First up, Catherine Hu, one of our senior residents, she is staying here at Moran to do cornea. Catherine was recently married. Turns out her husband is Polish. And so you may not know that Catherine has been learning Polish. And if you are interested in learning some Polish phrases, feel free to reach out to her. I'm sure she's going to speak to us about inflammatory deposits in ocular syphilis. Dr. Who. Okay, can everybody hear me. Yes, we can hear you. Thank you. And see the screen. Yes. Fantastic. All right. Hi, everyone. I'm excited to be presenting one of my research projects today as a senior resident. So just to jump right in. Like many great research questions and scholarly inquiries, this one started with a phone call from Dr. Chris Conradie for who those who don't know, he was one of our brilliant and beloved former residents and then our UBS fellow. He went on to do his retina fellowship at Michigan. So naturally one day, he called me to talk about his favorite topic, which was syphilis. And notably, he had noticed a unique OCT finding that he had only seen in patients with syphilis, and he was swearing that it was pathodinomonic. He was saying, you know, to the point where if a patient came to into his clinic with unexplained acute vision loss, and these OCT findings, he was pretty convinced that he could guess, you know, with 99% certainty that they had syphilis even before serologic testing returned. So pretty, pretty compelling. Thank you for watching the research and watch calls, but I can help you. He described these subretinal pyramidal lesions. So he described these subretinal pyramidal lesions with these characteristic sharp peaks, extending from the RPE into the outer nuclear layer, often with disruptions in the ellipsoid zone. And this became the basis of our research question and a point of curiosity that we wanted to explore. In the next background, ocular syphilis is observed most often during the secondary or late stages or of syphilis with posterior uveitis and pan-uveitis being the most common eye findings. In the Western world, the annual incidence of intraocular syphilis is 0.3 cases per 1 million adults, which is a fairly rare diagnosis. However, prevalence of syphilis including ocular involvement has continued to rise since the early 2000s. And although ASPPC or acute syphilitic posterior placoid corioretinitis is a well-described subtype with distinct retinal clinical findings and also well-documented imaging characteristics, other subtypes and imaging findings of ocular syphilis have not been as well described in the current literature. So that boiled down to our research question. It was basically do these hyperreflective, presumptively inflammatory pyramidal deposits serve as a potential non-invasive biomarker for syphilitic uveitis, the ones that Dr. Konradie had described and seen in the day-to-day clinic. And the purpose of our research was to better characterize these lesions as an additional finding in syphilitic uveitis, but also ultimately to evaluate the role of OCT in the diagnosis of syphilitic uveitis. And the big question and the big picture was hopefully leading to more timely diagnosis and treatment. So our study was a multi-center consecutive retrospective case series. All patients were identified via EMR from 2012 through 2020 at both the University of Utah here and also our partnership with the University of Michigan. And both of our centers are large academic tertiary referral centers for uveitis. Excuse me, I have bad allergies. We included all adults with intermediate uveitis, posterior uveitis, or pan-uveitis secondary to syphilis, for which diagnosis was made through clinical examination as well as confirmatory serologic testing. No patients were excluded except in cases where there were no concurrent imaging records available. And of course we also looked at clinical data, including vision, laboratory analysis, and also retinal imaging. So in the diagnosis of our OCT, a patient was considered to have a positive OCT finding only if they demonstrated a total of three or more hyperreflective pyramidal lesions on OCT scan that extended from the RPE, as we had previously described, into the outer nuclear layer with the destruction of the ISOS junction by two reviewers myself and Dr. Konrati. And these were images that we reviewed at the initial visit. We also reviewed all lines of the scans from the presenting visits and also all follow-up visits. And results were considered negative if us as reviewers could not come to a consensus. The resolution of pyramidal lesions was considered complete only if the hyperreflective pyramidal lesions had disappeared, and at least some of the ISOS junction had been reconstituted in that same area that was apparent. There was one patient that we had described. He had HIV and also a history of treated neurocephalus, but there was concern of treatment failure and recurrence of disease about six months after his initial presentation and initial round of treatment. He presented with worsening visual acuity of 2150 and the affected eye with the development of these lesions on OCT had previously not been seen before. He also had an uptrending RPR titer, despite not having any additional exposure. However, after undergoing a second round of IV penicillin alone, the pyramidal deposits completely resolved as early as two weeks after his initial dose, and then the, and his vision returned to 2020. And you can see here that the arrows correspond to the anatomic location of lesions in resolution after treatment. Of our results, we had 40 patients representing 62 eyes from the two from the two centers, and the mean age was 42.9 and 87.5% of the patients were men. Pan uveitis and posterior uveitis were far more common than isolated intermediate uveitis, and 90% of patients were treated with a standard two week course of IV penicillin as directed by each Institute's infectious disease subspecialty services. 45% of our patients, about 43% of our patients had a underlying diagnosis of HIV, which was a new diagnosis for seven patients. We have the OCT findings that we were particularly curious and looking at 28 eyes or 45% of our patients showed these hyper reflective pyramidal lesions on OCT. 54% of these eyes with these lesions did not have a retinal plaque with lesion or really any retinal lesion for that matter that could be detected on either examination or other imaging modalities like auto fluorescence. No unaffected fellow I demonstrated these lesions and complete resolution of these pyramidal lesions was found on OCT for 68% of eyes after treatment. So finally, we also looked at follow patients longitudinally for visual recovery. And at the time of diagnosis visual duties range from 2020 to NLP with a mean of 2043 on a cell and I chart. After IV antibiotics, after after treatment with IV antibiotics, statistically significant improvement was observed in me in mean acuity excuse me to 2026 with the p value of 0.01 and 68% of patients gain at least one line of visual improvement after treatment with IV antibiotics. The correlation found between presenting or final visual acuity and the presence or absence of the OCT lesions that we were looking at, and vision threatening long term complications were overall uncommon you can see here with pretty low percentages. However, they did span from optic neuropathy retinal detachment, see me and also disease relapse, including these long term complications that were permanent and also had visual visual deficits and consequences. So, just to wrap up with a quick discussion, our experience suggests that hyper reflective outer pyramidal deposits of the RPE and outer retina can be found in ocular syphilis. In addition, but not in place of routine specific troponemal and non troponemal serologic testing of patients PVE it is these non invasive image findings may serve as a non invasive characteristic clinical finding to monitor disease activity and and also treatment treatment response and treatment efficacy. Most of these outer retinal abnormalities resolve after IV penicillin therapy as seen in specifically in our study and can be may resolve within two weeks of starting therapy, which is much more rapid than our PR responses. Lesions were observed in the absence of ASP PC or basically in the absence of placoid lesions and similar lesions peach Prango lesions have been described in three prior case reports to our knowledge in the current literature, but only exclusively exclusively associated with ASP PC. So to our knowledge no prior reports have suggested that they may be found in patients without ASP PC. The resolution of these lesions coincided with good visual recovery. We actually specially speculate that all lesions would have eventually resolved ours was a 68% resolution rate with treatment of IV penicillin. However, a small subset of our patients were lost to follow up or return care to their local ophthalmologist for which we know how records. So just some key points. If left untreated ocular syphilis may lead to your reversal vision loss and, as we all know, can be considered the great masquerader of ocular disease. It has been a major inflammatory disease, since it has the propensity to mimic many many other diseases. So timely identification and treatment may improve of not only ocular syphilis but also neuro syphilis and may not only improve visual outcomes but also patient morbidity and life expectancy and the importance of testing for HIV co infection as we saw 45% of our patients had HIV and seven was a new diagnosis with the presentation of their I findings. So with that I'd like to thank everyone we were fortunate enough to publish our findings in in ophthalmology retina.  We've been just instrumental in my overall ophthalmology career. Those are colleagues at Michigan at the Vitis department.  