Good afternoon, and welcome to the National Archives in Washington, D.C. I'm Colleen Chogan, the Archivist of the United States, and I'm pleased you could join us for today's talk about Driving the Green Book, a road trip through the living history of black resistance with its author, Alvin Hall. Before we begin, I'd like to tell you about two programs coming up later this month on our YouTube channel. On Thursday, June 15th, at 1.30 p.m., Matthew J. Claven will tell us about his book Symbols of Freedom, Slavery and Resistance Before the Civil War. Symbols of Freedom describes how enslaved people and their allies drew inspiration from the language and symbols of American freedom. And on Wednesday, June 21st, at 1 p.m., Andrew K. Dimer will discuss his new book, Vigilance, the Life of William Still, Father of the Underground Railroad. Still, an abolitionist who managed a critical section of the Underground Railroad in Philadelphia helped as many as 800 people escape enslavement. Next week, from June 17th to June 19th, the National Archives in Washington, D.C. will display both the Emancipation Proclamation and General Order No. 3. The Emancipation Proclamation, issued by President Abraham Lincoln in January 1863, declared that all persons held as slaves within the rebellious states to be free. General Order No. 3, issued by Galveston's Union Army Commander on June 19th, 1865, informed the people of Texas that all enslaved persons in the state were now free, two-and-a-half years after Lincoln's proclamation. Since then, the celebration of Juneteenth, a combination of June and 19th, spread from Texas to other states and is now a federal holiday. After the Civil War and into the 20th century, though, Jim Crow laws continue to deny black Americans full freedom of movement and participation in society. Restrictive laws and hostile communities made travel dangerous. To help black travelers navigate their way in safety, the Green Book pointed out trusted places to buy gasoline, eat meals, and sleep overnight. What had been an essential tool for African Americans on the road between 1936 and 1967 is now hardly known. Today's author, Alvin Hall, will share his modern-day explorations of the roots described in the Green Book and introduce us to a number of people who used the Green Book during the years the guide was published. Alvin Hall is an award-winning television and radio broadcaster, author, and financial educator. His numerous radio programs include The Tulsa Tragedy that Shamed America and Jay-Z from Brooklyn to the Boardroom. For five years on the BBC, he hosted the highly rated and award-winning series Your Money or Your Life. Now let's hear from Alvin Hall. Thank you for joining us today. Thank you. I am very glad to be here to talk about my journey with the Negro Motorist Green Book. It might surprise people to find out that my journey with the Green Book actually began on an airplane. On one of my trips to London, I opened a magazine and saw an article about summer travel. And in this article, it mentioned the Negro Motorist Green Book, a publication I had never heard of. And I always like to say, and I am a well-educated black man, and I didn't know about this. So I decided to explore the existence of this magazine or this publication when I got back to New York City. I went to the Schaumburg Center for Research in Black Culture in Harlem. And to my surprise, I found the largest collection of the Negro Motorist Green Book in America. And from this slide, you'll see the various covers. It evolved from being the Negro Motorist Green Book to being the Negro Traveler's Green Book to being the Traveler's Green Book, a guide for travel and vacation over the years. This publication was founded in 1936 by Victor Hugo Green and his wife, Alma, at the time they lived in Harlem. And they would go south to Richmond during the summers to visit Alma's family. And during that period of time, they would find aggravations and frustrations and embarrassments during their drive south. They could not stop at a restaurant. They could not use a bathroom at a service station. And there were also gas stations that would not serve them gasoline. Rather than just succumbing to this, Victor decided to create a publication that he and his friends could use to avoid these aggravations and embarrassments on the road. So he founded this publication by first talking to his friends, many of whom traveled around New England. And he managed to put together a list starting in New England in 1936 of all of the places where black people could find safe harbors and welcoming services over that period of time. The publication came out every April and May of every year. So you could put it in your glove compartment when you went on your drives or your holidays and you could use it to find safety and the services that you wanted on the road as an African American. As you can tell from this picture, Victor's organization was also very progressive for that period of time. His staff was all women, all women who helped him create his vision along with Alma. Of course, when I got the green book and it was spread out on the table in front of me, I started to go through the green book and to look at all the ads. Remember it was a state by state city by city listings and over the years, it would expand to be able to accompany this type of advertising. And I chose these for a specific reason. You have the Linux lounge, which was located in Harlem at 288 Linux Avenue for many, many years, even during my time in New York City. You have on the left Vernon Shaky Terry's ESO station. The ESO stations are very important in the history of the green book. They were the only nationwide gas stations that carried the green book. And this ties back to the Rockefeller. We need to remember that ESO was owned by Standard Oil at the time. And the Rockefeller family had been involved very much in abolition movement years back. And so it's not surprising that they would be much more progressive, not only in giving blacks the opportunity to own franchises of the service station, but also to work at that company. But all of the information in the green book existed before. And as this little clip will illustrate from a letter written to Victor, it talks about the network that existed before as automobile travel increased. It's a great pleasure for me to give credit for credit is due. Many of my friends have joined me in admitting that the Negro motorist green book is a credit to the Negro race. It is a book badly needed among our race since the advance of the motor age, realizing the only way we knew where and how to reach our pleasure resort was in a way of speaking by word of mouth until the publication of the Negro motorist green book with our wishes for your success and your earnest effort. Respectfully, William Smith. He mentions word of mouth. So prior to all of this information being gathered in the green book and several competing publications, people dependent upon word of mouth. You have sororities, fraternities, the masons, other groups of professional people who when they had to travel for work for conventions or other meetings would call up a friend or talk to somebody in their community who had done that route before and they would pass this information along. And people I interviewed during my road trips always talked about the power of this word of mouth network, how it kept people safe. And this is what Victor was capturing in the pages of the green book. Here, you'll also see other places listed in Chattanooga, noticed in the lower right. You even have a high end resort like Oak Bluffs in Martha's Vineyard, Massachusetts, being advertised in the green book. So it covered a broad group of businesses. Now, just like everyone else, when I first saw the green book, the first place I looked was the town nearest where I was born, Tallahassee, Florida. And look what I discovered. There was the Abner Virginia Motel on Bragg Drive. I was raised south of Tallahassee. I went there many, many times in my life and I never recall even seeing this place. So I decided to drive by there at the beginning of my first road trip in order to see this place. And here is what the Abner Virginia looked like today. It is in a wooded area, the original place where you would drive in has been demolished and now it's mostly used for section eight housing. But you still get a sense of what it looked like even back in those days with the live oak trees and the moss hanging from it. While I was in Tallahassee, I also discovered another place that I didn't know about in French town, which was the black area of Tallahassee when I was growing up. There's Tuk's house. This was an example of a tourist home that was listed in the Green Book. Tourist homes were privately owned houses where people would take in people overnight, very much an early example of Airbnb or a bed and breakfast. And Tuk's house still exists there. I think James Baldwin stayed there when he came to give a talk at Florida A&M University. And outside there, there is a plaque honoring the Tuk's. And you see that this type of honoring is increasing across America. So this was my introduction to driving the Green Book. Just so happens that a producer named Jeremy Grange in Wales in the UK had also come across the Green Book. And by the time I got back to America and started doing my research, Jeremy called me and I immediately called him back