It looks like everybody's here and it is 5.30 so with that I'd like to convene this meeting of the San Lorenzo Valley District, Water District Board of Directors for November 3rd, 2022 and we have a roll call vote. Not vote. Just roll call. Roll call. President Mayhood. Here. President Ackman. Here. Director Fouls. Here. Director Hill. Here. Director Smalley. Here. Okay. Are there any additions or deletions to the closed session agenda? Staff has none, Chair. Okay. This is the time where we would have oral communications from the public on the topic that will be covered in closed session. Holly, do we have any members of the public in attendance? We do. Okay. I have a feeling that they are not going to really need to be here until 6.30. But. I think so too. So. And Tony. I think as I am Tony, you're. Thank you for getting here early. But you need to come back at 6.30. When you can give the lay doc report. And I think she's going to be here. So, again, you should be there at 6.30. Okay. May hood. Is it worth just. Asking if anybody wants to comment on the closed session. I'm sorry. I, I, yes. Just in case you want to comment on the closed session item. Please go ahead and raise your hand. Okay. Seeing no hands raised. Go ahead and adjourn us. To close session. See you on the other side. Lorenzo Valley water district board of directors. Or November 3rd. Can we have a roll call. President May hood. Here. Vice president Ackerman. Here. There are no actions to report out of closed session this evening. Are there any additions and relations to the agenda? Yes, chair. First off, can we move on to the agenda? Yes. Can we have a roll call? President May hood. Here. Vice president Ackerman. Here. Director Falls. Here. Director Hill. Here. Director Smalley. Here. Okay. Yes, chair. First off, can we move? I have CTV moved. District engineer Josh will over to the, the panelists. And I would like to remove item. 11 D. A schedule of board of directors meeting dates from the agenda. Okay. All right. That brings us to oral communications. And this is the time when we have. Comments from members of the public. And then we will move on to the agenda. And then we will move on to the agenda. On topics that lie within the jurisdiction of the district, but are not on tonight's agenda. And let's see. We have among our attendees. Jenny Gomez. Let's go ahead and let Jenny speak. And you. Have the. I'll try to make it quick. Thank you for the opportunity to speak. My name is Jenny Gomez. I used to be on the San Lorenzo Valley. Environmental committee. For the water district. I'm on the fish and wildlife advisory commission for the county. I have been for. I think four or five years now. And the reason I'm here tonight is I wanted to bring this. Really good grant opportunity. And I want to thank you for the opportunity to be here tonight. And I want to thank the community. For an important project that would make a really big difference. In my community. And that's long Pico. And that project is. For Lake. Long Pico. Which is locally known as guacamole pond. And if you've ever seen it or come anywhere near it, you know why they call it guacamole pond. It is stagnant. Fetted. Stinky. It's about. It's been a blight and a hazard. To the community. For about 50 years. It has ongoing algae issues. A few months then. Neighbors. And a few organizations. Together with. RCD. You're kind of cutting in and out. So can you lean in towards your computer? Okay. Sorry about that. The. Project includes trail work. Invasive plant removal, which has already begun. We did an extensive mapping project. And like I said, county environmental health. RCD. Lumpico. Women's social club. The valley women's club has agreed to sponsor this grant project. And what it's for is. Aeration system. For the pond, I've spoken with a number of experts and they all say that this water is going to be stagnant and stinky and yucky and a hazard. You know, and there's nothing you could do about it except an aeration system, but an aeration system would make a big difference. And so we spec'd out of system. We have a grant that's ready to be applied. The deadline is tonight. And all we need is a plug. You guys have a. Pump station right next to it. It has a meter. It has space. It takes $7 of electricity per month. It's only a hundred. Watt. Compressor that needs to be plugged in. We don't have any alternatives. There's no other way to. Clean up this water. There's no place else to plug the machine. And solar is not an option either. Unfortunately, because the panels would be about $6,000. And it would take 71 years for that to pay off. If there was enough sun there. To run the system, which there isn't. Unfortunately, it was completely surrounded by redwood trees. So I just. Please don't pull the plug on this project. All I need is a yes that we can plug it in there. And it's about $5,000. And good health and good water for the community. I guess, Jenny. The problem I have is you're asking us to make a decision. And you're asked kind of putting the board and the district manager. And you're asking us to make a decision. And you're asking kind of putting the board and the district manager on, on the spot. I know you've been communicating with the district manager, but we can't really make a decision on something that's not agendized. And so this is something we can, we can look into. And if you want the board can talk about it. But this, this isn't really something where we can. We can just make a decision on it like this based on a oral presentation. In. Oral communications. So it would be helpful if you told me what, what you wanted us to do. I can go ahead and submit the grant tonight.  Otherwise the grant can be pulled. They're not going to be considered until December. So there's still several weeks where, you know, if, if you agree, you know, we can move forward with it. And then if you don't, the grant application can be pulled. I think it's really, you know, we only meet every two weeks. So you're really kind of putting us in a bind here. I promise I'll talk to, to Rick about it. But I guess the one thing I would recommend is to see whether the grant could be revised in such a way that, that you bring electrical, you know, off of there's obviously electrical up there. If we have electric, but you create your own electrical outlet, essentially that you control and deal with. But other than that, I think, I, I think my legal counsel is going to bonk me on the head in a minute here. If I talk anymore about this, because we really can't have discussions of things that are not agendized. I, I sense the urgency in your voice, but this, this is not, you know, it's not something we can do for you tonight. I'm sorry. Okay. With that. Let's see. Any other comments from members of the public. Seeing none. We come to the president's report and I have two. First, I just want to draw attention to two letters that are at the back of the packet as informational material. And these are letters from SDR MA, which is essentially our insurance provider, congratulating our management and staff for their proactive risk management and loss prevention that. Resulted in no property liability or workman claims that were paid out in 21 22. And this shows a lot of attention to working safely, which is great for everybody, but also just from the standpoint of the district. This is also a benefit to all of us because it means that. The, because of these efforts, it saves the district money in terms of reducing our annual, annual contributions in terms of essentially insurance premiums. So thank you to staff and recognize them. The efforts. Did you want to comment on that? Yeah, so it's really great. And have they committed to reducing our premium. Because they raised it pretty substantially based on experience over the last few years. It's, if you read the letter, they say you get some points, whether that, you know, I, I don't know. You'll have to see whether that's, you know, 25 cents will get you a cup of coffee or what, but. Color me skeptical. Yeah. Okay. The second thing I'd like to do is to give a short presentation on an airborne electromagnetic survey that is going to take place. And Carly promised to put up a very short PowerPoint for me that I'm going to use to do this. Just four slides long. And if you can just blow it up to the full screen there, that would be great, Carly. And the reason I want to give people talk about this is it's, it's literally heads up. Starting November 6th for a couple of weeks, there will be a helicopter flying over the Santa Lanza Valley watershed at about 300 feet. Towing this instrumented loop that's about 75 feet across. That kind of looks like a gigantic kids bubble wand and they'll be flying over areas in the San Lorenzo Valley. Excuse me in the San Lorenzo River watershed. This is part of an airborne electromagnetic survey. They'll only be flowing in daylight hours. There will be no flights over areas where there's concentrations of businesses or houses are really high, high power electrical lines. So we won't see them over Scots Valley or downtown Felton. However, you might see them in areas around Brookdale on Pico and Glenwood. There's a flight line that's going to go through that area. Bean Creek, Xianti Creek and Lockhart Gulch and Ben Lomond, Quail Hollow and the Olympian area. Next. And what these things do is they, the loop has a magnetic field that's created by current flowing in the loop. And that magnetic field induces a very weak electrical current in the ground, sort of like when you're stuck in a big MRI tube and it induces electrical changes in the electrons in your body. The same thing is happening underground. And these penetrate down to a depth of about 1000 feet. And the data that we get back from this is used to create images of underground geological structures. And they can be used to map. The most important thing is being able to map aquifers. That is places where you have rocks or deposits that are coarse grained enough that you can store water in the pores between the grains, as opposed to impermeable rocks or clay bearing rocks or rocks like the Monterey formation, which actually block the flow of water. You can also determine the depth to the water table, connections between surface water and groundwater, and also places where sea water is intruding into aquifers near the coastline, because the sea water has different conducts. Sea water is salty, so it connects electricity a little bit better. And so you can actually map that. Next. This survey is being undertaken to support drought response and the implementation of the California Sustainable Ground Water Management Act of 2014. And these slides are being paid for by the California Department of Water Resources with funding that was provided by Prop 68, which the voters approved. There's no cost to us as a water district or for that matter to our local groundwater agency. And the goal is to create a statewide grid of