These are my references, and I'd like to take any questions. Are there any questions for Catherine. I didn't see anything in the chat. That was wonderful. Thank you. Congratulations. So very impressive. I'm a little bit sad that you're not going into retina. I would be very much interested in the structure function correlation. So you reported that 54% of patients showing this OCT sign had no other clinical science. And is there work done in regard to, for example, correlating microparametry with these changes. Yeah, that's a great. That is a great question. I'm not quite sure in terms of that specific other imaging modalities and of course you know with the structure function and correlation like you said we aren't able to. In other cases we are able to biopsies we don't know exactly what's going on and the evolution of these lesions were not quite well defined yet and we're not quite understanding what they actually are. Like we said we assume that they're inflammatory lesions. But yes, there was 54% to where there wasn't a. There wasn't a grossly obvious pathway lesion, but there were other signs of you know posterior pan uveitis, or, or intermediate uveitis even. We have one comment from Amy Hartnett she said great presentation Catherine. Thank you so much. Very good. All right, thank you. We'll move on to Marshall Huang. He is one another one of our senior residents. He is leaving us to do glaucoma in Minneapolis at the Minnesota eye consultants. Marshall is going to talk to us about perspective clinical trial assessing the effect of NMN on dry and D. Now as far as a fact that you may not know about Dr. Huang. Apparently once was inadvertently included in a photo series that went viral. The photo series taken by Angelo Maradino about his wife's breast cancer experience. And no I did not know that about you. Dr. Wong. Dr. Hawthorne for that kind of direction. Today I'll be discussing my project on NAD plus supplementation for non exodative macular degeneration. My only financial disclosure is that pro health provide the NMN supplements free of charge. The primary objective of this project is to determine whether supplementation of a NAD plus precursor results and a change in the flio pattern seen in and AMD patients. This project will be the change in the flio pattern of the mean for us and five times in the long spectral channel from enrollment to final study visit as measured by failure. The second outcomes include visual purity and contrast sensitivity. I will now discover discuss the rationale behind using NAD plus. The first question is why would supplementation of NAD plus be helpful in AMD. While we the exact pathogenesis of AMD remains unallocated, we know that RP dysfunction and degeneration are key features of age rated macular degeneration. The RP is uniquely metabolically active in order to provide support to the retina. Supplementations include phagocytosis of shed photoreceptor outer segments, recycling of retinoids and production of cytokine. It also needs to mediate the exchange of nutrients between the chloride and photoreceptors, particularly glucose. In order to protect itself from reactive oxygen species and preserve glucose for transport, the RP uses high levels of reductive covoxylation to produce NADPH from NAD plus. This shows that increasing age and oxidative stress depletes NAD plus. Next question you might ask is how do we know that oxidative stress is even related to AMD. Many genes have identified as strong risk factors for the development of AMD. Of those, the most promising and most studied are complement factor H and the arms to HGRI1 low side. Although the exact function of these genes in the RP is unknown, studies suggest that they help protect the RP from oxidative stress. In addition to HG and CHF, they show that the percentage of viable human IPS cells differentiated into RP cells after the addition of 4H and E, which induces reactive oxygen species formation. They then show that cells are rescued by the recombinant full length CFH. Overall, this suggests a CFH protects against oxidative stress in RP cell. This study looks at superoxide dismutase 2 activity in response to oxidative stress in cells with either the protective or the risk alleles of the arms to HGRI1 low side. They use A2E in this study to generate singlet reaction oxygen species to simulate oxidative stress. In Figure A, they show a significant increase in SOD2 activity for patients with a homozygous GG allele, which is protective, but no increase or even a decrease in SOD2 activity with homozygous and heterozygous risk alleles. Figure B shows the antioxidant activity of human RP cells before and after the addition of A2E. There's an increase here in the antioxidant capacity in response to oxidative stress in RP cells with protective allele, but a decrease in the risk alleles. This also suggests a protective effect at the gene against oxidative stress. So why do we choose NMN as a supplement? Here's the NAD metabolism. This is NAD plus on the left, and here's NMN on the right. I am just showing this to highlight that NMN is a direct precursor to NAD plus, nicotinamide riboside or NR is also a possible precursor with commercially available supplements. But as you can see, it must first be converted to NMN in the body. This is our rationale behind choosing NMN as our supplement of choice. So is there evidence that NMN is likely to protect the cell from oxidative stress? Well, here in the study, the authors show that NAD plus concentrations are significantly depleted by hydrogen peroxide in human RP cells. They also show that the hydrogen peroxide causes significant cell death. However, supplementing the culture medium with NMN completely prevented the cell death induced by the hydrogen peroxide. So what evidence is there that NMN might be beneficial specifically in AMD? Well, in this study, they looked at the expression of proteins associated with AMD progression in human IPS derived RP cells from AMD and control patients. They included patients who are homozygous and heterozygous for the arms to HCI1 risk scale and the heterozygous CHF risk allele. Overall, they show higher levels of expression. And the AMD cell lines compared to the control with decreased expression in these proteins after the addition of NMN to the culture medium. They also looked at multiple other associated proteins showing a similar result. So this is the overall proposed pathway for how oxidative stress, which the RP cells a particular sense of to eventually lease RP cell death. First, oxidative stress causes DNA damage, which act as PRP. PRP, which is a family of proteins involved in cellular processes such as DNA repair and genomic stability, depletes NAD plus to repair DNA. As NAD plus is depleted, SIRT1 activity decreases, which is the most conservative million dependent histone DSLAs. The decreased SIRT1 activity causes increased histone acetylation, which loses chromatin and decreases the specialization of RP and increases production of aberrant proteins. The next question is why FLIO? Studies done by the Bernstein lab has shown that patients with AMD have a ring shaped prolongation of the mean fluorescence auto fluorescence lifetime in the fundus auto fluorescence lifetime in the long spectral channel. This can be seen even in patients with very early AMD with minimal other findings on imaging. It's possible that this is the technique very early metabolic changing the MACA, which could potentially be reversible. With this technique, we hope to see real time changes rather long term progression. And here's the chain, the long spectral channel prolongation that we're describing. Now that I've laid out the rationale briefly out the method with the prospective pilot study without a placebo control. Given that we already have based on FLIO images for patients with early AMD that shows the ability of the long spectral colonization at the time, we did not feel that doing an additional placebo control was necessary for the pilot study. We had an initial recruitment target 20 subjects. And we included any patients greater than four years of age with early or intermediate dry AMD that has had cataract surgery in the study I we excluded any patients with other MACA conditions, or who did not have the characteristic FLIO pattern. We had five total study visits one at baseline than one each at week one, four, eight and 12, and they all included visual duty contrast security, footlamp exam, MACA, OCT, on this all for lessons and FLIO. This is the NMM product that we use we use the total of 900 milligrams per day for a total of 12 weeks. And now for the results. We were able to enroll a total of 10 eyes or five subjects. All of those eight eyes completed the study. One subject dropped out about halfway through the study she reported mild flushing of the skin on her arms that results after stopping the supplement. No other adverse events were reported. Our secondary outcomes of visual acuity and contrast sensitivity remain stable throughout the trial. Here are the FLIO pattern in the LSE of three representative eyes at baseline and 12 weeks qualitatively we did not see an obvious change in the FLIO pattern. We then analyze the mean for us and five times in the central ring, the inner ring out of ring and the full Mac as defined by the ET DRS grid. The area between these lines to find the outer ring, which is found to be the area of interest in the prior study. This grass out the change in the mean for us and five times in the long spectrum over the 12 weeks. There's an overall trend towards an increase in the mean for us and five times. And here in this analysis we use the pair t test to compare the mean for us and five times at the 12 week time point with the baseline images for both the LSE and the SSC. This shows a small increase in the mean for us and five times in the long spectrum channel that approaches the physical significance in the on the two tails to test. There's also an increase in the mean lifetime. Overall, we see a average increase in the prolongation of the mean for us with lifetimes in the long spectrum channel in the outer ring. We were hoping to see an average decrease in the mean for us with lifetimes with NMM supplementation. However, we do not see evidence of this in the study. We previously showed that more advanced AMD is correlated with increased prolongation of the long spectrum channel. However, we do not have accurate data measuring this rate of change with an individual. While this confirms the AMD. Oh, excuse me. Well, this confirms that the flio pattern in the long spectrum channel is the area of interest in AMD. The remaining questions are as follows. Does NMM affect the rate of this prolongation along spectrum channel? And what is the natural rate of progression of prolongation and AMD patients. So some of the weaknesses of the study include a small patient population, a lack of a control group and a short study duration. Other weaknesses include the lack of measurement of the serum levels of NMM before and after supplementation. Also, there's not really good clarity on what compounds we're exactly picking up on flio. Our next step will be to establish a baseline rate of mean lifetime prolongation in AMD patients to use as a control. This project is already ongoing, and the reason we decided not to enroll control patients for this particular study. However, after analyzing the data that we have in our database of these AMD patients without supplementation, we found that it was not directly comparable to the patients in this study. For this reason, we need to a more standardized set of control patients. We would also love to increase the enrollment and duration of the study. And a special thanks to Dr. Bernstein for supporting the study. A big thank you to our resident and flio expert Lydia, who helped me a lot with the data analysis and the project overall. Thank you to Alex Vitale for helping to teach me and the imagers how to use the flio, and Marcel for doing all of the flio images for all of my patients. Our prior resident Brad Jacobson helped me find patients to recruit for the study. And finally, I thank you to Elizabeth Deborah and Kellyanne. I don't know what to say. I guess I just keep going. Here are some of my references and thank you for your attention. Any questions I can answer. Marshall, there are two questions that were in the chat. One from Judith Warner wanting to know why cataract surgery. And from Kathleen degree, I think you already answered about the follow up period. Is it long enough and you said it was short. Yeah. I'm going to do this question. Yeah, so for Dr. Warner's question we wanted cataract surgery because we found that the lens can significantly affect the flio imaging. So with patients with different degrees of nuclear sclerosis, it makes it really difficult to compare between patients, but having patients are suited for it creates a really nice baseline of comparison for us. So really good question. And in terms of follow up time, I, you know, it's hard to know if it's long enough, I would