because he was interested in doing a BBC program on the Green Book. I said, put my name on this program. And it was commissioned by the BBC back in 2016 before the movie came out. In constructing a journey for this one episode program of about 38 minutes, we decided to do a trip through time and space. The space would be from Tallahassee, Florida, near where I was born, following the historic civil rights route through Montgomery, Selma, Jackson, and Memphis, and ending in Ferguson, Missouri. The time was from my past because I was born in segregation south of Tallahassee, Florida, into the current events surrounding Michael Brown's death in Ferguson. So we were really following what had happened over that period of time to get a sense of what people were thinking about history and as it relates to current events. So Jeremy Grange and I did this trip over five days and it was a revelation. This program, which aired on the BBC, was one episode. And in my soul, I knew there was more there to be seen. So I decided to create a second idea. And this idea was for a podcast. And I was looking around for some great way or some connection to tie this to the Green Book. And I recalled an exhibition at the Museum of Modern Art where they had an infographic that captured my attention. It showed the increase in the population of northern cities as a result of the Great Migration. Many people moved north to seek more opportunities in the burgeoning automobile industries and other industries of north. But another reason that people left was terrorism. The hanging, drowning and dragging of black people and sharecropping all of the financial hardships that came with that. So as people left the south, they moved north. And if you look at the chart that's on the screen, you'll see something very interesting. In 1910, Detroit had an African-American population of approximately 61.2% of the total. By 1970, the African-American population of Detroit was 43.7% of the total. If you look at those two sides, you can see that it was the largest increase within any northern city. And that gave me the idea of for the second road trip. This would be a road trip from Detroit where many black people had moved during the Great Migration south to the states that they would have come from. Tennessee, Kentucky, Alabama, Georgia, the Florida Panhandle, and finally New Orleans. So over 12 days, driving 2,021 miles and doing approximately 40 interviews, we took that trip. I put this slide up there because I think it's really important for us to remember that not only did people move north to for better job opportunities to earn much more money than they had earned during sharecropping, but also there was all of this terrorism throughout the south. And at the Equal Justice Initiative at the National Memorial to Peace and Justice, they've captured the dirt from places where people were subject to terror killings. And this was an early display of that and focusing on Alabama. It was very, very moving when you look at all of the different shades of the dirt that was in these yards, which in many ways reminded me of the shades of all of the different black people in America and how no one was exempt from terrorism during that period of time. So for this road trip from Detroit to New Orleans, I borrowed this map, which was in USA Today, which showed the various ways you could do that trip.  And on this trip, I was joined by my associate producer and great friend, Janay Woods-Weber, and a field producer who would record the interviews and help organize the trips in advance, Oluwakeme Alaudesuyi. I chose these two people for very specific reasons. I was born in the deep south during segregation. So many of these, many of the things we were likely to encounter on this trip would be familiar to me. And I had a deep roots in the south.  She was raised in a community largely white in Massachusetts. And there, as she said, she knew the bullet points of black culture, but not in detail. So she would bring a different perspective to the information that we learned and the interviews that we were doing. Kemmi was born in London, raised in Nigeria, and moved to America, to Illinois, when she was a child. So she came from outside of America and had none of that history. I wanted us during the drives between interviews to have deep discussions about what we heard, what we felt, what we thought. How was it affecting us? Because that was going to influence how I wrote about the material in the book. I wanted the book to appeal to a lot of people who didn't know this history, but I wanted it to connect to them emotionally. Black person driving a car that was perceived as an affront to the Jim Crow customs, to the idea of African Americans being almost a separate caste in Southern society. So in many cases, African Americans might travel with a chauffeur's cap in the car or even wearing a chauffeur's cap so that it would appear as if they were driving for a white person rather than driving independently or autonomously. And it's very interesting those contradictions because, of course, it was certainly okay for an African American man to serve as a chauffeur or a driver for a white family. But for a Black man to own his own car was perceived as being something that was kind of against those laws of segregation. That interview with Allison Hobbs, a professor at Stanford University, was in the back of our minds when we started this trip. We wondered, what could happen on the road? What echoes of the past would we encounter? And unbeknownst to me, Janae was so concerned about this, she did most of the driving, that every day she would check the car to make sure we didn't have any broken taillights. So there would be no reason for police to stop us on the way. But interestingly, we never talked about this fear. We talked about just, we referenced it, I think, in our behavior. But we were often, I think, afraid that if we said it, it might become a reality. So we started in Detroit. And on that first stop in Columbus, Ohio, we met the most amazing person, Mary Ellen Tyus. And she introduced me to a world I knew nothing about, the world of high-end resorts for African-American during segregation and Jim Crow. She had, from the time she was born, been going to Idlewild, Michigan. Her grandmother had gone there. Her mother had gone there. And now her children are going there. This is one of those resorts that was referred to as the Black Eden. It was so remarkable. And she talked about what was a perfect day at this resort. They would be completely away from the white gaze. All of the concessions were owned by Black people. All everybody around them were Black people. So no one there was likely to be Jim Crowed, a term I learned during my interview with her. And here is what the place looked like. It was quite magical. Once I learned about this, I then discovered that there were these other locations all across America. There is Fox Lake in Angola, Indiana. There's Oak Bluffs in Martha's Vineyard. There is Highland Beach in Maryland. And there was American Beach in Florida. All of these places were places where Black people went, typically during the summers, to get away from the prejudice, to enjoy themselves, to have fun with other Black people. Ironic when I found out about this place, I discovered that friends of mine, two of them have recently begun looking at and one actually bought a place. And this is a picture from Highland Beach, the one that was started by Frederick Douglass' son. And this was so meaningful to me, this particular picture, when I saw it. Because one of the things that everyone talked about during my entire road trip was how African-American parents sought to protect their children from the prejudices that were in the broad society. This was one of the most profound things that I learned along the way. And it made me reflect on how my parents had protected me from the racism. Although I was raised in segregation, much of the horror of it, I really didn't know. This was one of the best lessons I've ever learned. And I have a quote about this, a little passage about this. My grandfather would say to me, things as a child, he said, whenever a white person comes up to you, don't look them in the eye. You always say yes, sir. You always say no. There were these strategies that you had to adopt to stay safe. And my grandfather was a proud man. He was a smart man. But in the presence of white people, he would become this something else that was deeply painful for him. Because he wants to model something for me. At the same time, he wants to keep us safe. And it's that duality, that burden that I think few people understand. That is Brian Stevenson of the Equal Justice Initiative in Montgomery, Alabama. And that statement was so true across the board. Everyone talked about how the parents loved their children, sought to model them, but also didn't want them to be captured in the hatred of racism. They wanted their children to strive to become educated, to achieve things that they had not been able to achieve themselves. And that's why, although this started out to be a road trip, in reality, at the end of the trip, I couldn't do a pure road trip program because there was so much humanity. There was so much history. There was so much personal experiences and grace that needed to be captured, the emotional connection to that history, so that people would understand and hear the