Welcome to the Vancouver Police Department's Commendation Ceremony. This event is a very special event for the BPD family, and I'm glad that all of you could join us this morning. Today we celebrate excellence and the achievements of individuals in the community and the sworn and civilian members of the BPD. My name is Simi here, and I'm the Director of Public Affairs with the Vancouver Police Department, and I have the honor of being your host this morning. But now that you are all seated, I'm actually going to ask you to please rise and direct your attention to the back of the room to welcome the Lieutenant Governor of BC and members of the official party. Thank you, please be seated. And thank you to Sergeant Major James Pearson and our Piper Retired Constable Tim Fanning for that. So before we begin, I'd like to take a quick moment to recognize some special guests who have joined us today. Please hold your applause until the introductions are finished. Of course, we are delighted to be joined by her honor, Judith Gishan, Lieutenant Governor of BC. From the Vancouver Police Board, we are joined by Mayor Gregor Robertson, the Chair of the Board, Dr. Sherri McGee, Vice Chair, and Ms. Claire Marshall. From the Vancouver Police Foundation, we are pleased to welcome trustees, Gridley Baines, Randy Cook, Joel DeMarsk, Wendy King, Andrew Latchford, Frank Palmer, and Darcy Ray. And we're also joined by the Executive Director of the Foundation, Martina McOva. From the VPD Executive, we are joined by Chief Constable Adam Palmer, Deputy Chief Constables Howard Chow and Steve Rye, Superintendent's Michelle Davy, Steve Ely, and Marcie Flamande, and Senior Director's Nancy Ng and Jason Roode. I also want to recognize members of the Commendation Board who are here today. Of course, you just met the Chair, Superintendent Steve Ely. We're also joined by Inspectors Vince Forsberg, Ruben Sorge, Glenn Newman, Jim McCartle, and Suzanne Muir. Finally, I would like to extend a big warm welcome to the friends and family members of the recipients of today's awards. So to kick things off, I'll ask Chief Constable Adam Palmer of the VPD to say a few words. Thank you, Simi. Good morning, everybody. Lieutenant Governor Judith Guichon, Mayor Robertson, members of the Vancouver Police Department, ladies and gentlemen, it's my honor to be here to celebrate and recognize members of the Vancouver Police Department and citizens from our community for their incredible acts of bravery and remarkable service to Vancouver. Placing is a challenging profession, but we're very fortunate here in Vancouver that for the past 132 years, since 1886, we've had such hardworking men and women who dedicate their lives to keeping Vancouver safe. Risking their own personal safety to assist total strangers that they've never met in time of need, but also showing care and compassion and looking out for people who are less fortunate in our society. While our citizens are home sleeping, our officers are out there 24-7, responding to 911 calls, answering calls for service. And in fact, today, as we're standing here, on this Thursday, we'll answer about 700 calls for service here in Vancouver. It's easy in a free society in a safe city like Vancouver to sometimes take that for granted. But I can say that I'm proud of each and every member of the Vancouver Police Department, sworn and civilian for their dedication and commitment and it's great to see the family members here today, which is so crucial, that family support, that love and care behind the scenes to make our members successful. Today, you're gonna be hearing stories about not only the brave men and women from the police department, but also from our community. Citizens that have stepped up, made a difference, under dangerous and difficult situations, and in some cases have saved lives. Also at today's awards ceremony, we're gonna be presenting the 2017 Police Officer of the Year Award, celebrating the achievements of a frontline officer who has made a career of truly going beyond the call and contributed significantly to public safety in our city. And for the second time ever, we're gonna be having a new award, which is the VPD's Civilian Employer of the Year, recognizing outstanding service by one of our fine civilian professionals. Also, we'll be awarding the Community Safety Leader Award for outstanding community service by a member of our community. In closing, I wanna thank the members of the Commendation Committee for all their great work in choosing the recipients and to the Vancouver Police Board for being the final decider on who receives commendations. In closing, I just wanna thank our Public Affairs section, CMU Director and her staff for making this event possible. Thank you everybody and enjoy the day. Thank you, Chief. We're delighted to be able to start today's ceremony with the presentation of a police officer commission. This is a new provincial honor to formally recognize high caliber senior members of municipal police departments and designated policing units for their rank, professionalism and dedication to policing in BC. The police officer commission regulations set out the criteria and qualifications must be met before a commission is issued. They are an exemplary service record with 10 or more years of service in BC, a baccalaureate or master's degree or equivalent, or the rank of inspector or higher for at least four years and a recommendation from a qualifying supervisor or police board. We're very lucky to have the Lieutenant Governor of BC here to present a police commission. I would like to invite her honor to provide a few remarks. Well, good morning, honored recipients, Chief Constable Adam Palmer, your worship, Mayor Robertson, Dr. Sherry McGee, ladies and gentlemen, families and friends. It is always an honor to join the Vancouver Police and especially for ceremonies such as this when we are recognizing officers for their professionalism and dedication to superior service to the people of Vancouver and British Columbia. I would like to begin by acknowledging with respect the wisdom, culture and traditions of the Musqueam, Squamish and Tsleil-Waututh of the Coast Salish First Nations on whose traditional territory we are privileged to be gathered this morning. Well, it's finally happened. My worst nightmare, I'm speaking after Chief Palmer. This is the first in many, many because he hardly even looks at a note. On the other hand, if I didn't have everything written down, I wouldn't be able to remember my own name once I got up here. Just recently, I listened to a retired Vice Admiral just this week, speak and was so impressed as he spoke about our democracy. And he said that I, as the Lieutenant Governor representing Her Majesty Queen Elizabeth, represent the history and the evolution of democracy from the Magna Carta over 800 years ago down through the ages. Our institutions and our politicians represent the voice of democracy. But it is those of you who serve on the front lines who represent the action of democracy. And I thought, what a wonderful explanation of how our systems work. He was far more eloquent than that and that was the gist of his comments. And it explains the role of you folks who are on the front lines, the ones who make things happen. You do the very demanding work of democracy. And although it was all very well for me last year, I visited a lot of schools and talked about our constitutional monarchy and how this system works, his short description made it all very clear and outlined so plainly, women in uniform and all of those who support you. You are the action people. The rest of us can talk, debate and pontificate, but when it is all said and done, you are the ones that take the action.  And so I would like to thank all of you folks on the front line. Thank you for carrying on doing the work, the very difficult work out in the community. And we know that through the years, you haven't done this alone. You haven't served on your own. Your partners, families and friends have been there keeping you balanced through the tough assignments and we salute you folks as well, because thank you also for your service. I also want to quickly mention that when I visited all the schools last year, in summing up the schools, I bumped into some of your members and the outreach work that they do with you and your community partners was wonderful. I could see that the relationship that was developing within the schools with the members there was a very special one indeed. So thank you for all the exceptional services and thank you for always making me feel like I am part of your community. Congratulations to all today's honorees. Thank you, Your Honor. Please everyone, join me in congratulating Inspector Mike Purdy. This is our Beyond the Call publication and it lists all of today's award and commendation recipients and it outlines why they are being recognized. So feel free to follow along in the booklet as the ceremony progresses. So today we will present the Jim and Vicky Chu Community Safety Leader Award, four awards of merit, seven chiefs commendations and four chief citations. We will also be recognizing the 2017 Police Officer of the Year and the 2017 Civilian of the Year. A quick note for those of you sharing photos and any other content on social media or hashtag for the event is beyond the call and feel free to take the Vancouver Police Department. Our handle is at Vancouver PD. At this point I'd like to invite Mayor Gregor Robertson, the chair of the Vancouver Police Board to say a few words. Good morning, everyone. Welcome and thank you all for being here. It's wonderful to see a room full of great citizens and heroes and this is one of my favorite days of the year to celebrate all of you who have committed acts of bravery and incredible support for members of our community. We're so lucky to live in this city. First, I want to acknowledge we're on the unceded homelands of Musqueam, Squamish and Slewa to the First Nations and very thankful for their stewardship over the many generations here in this place. We are very privileged to live in a city that's as safe as it is. And when we hear stories of immense tragedy and challenge in other cities and communities around the world, I think it gives us a reminder of how good we have it here. And that doesn't come easy. We can't take that for granted. It is, as Her Honour said, the actions on the front lines of those of you who are first responders, those of you in the police who are charged with that duty and fulfill it so well and also those among us citizens who step up in the face of grave danger in a selfless way and commit these acts of great courage, gifts of bravery to the city that save lives and make sure that our city is one of the safest cities in the world and we keep striving to do better. We keep striving to be the safest of all. Our work isn't done, so it's a day-to-day challenge for us. And this is an important day to celebrate and acknowledge the acts of courage and bravery and selflessness that are so important to making progress as a city and keeping this one of the most livable cities in the world. I'm really privileged to work, well, first of all, to be representing you as your mayor and also to be working as the chair of the police board. We are a civilian oversight board thanks to Dr. Sherry McGee and Claire Marshall who are here from the board. A group of citizens who keep an eye on things. We're very lucky to work with the police department that is incredibly responsible, transparent and accountable for actions and constantly striving to rise up beyond the call and to do better. So to all of those police officers, members of the VPD who do such great service, those who are being honored today, a huge thank you for your incredible contributions and to all of those citizens as well. It's an incredible benefit to the city, the actions that you've taken and looking forward to hearing the stories. This is one of the exciting events where we actually get to hear the backstory as we honor those people. It's great to hear what really happened and imagine how challenging, difficult the circumstances are. So our board is really the link between the VPD and the community. And if you have feedback, if you have concerns, questions, ideas, you can share them with members