say based on the study, it's not because we're not really seeing significant results. And based on previous studies, such as the era to studies, we would expect to need, you know, many more months, maybe years to see us in the current fact and macro degeneration, but really hard to know overall. And I do. And with Dr. Pettie's questions with the clear lenses versus the outcome blue blocking lessons, a flex affecting flio. I'm actually not sure about that. That's a great question. My guess is that the effect would be relatively minimal compared to say a crystalline lens, but all of our patients here did happen to have clear. Interactor lenses put in. Okay, any other questions. Thanks Marshall. That was, it's been fun to watch this process and this topic and evolution over time in your presentations will miss hearing about. I'm going to turn things over to Dr. Fleckenstein. Okay, so with this, we go on with our next speaker, Mike Murray, and he will actually do a corner fellowship at the University of Colorado in Denver. And what you may not know about him, he celebrated his 10th birthday in North America, Utah, his 20th birthday in Europe, Sweden, and his 30th birthday in Tanzania, Africa, and he's actually planning to go on with this tradition and this is where he have been when he's turning 70, maybe has traveled all the continents. And today, and he will present us the surgical outcomes and demographics of Navajo nation outreach. Mike, the stage is yours. Okay, I'm unmuted now I think can you all hear me. Yes, wonderful. Perfect. I came down with a little bit of sickness it's not covered, but please excuse my voice it's not going to be as pleasant as my other chief residents. I'll be presenting on surgical outcomes and demographics in the Navajo nation outreach. Iran has been going and providing clinical and surgical care to the Navajo nation, at least since 2013. This is a map of the Navajo nation which is the largest by area and also by population of all the Native American reservations in the United States. There have been primary locations in Montezuma Creek Monument Valley Navajo Mountain as you see there, and it serves a population of over 170,000 people. There have been really a dearth of studies about the Navajo nation about Indian reservation care in general. The studies that were done in the 80s suggested that trauma might be the number one cause of blindness. And they were severely limited by the presentation of patients in those studies and mostly being in the emergency setting. So it's a big need for data analysis and care as well to the Navajo nation. Some of the patients that you see down in the Navajo nation and they're really so grateful for care you'll notice Dr. Hoffman over there even during the COVID-19 pandemic were able to do continue to do clinical and some surgical care as well. So if a patient comes in and we've had over kind of 2500 patient visits that we've analyzed in this study, they'll check in and they'll do a visual acuity and their history. If their vision is better than 2040 and they have no concerning history they're screened out, but if they have poor visual acuity will work on their refraction and see if that takes care of their visual acuity and refracts, you know, better to 2020 or so. And if not, they're screened into being dilated and checking for other pathologies.  We screened out about 300 patients so total maybe about 2200 patients. This was the demographics. A maximum age of 92. I remember that patient who's very, very cute and nice and a female predominance in the clinic. And then you can see from the different sites. Montez and recruit Monument Valley and Navajo Mountain Navajo Mountain is more remote area harder to get to. In the patient histories is a high rate of diabetes, as well as hypertension as you can imagine in this kind of genetic population where they're genetically predisposed to hang on to all of the energy as they've been kind of the hunter gatherer stage and trauma is about 4% hyperlipidemia a little bit lower. Now we used the visual acuity that was suggested by born at all and they did a estimate of what the worldwide visual impairment would be some mild visual impairment would be from 2040 to 2060 moderate would be from 2060 to 2200 to 2200 to 2400 and then blindness rated as worse than 2400. There are higher rates of blindness in patients both with or without correction. And these are higher than the world estimates. The finding that we've had and Dr Hoffman will tell you that this is true in the adult and pediatric population is a high level of sale in these patients, especially when you're doing their refractions and in the kids when you're doing retinoscopy. Not a high rate of glaucoma in these patients, but we do see some angle closure and some other kind of severe forms of glaucoma. This is kind of a demographics and diagnostic table, high rate of cataracts, and then a high rate of refractive error as well. There's obviously a lot of diabetic retinopathy. And then you can see the levels of glaucoma are the era, etc. So these patients, the main causes of blindness, which to remind you worse than 2400 division cataract and refractive error were the highest. Then there are several patients with retinitis pigmentosa, diabetic retinopathy, etc. The surgical data, it was actually difficult to analyze. And in going through this data, we realized basically that keeping better records and having better follow up. And some of these patients will help us to know a little bit more of our benchmarks. And so preoperative and postoperative visual acuity data was really. Excuse me. It was really harder to analyze here, but there was a low rate of PC terror, especially in these complicated cataracts. In Posa Pythema, there were a couple of cases of a terugin mal adherence, but overall I wanted to emphasize with this slide that we're providing high level care to these patients. Sometimes in the outreach world. There is a element of distrust in the community that they're going to practice on the native patients and so this is important data for us to publish that we're performing safe surgeries on a good level of complications there. In conclusion, really interesting that 73% of the bilateral blindness in this know how nation cohort was preventable, either through refraction or cataract surgery, and the rate of blindness was six times worse than the worldwide study. An interesting finding that we found was RP is a lot higher than reported in US population and sometimes you might think oh this is just because there's one family that is all related but only two patients of our seven patients were related. So our data is limited because we are analyzing the patients who are coming to our clinics. However, I do think it's important to know that's the first ever study to report on outcomes in Navajo Nation and this presentation. There's a couple of current and future projects that are kind of off sheeting from this data. So we're working on a pseudo exfoliation study, working on a pediatric review, if you saw, there's a grand rounds a couple weeks ago where Ryan Wallace talked a little bit about the progress with that study. And then in our surgical outcomes we're improving our kind of future data entry so that we'll have better analysis. We really want to increase capacity in the technicians in the Navajo Nation and so we have a grant and we're working on training the technicians down there to have a high level of knowledge so they can triage and assist in the care of patients when we're not there. I just wanted a big thank you to Ryan Wallace, he's been the, I don't know what it's called but Dr. Chia is kind of research fellow this past year, and has put in a lot of work. Laura McQuarrie has run for Alta, and then Teresa, Dr. Petty, Dr. Chia, Dr. Hoffman for all their work in Navajo Nation couldn't have done this without all their help. These are some of my references. And then happy to take any questions. Mike, thank you so much. This is so impressive and important work that you and the team are doing and actually Jeff Petty is commenting. A challenge with your work is the sampling bias patients are actually coming to the eye clinic more likely to have pathology than the population and how should you consider this when comparing with other population reports. Yeah, I think that the highest tier when you're doing demographics research would be really to get out and to randomly sample the population and go door to door. And it would be amazing to do that type of a study. We don't at this point have the funding and the means, or at least I haven't been able to do that but would love to. And you are accurate in that we are biased by the sampling for sure. I had one comment. I listed at the beginning of my slide but this was done all under the Navajo Nation IRB process and so they approved the presentation of this data. Thank you so much. Any other questions. Just a quick comment. The kind of gold standard is called a RAB stands for rapid assessment of avoidable blindness. It is something we've explored doing there. It requires teams actually going, you basically you designate geographic areas, and then you can do a random sampling of those geographic areas and then send teams out. But you have to get a certain percentage of the population to be evaluated. It's a very, very limited screening. I mean it's essentially visual acuity, kind of limited examination, but enough of an examination to identify the cause of blindness. There haven't been any done in Native American populations. It's a little controversial on whether it perfectly applies the way it does in other global settings, but it certainly is the one that we've been discussing and tossing around. So maybe we'll all be taking a field trip at some point in our teams. Stay tuned. Happy to help out with that. It would be amazing to get that data honestly. Thank you all. Bob, you proceed. You're still muted. I think I'm there now. Mike, that was a wonderful talk topic that near and dear to my heart. And I appreciate you doing that. Next up, we're going to move on now to the next year. Our second year residents, Sean Collin has spent an enormous amount of time on this topic that he's talking to us about the Utah assessment review community eye health study. First, I do need to share with you that Sean is apparently thrilled and doesn't think we all know that he's thrilled about a new climbing gym called the Salt Lake bouldering project, which is in the greatery district. And I think with that we may have to go check that out. Yeah, so that's a little plug for this for this new gym trying to help them out. It may or may not be the inspiration for the title of my qi project. But let me share my screen here. For now talking about the arches project so again I'm Sean Collin can everyone see my screen. Cool. So this slide is a slide that I showed last year. But just wanted to rehash a little bit about needs assessments and qualitative research. qualitative research is generally hypothesis generating research as opposed to most of the research being discussed here today with it, which is hypothesis testing research needs assessments are a form of qualitative research and became a requirement for all nonprofit hospitals by the with the passage of the Affordable Care Act. However, most I hospitals have been effectively exempt from this requirement, either because the private for profit hospitals, or because they fall under the larger