lived stories of these people. I wanted to capture their voices in the podcast. As we drove from Detroit to New Orleans, one of the themes that came up was Little Harlins. I have a chapter in the book called Little Harlins. These were the main streets where Black people gathered, where there were thriving businesses within the Black communities across America. There was Jefferson Street in Nashville. There was Walnut Street in Louisville, Ferris Street in Jackson, Mississippi, and the Avenue, Jefferson Davis Avenue, now Martin Luther King Boulevard in Mobile, Alabama. Every city had one of these places called Little Harlem, and they were very active. They weren't the slums or the threatening places that you see portrayed in many movies. They were really places of glamour, of success, of pride, of dignity. A quote. It was difficult. Most times, Black families traveled safe routes, and you were very cautious. Cautious from where you stopped when and how you present yourself. You traveled during the day. You tried to get to where you were going before nightfall, because the least little thing could trigger violence. Saying was, you know, Negroes, they used the N word then, were not supposed to be caught in those towns, you know, after sundown. Now my dad would tell us when we were driving up through North Mississippi. He's the other little town called Duck Hill, and he didn't go to those places. He would always say in Duck Hill, he said they tired and feathered a Black man. Those are quotes from some of the people that we spoke to along the trip who talked about their on-the-road experiences. When they left these communities, these Little Harlems, where they were safe, when they went out on the road, that's where they became vulnerable. That's where they had to implement travel skills and thought that would help them to survive on the road. When I talked to young people, young people are particularly surprised to find out that you couldn't stop at any service station and buy gas because they might not serve you, that you couldn't just buy food anywhere. It wasn't available. Those were the rules of segregation out of sight, out of mind. So these Little Harlems were the safe places. When people left those little Harlem, that's where the danger occurred. And one of the dangers was accidentally stopping at night in a sundown town. Sundown towns are basically these communities where African Americans are not permitted to be after sundown. If you are caught there, then you were harassed. You could be put in jail. You could be treated, violently treated as a result of it. And many people think that because the South was known for its virulent racism, that sundown towns were characteristics of the South. That was not true. They are much more of a Northern phenomenon. Indiana, Ohio, Detroit had sundown suburbs. Long Island had sundown communities across the North. There were all these communities where African Americans could not be after dark. And how were these policies put in place by the police? The local police would look for African Americans in these communities and then harass them if they were there. And so now you can see some of that behavior. Today some of these sundown communities still exist, but now it's treated silently. So what happened to all of these little Harlems? Here is what we discovered. In town after town where there's not been the will of people to keep up these communities, many of them have been abandoned. And in some cases all of the land may be owned by a city or local developer who seems to leave it to benign neglect. This is Farage Street. And here's another one. This is also on Farage Street. And we have a little clip here to talk about this. Well, this street was, I guess you can call it a safe place, a safe haven for African Americans. Two blocks east, west, north, everywhere you go. It was the white section of town where black folks couldn't go. Everything on Farage Street, however, was built by freed slaves, no architectural degrees, no major education. They built their own buildings, made their own businesses, their own clothing stores, their own fire department, their own restaurants, drug joints, all happened right here on Farage Street. It was like, in fact, it was called Little Harlem. The train station is two blocks over. When folks get off the train, they come straight to Little Harlem. And the streets was packed. The streets were packed all the time. And look at it today. It's no longer packed. We had about three theaters around Farage Street. We had the Amit, the Alamo, the Book of Tea. And we had one on another street that was black businesses and Jackson was on next street. So on that street, there were bother shops and grocery stores and novelty shops and cafes and juke joints. One of the joys of doing this road trip is meeting these people and sharing and hearing their stories and their different accent. It really was quite emotional for me as I went from town to town to meet people who had wonderful stories, but to hear the varied accents of African Americans across the South was one of those joys that lives in my heart today. Many of the places, this is what you will find. As a result of the building of the interstate highway system, many of the businesses that had been featured in the Green Book became isolated. And as a result of imminent domain and other local practices, they were destroyed. In this case, this was Summers Inn and Subway Lounge. And if you look at this sign, you'll notice that this place was destroyed in 2004. So in many communities, these places managed to last quite a bit, but then business went south and therefore they tore down the buildings. And this is what remains very similar to Tuk's house in Tallahassee.  And we were so lucky in Jackson that we met this guy on the street who was delivering flowers, and he told us about Collins Funeral Home and the fact that Mr. Collins was there. So this is a clip about what we discovered about the funeral home. This funeral home is the oldest Black funeral home that's totally owned by Blacks in Jackson. And there's only one second oldest funeral home in the state of Mississippi. There's only one minute that's owned by Blacks and that's Jefferson and Vicksburg. And this has been there at the same location all these years? It started across the street and it came from over there. Mr. Collins is over there. You can talk to him if you want to. That would be great to talk to. So here I am thinking, what do I do? I don't know anyone in this town. I didn't have a green book, but I had been taught something by my parents about what you do when you're stranded in a place where you don't know anyone. See if there's a Black funeral home, call them and see if you can stay at the funeral home. I did that. I asked some Blacks on the street, you know, there's a Black funeral home there. They told me there was. So I called the funeral home and the funeral home owner told me that I could come and stay. I told me who I was that I was a teacher. But that was the kind of thing that our parents taught us about how we needed to be flexible and what things we could do when we were traveling if we got on a predicament like that. That happens to me. If you want to sleep in, that's fine.  That's one thing you can rest assured.  And I've been here over 50 years and nobody's ever bothered me. That was Mr. Collins, the owner of the funeral home and the guy before him was Jerome Gray, who is an activist who lives outside of Montgomery, Alabama. I love this sequence because most people don't realize that the funeral homes were a safe harbor.  When we got to Alabama, especially Birmingham and Montgomery, we discovered some wonderful places of fellowship that no longer exist, or in some cases that are being repaired. And one of the ones was the Benmore Hotel. This is on South Jackson Street. And this has the advantage of being one of the highest points in Mississippi. At the top was the Starlight Lounge. And here I think in this clip, Jerome Gray talks about this hotel. Where there have been barriers, Blacks have found ways to get around those barriers and really have fun in a way, because these places that were cited in the Green Book, those places really became wonderful places for Blacks to go to and meet, not just to travel, but it became a social gathering site. It's like the Benmore Hotel. I became bewitched by the Benmore Hotel. It is quite an amazing place. It is largely abandoned today, as you can see. There is one business still there. But we also recorded some people who had been there. I wanted there to be some memories about the Benmore Hotel, both in the book and in the podcast. A regular meeting place for civil rights activists in Montgomery was listed in the Green Book, the Benmore Hotel. And it is still there. It looks as if it's about four stories tall, a brick built edifice planted squarely on the corner of High Street and South Jackson, occupying probably a quarter of a block. The sign is still there, Benmore Hotel and Majestic Cafe. But the business is long gone. And it's a little hard to imagine, given all of the bars and chains and lots that are currently on the doors. But this was once a really glamorous place. It was nice, nicely furnished. Downstairs was the Majestic Cafe. And it had opaque, embossed windows. Dr. Gwen Patton and Jerome Gray were both active in the Civil Rights Movement and both have fond memories of the hotel. It was a wonderful place to meet and to fellowship. And the other thing, it had the distinction for being one of the tallest buildings in Montgomery. So Benmore Hotel really gave you a bird's eye view of Montgomery. They had an elevator called, his name was Cat Wilde. And you ride the elevator all the way up to the roof. And that was called the roof. And you could dance and they had live music and we could buy your elevations and roof stories. Absolutely grand. Since doing this program, I discovered that when Ike and Tina Turner were on their tour on the Chittolin Circuit, they played at the top of this hotel.  