electromagnetic surveys over those groundwater basins that are in overdraft. And they haven't quite gotten to our area yet, but you can see these black lines there. They've done a lot in the Central Valley, and that's because the highest priority basins were the ones that were severely in overdraft and have already been done. Next. And the final one. This technique was actually pioneered by one of my colleagues in this area and one of my colleagues at Stanford, Professor Rosemary Knight, where she did it along the coast near Watsonville in the Paharo Valley water area. And they were able to map actually where seawater was intruding into the aquifers in the Watsonville area and up to Aptos and SoCal because they'd been drawing down the water tables so much. We proposed, when I say we, I say the Santa Margarita groundwater agency, proposed flight lines in our little triangular area there that I've highlighted in the map at left to better understand the underground structures in the San Lorenzo Valley watershed. And the main purposes when I kind of was the main person that did this was chose them was citing where we might cite new groundwater production wells within existing areas or rainwater infiltration basins, understanding the linkages between creeks, springs, and marshes to groundwater so that we can better understand how taking down groundwater of ground water dependent ecosystems and fisheries and figuring out the characteristics of shallow rock formations that might be contributing to some of the private well owners having problems with their shallow wells in the Monterey formation up in the Washington Gulch area. And so I just wanted to let you know that this is what was happening. It might otherwise be alarming to see these helicopters flying over at low elevations carrying this loop right over the ground. It's nothing that's harmful. And eventually in a year we should have some really interesting sort of cross sections that show us, help us understand the geology. Okay, so that's that. I would now like to go on to the first of new business, which is the Long Pico assessment district annual report. Rick. I do believe Tony Norton the chair will be here to present this time. Okay. Let's go ahead and allow Tony Norton the chair.  Can you hear me now? Yes, we can. Great. Well, I didn't know that I was going to be presenting it. So that did I would. I'm have to say that we are really excited to be presenting this and has everybody. On the opportunity to read it. To read the report. Yes, it was in the board packet and we read it. Great. Then you'll notice that we, every, all of the funds that would be flowing into, to support the projects. Have they, it's already been spent. So we'll, we'll continue of course to pay. And the money will still come out of our tax. At the same time as I presented in our tax bill, but that, but, but it's, it's all been spent and you, though, I think we did a great job in the report of explaining how we're going to be able to, you know, I think we did a great job in the report of explaining how it was spent and we are, we're proud and we're, we're so appreciative of all the support that we were given by our Rick Rogers and his team and Holly. And Kendra there and Stephanie. They were all so supportive. So we'll still, of course, there's one project that still needs to happen. But the needs still needs to be completed. There's lots of steps that as Rick has explained before, we can get to that point that it's on, you know, on already been approved the entire project. So that's the future. I am booster. And I, you know, it's a long report. So I won't go into everything we do have. It's, it's pretty self-explanatory. Yes. So does anybody have any questions? Well, let, let, I see Rick has his hand up. So let's let Rick make a comment and then we'll go to the board. Great. Thank you, chair. Yes. You know, we're asking the board tonight to review this report, receive it and accept the, the annual report from the Laddock committee chair. Post this report on the board. We have a section dedicated to Laddock. Hold questions and answer discussion. You know, it was another very successful year. A lot of the, or the storage tank projects did come to completion. As Tony stated, there are two projects left on the project list. One has been awarded bid that we have probably a year out of pipe delivery. And that is the main line replacement along Zioni drive up to the lump Kiko booster. And the second one is the lump Kiko service lines from the main to the meter. There was a price. Excuse me. There was a project. To replace those service lines. And we opt to do that by force account. District staff at this time. Are replacing those on an as needed basis. The, the rate of failure. Has slowed down considerably with the replacement of the, the PLO. That were giving very high pressure to the service lines that were rupturing these service lines. These service lines still need to be replaced. They were unfortunately installed with a material that was very new to the industry. That did not have a very long life expectancy. Was not known at the time. Put those in. And it was done system wide. In fact, we even had some of those. Not as many city of Santa Cruz had several thousand. That they put in that they had to replace. So it was industry wide that those service lines had to be replaced. So we're doing those by force account. We can do it a little cheaper. And, you know, we have expense. All of the, the, the funds from the assessment district. But all in all, it has been a great experience with the Lompeco folks on the consolidation. Their value customers of the district. And we are supplying them with a safe bottle, wholesome. Water, a very good water quality. And we have been able to do that. And it's been a great relationship. And with that, I'll, I'll turn it over to. The chair. Okay. Thank you for adding that clarification. Bob, you are our liaison with the late. Committee. So I'll go ahead and start with you. If you have any questions or comments. Yes. Thank you. I think, you know, I'm sort of recently been appointed to that. Position. So I don't have a lot of history. On the specific activities of the. Of the Ladoch group. But I know that they've been working very hard in this. And I think the. This report as well as previous reports indicate that. I do have some personal comments from a board member. I don't know if you have any questions or comments. Yes. Thank you. I think, you know, I have some personal comments from a board point of view that I can reserve for later, but as the member of the Ladoch. Board related board liaison for the Ladoch. I wanted to thank Tony and the entire team for their work, their dedication. It's been a long. Journey to where we are now. I think there's four years left on the tax roll for the assessment. So we're, I think, over the midpoint. And I'm very glad to see that these projects are. At the stage that they're at. Okay. Let's see if any other members of the board have any comments or questions before I go back. It sounds like Bob would like to elaborate more later, but let me throw the rest of the board first. Jamie. I would just congratulate the district staff and the. Long Pico. Residents for the commitment to this because I mean, it's been years and these kinds of. You know, partnerships take years. It takes years to make these kinds of decisions to raise the money to go through environmental processes. And so we appreciate, you know, your patience and your good work for all of these years. And, you know, would that it were that every consolidation. I can have this kind of a happy ending because I know, you know, we're, we're going to be on this track with our, our friends in the, our various Boulder Creek communities for a while. So. I love that we have a model that has led to success here. Anybody else from the board, Mark. Jeff. Nope. Okay. Okay. Then let me just go back out to the public first and then I'll get back to you, Bob. Okay. Any other member of the public want to. Make a comment. Except I'm sure Tony is out there blushing from all the praise, but we'll come back and let Bob go ahead and. Make whatever other comments or questions he wants to do. Thank you. Thank you. Thank you. Thank you. Thank you for this experience. And I hope that we. Apply those lessons to the consolidations going forward. I think we've ended up at a good spot, but there was a time in this consolidation process. Where things were not going particularly well. The board had sat on its hands for. A couple of years relative to getting the project started. And during that time cost escalated significantly. And I think it's important to make sure that. And anybody else we consolidate with. That, that this board. Will. Immediately initiate projects and not wait like that. And I think it's also incumbent upon the groups that are. Working on consolidation. To make sure that those kinds of assurances are built into the agreement. And I think it's important to make sure that. That we're moving at a board meeting. In 2017, 26, no, 2017. Where one of the board members said, well, you know, if we run out of money, we'll just go back to you guys and get more. This was. This was anathema to the spirit that I think. Long Pico wanted to enter into. And certainly I think the vast majority of the community. I think it's important to make sure that we do that. Let's, let's make sure that we do. A little bit better on the next one in terms of getting the projects going. I also had a question, Rick, about. What is meant by maintenance. On the service line, because for my. Perception. We're already out of money anyway, but we are installing the, the line down. That's basically. Being paid for by the. By the community at large. That's what we need to do. And I'm just not sure what maintenance means. Means force account labor, basically Bob. Well. Does that mean. Does that mean that we wait for the service line to fail? Meaning that we cause disruption to our customers. Oner's lives to replace. Or are we doing it at a. Reduced pace where maybe we do 50 a year or. 100 a year or something like that. I'm not sure what force labor means in that. We do it. Usually they start to leak. Not total failure. You know, catastrophic failure or the customers out of water. Usually they start to leak and then we schedule and go out. We go out rather quickly because when they start to leak, there is a catastrophic failure coming. And, you know, no matter if we do it, you know, if we do do it. Scheduled wise and do it, we would still disrupt service, but we would be able to notice customer a little. While, you know, several things before, instead of 24 hours before. That we were going to turn water off the individual. So it takes, so we dig down to the corp stop. And turn off.  