of the police board. Three of us, as I said, are here. Don't hesitate to touch base with us. We're all about that level of accountability, which is so important in policing and in a democracy, as our Lieutenant Governor said. So we are going to be honoring the Vicky, Jim and Vicky Chu Community Service, our safety leader award. This is a relatively recent award to honor our past police chief, Jim Chu and his wife Vicky, who also served as well. And that was created in 2015 and it recognizes a citizen who has made an outstanding contribution to crime prevention and community safety. And this year, Danny Gelman will be honored with the Jim and Vicky Chu Community Safety Leader Award. So, and when you hear about the work that Danny has done, you'll agree he's a very deserving recipient of this award, incredible service over many years. The board is also honoring ordinary citizens for the extraordinary acts of bravery. The civilian awards of merit recognize citizens when they are in the face of a life-threatening situation, step beyond what anyone might have expected with courageous, selfless and really the human touch in helping to save people from a grave situation. So we just want to make sure that people are honored and recognized for their amazing things, what they do to protect our city. And I just want to encourage everyone to keep striving to keep our city safe. We can't take this for granted. We are lucky to live in a city like Vancouver where we make steady progress on this. We've seen violent crime and property crime decline dramatically over many years now, thanks to the work of the VPD and the many citizens and the many citizens who volunteer their time, not just those who step up in the face of danger, but those who serve and volunteer in our community policing centers, those who support us with emergency preparedness when there is great danger affecting the city, there's many citizens, thousands and thousands of citizens who give their time, their energy and their passion to keeping our city safe and we're ever thankful for that commitment. So the board is honored to be saluting our inspiring heroes. And again, congratulations to all the honorees and let's enjoy the great stories today. Thank you. Thank you, Mr. Mayor. The recipient of the 2017 Jim and Vicky Chu Community Safety Leader Award is Mr. Danny Gellman. Let me tell you a little bit about him. There are many dedicated people working behind the scenes in our city, volunteering their time to make Vancouver safer. Danny Gellman is one of these people. For more than 30 years, he has been making contributions that are truly inspiring. Danny began volunteering with the VPD in the 1980s when he filmed the motorcycle drill team performing at the P&E. He went on to join Citizens Crime Watch and since 1993, he has been involved in the recovery of more than 4,600 stolen vehicles. He has spent thousands of hours volunteering with the Auto Crime Enforcement Unit and has deployed more than 1,600 big cars. In 2010, Danny began volunteering with the Granville Community Policing Center. Over the years, he has led, mentored and inspired more than 80 volunteers. With this positive attitude and cheerful demeanor, he has contributed to remarkable improvements at the Community Policing Center. Danny has also volunteered with ICBC, particularly with its VPD partner programs like SpeedWatch and Auto Crime Controls. And that's not all. Danny also volunteers seven days a week for a minimum of two hours a day with the City of Vancouver's Keep Vancouver Spectacular program. Each week, he collects on average more than 3,000 cigarette butts and 29 bags of litter. The people who work alongside Danny say they can always count on him to show up, give it his all and bring a great attitude with a smile on his face. His love for policing and public safety have clearly been his life's passion. For his efforts in leadership and contributing to the safety and livability of our city, Mr. Danny Gelman is awarded the Jim and Vicki Chu Community Safety Leader Award. Next, we move on to the award of merits. As Mayor Robertson stated, this award is presented by the Vancouver Police Board to citizens who on their own initiative and in the face of actual or anticipated danger have made an attempt at saving a life or have assisted the police in preventing a crime or apprehending or attempting to apprehend an offender. Mayor Robertson and Chief Palmer will be presenting the awards and I'll ask the recipients to please wait until I've finished reading the commendation before coming to the stage. And when you do come up, please come up to my left and then exit to the right. Our first award of merit goes to Mr. Gary Sandu. Seconds after he parked his car in the 2400 block of Willow Street in October 2016, Gary heard someone yelling thief and then stop. He looked up to see a man running towards him, carrying a black bag as another man gave chase. Without hesitation, Gary stepped into the first man's path and attempted to grab him. He was unable to hold on to him, but his intervention caused the thief to drop the bag. Gary handed the bag over to the owner, a jewelry salesman who had been getting into his car when the thief struck. Gary was also able to provide police with useful information about the thief's getaway car. For trying to prevent a thief's getaway, despite not knowing if the thief was armed or violent and for recovering stolen property worth $300,000, Mr. Gary Sandu is awarded the Vancouver Police Board's highest award for civilian bravery, the award of merits. The next award of merit goes to Mr. Nicholas Shaw and Mr. Max Rathburn. Nicholas is not here today, however, Max is here to accept the award. One evening in August, 2014, Nicholas was at home when he heard a commotion in the lane behind his house in the 1700 block of commercial drive. He stepped outside and saw a man standing over an elderly woman who he had just knocked to the ground. Max was driving into the lane with his family when he came upon the crime scene. He saw the unconscious woman on the ground, heard Nicholas call out and saw the attacker flee. He quickly jumped out of his car and joined Nicholas in pursuit of the assailant. The two men caught up to the offender and held on to him until police arrived. The 79-year-old victim suffered considerable facial injuries, including the loss of two teeth. For preventing further injury to a vulnerable person, chasing and capturing a violent offender and holding on to him until police arrived, Mr. Nicholas Shaw and Mr. Max Rathburn are awarded the Vancouver Police Board's highest award for civilian bravery, the award of merits. The next award of merit goes to Ms. Emily Stevens. And her hectic lives, sometimes it can be easy to miss another person's suffering. However, when Emily Stevens was crossing the Granville Street Bridge at the end of a busy day in June 2017, she was drawn to a woman who was in obvious distress. Emily stopped to speak with a woman and very quickly determined that the woman was intending to jump off of the bridge. Emily tried to persuade her to leave the bridge, and when she could not, she called 911. The woman got up on the bridge railing and Emily grabbed a hold of her, struggling to keep her from going over. When two police officers arrived, the woman was halfway over the railing. Despite being seven months pregnant, Emily was still holding on to her with all of her strength. The officers were able to pull the woman back to safety. For trusting her instincts and taking the time to save a woman intent on hurting herself and for putting herself at risk, Emily Stevens is awarded the Vancouver Police Board's highest award for civilian bravery, the award of merits. For the merit goes to Ms. Susan Chambers and Ms. Charlotte Tardy. Charlotte was not able to be here today, however, Susan is here to accept the award. It's hard to know what compels someone to jump into action in a crisis while others may stand by, but a Vancouver woman is alive today thanks to the quick actions of two strangers. It was a warm spring evening in May 2017 at English Bay when Susan and Charlotte noticed a distraught woman enter the water and swim out to about 50 meters. They could see she was in distress and her mental health appeared to be deteriorating. The beach was crowded and people began to call 911. Susan and Charlotte did not hesitate to go into the water after the woman, but helping her back to English Bay Beach was a very difficult task. She did not want to be rescued and struggled all the way back to the shore. Even while waiting on the beach for police to arrive, the struggle continued, but her rescuers were determined from preventing her from re-entering the water. When police arrived, Charlotte acted as a translator as the woman did not speak English. An ambulance took the woman to the hospital to receive the help she needed. For putting their safety at risk to rescue a stranger in obvious need, Ms. Susan Chambers and Charlotte Tardee are awarded the Vancouver Police Board's highest award for civilian bravery, the award of merit. We will now present the Chief Constable's commendations and citations. The Chief Constable's commendations can be awarded to police officers and civilian members of the VPD for demonstrating skill, judgment, dedication, or integrity over the course of a single investigation, operation, or incident, or for demonstrating the highest standards of police conduct or humanitarianism in a single operation, incident, or investigation where there was a high risk or exposure to danger, or for demonstrating over a period of time, exceptional skill, judgment, dedication, or integrity in the performance of duty, or for developing a method or program that has a substantial effect on the operation of the department. The Chief Constable's citations are based on the same criteria for recommendations. However, a citation is awarded to two or more members working together regardless of unit, squad, team, district, section, or division affiliation. The citation recipients can pick up their individual commendations from the reception table at the back of the hall before they leave today. I ask the recipient of the commendations and citations to please wait until I finish reading the commendation before coming up to the stage. On April 14, 2015, Vancouver police officers were called to the 400 block of Gore Street for a report of a man randomly stabbing pedestrians. Constables and Fontaine, Albert Liu, and Greg Parks were the first to arrive. They found an agitated man armed with a knife in an area with heavy pedestrian and vehicle traffic. Three people had already been stabbed. Constable Liu used non-lethal beanbag rounds, but to no effect. Constables Park and Fontaine tried to draw the man away from the crowds. When the attacker grabbed another innocent bystander and began repeatedly stabbing her, Constable Parks fired his weapon. Constable Fontaine provided first aid to the innocent bystander until ambulance arrived. The victims suffered life-threatening wounds, but eventually recovered from her physical injuries. For putting themselves directly in harm's way and preventing further injury or death to innocent citizens, Constables and Fontaine, Albert Liu, and Greg Parks are awarded the Chief Constables Commendation. One of the most serious incidents a police officer can face is dealing with someone in a heightened emotional state. Constable Sinda Michael has dedicated herself with dealing with these high-risk situations through crisis negotiations. In her 17 years with the crisis negotiation team, she has attended more than 300 critical incidents and gained a reputation as one of Canada's most accomplished crisis negotiators. She is sought by police agencies from around the world for advice. Constable Michael has been instrumental in developing the VPD's crisis negotiator program and has taught and developed courses at the Canadian Police College. She has been invited to attend the FBI National Negotiator Course in Quantico, Virginia and the UK National Negotiator Course in England. She has spoken at conferences across North America. Constable Michael has also helped develop and teach workshops to psychologists and psychiatrists who provide consultative advice to law enforcement, some as far away as Malaysia and the United