And I just love this picture. I wish the Smithsonian Museum of African American History and Culture could go in and just take this out because so many of us remember getting our hair cut in places like this. We remember the conversations that occurred and the memorabilia and history that the people who cut hair there embodied. But the Malden Brothers Barbershop is also important for another reason. It was where Martin Luther King got his hair cut. And Nelson Malden was one of the people that I spoke to. And here's a clip about that we did in this barbershop. This is the last remaining business in the hotel, the Malden Brothers Barbershop. And you walk in and the first sign you see is colored waiting room. It's quite amazing. And then on the other wall, you have all of the pictures of his clients, people whose hair he's cut over the years. I can honestly say, like everybody would say, if the walls could top, you know, we had no more than what we know, you know? Which chair was his? The first chair right here. His chair, and that's where he used to sit. And this is where he cut Martin Luther King's hair. And this chair right here. This chair right here, that's right, the very one. So he came in the shop, like most New Customs, what was the name? He said, Martin Luther King. I said, where are you from? He said, Atlanta, Georgia. So if I finish cutting his hair, I gave him the mirror, say like this hair cut, and he said, pretty good.  That's kind of an insult. But he came back two weeks later and I was busy when another Bible was breaking, but he waited on me. So I remember that side cast this statement he had made. I said, that must have been a pretty good haircut. He said, you all right. Despite segregation and all this, people had great stories and fun memories to share. Here we are in Memphis, Tennessee. And I just put this up to show you the difference between Tallahassee, Florida, one listing in Tallahassee, Florida, and the many listings that were in Memphis, Tennessee. There were actually more pages than this, but I just wanted to show you that every city was different and how they presented the ads in the Green Book was very important. Of course, any Green Book stop could not tour, could not be complete without a stop at the Lorraine Motel in Memphis, Tennessee. The Lorraine Motel is iconic. Not only was the place where Martin Luther King was assassinated on April 4, 1968, but it has also become the National Civil Rights Museum and people take pilgrimages there all the time. It's one of those places that was saved. It shows how the community pulled together after the assassination of Martin Luther King to save the Lorraine Motel. It was the African American community who led this, led by local people who were trusted by the community, who helped save this iconic motel. And across America, now, we're watching this sort of desire to save these places, to not let them go to ruin, come reach fruition. Another one that we went to was the A.G. Gaston Motel in Birmingham, Alabama. Look at this place. It has a sort of Frank Lloyd Wright feel and it was elegant. And we met this wonderful lady who's in charge of the restoration in Birmingham. And she talked about A.G. Gaston, what an entrepreneur he was, how when he saw a need in the African America, he'd create a business to meet that need. And as a result, he became a millionaire. Not only did he own the A.G. Gaston Motel, but he owned a penny savings bank. He owned an insurance company. He owned a funeral home. He owned a construction company. And that construction company is now responsible for the restoration of the A.G. Gaston Motel. And they're trying to take it back to the Splendor. And these were some pictures that we took along this trip. And we took this specific picture because upstairs was known as the War Room. This is where Reverend Dr. Martin Luther King, where Reverend Fred Shuttlesworth, Ralph Abernathy, and many leaders of the Civil Rights Movement, would meet to plan out various actions in Birmingham. And this hotel was bombed as a result of that, of their meeting there. People, this was during a period when Birmingham was known as Bombingham following the notorious death of four young women at the 16th Street Baptist Church. Of course, we had to go to Selma.  And as I walked across the bridge, so many thoughts came to mind. But this clip, I think, is really important for us to think about. Every year in its introduction to the Green Book, Victor Green wrote that, there will be a day sometime in the near future when this guide will not have to be published. That is when we as a race will have equal opportunities and privileges in the United States. With the passing of the Civil Rights Act in 1964, it seemed that the Green Book would no longer be needed by black travelers. Yet there are many people who feel that the Green Book, or something like it, is still needed today. That quote has stayed in my mind. And I was lucky enough near the end of the trip to meet the wonderful Hank Sanders, who had been a member of the Alabama Legislature, the first African American elected since Reconstruction. And he shared many, many memories with us. But there's a story that stays with me. He was a part of that march from Selma to Montgomery. And he was a part of the group that was there when Martin Luther King asked the question, how long? And the group would respond, not long. He would ask again, how long? Asking about how long before we have civil rights. And the group would answer, not long. I asked Hank Sanders, what would he say to Martin Luther King today if King were alive and asked him how long? And he said, I would say to Dr. King that I did not know you were talking biblical years. That Hank admits that he underestimated the depth of white supremacy in America. He thought five or 10 years, everybody would have equal rights. Everybody would have the right to vote. That all the challenges that were associated with getting civil rights would be over. And he said at the very end of that, but Dr. King gave his life for the cause. And Hank said that he would continue to fight until his life was done. When people travel during this period of time, they created pleasures for themselves. They played games. Black people bought big cars so they could be comfortable on the road. There's all this myth surrounding the types of cars that black people bought.  You wanted to have some power in case you needed to get away from a difficult situation. But it was the food that was a common memory, those shoebox lunches. Everybody talked about the fried chicken, the tea cakes, the deviled eggs made without mayonnaise, the drinks that they had on the road. So at the very end of the trip in New Orleans, Jenae Woods-Weber and I had to go to, well, there's a clip here, I'm going to skip that, had to go to Dookie Chase. It was a joy, a total joy for us to be able to go to there. And what we did, we not only had created our own version of the shoebox lunches, but we also had the wonderful experience, the absolutely wonderful experience of going to a place that had been listed in the green book at the same location for year after year after year. It was a survival. And that's what we took away from this entire experience, that African-Americans survived. Yes, there were horrible things that happened during that period of time. There's no denying that at all. But African-Americans did not allow themselves to be captured by that evil, captured by that darkness, many through humor, but largely through grace found themselves through that period of time and were able to build better lives for themselves as well as their families. And as I end this lecture before I take any questions, I'm going to give the last word here to Brian Stevenson of the Equal Justice Initiative. That Black people have had to create mechanisms for survival is an indictment of America, but it also is a testament to people of color that we have found ways to cope and survive and navigate this incredibly unfair and complex world. So the green book and a lot of other things like it were the tools that people used to navigate. Black people had to visit families and friends who were not nearby, so that meant they had to use transportation just like everybody else. So to have a guide, to have a mechanism, to have a source book that would help you navigate that was really important. In every city along the way from Detroit to New Orleans, Detroit, Columbus, Louisville, Kentucky, Nashville, Memphis, Jackson, Birmingham, Montgomery, Mobile, and finally New Orleans, we met people who shared their rich experiences and I believe wanted me to pass on their wisdom, their courage, and their strength to my readers the way they had passed it on within their families and communities. These people survived and one interview still affects me. It