umbrella of an academic center. The hospitals are notable exception the only exception to my knowledge and they published their first need assessment 2016 published another in 2020. Each one being a four year effort and those were major inspirations for what we were trying to do are trying to do. We intentionally asked this very broad question statewide where we succeeding and where we falling short and providing eye care to us most underserved and vulnerable populations. We had a stakeholder kickoff in September of 2020 that I discussed last year that was really just informal discussions with some of the stakeholders and I care throughout Utah. Either the day before or the day of resident research day last year we sent this survey out a stakeholder survey to 441 stakeholders in primary care ophthalmology, optometry, administration, public health, etc. Anyone who we thought might have any sort of vested interest in I care throughout Utah. We got the result back map and sort of looked through it and then we had a stakeholder focus group in January of this year, where we dove a little deeper into some of the things that came up in the survey. So, new from last year is the data and the responses from the survey so we got 61 responses from 441 invites. It would be a little bit better than it sounds, because we know that many of the surveys were sent to old emails that were no longer in use sort of from the US registry. It was also rather long survey. And so, you know, 61 responses was was fairly good we ended up sending out the survey multiple times and calling all of the people on our list to train increase that number. So we got a lot of representation within those 61 responses from ophthalmologists, optometrists, and then community care organizations and other health care providers. You can see here a map of our responses, clustered along the Wasatch Front, but we did have statewide representation and really the distribution of the responses mirrors the population distribution of our state, pretty well. One of the things in the survey is that greater than 80% of respondents reported that their organization was specifically equipped to provide care for uninsured and underinsured individuals meaning that they provided free care or financial assistance, greater than 80% also reported being able to provide care for people with disabilities and for non English speaking people. So whether excluding ophthalmologists and optometrists, all but one respondent rank vision health as important or a central focus obviously we would expect that ophthalmologists optometrists would rank it as a central focus. But so knowing these things the question remains, you know if we have clinic that are capable of taking care of these patients and and it's a it's a reasonably high priority wise and not happening. I have a couple more questions so what should be the top priorities for eye care in Utah. And in this regard diabetic retinopathy screening care came out on top vision screening for children and access to glasses and corrected lenses was close behind. We also asked our stakeholders, what they perceived to be the greatest patient barriers to receiving eye care. With most commonly cited barrier lack of insurance was also commonly cited and goes hand in hand with cost of care and then cost of missing work or income to attend appointment was next. But I think that the fourth one here on this list is actually something that ended up coming up quite a bit in in comments and in the focus group and that is knowledge and awareness of eye disease among patients. So we had our stakeholder focus group in January of this year. It was about 10 participants we sort of asked everyone who responded to the survey if they'd be willing to participate. And again we had pretty good representation from ophthalmologists optometrists health practitioners from, you know, in the primary care setting and community clinics. And a few things that came up. First of all, we have many willing eye care providers in the community one of the respondents stated that he was willing and able to see anyone who came through his door regardless of their ability to pay. And also that he knew that other providers in his area were also equipped to do that. At larger academic institutions. Some people reported that although they felt like they're, they knew that there was a way to provide subsidized care. It was a little bit more difficult they didn't really know how to provide subsidized clinical care. For the ancillary test was very difficult and free care was not possible. They did mention though that providing surgical care or circle care was quite available for uninsured and underinsured patients. That was a major strength. As far as our community clinics that were providing primary care. Most of the providers there expressed this feeling of just not having anywhere to send patients so in some of the rural areas like Moab. There's, you know, one eye care provider within an hour and they are known not to take patients who don't have insurance. In some of the more urban areas, you know, free clinics and fairly qualified health centers rely on services that are that are intermittently available that move locations, and they just expressed know when they have a patient who needs eye care. It's very hard to figure out where to send them. And then finally something that kept coming up is that patients don't really see the value in eye care screening one practitioner from a community clinic said that with regards to their teleophthalmology program patients response was well if it's free why not know patient ever said. Yeah, I really need to, you know have my eyes checked. So patient education is lacking and a lot of folks mentioned ways that we could meet people where they are educate them screen. You know where patients are so point of care screening at primary care appointments educational material at libraries, educating our own schedulers and receptionist to be able to give patients options when the question of how much an appointment will cost come up. And then educating school nurses and teachers to make sure the kids are getting the plug into the resources that are available. Our takeaways. You know we had a lot of people calling for better collaboration and this really seems, I guess it seems obvious but even more so after sort of the responses recognizing that we have willing providers we have patients who need providers. Large strides can probably be made just by connecting those patients with the willing providers. Patient education is something that kept coming off in another place where you know relatively low cost interventions could have a significant returns. And then we also recognize that within our own study group and within our pool of respondents. We did not have a very diverse group and going forward in this study, we'd like to more actively seek out voices and opinions of people who identify as black and didn't as people of color. And in general to sort of seek out minority voices and opinions. The steps here are to connect I care providers and community clinics through a referral network database online I think this is one of the most important things that we can do to, you know without creating any new resources just to tap into what's available. And at the same time we're working on implementing point of care screening through teleophthalmology at many of these community clinics throughout the state. I'll talk about that a little bit later on with my quality improvement project. The first steps that we'd like to take in the near future. With regards to this needs assessment, but I'll leave it there for now and open up any questions if anyone has any. Sean Sean I have a comment and a question for you. So, you know, one of the fundamental questions we have to answer in our building is what, what role do we take when we have limited resources, you know what are what are the essential, you know, how does Moran fit into the puzzle of providing unfunded care is it primarily as a, as a facilitator is a providing care, etc, and a little bit of background, providing free clinical care is relatively simple for all the providers throughout the state. And establishing a free eye clinic is relatively simple, compared to providing surgery actually surgery. Most of the time as you look around the country is surgery is the, the, the kind of orphan area of care where yeah you can diagnose diagnose diagnose but there's really no pathways or avenues for surgery. And so that's where, you know, 11 years ago. That was really the reason with Brian stag, you know, Brent price and others that we really leaned into let's, let's provide surgical care as something unique that we can do the community, both because one we can but two we can provide a pretty broad spectrum of care as well for people that need it. And so now, as you consider the rest of the state, and really leaning into the clinical care you mentioned the need for a better collaboration. Does that mean that you know Moran ice center becomes the entity that provides that is that something that needs to frankly come down through the state government. You know the eotophthalmology society we know well that short of them cooperating with eotophthalmetic society, you know that's only going to go so far so, you know, in the, you know, you're the wizard Sean you can you can create whatever system you want. What, what is the entity that really needs to be that central collaborator and what would your recommendations for next steps be. Like, well I think there needs to be a central collaborator but and perhaps that is the Moran or Moran outreach, but that does not mean that the Moran or Moran outreach can or should be providing. Even even a majority of the care maybe maybe even should be providing less care we should be maybe tapping into even more the resources in the community that are available so. As far as I can tell right now it seems like it's going to be a very manual effort, calling clinics one by one, talking with physicians there and saying, What can you do for patients without insurance, who have Medicaid, can you see them, you know, will you see them how will you see, and then creating a database that is accessible to community clinics, where they can go and see the providers in their area that are willing to, to, to provide care for their patients and what that might look like for their patients. To me that's that's what I see as being the, the ultimate way of doing things I think there's, I think state funding would be great and very helpful. But there's just things are so scattered. Even getting into things as rudimentary as EHR integration and sharing of information it's so difficult to do that just having a resource for clinics to know, Okay, here are the places that you can reliably send a patient. And forcing them to rely less on, you know, twice a year screening events or mobile vans that travel around. I see that as being the most promising route forward. And if we don't have time off you can cut me off with this maybe this will be just a rhetorical question, you know, playing devil's advocate, you know, so so on some level I agree Sean, because we have the footprint we do and the prominent place in the state, I think we are perhaps the path of least resistance or most likely entity to be able to provide some of that. However, you know, all the surroundings, most of the surrounding states don't have an academic I center