Arab Emirates. For educating hundreds of officers, negotiators, and medical practitioners in life-saving techniques and making a difference in how police agencies around the world manage difficult and often volatile situations, Constable Cindy Michael is awarded the Chief Constable's Commendation. Many police officers will tell you that the most difficult cases they investigate are those involving harm to children. When Sergeant Michelle Torvik was working as a constable in the sex crimes unit, she was assigned a historical case of child abuse. The investigation was particularly challenging as the victims were dealing with blocked and faded memories of crimes that had taken place more than a decade earlier. Sergeant Torvik rigorously pursued the case, which resulted in a guilty plea from the offender. Her commitment and dedication to finding justice for these young victims was exceptional as she was receiving ongoing and aggressive treatment for an advanced and life-threatening cancer at the time. For completing a sensitive and disturbing investigation diligently and successfully, despite facing a debilitating health crisis, Sergeant Michelle Torvik is awarded the Chief Constable's Commendation. People become police officers for many different reasons, but a common factor seems the desire to make a difference in the world or even a single life. When Detective Constable Alexander Charles joined the gang crime unit in March 2014, he launched an anti-gang initiative aimed at helping at-risk youth. Detective Constable Charles used his contacts and experience as a former UBC Thunderbird and BC Lions football player to form gang tackle. The goal was to show students the consequences of poor choices and to build relationships with kids who rarely talk to police. Gang tackle was supported by the Vancouver Police Foundation. It brought together professional athletes, UBC Thunderbird alumni, and police officers to play flag football with teens selected by VPD's school liaison officers. More than 200 kids have taken part in gang tackle since it began, and many have made positive changes in their lives. One participant went from a life of crime and drugs to successfully obtaining a university scholarship. For devoting countless hours on and off duty to his community and making a difference in the lives of at-risk youth, Detective Constable Alexander Charles is awarded the Chief Constable's Commendation. Every day, police officers protect the citizens they serve. Two of the VPD's finest have taken that responsibility to a whole new level. The women's personal safety team began in 2012 following the Women's Safety Fair where five police officers gave an interactive presentation aimed at empowering women by teaching them techniques to increase their personal safety. Requests for more demonstrations started coming in and Inspector Colleen Yee and Detective Constable Alice Yee stepped up to coordinate a new women's personal safety team. They obtained funding from the Vancouver Police Foundation for much needed safety equipment and demonstration tools. In 2016, the team grew to 30 officers. All officers volunteer their time with no financial compensation. Team members have presented more than 60 workshops to about 2,000 women. For proactively building collaborative relationships with diverse members of the community and providing women with the skills and confidence they need to feel safer, Inspector Colleen Yee and Detective Constable Alice Yee are awarded the Chief Constable's Commendation. Police officers are exposed to many disturbing things throughout their careers and many of them carry the scars. It's the wounds that you cannot see that are often the most serious. An awareness for the need for mental health resources for first responders has been growing. Constables Emma Hyde and Garrett McDonald are two of the VPD's champions for employee mental health. As the coordinators of the VPD peer support unit which began in 2015, they are dedicated to ensuring the mental wellbeing of all Vancouver Police members. The duo teach courses on recognizing signs for concern not only in one self but in others and they offer tools, resources and support. In 2016 they facilitated the involvement of the VPD's critical incident management, critical incident stress management teams involvement in 31 incidents in which officers received support from their specially trained peers following critical incidents. Their reach has extended beyond the VPD to police recruits at the Justice Institute of BC and other first responder agencies. They've offered support to more than 2000 people 24 hours a day, seven days a week for having a profound impact on the mental wellness of VPD members and their families, breaking down the stigma of mental illness and helping all wounds heal. Constables Emma Hyde and Garrett McDonald are awarded the Chief Constables Commendation. For almost 20 years, Dr. Randy Mackoff has been taking care of the mental wellbeing of members of the VPD. His deep cultural insight into policing and his genuine care have had a positive effect on the lives of many. He is steadfastly available to all staff during times of personal or professional crisis. Dr. Mackoff is an integral part of the critical incident stress management process and the VPD peer support units. He trains police officers to help their fellow officers in times of need. Every year he interviews members working in units designated as high stress to ensure they are coping well. Dr. Mackoff has guided the response and best practices for officers dealing with critical incidents. He played a key role in developing the VPD's crisis negotiation team and trains all negotiators who are called on daily in serious incidents. He has assisted at hundreds of critical incidences day and night for playing a vital role in supporting the mental health and welfare of VPD members and training police officers to use the safest, most effective methods in critical incidents. Dr. Randy Mackoff is awarded the Chief Constable's Commendation. In September 2016, the VPD Identity Theft Unit launched an investigation into a group of criminals believed responsible for residential break-ins and identity fraud in excess of $100,000. Their crimes involved the theft of mail, identity documents, and credit card data. 30 people were identified as suspects into fronting major banks and credit card companies, retail companies, casinos, and CAD companies. The crimes were committed across the region and investigators worked closely with the RCMP, Calgary Police, Edmonton Police, Canada Border Services Agency, the Canadian Bankers Association, and Crown Council. 18 people were arrested, including two in Alberta, and the unit recommended 225 charges against them. They all pled guilty. For disrupting and dismantling the criminal operations of an organized crime group, bringing justice to victims and saving future victims significant losses, the falling members of the Vancouver Police Identity Theft Unit are awarded the Chief Constable Citation. Sergeant Rick Taylor, Detective Constables Ryan Jeffery, Francesco Miguel, Jason Ruzicchi, George Speck, Sean Ward, Constable Ryan Stafford, and crime analyst Cynthia Brown. About their careers, police officers encounter criminals who prey on the most vulnerable in our society. People at an economic disadvantage with addiction issues are living with mental illness. As part of the BPD's anti-fencing unit, Detective Constable's Doug Fowle, Allen Ivezek, and Kirk Miles regularly investigated predatory fences dealing stolen property, a term they developed to define the exploitation of the vulnerable people, these well-insulated fences compelled to steal. Over four years, the officers developed and implemented innovative and effective crime prevention programs and through proactive investigations into the fencing operations, they worked to hold these fences accountable for their crimes. They worked alongside Crown Council, the City of Vancouver's Business Licensing Office, and retailers and their lost prevention officers. Their sustained efforts resulted in an unprecedented number of successful investigations. Criminal charges were laid, business licenses were revoked, and property was seized. The consequences for these predators were not just through the courts. More than $5.8 million in assets were referred for civil forfeiture. For demonstrating exceptional skill, judgment, dedication, and ensuring vulnerable people received protection, and for bringing criminals to justice, Detective Constable's Doug Fowle, Alan Ivesic, and Kirk Miles are awarded the Chief Constable's Citation. It was a Monday morning in July 2016 when a group of officers came together to stop a man intent on jumping off the Lionsgate Bridge. When the officers first arrived at the bridge, they found the man outside of the railing, facing outwards, and holding on with his hands behind him. They tried to coax him to safety as negotiators rushed to the scene. Heavy traffic on the bridge, including pedestrians and cyclists, and strong wind made it challenging to communicate with the man. While negotiators worked with the distraught man, other officers devised a rescue plan that would ensure everyone's safety. As the man let go of the railing and moved his feet closer to the edge, the team was ready. They quickly moved forward to grab on to him. Each officer assigned a different part of his body to hold on to. A chaotic scene ensued as a member's spot to hold on and the determined man fought to let go. One of the officers went over the railing using his safety equipment, and together, they were all able to secure the man to the bridge and pull him to safety. For coming to the rescue of a distraught man intent on ending his own life and risking their own personal safety in a dangerous situation, the following members are awarded the Chief Constable Citation. Sergeants Jim Kenney and Eric Lott, Constables Steve Addison, Jennifer Antonel, Scott Brown, Kyle Chapman, Peter De Silva, Jason Howell, Eric Jordan, Jay Lawrence, Matthew Oliver, Courtney Park, Brian Spencer, and Dave Steverding. Dedication is a common trait for members of the VPD, and when a group of them come together with a common goal, they can accomplish extraordinary things. Starting in June 2016, the members of District 2, Team 7, patrolling Vancouver's downtown east side, began to create projects targeting drug trafficking, problem premises, and chronic offenders. Using surveillance, undercover officers, informants, and other investigative techniques, the officers successfully completed 13 complex projects in just 14 months. 