was with Frank Figgers in Jackson, Mississippi and it's the interview I had to get up and leave because I just, it just went through me. His voice was like the voice of my uncles near Tallahassee, Florida, who would always speak with such intention because they wanted to give me the wisdom, to give me the skills to survive, whether it was the historic patterns of getting up early in the morning, if you were taking a trip to get on the road and make sure you got to your destination before sundown, to make sure that you had food packed, that you had been careful about on the, what happens on the road, but also how do you make your life better where you are? And I always think of this quote by Frank Figgers, probably every day and certainly when I look at my book, do what you can with what you have where you are in order to make a better life and a fair deal. Frank Figgers gave me a great gift in that statement and I will always be thankful because it is telling each of us to do something, to be active, to do what you can to make life better where you are, the way Victor did when he and Alma created the Green Book, the way each of these businesses did in these towns. If you think about this, the Green Book is a history of Black entrepreneurship, of Black resistance and of Black resilience at a time when there were so many social strictures on America. Black people were able to create their version of the African American, of the American dream despite segregation and Jim Crow. Now I'll check to see if we have any chats here and here we have a copy of the book jacket. I also have given you the image of the podcast series and there's a link to the podcast so you will know more about that if you want to listen to the episode of the podcast and there is a bonus episode available. I've also done a documentary movie that's literally driving the Green Book on Long Island. One of the things that we found out was that many people did not believe that there was prejudice in the North that it could not have been in the South but just looking at sundown towns on Long Island and those memories that's really important to recall. I'm going to look at now the chats see if we have any questions. Are there any current projects in these old communities, revitalization and others? Yes there are. In Thomasville, Georgia for example, I know they're trying to restore one of the motels that were listed in the Green Book and I recently read that in West Virginia they are past local communities are looking at Green Book locations trying to give them historic designation and trying to help restore them wherever possible. Clearly as the knowledge of the importance of the Green Book comes out as a historic tool that enable people to negotiate these difficult times and survive these difficult times with dignity and joy more and more people want to focus on saving this part of American history. When I talk about the Green Book one of the things that people always assume was that when I wrote the book was going to be full of negativity you know all the dark things of course dark things happen but I wish when you read the book you notice the humor how people talk about these situations and the grace that they show. Race is the key word. I think we have no questions left so if there are no more questions I will end this. Thank you all for attending. I hope you learned something from this today. Hope it inspired you in some way and I hope that everybody will look for and learn more about the Negro Motorist Green Book and it's amazing history in America.


So, today we're gonna do retinal vascular disease, not including diabetes. I think Emmy has the diabetic lecture. So this is really two parts this week and next week. So, today we'll get through vein occlusions and arterial occlusions, and then next week we'll talk about some more of a hodgepodge of different vascular diseases, ocular, schemic syndrome, hypertension, sickle cell. So, to start with central retinal vein occlusions really, the main signs you're gonna see clinically, you're looking at four quadrants of dilated tortuous vessels with optic nerve edema, four quadrants of intranetal doppelgut hemorrhages, and then you'll often see macular edema. We break up central vein occlusions into the non-eschemic and the ischemic type. Non-eschemic is a milder form with better vision and these can resolve on their own without any treatment. And the ischemic form is much more severe, less perfusion. Typically we say more than 10 disc diameters of non-perfusion. Often you'll see a relative afferent pupillary defect, but not always. And the ischemic variation has a higher risk of neovascular complications and 60% will develop neovascularization without treatment. So, these are just two funnest photographs comparing our non-eschemic and our ischemic central vein occlusion. On your left, you'll have the non-eschemic form with the dilated vessels or tortuous and engorge. You can see four quadrants of intranetal hemorrhages, some optic nerve fullness and hyperemia. And then on the other side, there's the more severe ischemic variation with very engorge dilated, so I'll just use my pointer. You can see how dilated and tortuous these vessels are. Severe hemorrhages with macular edema, cotton wool spots and full-minute optic nerve edema. Looking at the cross section of the optic nerve and the vasculature, the central retinal vein occlusion occurs from thrombosis of the central retinal vein, just add or posterior to the lamina cabrosa. Interestingly, when we talk about a hemirentinal vein occlusion, it's an anatomic variation where the superior and the inferior retinal arteries meet, or veins, excuse me, meet posterior to the lamina cabrosa, and one of them becomes occluded posterior to the lamina cabrosa. So that anatomic variation occurs in about 20% of people and will spare a portion of the retinal vasculature. So here's a photograph of a hemirentinal vein occlusion. It's obviously much more severe than a branch vein occlusion, and you can see that this area of the retina is spared, but this large area is involving, and so that's actually more, we classify it as a central retinal vein occlusion and our management kind of is a combination of both. It's pretty uncommon to see a hemirentinal vein occlusion, but they're out there. So our risk factors for central vein occlusion, the biggest risk factors are age, hypertension, diabetes, glaucoma. If you don't have one of those, then we need to consider a hyperquaggable state and consider a workup and also look at their medication list. You can often see these in younger women. If they're on oral contraceptives, you'll see a vein occlusion in those people as well. And then, so what I'm gonna do, I'll talk about central and then branch vein occlusions and then we'll talk about the studies altogether because a lot of the studies kind of go together pretty well and we'll talk about treatments of both of them together. So a branch vein occlusion is caused by a compression of a vein by an artery in that common adventitial sheath and so usually you'll see this when the arteries are laying on top of the vein and then that compression leads to a thickened arterial, that thickened arterial wall is gonna compress the vein, lead to turbulent flow, endothelial damage and thrombosis. If you don't see it in an AV crossing site, you wanna consider an inflammatory cause. So this is kind of your typical fundus appearance of an acute branch vein occlusion. So you can see the compressions occurring right at this AV crossing site and downstream of that intra-retinal hemorrhages, cotton wool spots, significant macular edema. Our risk factors for a branch vein occlusion, typically patients are in their 60s, hypertension, cardiovascular disease and an increased BMI at age 20. You'll note that these are not on our central vein occlusion risk factors. The other thing that's different between branch and central retinal vein occlusion risk factors is that diabetes didn't make it as an independent risk factor from the eye disease case control study. So that's a pretty typical OCAPS type question. So just comparing the two, the branch vein occlusion, the different risk factors, cardiovascular disease and the BMI at age 20. And then for the central vein occlusion, diabetes is on the list. So if you see a PRBL and the only good risk factor or thing they have to say to you. I don't do it. And that's okay. Yeah, it's just statistics I think. You see it in diabetic patients, but it just didn't make it as an independent. But I don't do a whole big work up if they're diabetic and they have a vein occlusion. Maybe some people will, but I don't. But for OCAPS, it's different.  