which then begs the question, you know, should the academic I said to be the one to do this or should should this be something that really does come down through something more central through state government. And of course, once we get to should you know should patients be uninsured in our country. I think we can go on and on but that's a question that I continually ask is really, what's a fundamental role we should have. And in this, in a sense, you know, how do how do we, you know, facilitate that not just in Utah but even in Idaho and others where they don't have academic centers. So we'll look, look forward to more discussion on that that that topic that Sean, I'm really impressed with all the time and effort you've put into this project year to be commended on that that was, you know, you've done a good job. The next speaker is calls wisdom. And very interesting about coal is that he worked for the National Park Service, and part of his job was pumping outhouses on random islands. And today, he will talk to us about outcomes for combined up internal canal plastic with hydrous micro stent. Cole, it's your. See this and hear me okay. Okay. So the big pump they used to pump out these outhouses is called a honey pot, and they have it on barges between islands so there's been times at 2am on call that I've, you know, told myself at least I'm not running the honey pot right now. So we're going to talk today about kind of a unique cohort of patients who underwent a combination makes procedure at the Moran, and makes is minimally invasive glaucoma surgery, which has been all the rave lately as it's less invasive than conventional and there's also condom table sparing. And there's been some particular interest in combining ab internal canal classy which is pictured up here in the video, where a small micro catheter is inserted through agoniotomy, and then threaded through the canal and then withdrawn, ejecting this go elastic thereby dilate angstroms canal as well as the distal collector channels. That combined with a trabecular mesh for bypass stent such as an ice stent or hydrous has been done with the hopes of conferring additional IP lowering benefit. And also it's done because the goniotomy as well as the dilation of the canal with the abic device does facilitate placement of the stent. So we don't have any data proving that we should be doing this. So our main question is, should we actually be doing canal capacity in our hydrous patients and does it confer additional IP lowering benefit and reduction of medication burden. And so to do that you obviously need to cohorts you need your hydrous alone or in this case the cataract surgery and hydrous, as well as the abic hydrous cohort. So we're looking on cohort to today because we do have preliminary data for that group of patients at the Moran. And this data is also not been previously published. And so to identify these patients we looked at CBT codes over the last five years and then did a retrospective chart of you looking at IOP data and medication use throughout 12 months of follow up. We had pediatric patients or VA patients and then those with prior incisional IOP lowering surgery SLT within six months or anyone who is using steroids or had another IOP complicating diagnosis during that follow up. And so here are the numbers from those CPTs. Again, we're going to focus on the abic hydrous group right now. There were 134 patients underwent this procedure at the Moran since 2017. We also had primary outcomes including IOP reduction at each follow up period, and then IOP lowering medication use at 12 months compared to baseline. We kind of also uniquely applied a linear mixed effects model looking at a number of variables including the type of device so I track versus omni, as well as inter surgeon variability, the number of degrees cannulated with the abic device and then accounting for the correlation using a patient I random effect. We also collected rates of complications and the need for any repeat surgery.  The majority of those patients underwent eye track canal plastic with Dr. The majority of these were primary open angle glaucoma though there are a couple of different secondary glaucoma types and about a third of these patients ended up meeting the 12 month follow up period, as we're still early on with this color. And so jumping right into the primary outcome I'm going to stratify this by device type this talk is not meant to compare eye track to omni, but I do think it's useful to just look at them separately. So this is IOP and the graph on the left here is a that's an average IOP at each follow up point, and then B is just reduction from baseline so kind of a different way to look at the same data. You can see there was a stained IOP lowering effects for eye track that was sustained throughout the follow up period, and then that reduction from baseline was about 3.5 to four, with a little bit of decreased advocacy at the 12 month follow up period. And then omni, the device is kind of pictured here. Again, statistically significant decrease in IOP compared to baseline at each follow up period and that was also sustained in about the five millimeters of recovery to seven range throughout the 12 months. And then looking at medication use, we used a Wilcox and sign rank test at 12 months compared to baseline. And while this was not a statistically significant decrease we did see a hard decrease in the number of IOP lowering medications from 2.6 to 2.3. And then application rates was very low 2.7% with one psychedelic is cleft in the Omni group and one high FEMA both of which spontaneously resolved. And then the need for additional surgery was also low at 4.1% over the span of 12 months. This is a Kaplan-Meier curve here on the right. That shows kind of the timing of those additional surgeries. And then applying the linear mixed effects model we did not show any significant inter-surgeon variability. And then there was a significant reduction in IOP regardless of the degrees canulated so either 180, 270 or 360. And then we did not see like a dose dependent response so for any additional degrees you did not have any additional IOP lowering benefit. And then, like I said we're not comparing the devices today but using this model there was overall no significant difference in IOP reduction between the two devices. We do have a summary we do have now preliminary data demonstrating safety and then a modest IOP lowering effect of the combined avic-hydrous procedure which was sustained at 12 months. About 17% IOP reduction in the eye track group and then 38% with Omni, though that was limited by sample size. Overall no significant difference between these devices given that low sample size with the Omni group. So about 6% of these patients did not need additional surgery over that 12 month follow-up period. And I don't want to draw premature conclusions from this study comparing it to existing literature. You know the main study we have on hydrous alone is the horizon study. And there were significant differences between that and our study here. The horizon was a prospective study and as such all the medications were washed out prior to applying the intervention so that cohort had a higher baseline IOP. It was also a homogenous glaucoma population with poag only, whereas our retrospective study is a variety of glaucoma diagnoses, and they followed patients for 24 months. We're still young with our cohort and at about 12 months at this point, but we'll certainly continue to follow them. We're also limited by sample size. As I mentioned, less Omni patients than eye track. There's an ongoing study called the magic trial, which is the multi-center ab internal glaucoma study investigating canalplasty, which actually seeks to answer the question, which device lowers IOP more with 360 degrees of canalplasty. So our next step obviously is to look at that cohort number one, which is hydrous alone and then compare it to the abic hydrous group. We're in the data of you phase for that right now, and we will continue to follow this cohort over time. Specifically, I'd like to thank Dr. Chia, Dr. Danford as well as Ryan Wallace, who is our future Baylor off the resident, and then Bryce and Christian who are medical students were trying to convince them to go into ophthalmology, as well as Ben Brintz who is our statistician for this. I'm happy to take any questions as well. Thank you so much, Cole. Are there any comments or questions. So Dr. Zabriski raised his hand. Would you unmute yourself please. It's not letting me unmute. Oh, that's a great talk and great talk and I just wanted to just make one comment, you know, the thing that I think I like so much about this study is that it's our patients you know I've always argued so much that in these glaucoma surgeries. There's such nuance between populations and while you know while maybe this doesn't compare exactly to the rising trial I almost say well well who cares you know I mean this is our patients this is our cohort. And it provides so much information that is so helpful about what may or may not work in our patients and so, while these huge multi center trials like horizon are great for kind of establishing efficacy in general, these types of studies that establish efficacy in our patients is is just so congratulations as super helpful study and will continue to be as you as you follow your other core course and follow them longer term. I think, while Dr. Steg unmute as well to answer Marshall's question with the magic trial being omni goniotomy versus eye track. I looked everywhere to find if that's actually the case and actually on clinical trials.gov it says 360 canaloplasty omni versus eye track so if anyone knows the actual answer that be happy to hear it. Cole you're ready. Sure. So, I just want to first make sure I understood so all of these patients got the canaloplasty plus the hydras. Correct. Did you consider, have you looked at our patients that got just canaloplasty or just hydras. And did you consider comparing those. So what's the next step is we have all the CPT is for hydras alone. We have to sift out I stands, and so we're going to end up comparing hydras to a big hydras. Actually, Abigail Jebaraj with a team of medical students is reviewing a big alone kind of stratified by device so eventually we will be able to compare all three cohorts as well. Something that confuses me that you might be able to comment on is like every study I've ever seen about any of these mixed procedures. It's always like it's the same results. It's like three points lowering on average.  Are you talking about like even the randomized trials to are a lot of those just the retrospective ones. I think you got muted again. So what I've seen in a lot of these retrospective mixed studies is there they're still medicated post operative patients. So I guess my guess would be it seems like regardless of the medications use the clinician just always seems to settle on about what they need. So maybe that ends up being three or four. Let me just mercury. I'm not quite sure. Yeah, anyway, thank you thank you really interesting presentation I'm excited to see those comparisons. That's a great idea. I just had one comment about that. You know, Brian, I think that what you just said is the single most important thing that makes all the mix have shown us and that is the floor effect you know this this Episclerol Venus pressure you know this black box term that's just tagged on to the presentation you know which gives us intraocular pressure. We just don't understand that, but we know that regardless of what we do to the angle with mix that is always there. It's always untouched, and it just doesn't allow us to get the pressure below about 14 or 15, no matter what the procedure is.  