42 search warrants on businesses, homes, and storage lockers, revealed prohibited and restricted weapons, large amounts of cocaine, heroin, fentanyl, and crystal meth, and more than $235,000 in cash. The investigations also resulted in civil forfeiture proceedings for property worth more than $3 million. For their hard work and initiative in fighting crime, and removing dangerous drugs and dangerous weapons from our streets, the following members of District 2, Team 7, are awarded the Chief Constable's Citation. Sergeant Pete Sadler, Constables Mark Baird, Lorna Brinson, Sherman Chow, Jordan Ginther, Spencer Green, Bethany Jervis, Thomas Lint, Brian McKinnis, Conrad Nemeth, Andrew Penner, Byron Taghiem, Janine Tenino, Jason Trombley, and Brian Watson. Over a year since 1987, members of the Vancouver Police Department have recognized one of their own as police officer of the year. Each spring, members are invited to nominate fellow officers whom they think exemplify excellence at work, outstanding service to the community, and leadership. Nominations are detailed and contain supportive evidence and examples in each of the three categories just mentioned. The nominations are reviewed by the Commendation Board and votes are cast. I am pleased to announce that Sergeant Pete Sadler of the Operations Division, Patrol District 2, Team 7, is the VPD's 2017 Police Officer of the Year. One of the signs of an exceptional police officer is their dedication to sharing a career's worth of knowledge with those who serve under their command. Sergeant Peter Sadler joined the VPD in April 1982. He worked in a variety of operational investigative sections and was promoted to Sergeant in 2009. After stints patrolling downtown Vancouver, he then moved on to the drug units. In 2014, he moved on to lead a team of officers working in the downtown East Side. In the following three years, Sergeant Sadler initiated or supervised 27 projects in the area, resulting in large seizures of drugs and firearms. All in addition to handling the day-to-day policing duties for the busiest district in the city. His success was made possible by the committed officers he led. He mentored them in everything, from writing warrants to developing skills as lead investigators to handling sources and writing operational plans. The coaching he provided helped several members of his team move on to other key investigative positions within the VPD. Sergeant Sadler has recently concentrated almost exclusively on fentanyl trafficking, and his coworkers will tell you that there is no one Sergeant in the VPD more driven to tackle this crisis in Vancouver. He is a leader in dealing with mid- and street-level drug dealers, and several investigations have led to multiple firearms seizures. This work has had a considerable effect on decreasing violence in the downtown East Side and helps with the civil forfeiture of residences, vehicles, and valuable property associated with criminal activity. After 35 years of service, Sergeant Pete Sadler still approaches his work with the eagerness of a new recruit. For his enthusiasm and dedication to police work and his leadership and commitment to developing the skills of police officers under his command, Sergeant Peter Sadler is the 2017 police officer of the year. As Chief Palmer mentioned, their next award is a newest award. Since 2016, the VPD has been recognizing exceptional civilian members as our civilian employee of the year. There are many dedicated civilians working behind the scenes in police departments who are having a tremendous impact on public safety. The VPD is very fortunate to have many, one of whom is VPD's 2017 civilian of the year. Jimmy Nam, a 16-year member of the VPD, began in the information management section where he gained an extraordinary knowledge of the police database and the records management system. He was quickly promoted to a training and administrative assistant and began training sworn and civilian members on the databases. When he went to youth services in February 2013 as a crime analyst and program administrator for the mental health unit, he created new data collection techniques. As a natural problem solver, he became the go-to person for assistant design and data retrieval. His knowledge of information technology, computer programming languages and systems, psychology, statistical analysis, and police databases is immeasurable. Jimmy developed an early warning system to allow the mental health unit to proactively identify the people living with mental health issues who are most at risk to cause harms to themselves or others. This continues to be an important tool for the VPD's assertive outreach and assertive community treatment teams. He created a template to capture the number of patrol calls with the mental health component. This is critical information when determining resources and responses for both police and community health partners. And this work led to the VPD receiving a North American award for public safety innovation. This simple but powerful tool has been adopted by the RTMP and other police agencies in BC.  He is well respected by his coworkers who say he has reserved, thoughtful, sincere, and tumble. And if there's a way to automate a process, Jimmy will find it. Jimmy also finds time to volunteer with the VPD cadet program. For accurately capturing and analyzing data, having a significant impact on mental health services in Vancouver and maintaining the VPD status as a leader in police response to people with mental health issues, Jimmy Naam is the 2017 civilian of the year. So that concludes the award presentation for today. But before we wrap up, I would like to say some thank yous and recognize a few people. First off, thank you to the Roundhouse Community Center for hosting this year's ceremony. It was great to have with you. And I would like to also thank everyone who has worked behind the scenes for months to pull this event together. That includes a very talented event managers, Meneek Thomas and Laura Tynkesta, our incredible videographers and photographers and the entire public affairs team. I would also like to once again thank all of you for coming and congratulate today's award recipients.


break that wasn't a long break that's not the break the actual break is later I'd like to have everyone back here for the next session this is not yet the coffee break the coffee break will be later so in order to give attention enough attention to the next session and that we have more time also we have a bit longer time then okay I'm pleased to introduce the special session here in the plenary lecture because it is the paper with the best paper award it is about identification protocols and signature schemes based on super singular isogenic problems Steven Galbraith, Christopher Petty and Javier Silva are the authors and Javier please okay thanks so I have two goals for this talk first that you understand what the title means and second to give you a very brief intuition of construction and why it works so as Dustin has just said in the previous talk most of cryptography relies on different helmet type problem or RSA assumptions which essentially in the end depend on two problems discreet log and factorization and when we consider quantum algorithms these problems are broken so we start to look for alternatives one alternative one of the minority alternatives is the elliptic kfisodium is so we will see what we can build with them so to give you a little bit of perspective I want to recall what it's been done in the ISO database script in the recent years so we have hash functions, key exchange protocols, the signature verifier signatures, public key encryption, ID protocols, the number of signatures, a lot of stuff and particularly we already have ID protocols and signatures and we're building a new one so why the answer is that so the signature scheme that already exists actually relies on the ID protocol that already exists and they share the same issue and it is that they rely not on the pure isogenic problem but modified problem that gives some extra information to the attacker so this is a potentially an issue problem so what we are trying to achieve in our paper is to build the ID schemes and then signatures rely on the on the pure problem without giving any extra information okay so the outline of the stock is the following first I will recall the graph isomorphism proof I believe most of you will be familiar with it but it's worth recording because it will share a common structure with with the proof we are going to build then I will talk about the super-synical isogenic graph which is one of our main tools for building this identification protocol then I will explain the construction very briefly and talk about how we can get signature from that so graph isomorphism first this is a textbook example of zero knowledge proof so we have two parties Peggy and Big and Peggy is the prover that knows a secret and wants to prove to Big the verifier that knows the secret without revealing any information about it so in this case the secret is an iso in between sorry no they saw it is yet an isomorphism between two graphs so I will represent on the left part of the screen what Peggy knows on the right part of the screen but what Big knows so difference right now is that Peggy knows a secret this iso this isomorphism and Big doesn't so how does the protocol works well first Peggy takes a random permutation of the graph G1 and produces another graph G2 and sends this graph to Big but without sending the permutation so now we sense a challenge which is just one bit either zero or one I'm going to use the red color to represent what happens when the bit is zero and look what happened when the bit is one so when the bit is zero Peggy just reveals this vertical isomorphism and in the other case reverse an isomorphism between G2 and G2 with this just a composition of these two so very intuitively why is this secure first can Peggy cheat well on a very high level what happens is that the only thing Peggy can do if she doesn't know the this secret isomorphism and wants to produce a proof is to guess which which challenge either 0 or 1 is Big going to send so either she takes a random permutation from here or from here so she can cheat with probability one half to solve this we just repeat the protocol many times to make this this cheating probability negligible our property we want this interaction to reveal nothing about the secret and intuitively that happens because when the bit is zero we're just revealing this vertical isomorphism with which is independent from the secret and in the other case we're really the composition and this part is essentially masking this one so we have the zero knowledge for property so after that we have been an identification scheme and there's a standard way to make to produce a signature scheme from that there's some general transformations traditionally the most very well known one is yes we can use it to produce signatures from my identification schemes so this this protocol that I just presented has a structure in which we move between a few graphs but actually we can think of a very similar structure within one graph which is we take as vertices we take the vertices of a graph and we have a path between them that is secret and we will assume it is hard to compute and we replicate the same structure given a challenge we either give this path the virtual one or the path from e0 to e2 but the thing is what is this graph and why is this secret hard to compute so that's where the super singular is coming to play so to introduce the super singular isogenic graph I first need to introduce a very few very few simple definitions of elliptic curve theory so elliptic curve I believe we all know what it is it is an algebraic curve with a graph structure which we can essentially add two points by using this rule and I thought it is essentially a function between two elliptic curves and and the morphism is an exogenous from a curve to itself so we have this structure in which we have two points and we have an arrow between them and we want this arrow to be hard to compute so the natural problem we come up here with is the exogenous problem we have two isolated elliptic curves and we want to compute and the exogenous between them and this is really to be hard and the related problem is given an elliptic curve can be the endomorphism range but the thing is not for any curves are these problems of the same level of hardness actually there's a classification of elliptic curves I want to get I won't get into the details of that but essentially there are two types of elliptic curves either ordinary or super singular and we can solve these problems differently for each of these types and it turns out that they are harder to solve for super singular elliptic curve actually these two problems in this case are equivalent they're not known to be equivalent for ordinary curves and we have complexities of the order of p1 half classically and p1 fourth quantumly whereas in the ordinary case we often had a sub-exponential time so we will stick with the super singular case and finally what is this super singular solgene graph it's essentially we take all the solgene super singular elliptic curves over fp squared for a very large prime p up to some equivalent relation but that doesn't matter not just think of the vertices as the super singular elliptic curves and the edges will be the exogenous between this curve the functions between them and this graph has a very nice property it's called a ramanujan graph which essentially means it has lots of lots of edges between the vertices it has lots of connectivity and it is easy to start from one point only one vertex in the graph and reach any other point in a very in very few steps so we now have all the all the elements we need to build our identification protocol just to recall the very formal definition of what an identification protocol is you might have seen this as a sigma