So the vision is probably the biggest factor. Worst vision is gonna do poorer overall and less likely to have a good vision down the road. An afferent pupillary defect. If that's present, they have a worse prognosis as well as an increased risk of neovascular disease. Gonioscopy should be done at that first visit looking for subtle neovascularization of the angle and the iris and then every month. What is it? And then at that first visit, you wanna measure the intracular pressure and look at that closely because if they have early neovascularization of the angle, they can have early glaucoma and that would affect your treatment. You'll do a dilated exam, fundus photography, florectin. The florectin can be really helpful in differentiating a vein occlusion from ocular schemic syndrome and then your OCT will all be done at the first visit and then monthly thereafter. So when you're seeing those patients for the first time, obviously you wanna address the eye but then you need to look systemically at what else is going on and what you wanna do as far as work up. I typically will check the blood pressure in my office and if it's high, it's really high, I've sent patients to the ER, if it's moderately high to the primary care doctor, sometimes within that day or that week if it's pretty severe and then if it's not high then you've gotta think well, what kind of work up do we wanna do and who's gonna do the work up? Is it gonna be me or am I gonna work with somebody else to do it and I've done it both ways. If they have glaucoma or if they look like they're at risk for glaucoma then I work with their primary eye doc or get them to a glaucoma specialist to see if that's a risk factor. For your OCAPs, the work up should be done if patients are presenting with a vein occlusion and they're younger than 50 but I've worked up people that are older that have no risk factors too. So this is kind of your standard hypercoagulable work up. These are the more common things, this is what I would typically order as kind of a starting point if I'm doing the work up. These defects are less common and I don't typically order those but I've seen them ordered by hematologists when they're doing the work up so I kind of leave that to them but I've ordered these not infrequently when I'm kind of initiating the work up. So there's a few different reasons why people can lose vision from a vein occlusion. Acutely you'll see edema, hemorrhage or capillary occlusion. The chronic causes of vision loss are ischemia, edema, they can get subretinal fibrosis as edema resolves, pigment changes, neovascular glaucoma and vitreous hemorrhage. An essential vein occlusion, typically the neovascular disease occurs three to four months after that vein occlusion happens. So just some more funnest photographs to show the difference between an acute and chronic vein occlusion. So this is an acute presentation again at that AV crossing site, downstream hemorrhages and cotton wool spots with this tortuous vessel here. That's what you'll see acutely. And here's another acute vein occlusion. Not as good of a picture. And then this is actually someone I saw this week with a chronic vein occlusion. You can see the sclerost vessel, the floor scene showing floor neovascularization despite this sectoral PRP that's been started. And then one of your kind of tip-off signs is this collateralization that you'll see across the temporal raffae out here. And that'll kind of clue you into that they've had an old vein occlusion and that's pretty typical. And this is another patient of mine that's had a vein occlusion for 10 years. And you can see this kind of pruning here and then the downstream, this vessel's dilated and tortuous but this collateralization that's occurring and the kind of pruning of that vascular tree is pretty typical of chronic changes from a vein occlusion. And this is a nice angiogram showing those collateralization that can occur just outside the foveal vascular zone and this can actually lead to resolution of macular edema and a better visual prognosis once this is developed. So really all of our treatments are guided by some pretty large clinical trials. The first of which is the BVOS and the CVOS. So the BVOS came out in the mid-80s, kind of set our gold standard of macular grid laser for branch vein occlusion and macular edema. CVOS came out later in the 90s and then these later studies which are guiding our more current regimens, the SCORE BRAVO, the SCORE BRVO and the CRVO study looked at triumcinolone, the OZARDX trials, I don't think anyone would ever quiz you on Geneva but the OCAPs are gonna quiz you on BVOS, CVOS because those are really landmark trials. The SCORE is a pretty landmark study and then BRAVO Cruise is really where we entered the anti-vegetarian that was with the rhinobizumab. So the highlighted ones are the ones that you would see kind of popped up, I think, on any testing. So, BVOS really was looking at two questions. The first question they were trying to answer, is there a benefit to argon macular grid for macular edema secondary to a branch vein occlusion? 139 patients were enrolled and like I said, this was in the mid-80s. And then the second question was, is there a benefit to sectoral PRP to prevent neovascular disease? So the results found better visual outcomes in people in the group that had macular grid. The visual acuity range for all participants was 2040 to 2200. Treated eyes, 65% improved two lines compared to only 37% in untreated eyes. And treated eyes were more likely to have vision better than 2040 at three years, 60% compared to 34%. The treatment, it's important to note, began three months after presentation. So you weren't doing laser through all the hemorrhages that they presented with. I mean, now we don't do it anyways that quickly. We're doing anti-veg Fs, but at that point, you were letting those initial acute hemorrhages clear and then doing laser after that hemorrhage cleared. As far as the question of PRP and neovascular disease, they found that sectoral PRP decreased risk of hemorrhage from 60% to 30% and recommended sectoral PRP being started after development of neovascular disease. The CVOS came out later in the 90s and really tried to answer the similar questions to the BVOS study. Can photocoagulation decrease neovascular disease and does macular grid decrease vision loss from macular edema? This study also really defined a lot of our natural history from central readily and occlusions as well. So the findings, they did show that macular grid reduced macular edema, but there was no associated visual improvement with that and that PRP failed to reduce the risk of neovascularization. In younger patients, there was a trend toward better visual cuties, macular grid, but no improvement in older patients. So from these two studies, our laser recommendations that really kind of set our standard of care was that macular edema with a branch vein occlusion should be treated with grid pattern after three months and then neovascular disease should be treated with sectoral PRP after the neovascularization develops but not prophylactically. And then similar for CRVO, neovascularization treated after it develops not before. There's no reason to try and prevent it with PRP. And then there was no reason to do macular grid for macular edema in central vein occlusions. So that's what we did till the early 2000s, really when things started changing, really the limits of laser, 35% of patients with a vein occlusion don't respond. The vision is better than untreated, but it's not great vision. Patients are really 20, 40, 20, 50 and then there was no improvement really with a central vein occlusion. To really the best predictor of final vision from a central vein occlusion is what their presenting vision was. So if they're better than 20, 40, they're gonna stay in that range most likely. If they're worse than 20, 400, they'll probably stay that way. This is based on the natural history from the CBOS data. And then in that 20, 50 to 2200 range, a third will get better, a third will get worse and a third are gonna stay the same. So in like 2000, early 2000s, people started doing intravitural steroids and people were having a lot of anecdotal improvement with intravitural steroids and that led to the SCORE study. So that stands for standard care versus corticosteroids for retinal vein occlusions. So there's the SCORE BRVO and the SCORE CRVO study and the primary endpoint was the percentage that gained three lines or more at 12 months and patients were followed for 36 months. So for the SCORE BRVO, they compared the control which was observation with rescue macular grid versus a one milligram intravitural triumcinolone group and a four milligram intravitural triumcinolone group and there's really no significant difference between all three groups and there were more complications with the intravitural triumcinolone group. Intracular pressure was higher, requiring medications, cataract surgery was more common and so the final result at 36 months was that laser was better than intravitural triumcinolone and macular grid kind of remained our standard of care at that point after that study came out. The SCORE CRVO was a little bit different. Same kind of setup, it was one milligram versus four milligrams of triumcinolone and then the observation group, there was no laser for that group obviously and the triumcinolone groups did better than observation with around 26% gaining 15 letters. So at that point, our standard of care for CRVOs was to start triumcinolone, intravitural triumcinolone to treat macular edema. And then shortly thereafter, OzardX was approved, OzardX is an intravitural delivery device of dexamethasone that lasts anywhere from one to three months and a really large study found significant improvement in vision in the OzardX group and then not too long after that we really kind of got our anti-vegete studies. People were doing it before the, they were doing it off-label before it was FDA approved obviously, but then the anti-vegete studies came out. Obviously everybody knows that VEGF is a key mediator in angiogenesis and vascular leakage and so that's the idea behind