Nice thank you. Thank you Cole so there's much more discussion on going in the chat so please have a look as well. Thank you all for this great discussion and pop. Yes. So, moving on, we're going to move into our first year resident contingent. First up is Tyler Rethridge. You may think we talked to Tyler that he's some around here and has spent his life here but he actually if you talk to him has lived in many different places around the world and worked. And I urge you at all to talk to him about it at some point it's actually very interesting. Tyler's going to talk to us about the about asymptomatic ocular injuries associated with orbital fractures. Dr effort. Thank you very much. Is everyone able to see my screen. Not yet. You are a co host so you should be able to. You've got you. Swap screens here. Okay, so I'll be presenting on the incidence and severity of asymptomatic ocular injury in adult and in adult and pediatric orbital fractures. I have no conflicts of interest. So the necessity and timing of ophthalmology evaluation and the setting of orbital fractures is currently under debate. The most common practice pattern in the United States being immediate ophthalmology referral. However, in 2009, Melma at all performed a retrospective study evaluating the risk of severe ocular injury in visually asymptomatic patients with an orbital fracture, they included 126 patients, 46 of whom were visually asymptomatic, and of those asymptomatic patients, zero had severe ocular injury requiring immediate ophthalmology evaluation. And this concluded that visually asymptomatic patients with an orbital fracture do not have severe ocular injuries requiring emergent evaluation by ophthalmology. However, the study was performed at a level to trauma center. They had a relatively small sample size, and they only included routine orbital fractures whatever that means we so we sought to evaluate the presence and severity of ocular injury and visually asymptomatic adult and pediatric orbital fractures here at the University of Utah and primary Children's Hospital. We performed a retrospective chart review on approximately 2500 orbital fracture patients over the last 10 years of those about 1500 were evaluated by ophthalmology during their index hospitalization, and we're included in the study. The ocular injuries were reviewed and categorized into severe requiring emergent evaluation, moderate requiring urgent evaluation usually within one to two days, and then mild, potentially not requiring evaluation by ophthalmology at least in that week. Efficient symptoms mechanism of injury, visual acuity, orbital fracture characteristics were all recorded, and we compared the presence or absence of visual symptoms, the mechanism of injury and the visual acuity with injury severity. The majority of our patients were between the ages of 20 and 40. Most were males. Most were Caucasian Falls assault and motor vehicle accidents were some of the most common mechanisms of injury. There are some very interesting mechanisms such as plane crashes, paragliding injuries, and equestrian injuries. Patients were evaluated by ophthalmology within one day of diagnosis. Nearly half of our patients were hospitalized and 2% of those who were hospitalized unfortunately passed away during that index hospitalization secondary to the traumatic injuries they suffered. After categorizing patients into those who are visually asymptomatic versus symptomatic, we observed that visually asymptomatic patients were more likely to have a lower severity of ocular injury to the mild and moderate categories. However, about 19% of our patients were unable to report the presence of symptoms, most commonly because they were intubated and sedated. We observed that gunshot wounds were highly associated with severe ocular injury, and interestingly falls were associated with a lower severity of injury. However, those results did not quite reach statistical significance. Finally, we saw that better visual acuity was associated with a lower severity of ocular injury as one might expect. In conclusion, visually asymptomatic patients were less likely to have severe ocular injury. However, a significant number of patients were unable to express the presence of symptoms. The mechanism of injury, specifically gunshot wounds and poor visual acuity were associated with higher injury severity. Finally, prospective studies assessing the necessity and timing of ophthalmology evaluation and the setting of orbital fractures are required. For future directions, we hope to continue to develop orbital fractured protocols for the University of Utah like the one outlined here, which we have established with Primary Children's Hospital based on these data as well as other studies. Here are some of my references. There are many people to acknowledge for these works, including Deborah Harrison, Elizabeth Newtall, and Dr. Marks. Given that this is Resident Research Day, I thought I would share a brief story in the remaining time that I have. And this is on advice for those who hope to pursue a career in academia from one of the giants in the field of oncology, Donald Coffey. If you don't know his story, it's rather inspiring. He went from failing out of college to being a PhD scientist at Johns Hopkins. Towards the end of his career, he gave his students what was entitled the real final exam, which is outlined here. I'll read some of the excerpts from this that I think are most potent. He states I have no more insight into science than many others. I was just naive enough to list the obvious to which most of us are blinded because of measurements by false yardsticks and examples which are always in vogue. I know that with time you can expand and improve on your list. Number one is if this is true, what does it imply? This is referring to the results of your data. Number two, generate more than one concept to explain your data, then give all possible possibilities equal attention and effort. Number three, you don't have to assume anything that you can prove. Number four, the experiment that didn't come out the way you thought it would is the only experiment that is really going to teach you something new. Number five, every datum is screaming to tell you something, but you must do the listening and the thinking. Number six, what you are thinking about while you are coming to work determines your real interest and will direct your accomplishments for the day. And a complex experiment is usually the least productive. Number eight, it's time to do some experiments. Others must wait. Number nine, you are going to be surprised by the simplicity and beauty of the real answer. Number 10, all new ideas are resisted by you, authorities, editors, study sections, department chairmen, peers and friends. If this discourages you, you should retire early. However, most criticism can be constructive if you listen with an open mind. Number 11, a good paper is simple, clear and to the point. Number 12, if two good investigators disagree, and a paradox exists, most of their data are both of the data are probably correct, and we just need a new explanation that encompasses both observations. Number 13, give everyone credit. Number 14, do not be fooled by the authority of the printed page. Number 15, many bright people are paralyzed by negative thinking. And number 16, the most important ingredients are honesty, desire, clear thinking, confidence and hard work.  In turn, you will be contributing to some important answers for our present and future society. If you teach and lead, you will amplify your efforts and those of others. And if appropriate, the influence will continue after you cease. Questions. Tyler, do you think that, you know, in terms of who to evaluate and be safe to say that if we can't sort out that a patient is asymptomatic, we should take a look at them. Absolutely. A significant percentage of the 27% of those who were not able to report symptoms had severe ocular injuries such as globe rupture, entrapment, retroval of our hemorrhage leading to overall compartment syndrome. And I think the biggest issue that I have with Nelma at all study is that they didn't even address the fact that you may not be able to extract whether or not somebody has symptoms. And then they also included routine orbital fractures. I don't know what that means. I think every, every orbital fractures different. And as our data shows, you can't really predict the severity of injury based solely on the mechanism of injury. And for anybody who's taking call and taking call from the emergency department, our visual acuity and their visual acuity often is in disagreement. So I think that's unreliable as well. All right. Other questions. That was a great talk and it's an important topic. Well, if there are none, thank you. And we're going to move on. Okay, so Tony may have shared with us that in another life he could see himself in being a massage therapist. And this is obviously one of his hobbies he always respected and enjoyed. So today, and Dr. May is talking about more and 2020 retouchment rates for primary retinal detachments laying the ground for future QI projects. Take it away. All right, let me start sharing my screen here. All right, now can everyone do this. Yes. Perfect. My name is Tony my I'm a second year PGI to first year ophthalmology resident and my talks going to be about brands 2020 retinal retouchment rate. So, first what is a rental retouchment and this one of the terms I found in which the primary failure is when the attachment could not be accomplished during the surgery. The secondary failure is when there's a detachment after a period of attachment after that surgery, and the secondary failure is what we're going to be looking at today. And this could be before six weeks post-op and this is for an early retouchment, or after six weeks post-op considered a late retouchment. There's a lot of risk factors that can lead to re after surgery, mostly proliferative. As you can see here on the picture, there's scarring there's membranes contracting the retina. There can also be large break scrolled attachment hypotomy. Hi my a delay in surgery from the symptom onset to the time of the surgery. There's an effective closure where perhaps a surgical technique and good enough or something happened during surgery like complication that precluded a primary or good anatomical outcome. So the study that gave us our inspiration to look at this was the Massachusetts I and your infirmary infirmary quality and outcomes report to they publish every year and the one that we looked at was the 2020 report. This is for the entire Department of Ophthalmology and they report multiple outcomes for different departments and the one that we looked at mostly was the primary retinal attachment. Reattachment rates so they flipped it and did a reattachment instead of a retouchment rate but it's pretty much the same thing. And so for their study they included pars plantive intractomy sclerobuckle and pneumatic retinal pexy, and they wanted to look at only primary read the retinal attachment. And so they excluded pediatric patients