protocol or zero-knowledge proof of knowledge essentially we have two parties that's before page and b and they will interact in a certain way and Peggy will want to prove to be that she knows the secret without revealing the secret so we want three properties from this we want completeness if she knows the secret she should be able to convince big what we call sadness which is a if she doesn't know the secret she shouldn't be able to cheat she shouldn't be able to produce a valid proof and finally zero-knowledge property which said which means that this interaction reveals nothing about the secret itself so we had this with this structure we have it here again but now we can give a meaning to to any of the elements here now we have two isolyneoselectric curves if you see only one and the secret isolyne between them and the structure of the protocol will be to either given a challenge zero or one reveal this vertical isolyne or this isolyne from e0 to e2 so this looks very simple but it's not as simple as in the as in the graphics morphism case because they're the only thing we have to do to compute this isolyne this is what this morphism in that case was to take the the composition of these two now we can't do that and the reason for that is that isolynes are not the same as isomorphisms if we do that an attacker could try to could actually factor this this isolyne into each step each step in the graph and actually recover this this first part of the path which is the secret so if we do this we cannot expect to have the zero-knowledge property so how we solve this there's an algorithm that we can build and it is based on an algorithm for a related problem it was published a few years ago by Colt, Lauter, Tieta and Dignol and essentially what it does is it allows us to take this isolyne we have from e0 to e2 and compute another one that is that is independent on the path we took before so it's essentially a sense of re-randomization of this path so what we do now is when the beat is what we want we want to answer with an isolyne from e0 to e2 so first we take the composition of these two but we don't reveal it we just apply to it this new path algorithm and compute this re-randomized path between e0 and e2 and this is the one we reveal and this way we're solving the zero-knowledge problem we had before and also well I want to give you now an intuition of the security of this obviously some this is essentially the same as in the graph isomorphism case it's the same idea and for zero-knowledge zero-knowledge is usually formalized as simulation of the transcripts essentially we want to prove that we can produce transcripts which are indistinguishable from the from general transcripts but we can produce them without knowing the secret so let's see how we do that we have two curves you see running one we don't know the isolyne which was a secret so we start by taking a beat and if it's zero we reveal the vertical isolyne and we do that by just taking random walk from e1 producing e2 sorry and reveal the path and for the other case we just take the random walk from e0 to e2 and we could reveal this isolyne but it wouldn't have the same distribution because this re-randomization algorithm that I mentioned doesn't give you a uniformly random isolyne from e0 to e2 so what we do here is apply the same trick we re-randomize here too and we get an isolyne am I doing that and we get an isolyne which has the correct distribution between e0 and e2 and finally very briefly how to get signature from this so I've mentioned before there's there are standard transformations so classically we have transformation which is essentially replacing the challenges by a hash function of the the commitments the curves e2 and and the message we want to sign so what is happening is that Peggy is doing the protocol by herself and then when base wants to verify the signature all he has to do is recompute the hash and verify that the proof is consistent so this is proven to be secure in the random oracle model but this is what we are thinking about in terms of quantum security post quantum security Fiat Shamir is not known to be secure so we replace it by another transformation due to umru which is proven to be secure in the quantum random oracle model so this this transformation is in some way similar to Fiat Shamir it's more complicated but it's the same idea of using some hash functions to replace the verifier so to summarize what we did we start with isolyne problems which we believe are a good candidate for post quantum security we have an identification scheme based on the pure isolyne problem in contraposition to the previous scheme which was based on a potentially weaker problem a key to do this was this verandumization algorithm that was a key step of our proof and finally we can derive signatures in a standard way using generic transformations and that's the end of the talk thank you very much I think we have time for questions yes now can you provide some numbers key sizes signature sizes if you implement it in a secure way actually I can't provide the concrete numbers right now I don't have to deal but I can say this is not very efficient if you want I can give you some numbers later but I don't have them here all the questions especially in the back but I think yes so I'm wondering about how it compares so you were talking about previous signature schemes based on isolynes that were based on more specific problems than the one that you're considering but then if you take the security parameter into account and the difference in efficiency do those problems become incomparable or can you say that you have a more solid problem even regardless of that so I believe the previous scheme is slightly more efficient than ours but but there's this problem of the problem being potentially we're getting there's it's not that there's an algorithm that solves the other problem faster in general but there are some cases in which this additional information that is given can be exploited to produce some attacks okay if you have a question then you have to see either the speaker or me otherwise I don't see anyone else anymore okay so we thank everybody else again for the questions and authors of course for the paper


Okay, good morning, everyone. I'd like to welcome you to UVitis Grand Rounds. The topic today will be on the update on the treatment of UVatic macular DMA. I'd like to welcome everybody here, including the resident applicants that are joining us by Zoom. I'm going to give you an overview of what's new on the treatment of macular DMA and UVitis. This will be followed by presentations by Akbar Shakur, Marissa Larshall, and Marcus Altman on surgical and local and systemic treatment. So UVatic macular DMA is a major problem affecting all anatomic subtypes of UVitis. It's a leading cause of visual impairment. The MUST study showed us that 40% of patients do not have resolved macular DMA. That is it's persistent at two years and that 40% of patients relapse their macular DMA and that fully two thirds of those patients require adjunctive therapy that are on systemic treatment. So the underlying principle in the treatment of UVatic macular DMA is to control the information by whatever means necessary using a topical systemic periocular or with or without immunomodulatory therapy, depending upon the anatomic location, the laterality, the severity and the diagnosis of UVitis. Persistence in recurrent macular DMA is usually treated adjunctively with a topical regional or systemic steroids, again, depending upon laterality with an assessment of the vitria macular interface abnormalities and the modification of risk factors such as smoking, which are known to contribute to this complication. Our choices, the basic choices are regional corticosteroids, periocular corticosteroids, intravitral corticosteroids. There's the clinical impression that intravitral corticosteroids are more effective, albeit associated with greater increase in intraocular pressure and cataract. Indeed, five injections of intravitral prime serum will give you a cataract. Then, of course, there's the dexamethasone implant that has been approved, which shows efficacy in terms of inflammation and also in macular DMA, but is also associated with cataract formation and elevation of intraocular pressure greater than the study that led to its approval. So the point study was a randomized control trial that actually went ahead and compared these three treatment modalities with a primary outcome of the proportion change of the central subfield thickness at eight weeks and secondary outcomes of improvement and resolution of macular DMA. This is the bottom line result and that showed that while all three subgroups had a reduction in macular DMA represented by a number less than one, here the periocular had less of a reduction and only about 23% as opposed to 39% for intravitral trimestinalone and 46% with dexamethasone. I think this is more easily seen in this graphic representation of the improvement with the intravitral lines up here, intravitral injections up here as opposed to periocular injections which were clearly significantly and clinically superior as well as in terms of resolution macular DMA with the intravitral arms being superior to periocular. As expected, intraocular pressure rise was greater in patients with intravitral treatment than periocular. So the conclusions of the point trial is that while all treatment groups improved central subfield thickness and best corrected visual acuity, intravitral trimestinalone and dexamethasone implant were superior, both in terms of reduction of improvement and resolution of macular DMA with the expected modest increase in intraocular pressure. And so based on this, the conclusion is that for most patients, an intravitral approach may be the best initial treatment for patients with center-involving macular DMA. So there's a problem with regional corticosteroids in that they are relatively short-acting and hence less effective for chronic inflammation because it's associated with kind of subtle structural change each time you have a recurrence of inflammation and of course the cumulative risk of steroid exposure with cataract intraocular pressure elevation and optimized with each procedure. So a sister study which was recently concluded and recently reported at the American Academy of Ophthalmology a few weeks ago, the Meritz trial looked at non-steroidal alternatives for the treatment of macular DMA and compared it to intravitral dexamethasone implant. So there is evidence in retrospective studies that anti-begev and methotrexate are effective in the treatment of macular DMA. So all these patients had exposure to an intravitral corticosteroid. So this was a randomized three-arm parallel design study of comparative effectiveness. The three treatment arms of a repeat dexamethasone injection versus methotrexate or round-of-bizmab patients were stratified to either being on treatment with immunomodulatory therapy or not. And the fall at the primary outcome was at 12 weeks and then a monthly fall of until 24-week anniversary closeout. The primary endpoint was the percent change in central subfield thickness from baseline measured on OCT with similar secondary outcomes of a proportion of eyes with improvement or resolution of macular DMA, the change in best corrective visual acuity and safety outcomes chiefly related to intraocular pressure and decreased in vision. So I just want to show you what the treatment schedule is. It mimics what we do in clinical practice. All patients received one of their assigned injections up front. Patients in the dexamethasone were required to have an injection at eight weeks if they met re-treatment criteria, which virtually none of them did. And then methotrexate, again, was required if they met re-treatment criteria at weeks four and eight. And round-of-bizmab was given three injections up front as it is similarly in clinical practice. So the bottom line results here show that the dexamethasone implant was superior in reducing the thickness and statistically significant at all time points and at 12 weeks between methotrexate and round-of-bizmab. So it was a 35% reduction for dex, virtually nothing for methotrexate at 12% and 21% for round-of-bizmab. I think this is also more