Usually understand. So. Are we able to do these without having to incur any kind of overtime or off hours. Labor that is, are these leaks happen. Slowly enough that allows us to. Do all of this without any unnecessary cost or any. Off hours disruption to customers. You know, it's, it's a little bit of both, but we do do full cost accounting of all work up in Lampico. And even with some overtime, we're still putting those, replacing those service lines below the recent bitted prices we've got on some of our other projects we've compared to two. There's still a pretty good savings by doing an under force account labor doing it in the maintenance department. So I think doing it under labor is, is perfectly fine. I guess the only thing I was potentially talking about is doing it on a more of a schedule. I guess the last question I have in this is. How are you keeping track of the failures that are occurring and are those failures accelerating my, my understanding is there's a point at which this type is going to me over and you're going to have a lot of. Failures that are going to be happening in a relatively short period of time. Are we, are we seeing this at all? We aren't since we've lowered the pressure when we, when we replaced all the regulator valves, we bought that pressure down considerably. And that was excelling the failure and also kind of a more of a bursting, you know, not just a week, but an actual. Right. So since you put the regulators in the mainline regulators, it's slowed it way down. We do keep, you know, a list and I, I don't have that in front of me and I can make sure James gets that in his next monthly report of, you know, how many we've changed the date, the type, we're even keeping track of material, everything. So we have a good understanding. Exactly what's going on out there. And there's the material readily available to do these replacements when they do happen. I know we're having problems with some kind of parts. I'm hopefully. Yes. We keep a pretty good inventory of the three, I mean, of the one inch poly pipe sizes and we're doubling up stock on all of our brass. So so far we've been able to keep ahead of the material procurement issues. I want to make sure that we understand that the board understands the community understands that that assessment district had these service line replacement as a commitment. And until that is done, this project is not complete. That is our obligation to make sure that that happens. And while I would like to see that happen faster, that's, that's my objective. Let's, let's run for a little while and see how it works with the slow weeks that we're occurring so far. Thank you. Any other comments from members of the board. Okay. Then what I would like to do is. Move that the board receive and accept the annual report from the laid out committee chair and post the report on the page of the district website. I'll second that. Thank you. Any comments, questions about the motion in front of us from members of the board. Any comments. From members of the public. If not, can we just take, voice vote all in favor. I. All opposed. Abstentions. Okay. Unanimously passed. Okay. Next item on the agenda is. The recommendation to award. Construction. For the form and pipeline access trail rehabilitation project. Right. And the district engineer chair will present this time to the board. Josh. Thank you, Rick. As I believe everyone here knows, because we've talked about this a few times. After the CCU fires. We moved quickly. To get water back into the lion treatment plant. The fastest way to do that was to. Get the form and intake back online, because it's the closest one. In that effort. We brought in a local contractor, John Vanderstein, who did. Tremendous work for us. And as part of his work, he cut essentially an access trail. On which to place pipe. Or in which to place pipe. This project is the remaining piece of the FEMA funded project, which is restoration of that area, or at least. Providing permanent erosion control. We want to. Ensure that we're not. Creating risk for anyone downslope. Or. Towards form and creek. To that end. The district published an RFP. For design, which was one by four men. Briar and Loretta. Excuse me. They did the design. We published the RFP for construction. The first time we published it, we only got one bid. So we were not able to open because. One bit's not competitive. We republished the RFP. And then a fair amount of outreach. And received some funding. And we were able to. We were able to open the RFP. And then a fair amount of outreach. And received seven bids this time. Oh, most of them from fairly large companies, as opposed to some of the smaller companies that we've been seeing that on our projects more recently. The low bid was from McGuire and Hester. And I have provided in. My memo to the board. A recommendation that the board direct the district manager to enter into a contract with McGuire and Hester for construction. Of this project. With that, I will take questions. Jamie, I'll start with you. I don't really have a lot of questions about this. I think this is the necessary next step. So. All right. Well, we'll just go on Bob. Yes. Yeah, thanks. I, I was looking at this. I was actually intrigued by the. The material that was. That was there. That was the. The Tesco. The Teco Matt. And I went and looked at it. You know, you can find anything on YouTube now. I think so. I went and took a look at it. It's pretty interesting stuff. Is this kind of the. For the new standard for us for permanent erosion control, as opposed to any other. Nothing. Not really. We don't necessarily have a specific. Technique that we use on a regular basis. What we do. Is assess what we. What the constraints are of a site and what the risks are. And determine the appropriate methodology based on that. In this case, we're attempting to restrain fairly large degree. Teco Matt is the best choice. And it. Okay. So for this particular item. It's the best choice. I would, would, do we think that this would be the same for. The p vine or clear creek. Pipe's would, would the same kind of. Approach be used. Without getting into details of another much larger project. This particular product is likely to be useful in. We'll encounter in that project. I'm reluctant to. If you have any numbers about how much. But I mean, it is a well. Understood. And. Appears to be very useful. The YouTube I was looking at with. Much deeper slope than the form. They seem to be really happy with it. It was in Switzerland before. Yeah. Yes. The Teco Matt has become. Over the last 10 or 12 years. A fairly standard technique and a fairly standard material used. Or retention of slopes. Caltrans loves it. Yeah. And are we going to be doing the same drilling into the hillside and. Mortar and the bolts in the whole bit. In certain locations. Yes. We're going to be doing the same. We're going to be doing the same. We're going to be doing the same. Very site and situation dependent. In this case, we will be using soil nails or. Anchors. In certain locations. Okay. How does this do with respect to fire? Fire came through. Again. Like any. Like any other galvanized steel product. It's. Fairly immune to fire until you get. Fire. Fire. Or fires. Future of just moving through an area or unlikely to damage it. And are we going to be able to. More readily keep this area clear. Of debris. And any kind of, you know. File fires. Fuel. By having this down. Does that help us do that? The two are not related. Okay. Okay, great. Thank you. Mark, I realized I should have gone to you for a sister of the engineering department. Many, but did you have a comment or question? Two comments. Seven bids. Great job. Josh and the engineering department staff. In getting seven bids. And contractors that are. Reputable. The second is on the winning bitter McGuire and Hester. I've. Supervised projects of theirs before they're a very good contractor. They perform well for my clients on other projects. So I applaud the fact that we're able to get them. Good job. Thank you. That's all I have. Thanks. Thanks. Jeff, did you have anything you wanted to ask her? It looks like a very good project to me. Like Bob, I was fascinated by the. Teco Matt substance and. I've had. Opportunities to stabilize other types of ill sites. And this looks like like something I might have used if I know about it. Mark, did you want to pop in again? Yes, I do realize I have one or two. Cost related questions. Rick, is this cost budgeted? This is it. This is a FEMA project. So in a sense, it is budgeted. And it'll be a 90% FEMA. 10% district. Contribution. Out of the 15 million, right? Okay. Thank you. Thank you. Are there any questions from our two attendees? Would anybody like to make a motion about this? Sure. I'll move that. We direct the district manager to enter into a contract with McGuire and Hester for construction activities related to the form and pipeline access trail. Rehabilitation project. I'll move that. Thank you. 949 and 80 cents. Is there a second? I'll second that. Thank you for putting that together. All right. Can we have a roll call? Colleen. President Mayhead. Vice president Ackman. Yes. Director Smalley. Yes. Okay. The motion passes unanimously. We move to our last item of new business, the multiple user variance renewals for 2022-23. And we do have the finance manager here tonight to present this item to the board. All right. So it was recommended that the board of directors review this memo and approve a one year variance from multiple user status for the following property owners. A list of the account numbers is provided. Basically what this is, is customers that are multiple user status qualify for an exemption are charged the five eighth monthly basic fee as a single found family dwelling. While those who are multiple users are charged one inch monthly basic service fee. Customers are allowed to apply for a variance if they are not renting out the second dwelling unit. In which we would, instead of charging the one inch fee, we would drop them down back to the five eighths fee. So basically this is just a, another one year approval for the variance. For once it's not my dogs. Sorry. I'm grateful. It's nice to hear. Okay. Jeff, you're with me on the budget and finance. Would you like to comment on this? It makes sense to me. I, you know, if you've got, you know, with only one person or only one unit occupied, it just makes sense. And I don't think it has any significant impact. How many accounts do we have like this? Well, you can see at the bottom. The impact is only 8,300. Yeah. