, thank you everyone. And have a great day.