easily appreciated in terms of improvement and resolution of the dexamethasone implant being on top, showing that it was clearly superior to the other two with methotrexate really not performing very well. And the peak efficacy was at about eight weeks but still at 12 weeks, there was superiority shown in the dexamethasone implant. Oops, changes in visual acuity. Again, for the dexamethasone implant was the only arm that showed an improvement in visual acuity at all time points at about a line of visual acuity, five letters. A methotrexate showed no improvement and there was no statistical improvement in visual acuity in round-of-bizmab, only about one letter. As expected, intraocular pressure events were greater for the dex implant with IOP elevation greater than 24 and of course, associated use of intraocular pressure lowering medications. Intraocular pressures greater than 30 were seen infrequently in all three groups, less than 10%, and a visual decrease of greater than three lines was seen mostly in the dexamethasone, in the sorry, methotrexate group. So the summary of the results of the merit trial was that dexamethasone is superior clinically and statistically to methotrexate and round-of-bizmab at 12 weeks, both with respect to the reduction in central subfield thickness, improvement and resolution of macular edema and that only the dexamethasone implant showed a significant improvement in best corrected visual acuity at 12 weeks with about an improvement of one line. Dexamethasone had a higher occurrence of IOP elevation as expected and the methotrexate had a higher outcome or lots of free lines of vision, but this was due to mostly due to macular edema and most of those patients actually recovered when they were crossed over to intravitural steroids. So what do you do when you have recalcitrant macular edema that just persists? So there are some alternatives. We know that we have a reticent implant, we have glucinolone setonide insert, we have newly developed and newly approved supercoital delivery of primicinolone. We discussed the merit trial. I would also just briefly discuss some of the conventional and biological immunomodulators which do show a salutary effect on treatment of macular edema and there is more controversy associated with the use of actual retraction is a primary modus of treatment of macular edema in uveitis. So the flucinolone implant or the resistor implant is effective in treating intraocular inflammation with decreased inflammation and recurrence rate in the fallow eye, stabilization of visual acuity, but at a pretty high cost of cataract in 100% of fake guys and a very high percentage up to 70% of patients needing medical therapy or IOP and a pretty high rate of incisional cataract surgery. In the must follow up study at seven years, you can see that there was a tendency for in the line in arms which represents patients that were implanted to have an improvement in their macular edema but this was statistically significant really only in the first six months and this advantage was lost at about six years. Newly approved sustained released flucinolone setonide insert or UTIC has been developed specifically for uveitis which shows excellent anti-inflammatory efficacy and it is an office-based procedure which delivers an implant same steroid flucinolone but at about a third of the dose of the reticent. The thing that is interesting about this study is that at least in the first year of the study 71% of the patient had resolution of their macular edema as opposed to 48% of patients with sham. So that this is a office-based procedure which may be actually useful for patients with very chronic macular edema that require repeat intravitural injections. A kind of a novel concept is the supercruital delivery of medications specifically of trimicinolone developed by ClearSide Biomedical and now distributed as I peer by Bausch and Lohm. The concept here is that supercruital delivery would deliver a higher amount of steroid where it needs to be under the chloride RP and retina with less exposure to the anterior segment and hence maybe less exposure to glaucoma and cataracted side effects. This was trialed in the peach tree trial which was a phase three randomized controlled study in which supercruital injection was delivered at day zero and at week 12 and as compared to a sham, it wasn't really a sham. They didn't receive an injection initially but then they were able to be rescued at four weeks with mostly periocrine and intravitural steroid. It reached its primary out point at endpoint of greater than three lines of visual acuity gain in about 47% of patients but impressively since this was a study that was designed for the treatment of macrodina it showed a robust decrease in central macular thickness as early as four weeks represented on this blue line here and which sustained throughout 24 weeks in the study. There is really, there were very few cataract events in both arms and very few problems associated with elevation intraocular pressure. There is no comparative data with the fluosicinolone set and I insert or supercruital delivery yet but we will see because it's in the works. So I just like to mention that as you know, Humira and infliximab anti-TNF agents are used in the treatment and Humira is approved for their treatment of uveitis and that these agents themselves do have a salutary effect on macular Dema when treated. And a recent publication showed efficacy of TNF inhibition as opposed to patients treated with conventional DMARDS such as methotrexate and cell sept with a significant reduction of central rental thickness and associated improvement in visual acuity at one in four years and a reduction in the requirement for systemic steroids. I think that it's also important to note that in this study, rescue treatment was required and well over a third of the patients so that this need for adjunctive therapy is a very real thing. The other thing that is not mentioned in this study but I thought I would mention to you is that patients that are on immunomodulatory therapy have about a 75% reduction in the need for adjunctive therapy than patients that are not on that. So many of our patients are on immunomodulatory therapy. What about other immunomodulators? So we know IL-6 blockade is a new modality that is available to us in the form of tosylizumab or actemera, which has been approved for use in patients with severe refractory RA and polyarticular JIA and as the neuro people know in GCA. And case series suggests that it may be very helpful and beneficial in patients with uveidic macronutrient. In fact, recent publications showed that tosylizumab improved a complete response of uveidic macronutrient versus anti-TNF medications. So it's nice to be able to get this medication but it's extremely difficult to get approved for this indication or for uveitis. We're working on it. Interferon alpha 2A administered systemically shows great promise and is quite effective in reducing macrodema in patients with really chronic macrodema. It requires prolonged exposure to this medication. So they need to be on it for years. And the problem with this is that the medication is difficult to administer. It is associated with side effects that most patients experience through to maybe treatment limiting. Finally, I'd like to mention that paris pentatricum probably does have a role in the management of uveidic macrodema, certainly in the presence of obvious vitreous macular interface abnormalities as you see here but also in patients with recalcitrant macrodema that are refractory to medical care. There is obviously a wealth. There are a lot of papers on there that show an improvement. But I would say that the overwhelming majority in my read of the literature is that there's a partial complete regression of macrodema in 33 to 59% of patients. And this is mostly seen in patients with intermediate type of uveitis. So in summary, uveitis, uveic macrodema is a major cause of decreased vision. The treatment principle is really treat the underlying inflammation first and then adjunctively or persistent recurrent macrogene with intravitral corticosteroids. We've learned that intravitral triamcinolone and dexamethasone implant are superior to subtenance canal log injection and that the intravitral dexamethasone implant is superior to methotrexate and randavizum from the Merrick trial. We have at our disposal corticosteroid implants and inserts that may provide extended treatment such as at the UT and is IPR, but also the registered implant. Systemic and immunomodulatory and biological therapy themselves are salutary in the treatment of macrodema and will reduce the requirement for adjunctive therapy. And part of the treatment likely has a role in the management of macrodema, although this really will require all design perspective comparative treatment. So I'd like to turn it over to Akbar who will be discussing the surgical management of a intractable macrodema. Thank you. Can I do the presenter mode? It doesn't matter, don't worry about it. All right. Thank you all. Thanks Al for a great introductory talk. I'm going to be discussing one of the aspects of UVitis management that Dr. Vaitali discussed and specifically we're going to be talking about surgical management with implantation of deposteroids. And this is a illustrative case where we used a deposteroids implanted surgically as an adjunctive treatment to immunomodulatory therapy. So this was a 17 year old Asian girl who was referred for arthritis and that is often the case when they referred for arthritis, it wasn't arthritis. And she had floaters and lots of vision in both eyes. She had a three year history of this and was recent, was currently actually admitted for suicidal ideation to uni. She has a history of depression, anorexia. She complains of anodonia suicidal ideation and auditory hallucinations. And she has a diagnosis of MDD with psychotic features. At presentation, her best corrected visual acuity was 2400, 2300. Her intraocular pressure was 1719 and she had some cell in the anterior chamber. Cell in the vitreous, two plus in both eyes with haze and systoid macular edema in both eyes as well as periflebitis and this is her OCT. And a hallmark of severe systoid macular edema is the presence of this sub-retinal fluid in addition to the systoid changes, the spaces in that are intra-retinal. And geography showed significant vascular leakage with this very arterial or clearing this fern-like pattern you see in intermediate UVitis as well as papillitis seen in both eyes. So we thought this was most likely intermediate UVitis, could be inflammatory infectious. Of course, you have to entertain retinal vasculitis. So lab workup was done, which I won't belabor, but infectious and non-infectious etiologies were investigated, all of which were negative. So the final diagnosis was intermediate UVitis, likely of the parisplanitis variety with significant systoid macular edema, vascular leakage, ultimately near vascularization of the snowbank was found as well as vitreous hemorrhage, which was noted later. The slow taper of oral prednisone in consultation with the patient psychiatrist was started with concurrent initiation of steroid sparing immunomodulation, we use mycophenolate one gram twice a day. As one would almost expect, her symptoms improved, but her psychiatric symptoms worsened. She had aggression towards peers and family with psychosis and suicidal ideation. So we very quickly decreased her prednisone to 20 milligrams daily and administered intervitral steroids, specifically the Azidex implant in both eyes. And there was complete resolution of CME. There's no steroid associate ocular hypertension and her dose of mycophenolate was increased to the maximum, which is 1,500 milligrams twice a day, so three grams a day. Despite being on cell sept, her visual acuity remained at 2,200, her macular edema was still there, but improved. This time, an angiogram showed not only diffuse leakage and papillitis, but also these little areas of hyperfluorescence denoting neovascularization, which is a feature of inflammatory disease in some cases can be a feature of peripheral non-perfusion, but can also be just a feature of inflammation seen here in the later frames. This dark area of blocking here is vitreous hemorrhage. So