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. It's not 8,300. Yeah. I mean, this is, this is de minimis as far as I'm concerned. Right. That it's not, it seems only fair to the, to the customers. Yeah. I think it's 29 out of 472 multiple user accounts. Yeah. This seems only fair. Any other questions, comments from the board? Tom. No, no, no. The council will remove from there. I think due to the fact that. Ownership changed and likely the previous owners didn't tell them about this. We get the paperwork in on time. Is the paperwork being on time as a state law? Or is that a, is that a board level? Policy. but we do send out letters, we send out two notices giving them the chance to respond and fill out the form. I do know that it is like the the verbiage on the form is they're signing it under penalty of perjury and all that, you know, stating that, you know, they are not renting it out and things like that. So we do give them two chances to send us back the form and if we don't recede them, then that's when we remove them from the list. And in the case of those two, where the homes turned over, did it go to the new owners and they declined to return it? I'd have to look at the specifics of it. I'm not sure in this case one of our customer service representatives put together this list. I would have to double check on the specifics for these two accounts. But I can get that back to you. But if it goes to a new owner, we do send out a form to the new owners as well, when it changes ownership. Okay, so the two owners there, they're not complaining about the situation that they have right now, the fact that they're now being charged for multiple family. I mean, I would have to check the specifics of the two accounts that are being removed. Like I said, I don't know in particular those two. So I'd like to agree with Bob here that this needs to be looked into because we don't want to have a couple of accounts that are, you know, trapped in some catch 22 thing here that's, that's, you know, that's actually unfair. So we should, you know, take a look at this and make sure these people are being reasonably treated. Right. No, when they, when we, when they change ownership and they come up as the multiple user status, we, we send out the form allowing them to rest, allowing them to sign for the variance if they are not renting out the second unit. So that's something that is happening during the opening of the new account process. Yeah, they may not have understood or they may have. I just was curious basically whether it was an issue or not. Thank you. Rick. Yeah, this is district ordinance 43 and 47 that allows us to charge the multiple user and has the variance information in the ordinance. This is not a state law. That's what I thought, but I didn't, I didn't have the ordinance. Well, it seems to me that if we're sending out letters on the change of ownership and therefore also the change of the account name, we should be catching those, those people. Yeah, I'm just hoping it's, it's clear what, what it is. It may, you know, if people haven't lived in this kind of situation, they just may not know what it means. But, but yeah, if we've given them notice that word. Yeah, it explains it in the letter that we send. Okay, great. Thank you. Would a board member, well, let's see, are there any questions or comments from members of the public? No. Would a board member like to make a motion regarding the resolution? I'll move the resolution to approve a one year variance from the multiple user status for the property owners listed on the resolution. Thank you. I'll second that. Can we have a roll called out, Holly? Senator Mayhead. Aye. Vice President Ackman. Yes. Director Falls. Yes. Yes. Director Hill. Yes. Director Smalley. Yes. Okay. Motion passes unanimously. Next are consent agenda. We just have one item, the board minutes for 1020. Anybody want to pull this from the consent agenda? Hearing nobody. How about from the public? Okay, then we will consider the consent agenda adopted. District reports. Rick tells me he has no district manager report for tonight. There are no communications. I already covered the informational material in my president's report. So that, blessedly, brings us to 16. But Rick has his hand up. So I just wanted to state on the two correspondence from SDRMA, one point reflects to 1% discount of the total premium. I think we're eligible up to 10 points for no vehicle accidents for safety program and so forth. So it does give us a discount on our total bill. Woohoo. That's great. Well, 1% is better than a stick in the eye. No, we count nickels, don't we? Okay. All right. With that objection, I will adjourn this meeting. Good night all.


All this month at Appalachian Wireless, get the only truly water-resistant Android smartphone the Samsung Galaxy S7 for just $99.99 and get a second one free while supplies last. Service agreement is required. Better service? Bigger savings? That's today's Appalachian Wireless. Twelve teams suited up for a mine safety competition in Pikeville this week. For three days, miners from four states were given different mine emergency scenarios to work through.  They're set up with entries with certain problems along the way. They, as the team advances, and as you can see they have apparatus on so they are actually under oxygen. They're not breathing any of the external atmosphere. They come across placards that tells them water, roof fall, methane, explosive mixtures and they have to solve these problems. It's required for every coal mine in the United States to have a mine rescue team, whether it be men already at the company or third party. To comply with the Mine Safety and Health Administration, each safety team must compete in a mine safety competition annually. It's a pretty intense competition. These guys are special people that do it and they're very highly skilled and these competitions keep them ready to respond. Due to the struggling economy, the competition had a 35 to 40 percent decline in participation. As the industry declines, the participation in mine rescue, the affordability for coal companies to furnish a mine rescue team has been a lot more pressure on them. That's why we're so pleased we got the multi-state interaction here. Alabama, Virginia, West Virginia and Kentucky were the participating states. The competition concluded Thursday afternoon. Reporting in Pikeville for EKB News, I'm Shelby Steele.


Good morning, everyone. Good morning. So I'll get started. So for those who don't know me, my name is Katie Wing. I'm one of the cornea fellows. And today I wanted to present about the surgical management of peripheral ulcerative keratitis. And I should clarify that actually, we try to avoid surgery as much as possible in these cases. But I wanted to talk about situations in which you may not be able to do that. So let's go to the case that prompted this thought process. We had a 30-year-old African-American male who presented to our clinic in April of 2018 with discomfort in the right eye for two weeks. This is a photo of his eye, of his right eye. His vision was actually 2020, and his pressure was normal. But as you can see here, he had conjunctival and scleral injection leading up to the limbis, an area of peripheral crescentic ulceration that also had an epithelial defect overlying and stained with fluorescein. So he clearly does have PUK. Now, why does he have this condition? We actually performed a full workup. And his review systems was negative. We sent laboratory testing, which was negative for ANA, rheumatoid factor, ANCA, infectious conditions such as quantifera intreponemal testing, sarcoidosis. And we actually eventually did also perform swabs of the area of ulceration that were negative for HSV, VZV, PCR, and bacteria. His chest X-ray was negative. No high-lart lymphadenopathy to suggest sarcoidosis. And we unfortunately were not able to obtain a family history as he was adopted. But ultimately, it seems like this is probably an undifferentiated case of PUK, so not related to a systemic inflammatory condition, but clearly still vision-threatening. So he was actually lost a follow-up for a few months after this point. He came from Wyoming about 10 hours away, and I think that contributed a lot to that loss of follow-up. But he eventually did come back in July 2018 as well, still with discomfort. And as you can see here now, his vision's 2150, can hold 2100. And if you compare the photos from April 2018 to July 2018, you can clearly see progression towards the central visual axis of this area of ulceration. So he clearly has worsening disease. We actually initiated oral steroids immediately on high dose, especially given that his infectious workup was negative. And we referred him to rheumatology, who saw him within the week, and who recommended Rituximab given the severe nature and vision-threatening nature of his condition. Unfortunately, there were insurance delays in getting it Rituximab approved for this patient. And thus, a month passed, and then he came back in August for a routine exam. He complained of worsening vision for the past few days, and he had a flat anterior chamber at that moment. So clearly, he's perforated. This is not good. And in terms of where the area of perforation was, it appeared that actually in the inferior area of that christenic ulceration, there was a corneal flap already overlying an area that was probably previously side-L positive, although currently was side-L negative. So we elected out the point not to glue that area, given that it already self-sealed to avoid manipulation of the area. But we did recommend inpatient admission for a media IV salumetral, as well as inpatient initiation of Rituximab, given that it'd be easier to obtain as an inpatient. So what has happened to this patient afterwards? Well, I'm going to leave you guys in suspense. We'll go back to this patient at the end of the presentation. But first, I wanted to go over a few questions that appeared in my mind when this patient presented. The first is, in these cases of PUK, how often does perforation happen? And if medical management, such as gluing, or high-dose immunosuppression in inflammatory cases, doesn't work, what are the surgical outcomes if you need to do an emergent graft? And what are the surgical techniques utilized in these circumstances? So let's go over our first question, just how often does perforation happen in these cases? So this was a retrospective case series of patients who presented to a single center in Bristol to an ocular inflammation specialist of all cases of PUK over 2002 to 2012. The authors excluded infectious ideologies of perforation. These were only inflammatory cases of PUK. There were 85 eyes total, and 11, actually, upon perforation were already perforated. Five out of those 11 were initially attempted to glue, and the other six out of 11 went immediately to surgery, although all eventually required surgery. So even those five patients in which it was attempted to glue, the authors were not able to obtain anatomical success on that method. And my interpretation from this is that, actually, 11 out of 85 is higher than I would have expected, but granted, these are patients presenting to an ocular inflammation specialist, who probably actually are referred from other ophthalmologists. So this may not be the general PUK population, not at this tertiary center. And let's go to our second question, which is, if medical management doesn't work, what are the surgical outcomes? So this was an analysis