chronic rds and other things that would be a secondary rd like exudative tractional things that had proliferative vitro retinopathy. If there was a history of macular hole or trauma, or previous surgery, or if they also had more fans or syndrome, what they looked at was attachment between three to five months post stop. And based on the definition that I proposed earlier. This would be more late retouchments. So this is the chart that they had in their report, and their latest number in that red box in the gray column is 89%, which means that in post stop month three to five 89% of patients were still attached for primary rds. And I want you to look at the international benchmark that they have here and that's this gray shaded box behind the color columns. They did a literature review of five studies. And these five studies had outcomes for PPV sclerobuckle and pneumatic retinal pexy at least two out of three of those. And they made a range out of those. And that was anywhere between 59.4% to 95% for being attached after the surgery. Now I went into these studies myself and looked at it. And they had a lot of variations. They did not have the same exclusion criteria as Massachusetts I and your head if anything, a lot less where they included as many patients they could and did not have very good specific timeframes for looking at whether they were attached or detached three or five months post stop. It was more of a broad study. So the question now is how does Moran compare and I like this term that was suggested by Dr. Levin quality research project in that it is a combo between quality improvement and research study in that we are still looking at Moran's data here, hoping to find some way to improve ourselves and see what our benchmark is. But in order to do so we need to do a bit of a research study to find that out first. So this project was designed with the help of Matt Bob speaking with him on how do we best capture these patients he told me that the best way to do that was using CPT codes, because we can find the exact date that the patients had a rental detachment repair, and then also if they had a repair within the six months after and that would be very difficult to do just using a diagnosis code. We included the parse plan of the track to me sclerobuco pneumatic retinopexy similar to Harvard study, but we also added cryo and laser retinopexy. Just for completeness, these were the CPT codes that we used. And for our exclusion criteria we use the same that was used in the Harvard study, but also, but also added other entities like PDR severe glaucoma infection uveitis healers Danlos syndrome as well as complications in the initial ppv or tears or holes that were repaired, but did not actually have a true retinal detachment. So this summary for the design differences. A Moran study included cryo and laser while the Harvard study did not. We also expanded the exclusion criteria to take things out that had a lot of infection uveitis PDR glaucoma, and the such like I had in the last side. In the summary outcome we looked at if there was detachment within the entire six month post up, while the Harvard study only looked between three and five months, and we did this because we also wanted to include patients that had early read detachment to while there is did not. I wanted to put a disclaimer out that the following is just preliminary data only so please take it with a grain of salt. Like I have been doing myself I just finished this just a week ago. So this is still going to be undergoing review with the retina department and figuring out how we can best improve the accuracy of the data. So the CPT codes that were done by the Epic query with Matt Bob turned out 3332 322 patients that had those procedures done in 2020. That was through the exclusion criteria with chart review retrospectively, and that turned out 90 patients with primary RDS after we had excluded these patients which were 232 out of which 47, the majority of them had retinal holes or tears and the rest ranged from having traumatic RDS to chronic RDS proliferative diabetic retinopathy with traction RDS or pediatric patients and there was a lot of overlap between these also. Now these 90 patients with primary RDS 28 of them had read attachment surgery within six months. So if we were to put a simple fraction where the read the ones needing read attachment was on the numerator, and the total primary RDS was in the denominator. This turns out to be a rate of 31% for primary rental detachments. So just comparing this with the previous data that we've seen the gray box there is the international benchmark and Moran's number is on the higher end of it still within the benchmark on the higher side, compared to the MEI study that we use for respiration which was right around 11%. But I do want everyone to remember that our it's not directly comparable because there were some differences in our design in that Moran included more procedures, we expanded the exclusion criteria, and then we also counted all read attachments within six months post up. All of these reasons could be contributing to the difference in the rate that you're seeing. So just step back here and reevaluate the approach to getting this number, because even this number, looking at myself I did raise an eyebrow a little bit and asked myself, am I doing things correctly. So, these are a couple of the areas that I can see where we can investigate a little bit further and find out if the approach was actually correct. The first is the epic query where I can ask myself, are we missing people by just using the CPT codes was that method correct in the first place. I know just by going through the data, the very few patients, the patients were captured, and working at the VA myself there were many more retinal detachments and retinal tears and holes that were paired at the Moran that were not captured just using this method. So, I'll hopefully be working with the building and the retina department on finding ways where we can improve this. Next is our inclusion exclusion criteria. I know that we tried to revamp the exclusion criteria by adding more and added more surgeries just for our own future projects but should we also modify the criteria to copy the Harvard data so we can directly compare to the number that they have. And lastly, just data collection itself. There was a lot of tedious chart review in this process. And so, I'm sure there's a lot of human error that I myself probably had made and so I would need to go through this data again to make sure that it's accurate and hopefully involve someone else to also go through it to have a second pair of eyes. So this is returning a perhaps a better retouchment rate that we can trust. So our next steps here is to review the project design and methods with the rented apartment and the billing department. I'll need to review the data to ensure accuracy and also involve someone else to review alongside me. If all of these turn out to be satisfactory, then we can stratify the read attachment rates for individual procedures and then compare that with the literature, and then we can plot the read attachment time course based on which month they're happening in and perhaps if there's any correlation with the particular type of procedure. And then lastly dive deeper into what is causing the read attachment whether that's PBR, or surgical technique or something else that's there that we're perhaps missing. So, at the end, if Moran's read attachment rate is truly that number. My question is how can we improve. And I think this is a great project to lay the foundation for looking at future qi efforts, and how we can bring this number down if that's what it is, or is it different. What can we do to improve our approach for other departments to use the same kind of retrospective review looking at surgical issues. And the contributors are Hongam Lei, she's our retina fellow who helped me, helped it lead me through this project. Dr. Jacobi, who is our lead, and Amika Hansen, who is a medical student who helped a little bit on some of the data that we have in question, and math about who helped with the design of the CPT codes and Epic query and taking any questions. Thank you Tony. And thank you so much for this preliminary data, which of course is very, very important to us and so Joe Simonette has the first question. And on this really complicated subject, I have one question about Harvard's data and one question about our data so I'll just ask them both for Harvard for that three to five month range so how would they code like a case that detached month one, and then had repeat surgery and then was re then was a attached through months three and five which would be like the majority or almost all detachments related to pneumatic retina pexy those usually happen pretty early. So that's one of the questions about Harvard's data. And then our data. Can you just speak to kind of why I guess just retina pexy laser and a pexy and cryo pexy were included since we almost exclusively do that just for breaks that the rare occasion occasions we would do that for a detachment would be like to create a peripheral detachment I guess technically that's not really repairing the detachment so I was just kind of curious about how many cases you included from those CPT codes and and what the reason was for including those cases. Thanks. Yeah, great questions. So for the Harvard study. That's one of the questions I had for them to what happened if something came first and was state stayed attached. And the honest answer is I'm not sure because they did not fully explain their, their methods very well this was more of a public report, where it was a report on all the departments and it was more results based, and they didn't really get into the weeds of what their thought process was for each particular little study that they had in that quality outcomes report so honestly I'm not too sure either. As for our own data, we included the laser and the cryo just for completeness because we were thinking that we might be looking at these for future projects, not necessarily this particular retinal read attachment but in case we wanted to do things looking in the same way that we could do some repairs also, then we can go back and have these patients here. Okay, we have one comment from Judith Warner, where these only cases that came to the or did you cross check with the yellow sheets. Yes, and so these were not only cases that came to the or because we just did CPT codes. We also were able to capture patients that were prepared in the clinic or after hours. And someone came to the ED and the retina fellow came and did a pneumatic and repaired their RD. And so in cross check with the yellow sheets was difficult because we felt that the yellow sheets wasn't complete at this time only about 20 came back for the yellow sheets which was definitely a lower number than we expected for the amount of ORs and retinal attachments just a procedure so we had in clinic. So maybe Brian stack last quick question and then please look into the chat there's a lot of discussion going on. Yeah, I'll be quick. Just wanted to say this is a great project and measuring quality is super hard. And comparing quality between places is super hard because there's so many things that go into it like case mix and definitions and all that and I think you were kind of talking about that. The end that I really liked that I think