it, working in vascular occlusions and macular edema associated with that. So our anti-vegete studies that you would need to know would be the BRAVO and CRU studies. They were both Genentech, Sponsor, Granibizumab studies, phase three trials and they studied Granibizumab 0.3 milligrams versus 0.5 milligrams compared to sham and the treated groups approximately 50 to 60% of patients gained 15 letters and those in the sham group, 54% required rescue grid while in the treated group only 18 to 19% required grid laser. And the CRU's trial pretty similar results, kind of the same setup, 0.3 compared to 0.5 compared to observation and the primary endpoint was the change in vision from baseline to six months, 46 and 47% gainers compared to 17% gained 15 letters in the sham group and the improvement was pretty rapid in the treated groups patients just one week after the first injection had already gained nine letters and overall over six months the treated group gained 12 to 15 letters compared to 0.8 in the sham group. So it was pretty exciting to actually be able to offer some improvement for patients. So this is really the big shift in our standard of care is where we started doing anti-vegete agents for branch vein occlusions. Really the biggest drawbacks are the half-life of the medications and the need for continual injections. You guys are doing it at the VA and in all our clinics, it's hard to get people potentially off the injections. It seems like they'll need injections at least for six months and even up to 18 months on average. I have patients where I've been doing injections for three, four years and I can get them to eight weeks but if they go nine weeks they're worse and so I just have to keep doing it every so often I'll try and spread them out again but some people just need that continual injection. A flib receptor ILEA is also approved for branch and central retinal vein occlusions, pretty similar results and similar studies. I would be surprised if anyone's gonna kind of, these weren't really landmark trials, Galileo and Copernicus but they did the Galileo, I think ILEA got its approval for central vein occlusions in 2012 and then the branch vein occlusion came later, that approval just happened in 2014 but very similar results to the other studies. Obviously most of us are really starting with Avastin as an off-label medication. There's not a really landmark huge trial for Avastin and vein occlusions, it's really based more on a smaller case series and retrospective data and kind of extrapolating AMD trials and the CAT trial to vein occlusions. So just to look at a few kind of patients I've seen recently, this is a young, I think he's like 35, your old man who came into me with some weird kind of patchy network in his vision, had been going on a few days and this was his funnest appearance and this was his fluorescent angiogram so you can see his pretty significant macular edema, tortuous vessels that are dilated with four quadrants of blot hemorrhages, really no macular edema. I think he was 20, 30 at this point. Since he was young, he has a history of non-Hodgkin's lymphoma, had a big workup, MRI, whole thing and everything's come back negative but I kind of worked with a hematologist for that because of his other medical problems and I've been seeing him monthly for three months now and he's really improved quite dramatically in his visions 2020 and he's doing well. So I never really found a cause which is kind of weird, you know, but he's doing pretty well and this is obviously somebody that's doing a lot worse, a very severe ischemic CRVO and an older patient of mine and that was what he presented like, I think his vision was count fingers at one foot or something at this day and this is OCT. I have to have one of you show me how you grab OCTs off of axes, is it? Yeah? That's what I did but it's kind of, not great quality. Do you do a screenshot, that's what I was, yeah? Do you, okay. Anyways, so this is what OCT looked like, you know, horrible macular edema. I started with three of Avastin, after the three of Avastin, this is what he looked like so he's still kind of count fingers, not doing great. So I switched him to ILEA and after three ILEA this is what he looked like and he's, you know, 2070 and now I kind of do his maintenance, I did his maintenance injection yesterday and he's, you know, kind of holding that 2070 vision. He's not 2020 or 2030 but he's, you know, appreciably better than he was before he came in but I can't go more than eight weeks between his injections yet but it's been nine months so maybe I'll be able to get him out down the road, hopefully. So for Avain occlusion, for treating the macular edema we typically start with anti-vegetables, I'll start with Avastin, if they don't respond then I'll switch them and if you can get them. So the macular edema's pretty much resolved or pretty stable, then you can try spreading them out. Often if I feel like they're not getting a great response to the anti-vegetables then that's when I bring in the intervitial steroids and the ozardix and then not frequently but sometimes you'll try and augment with laser grid, especially patients that seem like they're gonna have poor follow-up or they're not gonna come back or if they're just not doing well with the injections you might add in some grids still. Do you use the steroids with anti-vegetables? That's a good question. It kind of depends on what the macula's looking like and sometimes I'll do a combination of both. If I feel like I can get more edema down with the steroid I'll add that in and keep the anti-vegetables going. And some people who could just do steroids and you might not need the anti-vegetables, it kind of depends on what they look like. It's not like a set protocol, I would say for that. But I probably don't do it as much as maybe some of the other providers. I like it but I reserve it for people that are pseudophagic that don't have a risk of glaucoma or don't have any really glaucoma factors. I feel like most of my patients respond pretty well to the anti-vegetables agents but it seems like they need them maybe every eight to 10 weeks. If they're not doing well then I add in Ozardx or an IVT and kind of see how they're doing but I don't do it quite as much as the anti-vegetables for sure. But it can be really helpful and some people really need both that steroid effect and the anti-vegetables effect. And then for treating neovascular complications really PRP and then plus or minus anti-vegetables agents if they have really fluorine neovascularization. You know often I'm working with the glaucoma team to kind of treat that and they like the anti-vegetables to try and save the angle especially if they still have an open angle with neovascularization they like that rapid kind of response resolving those vessels so that they can keep the angle open. If they have a closed angle then often the glaucoma doctors are putting in tubes or valves you know to help with the glaucoma. The nice thing about the injections is you can really see a pretty impressive response within 24 to 48 hours as far as neovascularization of the iris. The PRP obviously takes longer several weeks even a few months to see the full effect. So kind of depending on how severe the neovascularization is if it's on the milder side I'll probably just start with PRP but if it's pretty fluorid then I'll combine and do both of them. So any questions about vein occlusions? We'll move on to artery occlusions. So for a branched artery occlusion you'll see this edematous white appearance of the retina and the distribution of the artery. Usually patients will complain of a field defect that's pretty stable. Really you know when you're looking at a white retina there's not a whole lot of things that can cause white retina you're either thinking infarctoschemia, edema, you could have infection or infiltrate or potentially myelin, commotion but there's not a whole lot of things that are causing a white retina. The causes of an arterial occlusion most commonly especially in branched retinal artery occlusions is emboli either from the cardiac or carotid source. Other things to consider would be vasculitis, coagulopathies, trauma, collagen vascular disease and more rarely things like buchettes or leukemia. You know as far as looking at an emboli and trying to decide if it's coming from the carotid or is it coming from the heart, there's been studies, people can't really just look at an emboli and say oh that's a heart and I don't think that's very accurate and I think there's been studies that have looked at that. You can't just look at it and say where it's going to be coming from. I think it's pretty important though that these get a pretty aggressive work up through their primary care doc or their cardiologist and often kind of working with them to get that done. So just examples of the emboli, this cholesterol or hole in horse plaque is often at this bifurcation of a vessel, platelet fiber and you can see pretty well it fills the lumen of the vessel for several disc diameters and then the calcific embolus which is actually more commonly at the optic nerve head. So the hole in horse plaque or the cholesterol embolus is at this bifurcation of the artery, it's very refractile and this is coming from the carotids. It really is pretty rare for this to obstruct flow enough to cause an arterial occlusion and then the calcific embolus, you'll typically see that right at the optic nerve head and you can often see this associated with the central retinal artery occlusion. It's this more chalky white appearance and that's coming from the heart. The platelet fiber fills the vessel completely and can lead to an arterial occlusion. So central retinal artery occlusion patients usually come in with sudden and complete loss of vision with no pain. The retina is very edematous. You get this cherry red spot which do you guys know why you see the cherry red spot? Yeah, you're seeing that carotidal flow kind of through that foveal vascular zone exactly. The visionless is usually permanent. You rarely see people get better from this. Usually that kind of retinal edema and whitening will resolve over a month or so and then you're left with these really a pale optic nerve and really attenuated vessels. If they have NLP vision, it's not gonna be a central retinal artery occlusion.  