of 32 eyes, also a retrospective case series, from 1980 to 1994 of all corneal perforations related to rheumatoid arthritis that presented to more fields. There were 32 eyes total, and in terms of the success, zero out of six patients who got glued had anatomic success, as in the globe, integrity was able to be preserved on that alone. Three out of four patients who had lamellar care to capacity had anatomic success, and 10 out of 22 patients who had PKPs had anatomic success. So my interpretation of this is that, gluing really doesn't seem to be too successful, at least in this case series, although graphs, at least in some cases, were able to reinstate globe integrity. Actually, the graph success was also lower than I would have anticipated, but that being said, these are patients who are actively inflamed, and furthermore, the period of time, 1980 to 1994, is before we had a lot of the newer immunosuppression that is available today, for example, where tuximab was not available then, so I think that this may not be applicable to today's breath of immunosuppression. Now, this was actually a retrospective study of all corneas needing care to plastic for tectonic indication, including infectious trauma, trauma inflammatory, among others, from 1991 to 2009 in the Singapore National Eye Center, and the authors analyzed tectonic failure, aka anatomical failure, loss of the globe integrity, and physiologic failure, aka loss of graft clarity. There were 362 eyes who presented who needed care to plastic for tectonic indications in this time period, which is almost 20 years. Now, when the authors performed a multivariate logistic regression, they found that factors that were associated with tectonic failure was actually lid disease, which was surprising to me, as well as receiving a lamellar graft or peripheral graft as compared to a central penetrating care to plastic. Now, with regards to the type of graft, the authors did note that patients with inflammatory conditions tended to get the ALKs and the peripheral grafts versus those with infectious conditions tended to get more of the central PKs. So I don't think that the populations are totally equal and I actually don't think that's really captured in this multivariate analysis. So it's hard to say what to make of the data regarding the type of graft, but I do think that the lid disease data is actually really interesting because that's not something that I would typically care about or think about if a patient presented with needing a tectonic graft, but perhaps it is something that we actually should think about. When the authors looked at risk factors for physiologic failure, they found that inflammation was definitely a risk factor for physiologic failure, which makes sense and is what we would expect. And they also found that greater graft size, greater than nine millimeters, was associated with decreased graft success. Now there's two ways, I think, to interpret this data. The first is that a larger graft is closer to the limbis and thus perhaps more risk of rejection, but that being said, I think perhaps those patients with more severe disease required the greater graft size. So I think that once again, it's hard to know what to make of this data in terms of the graft size. So let's say someone does need a surgical graft. What are the surgical techniques utilized? So for this patient, recall, he had a perforation that we think was inferior. You know, do we do a large diameter PKP? Do we do a small eccentric circular graft? Are there other shapes that we can do? Actually, when you look at the literature, there's really a wide array of techniques that have been utilized, very varied, for repairing these patients. So techniques described include large diameter grafts, sclerocharitoplasty, eccentric small grafts, biconvex, crescentic grafts, no star-shaped grafts, unfortunately. So this was actually a study that looked at large diameter grafts. So recall, we talked about large diameter grafts earlier. And this study was actually a retrospective case series that looked at 35 eyes with large diameter grafts at one institution. Large diameter, this study was defined as 8.75 millimeters or above, although I've also seen it defined as nine millimeters and higher. For reference in the OR, I've seen that we have tended to use about eight to 8.25 millimeter grafts for a normal patient. This study actually was a non-inflamed eye, so eyes with keratoconus and pollucid. And the authors argue that actually at follow-up, 33 out of 35 patients were without graft failure. And also that they had fairly good astigmatic outcomes. So what they wanted to show a point of in this article was that large endrographs are not so bad. I don't know if this really would apply to an actively inflamed patient, but once again, perhaps in a patient with active inflammation, maybe a large endrograph is really your only option. Now another technique described is scleral keratoplasty. So let's say you have a patient with a large central corneal ulcer that extends into the sclera, causing scleral necrosis. What do you do in that instance? So this was a study that described a technique whereby you actually get the entire globe from the eye bank, you fixate the globe, then you use a 14 millimeter trefine to make a mark onto the sclera. Then you do a partial lamellar sclera dissection that extends 0.5 millimeters onto the peripheral cornea, and then use a full thickness, 10 millimeter trefine to punch a full thickness corneal button. Now the recipient is prepared the same way using the 14 millimeter trefine and then the 10 millimeter trefine and then the two ends are sewn together. And it's thought that this method can preserve the angle and thus hopefully lead to less chance of glaucoma in the future. Now this study actually looked at eccentric round small diameter graphs, so graphs that are off center but round. And this was a retrospective case series that looked at seven patients with eccentric small graphs for various conditions, for example, inflammatory conditions, but also corneal wound burns, et cetera. The graphs were 3.0 to 5.5 millimeters in diameter. Follow-up mean was 21 months. And at follow-up, four out of seven patients had no significant irregular stigmatism. Although three out of the seven did have a regular stigmatism, all graphs had anatomic success. So the author's point that they were trying to make in this paper was that small eccentric graphs are able to succeed and may even not cause significant irregular stigmatism. However, what if you're worried that a small graph, even if you place in the periphery, the sutures are still gonna cross the visual axis? What are some other options? So other techniques described in the literature include chrysantic graphs, and as you can see here, the pupillary axis is spared, or biconvex graphs as seen here. And there are various techniques described in the literature for how to harvest these graphs accurately. So we went over a few questions, which is how often does perforation happen in these cases? If medical management doesn't work, what are the surgical outcomes? And what are some surgical techniques that haven't been described in the literature? So back to our patient. Recall that he had perforation and inpatient admission. He received IV cell imedrile that day and also started a cruximab two days later. And actually, his AC reformed, which was great as he did not require surgery and he was continued on an oral steroid taper. This is him actually November, so a few months later, and he looks actually really great. His vision's 2200, pinhole 2060, likely because of the irregular stigmatism and also central nature of the area of prior ulceration. And he's quiet. He has no scleritis, no active PUK, his AC's quiet. And I think an interesting question is in the future, when and if he may be a candidate for a PKP for visual indication, so not tectonic but visual indications. So there's actually not a lot of data regarding this.  So I think in the end it will be a judgment call as to when and if and how to immunosuppress this patient around the time of maybe him wanting or being a candidate for a visually restorative graft. Thank you so much, and that's the end of my presentation. I apologize, I didn't get a chance to introduce Katie. She kind of snuck up here, but I'll take a second just to introduce Brock, one of our glaucoma fellows. So Brock came to us from Oregon and we're really excited to have him here. He's been great oncologist speaking from a resident's perspective. We just love having both of them on Katie here, so I'll turn the time over to Brock. All right, so thank you for the introduction. So when I was deciding on what kind of topic to present, I kind of pulled the residents to see what they think would be the most interesting and beneficial to them. And I kept, the recurring theme kept being that there's so many migs, how do I make sense of them, and then how do I apply this to practice and what's the role of migs? So glaucoma is a leading cause of irreversible blindness in the world. The only modifiable risk factor for glaucoma is lowering IOP. Traditional treatment algorithms are typically start with medications, then we do laser, then we do surgery, typically trabeculectomy or glaucoma drainage devices. The problem is that the laser effect is only temporary, and we have high complication rates with our traditional glaucoma surgeries. Over 30% for traps and tubes with re-operation, over 20% in the trap versus tube study. So anybody that does glaucoma surgery is familiar with complications. So these are just a few of the complications that we see with trabeculectomy from the trap versus tube study.  