laser was performed to the areas of retinal non-perfusion and fearly, and we started Adelimumab or Humira, and there was some improvement of CME, but not complete. Three months after starting Adelimumab, she seemed to be doing pretty well. Her vision was 2,100, limited by some macular atrophy. Her neovascularization remained, vitreous hemorrhage had resolved. But unfortunately, three months later, she developed dense vitreous hemorrhage on the right more than the left, and the vision decreased to 2,400 in the left and count fingers in the right. And you can see here, not only is there significant media opacity, but there's also, it's the right eye and the left eye, but there's also significant macular edema. So we finally decided, okay, this is a patient on significant immunosuppression on Humira and mycophanolate maxed out, not doing well, still bleeding, still has CME, so we bit the bullet and decided to do not only a vitrectomy, but also adjunctively a reticent implant in both eyes. And a similar vision then stabilized to 2060 with resolution of the CME still some. And some macular atrophy in both eyes. So just to talk about the Redisert, Dr. Bhaitali talked to you guys about the data, but as far as implantation is concerned, I had a really fast fellow, but three millimeters posterior to the limbus and incision is performed as full thickness, you have to make sure you break through the septi and the coroid, the wound is gaped, the Redisert is implanted using full thickness strut sutures. This is then dyed in a 311 fashion, making sure it's quite tight. And then the trailing sutures are buried interest clearly so as to avoid pointy things. The wound is then closed with interrupted prolineinino suture. The conjunctiva is closed, and the tenons are closed over the Redisert. And then lastly, the adjunctiva is closed the trailing prolinein sutures are pulled and allowed to fall flush with the spirit. It's amazing what you can do in one minute and eight seconds. So in summary, this is an 18 year old girl with now 18 year old in this particular time with significant bilateral intermediate uveitis complicated by massive CME vitreous hemorrhage and macular atrophy. She was unable to tolerate steroid due to suicidal ideation and surgery was indicated for failure of immunomodulatory therapy, vitreous hemorrhage and intractable systoid macular edema. So intermediate uveitis can present with varying degrees of severity. Manifestations may include vitreous cell and haze which can be vision limiting, retinal vasculitis, systoid macular edema in a good portion of patients and it's probably the most common cause of irreversible vision loss if there's a macular atrophy. Uveated glaucoma and cataract do occur at a fairly frequent rate and optic nerve edema. Retinal non-perfusion with new vasculation in the retinal periphery and optic nerve head with vitreous hemorrhage can be present in between six and 28% as well as other structural manifestations such as every retinal membrane. Late findings in untreated disease include cyclotic membranes, tractional or regmatosinous retinal detachments which are very hard to treat. Hypotony, which is a terrible complication and tysis. Deposteroid implants can be used as both a primary and adjunctive treatment for uveatic macular edema. To go beyond the reticert itself, one teaching point from this particular case is that not everybody can be treated with systemic steroids. Psychiatric adverse effects of corticosteroids are quite common in a meta-analysis of 935 stimulative patients. The average incidence of psychiatric side effects was 27.6% and 5.7% of those were severe. And that includes when there is a risk of harm to oneself or others. So do bear that in mind when you treat people with systemic steroids. There's no particular age predilection or dose dependence despite conventional wisdom. And there's a significant association with pre-existing mental illness to do talk to patients, psychiatrists. And there's a minimal, with a significant increase in risk in women. And I'll turn it over to Dr. Lorschel. I'll answer any questions if you're having. You've already mentioned that that is the knowledge of 5-month-long-term rate of an in-bed patient with 3-week-long-term rate. You know, even six years later, she recurred. So we needed all of them. With macular edema in the right eye, 32-year-old, she had a previous lab workup that was unremarkable. And her first episode of UVitis was in January, just in the right eye. Later that year, she received a subtenance kennelog injection for vitritus and macular edema. And then she went two years without another episode until 2019. And she presented with some anterior chamber inflammation and macular edema. Again, she was administered a subtenance kennelog injection, but the macular edema actually got worse. And so at this point, as per Dr. Vitaly mentioned, the intravitural steroids have been proven to be more effective than subtenance kennelog. And so an ozardex was performed, intravitural dexamethasone. And we can see the OCTs of these. This was when she presented with macular edema, was given a subtenance kennelog a few weeks later and it actually had no effect or even a little bit worse. And then after the ozardex, it flattened out. So now it's November. It's only four months after the last ozardex. And she presents again to the triage clinic with recurrence of anterior chamber inflammation and recurrence of macular edema. At that point, she was started on Durazol and received another ozardex. But at this point, it's a young patient. She's fake it. It is unilateral disease, but if she's requiring ozardex every four months, we have to think of other ways to treat this. And so we discussed several more long-term options as such as immunosuppression. She was a little hesitant to do that because it was unilateral disease. The UVIs itself was fairly mild and controlled with drops. It was really just the macular edema that was giving us grief. And so she opted for local treatment at this time. More of her medical history included gastric sleeve surgery. So we were really trying to avoid oral prednisone in her case. And so she'd had previous mild intraocular pressure rise with intravitural steroids, but a pressure of 25 not on glaucoma drops to me is not a complete contraindication to keep using intravitural steroids. Whereas a patient with a fragile nerve, glaucoma, if they're already on max drops and the pressure goes to 25, that's a completely different story. And so a pressure of 25 without glaucoma drops, we think we could just potentially treat prophylactically or there'd be a good response from intraocular pressure lowering drops. And so this was after the Ozurdex, of course the macular edema flattened out. And we decided to use the UTIC, which is the Long Acting Fluidine-Alone Intravitural Implant that can be administered in clinic. The UTIC was placed just one month after the Ozurdex. So I didn't wait for the macular edema to recur again. I didn't wait those four months for the Ozurdex to wear off. We just went ahead and implanted the UTIC soon after the Ozurdex. And this is, I think a popular technique because UTIC doesn't have that sledge hammer effect that Ozurdex does. It's not a big bolus of intravitural steroids upfront to get rid of the macular edema. It's sort of low and slow and this little maintenance of steroids in the eye can help prevent recurrence of macular edema. But we find it's not quite as effective as that initial bolus of using the Ozurdex. We can see the pressure increased mildly to 22 after the Ozurdex injection and then up to 27 after the UTIC. But that was without glaucoma drops. So COSOFT was added and the pressure normalized. So after a few months, the pressure was normal but of course her cataract was worsening and so she underwent cataract surgery. And to date, this patient has not had a recurrence of her uveatic macular edema. She's had mild episodes of anterior chamber inflammation treated with drops but the UTIC seems to be holding strong as far as her macular edema. Caveat to this, I looked back at my data and I have implanted 18 UTIC over the last few years. I think this is my only case that was like a slam dunk that after she had the UTIC that she had absolutely no macular edema in the following three years. So it's not that this is absolutely representative of the strength of UTIC. I think we find that more often in patients that are requiring Ozurdex maybe every three months consistently for macular edema, if you put a UTIC in the eye, maybe you can stretch those Ozurdex out to five months. And so over the course of several years it really reduces the number of intraocular steroid injections they require. But I think less commonly it's like one UTIC and they never have CME again. This is a different case, a 51 year old man that's otherwise healthy. We use NGAU to abbreviate non-gramulomatous anterior uveitis and he was presenting with painless blurred vision in the right eye. He had previous episodes of uveitis about one per year that had responded to topical steroids alone. The history of Lasik and his laboratory workup was unremarkable including HLA B27. So on his exam, his vision previously 2020 uncorrected in the right eye had dropped to 2070. And this time his anterior chamber was quiet but it was noted in triage to have inflammatory cells in the vitreous as well as macular edema. So it seems like his disease has now morphed into more of an intermediate uveitis. This is his macular edema at the triage visit. He was started on prednisolone acetate six times a day and I saw him a week or two later and his vitreous information had actually subsided. It was mild to begin with, some topical steroids can help with that but his macular edema didn't budge. And so at this point we have an otherwise quiet eye but with persistent macular edema. And so what can we do for this patient? This is really the art of medicine. Oftentimes there's no one right answer of how to treat uveitis. Of course there's some wrong answers like putting intravitural steroids in an eye with an infection but with inflammatory CME we have several different good options. And so you have to just take it case by case for a certain patients. Sometimes you get some information from the patient that may sway you one way or another such as a phobia of needles or perhaps they were on oral steroids in the past for something else and they just remember the side effects being intolerable. Of course there's some more absolute contraindications for certain treatments such as putting an ozardix in a unicameral eye or patients with really fragile glaucoma, advanced optic neuropathy and a history of steroid response. We'd wanna avoid periocular steroid injections and probably dursal, no dursal can be really hypertensive. And then Dr. Shakur mentioned the psychiatric side effects and of course for oral steroids we have to consider patients with uncontrolled diabetes and the effects on glucose. So I have a discussion with a patient. A lot of times I lay out the options if there's not an absolute contraindication and then oftentimes they can decide. And so this gentleman, he was young, fit, healthy. He said, let's try the oral steroids. I don't love the idea of a needle around my eye. And so we did a six week course of oral prednisone that tapered off the topical steroids and he had 2020 vision a month later with resolution of the macular edema. But unfortunately soon after about a month after stopping the oral steroids, he presented again now with some mild intraocular inflammation in the anterior segment, but no macular edema. And so at this point, recurring soon after prednisone taper we have to start thinking about other ways to treat this more long-term such as potential systemic immunosuppression which is beyond the scope of this talk. And so lastly is macular edema, the best part of my job or the vein of my existence. I think it cuts both ways. You can see a patient that's 2070 and you give them one injection or a few weeks of prednisone and they come back and you've cured them. They're the happiest patients. They're 2020, but on the flip side of it, you have a patient that presents with chronic macular edema. They don't know how long it's been there. Sometimes you put an Osoridex in or use some other treatment