is a really important area is, I think the absolute rate of complication matters less than the change in rate of the, or not of complication but about come. So the change in rate matters more. So I think what you're doing to measure the rate of read attachment is really important not so much to compare us to other places. But to like make improve like the continuous improvement. So I liked how you talked about like targeting doing that. And I think I was just wondering if you had thoughts about that like how you might target to improve like reduce read attachments besides, you know, just changing the definition over time, or like changing who you take but like what what could you do about that and have you thought about like measuring that as a study. Yeah, so that is one of my further down the line thoughts because I won't even trust the day I'm getting is a good in the first place so that's the first step. But yeah, you're right the second step is figuring out ways where we have actionable items or we can improve that read attachment rate. And I think to do that we need to figure out what's causing in the first place. I did collect some of the data collection I did collect some of the reasons why these three attachments are having say like it's PVR or something else. It will be difficult because a lot of times in those notes, there's not a good documentation of why the read attachment happened. There was a new detachment, and it's a little bit mysterious for me as for why these things are occurring. And so that will be probably a QI project or another study on what's going on in that place, then we can figure out how to fix it. Thank you so much all for the discussion again look into the chat as discussion going on and on and on. And now Bob I think our next speaker is ready with a Mac. Dr Kennedy apparently decided after watching a documentary with Larry Bird, where he used his non dominant left hand to play an entire basketball game.  I hope your teeth are okay. And at this point, he is going to speak to us about the language used to consent patients for training involvement in surgery patient comprehension. All right, Dr Kennedy. Anyway, go ahead and for john we're looking forward to hearing your talk. Can you all see my screen now. Yes. Okay, perfect. Well my name is Brandon Kennedy I'm a first year of biology resident here at the brand I center and I will be discussing presentation titled language used to consent patients for training involvement and surgery and patient comprehension. I have no conflicts of interest. So some background. So this this project really stemmed out of Dr Levin our chief here her resident research day presentation and grant rounds last year about training involvement consent and ethics and we, we had a lot of good discussions and learned a lot. We know that not only do we have this duty to disclose training involvement patients actually expect this as well, especially when residents are the primary surgeon. And also the degree of consent does vary based off of trainee level and whether this is disclosed or not. And lastly we talked a lot about the risk involved in potential complications when trainees are involved in surgeries. I remember last year as an intern hearing this talk and how's it the VA at this time so one of my responsibilities on ophthalmology is actually to consent patients for surgeries and lots of times these surgeries were surgeries I've never even heard of so these are some of my thoughts after the presentation last year. But really what I wanted to hone in on is this question here is does the way we approach trainee involvement in our consenting process vary. And I was wondering if this varies myself with other interns with residents with fellows and attendings and how they kind of approach this topic. So what we did is we actually did a pilot study and we we surveyed everyone here at the Moran eye center, just kind of get their response of what they actually say to patients when they're consenting for resident involvement and here's just kind of four examples here of what we heard back. And really what I want to highlight is what's in the bold terms here. And you can see just with four responses to our surveys there's actually seven different terms used to describe training involvement. And for someone like myself for everyone here is in the medical field we understand what a chief resident is a fellow, a senior resident attending physician so forth. But do our patients and parents of patients understand the difference between these terms and the verbiage that we're using. If so, great. And if not, do they really understand who will be doing the surgery, how much what level of training they're in. And are we actually doing our job of consenting. And that led us to the question in this. The study here we really set out to understand do patients understand the terms used to describe training involvement in surgery. So what we did was a prospective study with a web based anonymous survey and we surveyed the parents of pediatric patients over the Moran eye center in the Pete center. And the conclusion were patients who were having surgery within the next one month to kind of help decrease proximity university bias we also stratified for some demographics. And here is a snippet kind of of part of our survey, and you can see at the top. We wanted to assess the perceived confidence of our participants and their understanding of these common terms that we use when consenting for training involvement. So we used a Likert scale, you can see here going from not at all confident to very confident. Now we wanted to compare this perceived confidence with participants ability to actually answer these true or false statements kind of defining these terms and see if there's any discrepancy and their perceived confidence. Their actual ability to understand the terminology that we're using. So here is some preliminary data our sample size right now is about 38 with a nice 90% response rates. And we're aiming to answer this question of how confident our participants in these terms and you can see there's an overwhelming positive response, the majority of our participants are either somewhat or very confident in the common terminologies that we use with most confident being medical student least confident being fellow however still overall very confident in their understanding of these terms that we use. However, when we compare that with their ability to answer these true or false statements defining these terms, we we see some somewhat surprising data here. For example highlighted here, almost half of our population size said false that a resident is a physician. About a quarter said false and attending is a physician, then almost a third said true and attending is a trainee. In regards to our population data. So far in the preliminary stages however the majority of our patients actually all were English speaking adults ages of 20 to 40. The majority of them also had some type of college degree. So really kind of not to draw too much conclusion from this preliminary data, but you can already see a little bit of discrepancy of how participants or parents of these patients feel the confidence in the terminology that we're commonly using to understand the involvement in the consenting process versus their ability to actually answer these true or false statements about these terms that really define these terms. And if there is this discrepancy that I do believe that does pose an ethical dilemma of do these patients actually fully understand what they're consenting to, and the terminology who will be doing the surgery, what level training they're at, how much so really driving home that top point is what we've been talking about here is does this pose an ethical question in regards to our consenting process if patient comprehension is really not well understood, which leads us to the next steps moving forward, should we standardize the terminology or use definitions in the consenting process. I know at the Iran we do have a kind of a blank statement at the top of each consenting packet saying you know there will be a training involvement. Do you consent do you agree. But are we defining those terminologies are we saying the same language, when we're actually speaking to these patients in clinic versus what they're signing up for. And then lastly, still in the preliminary stages but would these results vary if there's a non English speaking population. The majority of our patients were English speaking and if there's an additional language barrier, could this make things even more difficult in regards to the patient comprehension of the common terms that we use when consenting. So that is my presentation and now I'd like to say special thank you, mostly to Dr. Levin, helping out with this project and kind of carrying it forward as well as Dr. Jardine. I'm Dr. Wylander who was our cornea fellow last year as well as one of our interns is Dr. McCarty. Thank you everyone. And for questions. Well, will you moderate. Brandon, do you have a question for you. Do you think that there are things that we should change right now before waiting to kind of look in and answering these other questions that would be, you know, a huge improvement in our current practice. Yeah, that's a great question. I don't know if I have the capacity to fully answer that as I have not rotated through a lot of the surgical specialties that we do our second year. I know at the VA as interns we were previously doing the consenting process and, and we were taught this consenting process and disclosing a training involvement kind of from intern to intern. So really there's no protocol. There's no definitions and I think we could definitely improve that process at the VA, which we already have started, because now we're doing a lot of the consenting in the H&P with the PGY2s and 3s who are further along in their training than also again at bedside. In regards to the Moran consenting process, I would have to take a little bit deeper look and then also hopefully gain a little more experience during the next couple of years to help answer that question. Great. Thanks. I think Tyler has his hand up here. Hey, thanks Brandon. I guess I had a question or I should say comment about you know when I can send patients I have to use like at the VA I can use statistics that come from large clinical trials that are performed mainly by senior attending physicians and not residents and I think it'd be interesting to elucidate whether or not trainees or how we adjust the stats that we report to our patients and how those stats would impact their decision whether or not it would at all would be kind of an interesting question to be back off of your project. Yeah, I agree and I find myself guilty of kind of pulling these stats, not all the times. Sometimes you know I'll talk about the studies that I know and the increased risk, specific to the kind of the level of training depending on how comfortable the patients are. It would be interesting to kind of see if there's any any protocol or any standardized approach to disclosing more data and if that would be a good step moving forward. Okay, I think at this point now I want to direct you to the chat there are a lot of really interesting comments. I think that you've stirred up a fair amount of discussion. I think it's also probably time for us to take a brief break we're going to take about 10 minutes.