So even though migs have an increasing role in glaucoma management, none have matched trabeculectomy or tube shunts for lowering IOP. And so despite these complications, unfortunately, traps aren't going away anytime soon. So I think that it's important that we not lose sight of that and that the role that migs have. And the other thing is that migs kind of come and go, as we know with Cypass, but trabeculectomy has really kind of remained a big part of management since the 1960s. And then there are some people that argue whether or not migs stands for minimally invasive glaucoma surgery versus minimally effective glaucoma surgery. So, and then the other thing is this is not a comprehensive review. I'm kind of giving a general overview and just kind of some pearls of different migs and kind of how they are fitting into our treatment. Okay, so the cardinal features of migs, you know, there's an ab and terminal microincisional approach. The exceptions are in focus micro-shunt, which I'll talk about later, which is an ab external approach. And that there's minimal trauma and disruption to normal anatomy and physiology. They have demonstrable and reliable IOP lowering with an extremely high safety profile, rapid post-op recovery and minimal need for follow-up. So basically the polar opposite of trabeculectomy is what we're after here. So unfortunately, the reality is there's really no free lunch. Zen, which I'll talk about in a little bit, has needling rates as high as 47% in the literature. Hypotony is still problematic with some of the migs procedures, especially Cypass, which is no longer with us. And then also having the sudden unpredictable IOP spike with a cleft closure of Cypass, which you can see in the top right-hand photo here. That's just the cyclodialysis cleft. And then even these ice dens, which you think can be especially benign, you can cause an iatrogenic cyclodialysis cleft. So this is not something that is completely foolproof. Also, the hyphema rates can be over 30% with GAT. And I've seen some really impressive hyphemas here today. So these are not necessarily minimally invasive. So the migs roll. So basically it's reducing IOP as well as the medication burden. So these medications come with a lot of side effects. Getting the medications inside the eye is very challenging. If you've ever actually watched your patients instill a drop, you'll see, you'll learn a lot and you'll see that a lot of these patients just they can't tolerate the drops and they can't even get them in the eye. And then just a couple of side effects here on the left. We have the prostaglandin associated orbitopathy and then the familiar follicular reaction that we see with our alpha agnes. So generally they're less effective in lowering IOP than traditional tribes and tubes. But they do kind of fill the gap between patients needing lower IOP without warranting the high risk of these traditional trapezolectomies and tube shunts. And so these are generally used for mild and moderate glaucoma. So as you see in the middle, these are the patients that we're really targeting with our migs procedures. They're not for advanced patients and really not necessarily for ocular hypertensive patients. So there's really, there's so many options. So we have our trabecular outflow targets. We have our ice stent or trabecotone, Cahook dual blade, hydrous micro stent, adventurinal canaloplasty, Trab 360 trabeculotomy, our GAT, and then we have our supracoital, which are Cypass, which is no longer here. And then the ice stent supra, which is awaiting FDA approval. And then we have our ZEN, our infocus. The ZEN is here. The infocus is currently approved in Canada, but is currently awaiting approval here. And then we can target aqueous production with our ECP. So just even within the last five years, we've got a lot of new arrows in the quiver, but kind of where do they fit and how do we make use of all these devices? So just kind of starting into a general overview so that you kind of have a general sense of how these devices work. So the ice stent is one of the first that came out. So this is an AB internos insertion of these micro stents in the Schlens canal. So you can see that I've kind of tried to sort out just the average IOP reduction from all these devices. So it was 8.4 at two years with the original ice stent, which you see on the top right, and then 8.1 at one year with the new ice stent inject where you implant two of these ice stents in the trabecular mesh work. So these were actually randomized controlled trials and prospective randomized controlled trials. And then the medication reduction was about one drop at two years. Moving on, trabectum, I've never actually seen one of these, but this is an ab interno trabeculotomy using a combination of electrocotterate irrigation and aspiration. So same thing, ab interno kind of going over the top of the trabecular mesh work to create a trabeculotomy. So IOP reduction was 6.2 at two years when combined with cataract surgery. And this was just a meta analysis. There wasn't any, there haven't been any randomized controlled trials. And then medication reduction just under one drop at two years. Next kind of similar is the Cahook dual blade goniotomy. So it's an ab interno goniotomy unroofing Schlens canal. So we have an IOP reduction of about six at one year. And this is just a retrospective analysis. There haven't been any randomized controlled trials. Same thing about one drop at one year from retrospective review. Next we have the hydris, which we just started doing here within the past couple of weeks. So this is an ab interno insertion of this larger kind of micro stem that's placed in this Schlens canal. So here we're getting a higher IOP reduction 9.4 at two years when combined with cataract surgery. So you can see that's just have a, I'll just show you on the, sorry about that. So this is actually the inlet. So this is actually inserted into the canal, fluid drains from the anterior chamber into Schlens canal and eventually off the distal collector channels. Next we have ab interno canaloplasty. So this is an ab interno insertion of an illuminated micro catheter. So initially a cleft is created through the trabecular mesh work using an MBR blade. And then this micro catheter is actually inserted into that cleft and then is introduced 360 degrees around Schlens canal and then is slowly withdrawn at the same time, injecting viscoelastic to dilate the Schlens canal on the collector channels. So this can be done as a standalone surgery. So it doesn't require that the patient have a visually significant cataract. And the IOP reduction was about four and this is a case series review. Medication reduction was one at one year. And then similar, we have what we call a GAT or a Gonioscopic Assisted Transluminal Traveculotomy. Same thing where a cleft is initially made and then the micro catheter is passed through Schlens canal. And then instead of just withdrawing it directly through the other end, the other free end is actually grabbed as well. And then you're basically unroofing the entire trabecular mesh work 360 degrees creating a direct outflow from the anterior chamber and bypassing that trabecular mesh work. So this can also be done as a standalone surgery. IOP reduction on average was about 8.4 at one year. This is also a retrospective review. And then medication reduction was higher at about two at one year. These patients do have a higher rate of high FEMA. And like I said, it can be pretty impressive at times. Next, so kind of moving on past the trabecular mesh work now we're in the suprachoroidal space. So this is the side pass micro stem. So same thing inserted ab interno directly between the anterior chamber in the suprachoroidal space. So IOP reduction was about 7.4 when combined with cataract surgery at two years. And this was a randomized control trial. Unfortunately, or fortunately, depending on how you feel about it, this was withdrawn from the global market recently. After they reportedly showed that there was increased endothelial cell loss when compared to cataract surgery alone. You know, these have had other issues. It wasn't just that they only had endothelial cell loss. The clefts would close kind of unpredictably and you would get sudden IOP spikes where the patient's pressure would be eight and then all of a sudden it would be 50 the next time that you saw them. And so it was kind of without warning. So those were some of the other issues that you have with that. And then hypotomy was also an issue with this procedure. Giving a fluid tracking around the cyclonellysis cleft through the stem. So next is a similar, is Eistence supra. So this is kind of a competing device. So this is the same thing. It's kind of inserted abintero into the suprachoridil space. Has similar IOP reduction, 7.8 at two years. This is a prospective single arm clinical trial. It's approved in Europe. They're using it now. Currently waiting FDA approval here in the U.S. So next, kind of moving onto a subconjunctival approaches. So this is a zen gel stem. So same thing, abinterno insertion. It's kind of a flexible tube implant that allows fluid to drain from the anterior chamber into the subconjunctival space forming up the lab. So IOP reduction was nine at one year. Medication reduction was almost two at one year. This is a prospective single arm clinical trial. So this kind of outlines how the procedure is done. One of the biggest issues with these procedures that the needling rates are incredibly high, upwards of 50%, if you look at the studies. So these are, they do have their issues and they have all the issues that you see with blood formation as well. Although they tend to be a lot lower bloods. So next is the infocus microchunk. So this is a little bit different. It's an abexterno subconjunctival insertion. So you still have to do it pretty similar to what you'd do with the trabeculectomy. And then this tube shown is placed through the sclera into the anterior chamber. So the IOP reduction was 16.2 at three years when combined with cataract surgery. So there's a lot of optimism. This might kind of be, maybe not quite the holy grail of what we're looking at, but definitely better than a lot of the migs that we've used so far. So currently they're using this in Canada. ICOMN that is a big proponent of this surgery. That's what he's doing a lot of right now. And so I'm really excited and hopeful that this will get approval here in the US sooner than later. Next is our endocytophocicliculation, or ECP. So this is now targeting aqueous production. So this is an abinterno cycloadestruction procedure of the scillary body. So up to the right you can see, basically you're actually looking at a monitor while you're inside the patient's eye to be able to target. The scillary process almost looks like little teeth. And as you cauterize them, they kind of shrink up. So it's actually kind of satisfying procedure. You can see that you're actually having some impact. Unfortunately the medication, the IOP reduction is not great. It's about two, but in some of these patients that have end stage or that have glaucoma and you're really hesitant to do a standard diode procedure, I think this has a great role for these patients. And medication reduction was about one at one year. And this is a prospective case control study. So as far as patient selection, so I think we kind of need to take a mechanistic approach. So the first question you need to ask, does this patient have a cataract that will immediately disqualify some patients from some of the makes procedures that we just spoke of. So if they're only a candidate for standalone makes, that includes the Zen, the infocus, which we don't have here yet, have internal canaloplasty, GAT or ECP. So a lot of the angle surgeries that we just mentioned, they don't qualify unless they have a cataract to do surgery as well. So if they have a lot of conjunctival scarring from previous surgeries such as a scleral buckle, they're not gonna be a great candidate for a Zen or an infocus shunt. Maybe we need to consider targeting trabecular mesh work or UVO scleral pathways. Some people might argue that makes really has no role in a lot of these types of patients. So maybe just a standard