form. And a month later, their OCT looks perfect and their vision has not changed. And that's because there can be chronic ellipsoid zone dysfunction and loss of the photoreceptors from chronic macular edema. And so the picture looks better and the patient notices no difference. And so that's one of the challenges with treating macular edema. And of course, the recurrent nature of it, especially in patients that are on systemic immunosuppression and their uveitis is otherwise quiet, but they have to keep coming every three to four months for injections. They're like, hey doc, what's going on? I mean, you've fixed uveitis and why do I still have to see you every three months for injections? And so a little bit of both, I think is the answer to that question. And that's all I have. Okay, so hi. I'm gonna talk about sort of additional local treatment options for uveatic macular edema. Particularly, I'd like to focus on two cases that hopefully highlight and kind of emphasize some of the concepts that Dr. Vitale had gone over with respect to some of the trials for local steroids. And hopefully highlight how that kind of played out in clinical practice for two patients. So the first patient is a 54-year-old gentleman with sarcoid-associated intermediate uveitis that was biopsy proven at least in his lung. It was diagnosed in 2010. He made his way to uveitis clinic in February of 2016. I'm in the setting of having chronic floaters in both eyes with redness, pain, light sensitivity, his vision was 2030 in both eyes and he had normal intraocular pressure. This is just his optosphoto. It's a little bit hard to appreciate, but just on exam, really the only thing that was notable was that he had mild vitreous cell with some vitreous haves and the same thing in his left eye. So mild active intermediate uveitis in both eyes. This was his fluorescent angiogram, just showing that there is peripheral retinobascular leakage in both eyes. There's hyper fluorescence of the optic nerve in both eyes indicative of papillitis. And then kind of more subtle is that you can appreciate there's this small amount of petaloid leakage in the center of the macular in both eyes indicative of angiographic CME, but on OCT, this was not clinically apparent. So there was no clinical CME related to the active uveitis. And so the assessment for this patient is that he has symptomatic active intermediate uveitis with widespread angiographic leakage without macular edema. And so just getting to the slide that Dr. Vitale showed, this patient isn't sort of in the spectrum yet of clinical macular edema. And so really we're gonna focus on just treating his inflammation. So for him, we focused or started with systemic corticosteroid with oral prednisone. Understanding that something like topical steroid probably would not be sufficient for an intermediate uveitis with sort of significant involvement of the retinal vasculature. Local steroid, such as periocular intravitural steroid probably wouldn't be the best choice with a bilateral process. And immunomodulatory therapy might be a little bit too aggressive kind of for a first time episode. And so this patient was treated with systemic corticosteroid oral prednisone starting at 60 milligrams and tapering over several months. He ended up coming back four months later after finishing the prednisone taper now with decreased vision, his right eye, which I'm gonna focus on. So he is now 2060 in the right eye at this time, still normal intracular pressure, albeit increased vitreous cell and a bit more vitreous haze. And what you can see on the angiogram is now there's increased sort of the central petaloid leakage in the right eye. Sort of this angiographic macular edema, now corresponding to clinically apparent central macular edema in his right eye related to active uveitis. And so this patient was actually enrolled in the point trial. I remember that this was the trial comparing periocular corticosteroid, so subtenons can along two intravitural steroid, either ozardix or triumcinolone. And so this patient was randomized to receive periocular steroid with STK. And I'm just gonna kind of go through kind of his OCT. So he received his first STK at the time of enrollment. And you can see that a month later, he had complete resolution of his macular edema, as well as good treatment and resolution of his active intermediate uveitis with the vitreous haze. And then all of his subsequent visits for the trial for the full six months, he had sort of resolution or no recurrence of the macular edema and his visual acuity remained in good range. And so even after that for the subsequent three years, he was just observed, he remained quiet, no intraocular inflammation and no macular edema. And then in January of 2019, he had a subtle recurrence, just a slight amount of sort of juxtaphovial intratenal fluid with symptomatic blurring of his vision. And because he did so well with STK the first time, he was treated again in the same way with an STK, which resolved the intratenal fluid. And then another three years later, he came in now with symptomatic blurring of vision, his left eye. So this is OCT of the other eye. He did not have any active intraocular inflammation, but he did have increased macular edema in the left eye. And so again, because this patient responded so well previously to STKs, he was given an STK in the left eye, but in this case, it did not show any improvement. He actually got worse with the macular edema. And so at that point, he was switched over to receive, oh, sorry, and so this was the angiogram showing that in the left eye at that time had sort of again, that active petaloid leakage with papillitis in the left eye. And so he was given an ozardix and at that point had really good resolution of the macular edema with improvement in vision. And so just to highlight and to go over again, the results of the point trial showing that in general, the intravitreal corticosteroids were significantly better than periocular steroid at improving macular edema, as well as improving visual acuity related to macular edema, which ended up playing out for this patient's second eye, the left eye that it happened in, but sort of in the real world, so this is sort of a recommendation. So this patient was one of those patients who had a good response initially to periocular steroid, which is why it was used and was effective, at least for the first several recurrences of the macular edema. So the second case is a 73-year-old woman who has HLAB-27 associated anterior uveitis. She has ankylosing spondylitis. She's had prior vitrectomies and epiretinal membrane peel, cataract surgery, and she had an Ahmed valve placed in the left eye for uveidic glaucoma. She was previously on systemic immunosuppression with oral methotrexate, but that was stopped due to adverse events and side effects. And as far as her ocular presentation, her sort of active ocular issue was not really any inflammation in the left eye, but it was recurrent macular edema related to prior inflammation for which she was receiving serial ozardx injections with good response. And so for this patient, we're sort of focused on not active uveitis, but recurrent or persistent macular edema. And so this patient with a unilateral disease was receiving regional corticosteroid with ozardx that was working with good effect. So just as an example for the left eye, this was back in August of 2016. The patient presented with central CME in the left eye, received an ozardx with good improvement. And then again in 2017 had recurrence of central uveidic macular edema and received an ozardx again with a good central improvement, at least by four months later. Again, had recurrence the subsequent year in April and at this point was actually enrolled in the Merit trial, which again, just to summarize, compared patients with the three different types of intravitural treatments. So either ozardx, methotrexate, or anti-vegif with ranivizumab. And this patient was actually randomized to receive methotrexate. And so I just go through kind of, she had ended up having four serial monthly injections of methotrexate and what she can appreciate is that there really isn't much change at all in her macular edema over time. And so at that point, the patient was crossed over to receive ozardx and again, had a really good response as she had previously with essentially resolution of her macular edema. And so even after the trial, the patient continued to receive intermittent ozardx with really, which had good efficacy for her macular edema. Unfortunately, at the end of 2019, developed endoplamitis from exposure of her Ahmed valve and the Ahmed was implanted. And so then when she subsequently recurred with her macular edema several months later, the question was, is how to treat this? The goal or the worry in this case was that doing another ozardx might induce a significant intraocular pressure response. Now that she did not have a tube in place. And so the patient was decided to try maybe kind of the third arm of the merit trial, which was to do an anti-vegette treatment. And so she received a vast in the left eye and actually got quite a bit worse. And so subsequent to that was then given an ozardx which she had a good response to previously. Unfortunately, developed a quite significant sterile endoplamitis which was treated. It was not found to be infectious in nature. It happened just a couple of days after her injection. So ultimately then given sort of the numerous issues with the ozardx inducing sterile inflammation, the patient then underwent a couple of months later a reticent implant with an Ahmed valve placed at the same time. She required several perioperative or she required perioperative steroid as well as a couple of adjunctive periocular steroids to help control her CME. And then at this point now, two years after that she remains quiet without any CME. But as you can see just with the recurrences she has distortion and damage to the central retina from these recurrent episodes of macular edema. And so I just want to highlight this is the last slide that Dr. Vitale had to summarize. So really the first key for treatment is for you get a macular edema is to treat the underlying inflammation. And then after that there are these adjunctive treatments. So the first being with our first patient kind of highlighting the results of the point trial which is that in general, intravitriocortico steroid with ozardx or Trampson alone is more efficacious than periocular steroid for uveic macular edema. Although again that is just a recommendation and so some patients can have a good response and do show significant improvement as our patient initially did. And then there's the results from the Merit trial which as our second patient showed that intravitriol steroid tends to do significantly better than either methotrexater or anti-vegF. And then depending on the comorbidities and other factors and if additional treatment is needed that there's these options for corticosteroid implants such as the Reticert which our second patient finished with and has been doing really well with. So that's all I have. Hopefully highlighting those principles that the other three have gone over so far.


The United States dispatched Army, Marine, Navy, Air Force, and a total of 1,789,000 search members in honor of the following heroes of the U.S., the Republic of Korea, and the U.N.C. sentencing stage during the Korean War. At this time, the United States Secretary of Defense, the Honorable Lord Austin, will lay a wreath in the memory of their sacrifice. Ladies and gentlemen, please join in a moment of silence followed by the playing of tests. You're proud of your contributions, and we are very proud of your contributions as well. But I can tell you, around the world, as you see our troops deployed and working together, it is impressive. Again, the United States military is the most powerful military in the world, and we absolutely take pride in our relationship with our Korean counterparts. God bless you. Thanks for all of your sacrifices and the sacrifices of your families. Again, we owe you a debt of gratitude that we can never repay for these. So, to all who have a hand in on it, please convey my thanks. One, two, three. Perfect. Great. Thank you. Okay, guys. Go get warm.