So looking back at our cross section, the etiology of a central retinal artery occlusion is thrombosis here at the lamina crevosa. This kind of shows where a set cellular retinal artery is arising from and it's coming from a separate vascular source. It's coming from the posterior ciliary artery that some cellular retinal arteries present in, I think it's about 30% of eyes have a cellular retinal artery and if you're lucky and it's affecting the macular circulation, you can get some vision that'll be preserved. You know, when you're looking, oh, this shows the, so this shows where that cellular retinal artery's coming from here. If you have an occlusion of the cellular retinal artery since it is coming from that carotidal source, you, it's strongly associated with giant stilarteritis so you wanna make sure you're working that up. So here's some examples. This lucky person has a cellular retinal artery preserving this area. Unfortunately, they still have a cherry red spot so their vision's probably not great but they might be able to get some vision out of this area. And this person has a cellular retinal artery occlusion in the setting of a central retinal vein occlusion. So I think the most important thing when you're looking at artery occlusions is really looking at the entire patient and their risk factors and their medical evaluation. There's a high association with cerebral infarcts and an increased risk of mortality. So, you know, this is kind of the protocol that, you know, Dr. Katz worked with the stroke team to set up that we have at the Moran. You guys are probably all pretty widely familiar with this. Does it work pretty well? Yeah, because it's interesting, you know, as like a retina specialist, often like we're seeing the arterial occlusions later, we don't see them in our clinics right that day. Usually they're going to triage or you guys, I think, and so it seems like you guys, at least I haven't really had to facilitate this much since it's been implemented. But the idea is that if you have an arterial occlusion that's occurred within a week, calling the stroke team and getting them admitted to inpatient neurology for a workup, but you guys haven't had much that's been working pretty well. Oh, good, okay. Does the VA do the same thing? Okay, well that's good. So then if it's more than a week, then we start the workup. The workup should include an MRI, an echo, carotid dopplers, you know, some blood work and then starting aspirin and statin, if indicated. There's really not a good treatment for central retinal artery occlusion. You know, people have tried a lot of different things when there's anecdotal reports of some things working. People try ocular massage. So what I would do for that is just put, like a gonial lens on the eye and kind of gently massage the eye. The idea is that you could potentially dislodge the embolus further downstream and maybe get some improvement in vision. I've tried AC TAP, some people do hyperbaric oxidant treatment. There's always anecdotal reports of some things working, but there's really nothing that works great. I've seen reports of people doing yaggles or to an embolus and breaking it up and restoring blood flow that way. You've never seen that? I've also seen, you know, big complications from that, big hemorrhages. Yeah, exactly. And then there's, you know, reports of people doing catheterization of the ophthalmic arti with TPA, with some. Did you? I thought they stopped doing it. Yeah, they said that their policy wasn't to do home. Yeah, that's right. But then I think maybe it just depends with the exempting of neurologists. Oh, that's true. Dr. Joe Witt, like all Dr. Warner, they did it. Oh, really? How's the patient doing? Sure, I don't know. Yeah, I'd heard, I thought a grand round someone said that they stopped doing that. Their policy was to not? Yeah. So it just depends on the neurologist or the interventional radiologist? I think the neurologist, because the neurologist can't flip the phone at all. Oh, okay.  So neovascularization is less common, but if it happens it occurs, or it's less common than a vein occlusion, but if it happens it occurs quicker, usually within one to two months. And then just briefly, you know, this is rare. I think I've seen this once, an ophthalmic artery occlusion. Vision will be light perception or NLP. The fluorescent will show no caroidal or retinal filling and you won't have a cherry red spot. And patients who have had an autopsy done with giant cell arthritis, 76% of those will have ophthalmic artery vascularitis. Other causes could be internal carotid dissection, mucor and complications of surgery. Gosh, we got through everything pretty quickly. This is just interesting, to me this is interesting. So I don't know if I can click on this if this will work. So when I was a resident and fellow we were doing radial optic neurotomies for this. I don't know if you've seen this video.  I did it a couple of times. We don't do that anymore. Now that this was before we were really commonly doing anti-vegetables. Yeah. So people have tried various surgical interventions for vein occlusions, arterial occlusions and with some success, you know, another thing people do is try and create these retinal chorital anastomoses and they can do that similar to with an MVR blade or with really hot laser. And so what you'll do is say you have a vein occlusion and you kind of pierce the retina down to the depth of the choroid and several quadrants and the idea is just to induce collateral blood flow and, you know, you see reports of that working well, but it's hard to know because some people would get better potentially anyways, but, you know, the patients that I remember doing those radial optic neurotomies were really horrible, ischemic CRVOs with count fingers vision, but, you know, they didn't do great after the surgery either, you know. So I think things are a lot better now. The retinal vange thotomy, people try and kind of, if you have like a branched artery occlusion with an embolized pupil, try and kind of thread a canula or kind of use an MVR to kind of dissect the sheath between an artery and vein and kind of relax that and allow blood flow, but it's not commonly done.  Do you guys remember which one was the one that set macular grid as the standard for BRVOs? BVOS, yeah. And then what was the ranabismab trial for BRVO and CRVO? BRAVO and CRU's, and then the SCORE, which one's SCORE? Yeah, yeah. So SCORE, there was, you know, for BRVOs, no reason to do intervitual trimes in alone, and then, but for CRVO, it showed a benefit. Trying to think, what else? I think the other thing was, which are you more likely to see neovascular disease develop with a CRVO or a CRAO? Yeah. And the timing after CRVO, I don't know if you remember that, it's usually three to four months, yeah, but a CRAO, you'll see it within a month or so. So it's more rapid, but less common. Yeah, Nico? I remember the studies, but the antibodular studies, did they compare it instead of sham to the laser treatment? So they don't, so what they did is they have sham injections, but then if the investigator felt it was warranted, then they would get rescue grid laser. And so I put it in here, the rate of the person, I think I put it in how often they needed rescue grid. But they- Well, what's the reason they didn't compare it to that? Yeah. Well, I mean, essentially they did get grid. You know, so grid laser doesn't start till three months after the vascular occlusion, right? But you can start anti-vegfs right away. So the patients were basically getting intravitual injections or a sham intravitual injections for three months, and then at three months, if they still had macular edema, then you could do a macular grid. Does that make sense? Because that was kind of our standard of care. So I think with, if I put it in here. When do you use it when they're all having macular edema in the first time? Yeah, for, yeah, we were treating macular edema for the vein occlusions. We weren't just treating the vein occlusion. It was only indicated if they had macular edema associated. So for Bravo, it was 54% and the sham group required grid. And then the treated groups, 18 to 20%. And then for Cruz, there's no macular grid. So they were just getting pure sham. Any other questions? Good. All right, so next week we'll do, next week's kind of like a mix of weird vascular topics, but I'll try and pull it together. It doesn't have a nice flowing theme. Well, thanks for coming early.