tube shunt would be a better idea in some of these patients. And then is there inflammation present? So same thing, these patients are gonna do poorly with some conjunctival nigs if you're concerned about a lot of inflammation in them scarring down their blood. And then ECP, you're intentionally destroying that set of your processes. So probably not a great idea if they're already having a lot of inflammation. Is the angle scarred due to PAS? So a lot of times, sometimes you can get away with going to sneak your lysis if the PAS have been present within the past year. But MIGs really aren't approved for coposar glaucoma, but we've been using them here after following gonious sneak your lysis, you can actually get a good view of the angle. And then you can oftentimes still do some of these MIGs procedures to open things up after that's done. And then is there a chemical burn or OCP affecting the collector channels? So they're probably not gonna be a great candidate for trabecular outflow procedures. You could consider targeting the super facility space. Unfortunately, we don't really have any of those targets right now with PsiPAS being recalled. So again, these are some challenging patients to deal with. So kind of moving on to a case. So this was a 36-year-old monocular patient with juvenile open-angle glaucoma. He was enucleated. He had had multiple glaucoma surgeries and then had a ticicoli. So his right eye was enucleated and his left eye, his vision was 20-20. You can see his IOP was 26 on Latina Prosper monodine, COSOP, or PRESA, kind of on maximum medical therapy. And then he'd had a repeatable progression of the spurinazole step on hypervisual field testing. He's already had SLT. He's got a clear lens, open-angle. So kind of what would be the next step in management. You can see that he's got a spurinazole step. He's got a dischem on exam and then he's got inferior thinning on OCT. So are we gonna go with the traditional approach and do a trabeculectomy on this 36-year-old? Trabeculectomies, they do fail over time. And so you really wanna try to keep as many doors open as possible in a young patient. So first of all, he's only a candidate for standalone migs. He doesn't have a cataract. So the traditional pathway would be a trabeculectomy followed by a tube, then maybe a diode. So realistically, this patient's gonna live a lot longer than probably what those surgeries would get him time-wise. So like I said, you need to keep a lot of future surgical options open. So you could consider a standalone-angle surgeries. You could do canaloplasty or GAP. It would spare his conjunctiva for future surgeries. Or you could consider going to a sub-conjunctival surgery with the zen or the infocus. So for him, he ended up getting a GAP. You could also make the argument of trying canaloplasty. But if you remember, the IOP reduction was about four on average in patients from that study. So probably not likely to get him where he needs to be. So a GAP was chosen for this patient. And as you can see, he's done, initially he had a large hyphema, but then had done very well. Afterwards, IOP was 18 on just cosoptin-latanoprost. Vision was 20-20. And hopefully, ideally, this patient will will keep his vision for the remainder of his life depending on how long these work. Okay, and those are my references. And any questions that I can take? Yes? You mentioned several of these migs. Pressure drop about six to eight millimeters in volume of cataract surgery. Yeah. Not cataract surgery, just by itself. How much do you give for just taking the cataract down? Yeah, so if you look at a lot of studies, it's between on average about three and four points. So people that would argue that minimally effective glaucoma surgeries would point that out. But it's really not a huge pressure reduction that you're getting from a lot of these surgeries in there. They've also done cost analysis on a lot of these surgeries and the companies will tout that it is cost effective, but you do feel somewhat, I mean, when you see how much of these devices are costing patients, it's, and they're getting minimal benefit in a lot of these cases, it's hard to argue doing migs in certain patient populations. Yes? So when some of these devices get recalled, what happens? I mean, here you've got a device and somebody that's recalled or problem. I mean, what's the procedure? Yeah, so great question. So I can tell you there was, so I was on the AGS, American Glaucoma Society, was served the day that the side pass was recalled. And I mean, there were probably 50 emails from people, from different providers, asking what do we do? How do we approach the subject with the patients? So here what we've done at the Moran is that we made the decision to notify all the patients, track down all the patients that have had a side pass implanted. And then what we're doing, the companies make general recommendations for what to do. But basically what we're doing is we're bringing all of these patients back in, kind of explaining what this means. And then we're getting baseline gonioscopy to evaluate the placement of the side pass, see how close it is to the cornea, because presumably the closer it is to the cornea, the more anethyloial cell loss that you're gonna get. And so we're getting baseline specular microscopy counts, anethyloal counts, and then doing a baseline goniota to check the position of the side pass device. And the tricky thing is that a lot of these companies, they're saying that it's really easy to just go ahead and trim the side pass device. But I think that's been a lot more challenging when you actually talk to the people that have tried this. And so that's kind of been a source of frustration is that the companies want to say this is an easy fix, but in reality it's not. And they're kind of trying to save face with this device. So yes, patrols. So this is actually a perfect example of naive thinking on the part of these companies who produce in these things. It reminds me back in the days when enter chamber intraocular lenses had a whole proliferation of many, many different variations on designs of putting enter chamber lenses in. And I remember there was a forum, and I can still remember sitting there, and I'd say, but some of these, how are you gonna get that thing out? So we thought about that. And the response of our planners is that we're not gonna have to take it out. Well, it's totally naive. I mean, this kind of stuff happens so often, and I don't think anybody thought this through.  If indeed it's ultimately causing significant problems, either in this horrendously spiking, hard to control enterocular pressure, which would be a complete failure, right? We're doing this to control glaucoma. Well, the corny is failing. And then the ability to trim it, I mean, they've made it out of material that, I follow that very carefully. I don't think anybody's got a technique really to trim this thing. So we've put something in without understanding the full ramifications, without understanding that a hallmark of any biodevice is, there is a chance you're gonna have to get it out. And what's the one, the I-stand Supra? That's titanium. Yeah. What are you gonna do if that thing needs to be? And so, and I look at it and the rest, I said, well, there's probably a fair possibility. And you know, I don't know, but you look at it that this thing could, doesn't look like there's a strong area or it could be fixed, it could come out.  I don't know how you're gonna trim that. So I don't think, I think we continue repeating some of our same mistakes. And the one that always you have to ask yourself when you're talking about a biodevice is, in the chance this fails, which has been shown over and over again to be real, how are you gonna get it out? Or how are you gonna adjust it? And I think that's a big failure in regards to what people are doing in association with these areas. This is a hot area, I mean, it's a real, I mean, a lot of people are saying this is the whole new area of surgical glaucoma treatment. And you know, I think that it is exciting, but again, people have to consider those particular ramifications or just what it's gonna mean. Yeah. Where we are. I think the side passes is gonna be like, I hope it's not as bad as the Azar lens. The Azar lens, for those of you who don't remember, was a hot lens. This is back when people were doing entry capsule or cataract surgery. So they took the whole thing out, didn't have any place else, entered chamber lenses, and the hard lenses, which did fairly well support the test of time, but they hurt if you touched them because they were hard. And so this particular lens was just you just slap it in. It was a piece of cake. A lot of people weren't even using operating microscopes and that was as easy to stick in there. It was a disaster. It long term probably has 100% complication rate and getting that sucker out was just absolutely impossible and it would often rip the eye apart. And you know, and over time, I think side passes is gonna have an increasing issue problem. So I just, you know, warn those in the glaucoma side that a rule that you always need to consider and about advice is if you got to adjust it, how are you gonna do it?  And sadly, I see that being ignored. Yes. Always new things coming from a practical standpoint when someone's out of training, what's the process for glaucoma surgeons in the community learning to do these new procedures? Yeah, so, you know, from what I know from Roger Furlong, who I'm gonna be joining, he's in Missoula, Montana. And so trying to, he's far away from an academic center, trying to get kind of up to speed on these. I mean, you're kind of relying on the surgery reps to basically kind of coach you through doing these surgeries.  And then the next day, you kind of, you try to stack up a number of these types of surgeries so that you get some reps in with them. You initially, you're followed for the, you know, the first, you know, however many number until you feel proficient with that type of surgery. But yeah, it's very, very different. So yeah, I think, I have the luxury of being in training right now with people that have done a lot of these and you know, they're just amazing surgeons. So that's, you know, I feel like that's gonna be really challenging once I'm out in practice and then just kind of, you know, these dealing with complications and then who to talk to when you're kind of in an isolated place like Montana. There's, you know, just a handful of glaucoma specialists in the whole state. And so I think, you know, keeping communication and with our teachers here is gonna be really, really, you know, important for me going forward for sure. Some of this looks very technically challenging too. I mean, some of the stuff you're proposing, like I said, and when things are particularly challenging, often I think that what is being done is not necessarily what had been proposed. That often results in complications. And again, the entry chamber lens, you know, a lot of people did just slap them in and they didn't go where they're supposed to.  So that's the other thing that I look at that and I'm saying, I'll bet you there are a lot of people doing this and that's not where it's going. Yeah, yeah, I think there's definitely a misconception that NAICS are, you know, because it's minimally invasive that it's easy. And I can attest that I've been very humbled by learning a lot of these new surgeries. The side pass was probably the easiest out of all of them. Well, that's what made it popular. Exactly. So that's one of the biggest issues is because it was so easy, you know, we had a lot of, you know, a lot of people doing them. And, you know, I think that's one of the problems with that that we're gonna have to deal with that in fact a lot of coma specialists are gonna be the ones kind of dealing with all these issues down the line. So, yes, Dr. Mendelssohn. Well, we have to finish with a positive spin. So at least a couple positive things have come out of just the migs that they, and the surgeries that we're going to get out. First off, we're not very good gonioscopists, especially in surgery. And one of the things that's good about this is it's teaching us to do gonioscopy better, especially surgical gonioscopy. So for residents and for fellows in training, you get a better idea of the anatomy and what's going on. Second thing, though, is it's giving us a better understanding of Schlem's canal in the drainage of aqueous and what's going on. I mean, 20 years ago, Murray Johnstone in Seattle was looking at Schlem's canal and looking at trains. Nobody paid any attention to it, but at least now with these mixed devices, we're looking at how the aqueous drains. And as people are talking about, you want to try to put these in where you get maximum drainage and that there is definitely drainage zones that are coming out through Schlem's canal and that, again, when we're doing these procedures, this is going to give us a better understanding and maybe in the future we'll know exactly where you should put these in and where you get maximum drainage. And so, at least there's a couple of positives, maybe not so much for these devices, but for future devices that they could come out of this stack of what's going on. Right? Yes. So I think that's a great point. One thing that makes have really taught us a lot that's been incredibly valuable, as Nick was saying, about just the outflow system and how complicated it is. And that if you look at the Goldman equation, that episcleral venous pressure is just a tacked on value at the end of that equation that's just kind of always there. And, you know, we've discovered with the MIGs that there is absolutely kind of this floor of pressure lowering that regardless of the MIGs, if it's a conventional outflow type of device, you just can't get below that floor and in terms of pressure, you know. And so it's been fascinating to just watch that and kind of learn more about and try to understand that because it's definitely there. That was the main attraction, I think, of the side-pass shunt for us and why a number of, we have 110 of them here at the Moran that we're putting in. The attraction of it, it's easy putting it in, it was big. But the biggest thing is that it was a chance to bypass the conventional outflow system and maybe get away from that pressure floor that we keep hitting with all of the MIGs. And indeed, you do. I mean, the thing that is just so enticing about that side-pass is that early on, we have these really low pressures, which for so many of these patients, that's what we're aiming for. But then, unfortunately, they will, some of them blow up and now we've got the corny issue too, so we were really kind of suckered into that, unfortunately. But that was the attraction of it, is bypassing. And of course, that's what traditional traps and tubes do, is that they are a bypass. We almost call them bypass surgeries now because they bypass the conventional outflow system. Zen tries to do that, but Zen has a whole host of other problems. The end focus, as you mentioned, we're all just waiting for. And those that have access to it feel that it's just fantastic. You showed the number there, 16 millimeters on average lowering, and that's a whole different ball game compared to the other MIGs. One thing to think of about these MIGs, Dr. Harry was mentioning, most of those numbers that you showed, they're a very excellent presentation. Most of those numbers that you show are 6.2, say, millimeters pressure lowering below a non-medicated baseline. Most of these studies, they wash out all the medicines first. I wish MIGs were better at lowering pressure below the medicated baseline. If you look at the ice tent and the Pippinville Ice Tent Study, for example, it was about a 6.2 millimeter mercury lowering of pressure, but that was an unmedicated baseline. The amount of pressure lowering below the medicated baseline was maybe about one millimeter, almost just a little less than that. Just doesn't make it look as good when you're presenting that. MIGs have been fantastic in terms of, and we use them all and we like them all, and they've been great to teach us, and they're gonna continue to be part of it, but Dr. Ulster's point is so valid, though. I have tried to get a side pass out of an eye, a one that had actually extruded out, I'd probably from some eye rubbing or something like that, that had extruded out about week one or I think it was maybe day 10 or something like that. And so I went back in, I could not get that out, nor could I trim it with any scissor that was available to me. So that was, and is extraordinarily discouraging, just specifically about the side pass. So, you know, that's an unfortunate thing, and we do have to be absolutely right. You know, one thing about an omette valve or a bare valve valve, I can get those out. I can get those out. Any time it needs to come out, I can get it out. And I've had to remove some food. This side pass shot, it was no way. And I don't know, I've never tried to remove a Zen, but it's, again, it's gonna get tacked down, right at its point of entry through the square end. And in focus, I don't know, we'll see. I hope in focus it's as good as built, because we're all, I've taken a Zen out. It's, I mean, it was almost hard to find because it was so enveloped in tenons and it's such a tiny little stent. So, yeah, they just get completely encapsulated. And once you actually got it and grabbed it, were you able to... We were able, yeah, we were able to pull it out, yeah. Yeah, you could also trim it right up against the square end, I guess if you could. Yeah, that's nothing you can actually trim, but it does end, but, yeah. There's a risk, yeah. If we had to do an EK on these side pass patients, is there like a major issue with air going into that supercellular space? I don't know. I don't think so. Yeah, I don't think so. It's some mis-elastic in the side pass. Yeah, yeah, yeah. You know, I've actually gone in on one of the side pass shunts that I had that had this kind of catastrophic kind of pressure spike. I actually went in and injected viscoelastic into the shunt itself to just try to revitalize it. It seemed like it worked for a while. Not that much, but I really don't think that as an air exhaust, so to speak, that it'd be a problem for you. I don't think so. It's fascinating stuff. Thank you. Thank you.


The government of Taiwan has provided some 2.5 million EC dollars towards a project aimed at retrofitting existing classrooms to become smart classrooms, reflecting the integration of information and communications technologies into the education system in St. Lucia. The smart classrooms last Wednesday was launched at the Patricia D. James Secondary School. The Department of Education aims to equip all schools with smart classrooms so that the students can begin to experience 21st century learning and teaching. Peter Luise is the acting principal at the Patricia D. James Secondary School. The aim of every school is to nurture smart citizens. And what better way to achieve this objective by creating a smart classroom environment? As we are aware that smart classrooms are technology enhanced classrooms that fosters opportunities for teaching and learning by integrating learning technologies such as computers, specialized software, audience response technology, assistive listening devices, networking, and audio-visual capabilities. With the COVID-19 virus which now confronts us, the use of technology has taken front stage in the teaching learning process. Permanent Secretary in the Department of Education, Innovation and Generations, Michelle Charles, expressed gratitude to the government of Taiwan for its continued investment in St. Lucia. Because every time I get called to one of these launches of our smart classrooms, I realize that we're closer to achieving our goals at the Ministry of Education. The goal of integrating technology into education. For us, occasions such as these really show that we are moving in the right direction and these actions are well aligned with the vision of the ministry in that matter. Of course at the Ministry of Education we have a broader ecosystem of e-education and this is just one component of it. But every time it happens, I recognize that we are definitely doing the right things for our students and for our teachers. And I mention the teachers because the environment in which we're working is changing. It's not education or instruction as we knew it before. And sometimes we find persons among us who are a bit averse to embracing the technology. But when we move forward, when we provide the devices and the necessary infrastructure that teachers can use, it shows that the ministry is really prepared to help them move in the right direction. Ambassador of the Republic of China Taiwan to St. Lucia, his Excellency Peter Shen, highlighted the significance of ICT in education. ICT in education project is a significant initiative implemented by the government of Taiwan and St. Lucia to build smart classroom in St. Lucia and empower teachers and students by embedding ICT into teaching and learning experiences. There are many development priorities for our country but education is of the paramount importance. Dr. Fiona Philip-Maya is the Chief Education Officer in the Department of Education, Innovation and Gender Relations. It is a tool that we cannot move away from that our students need in order to function as global citizens. So I do not want us to only think of it as a gift and to think of it as a necessity. And because the necessity we appreciate it, we are grateful for it and so we are going to use it effectively, use it respectfully and ensure that it comes back to add value to the lives of the students entrusted into our care at the Patricia D. James Secondary School. Smart classroom equipment was presented to the Patricia D. James Secondary School last week.