 So, welcome to Grand Rounds today. We have the unbelievable pleasure of learning about the slave labor that Shamima has performed this last year. I believe she's the most prolific cornea fellow ever, at least in my long tenure here, in terms of putting out research papers. But also, she's someone who I think each resident would vouch as someone who's an excellent teacher who really cares about people's education, despite only being here one year, she's really become, I don't know, kind of a member of the resident family in a sense, and that doesn't always happen with fellows. She was recently married after a long search, and she's still happy. They are living apart, and I think that's one of the big reasons why they're so happy, because my wife is happier when I'm away, so without further ado, Dr. Sikter. Thank you for that memorable introduction. It is a pleasure for me to present this morning, I really do appreciate all of you coming in. It's nice to present in June, you kind of have the whole year to look back, and it's been an amazing year, and I hope that over the course of the next hour, you all are able to appreciate some of the wonderful opportunities that I've been able to participate in, and how I feel very, very lucky to have been a fellow here at the Moran over the past year. So basically, we all know that this fellowship is awesome, and so I just wanted to take a moment to step back and sort of quantify how amazing it is. This is a little sample of some of the surgeries that I've been able to do this past year. And so I think Dr. Wilson picked up on the highlight of the slide. There were eight globes, and seven of them were with Dr. Slade. So it's been an honor and a privilege to close globes with you, Dr. Slade. I think you'll be on call at the beginning of the year because you are, like, the resident expert, and hopefully you can share some of the pearls that we've shared listening to Lady Gaga on Pandora while closing globes. So it's been very, very entertaining. And then, actually, the eighth globe was with Bryce, and so that was an honor to help close Bryce's first globe. But it's been a great year, as you can see, lots and lots of surgery. And this is definitely one of the reasons why this was such an attractive fellowship. But there's another component that I didn't quite realize was so enticing about this fellowship, and that's the opportunity to engage in research. So as of today, I've submitted 16 papers and nine have been accepted. And technically, if Dr. Oberg and Dr. Holt kind of finish up the last round, we'll submit two more papers this week. And I had the opportunity to be involved in two Arvo posters. I had two invited papers, and I gave two talks at Ascrist, which was a first for me. So that was a delight. And so what I'd like to do is sort of go through some of the papers that have been accepted and share with you a little bit about that experience. So the first paper was actually accepted into JRS. And this was a prospective study looking at artisan, iris-supported phakic IOLs in patients with keratoconus. And so the interesting thing about this paper is it looked at 13 patients with 16 eyes, and these patients were defined as having stable keratoconus, defined not only by keratometry, but also refraction. And there were a number of reasons why these patients were considered a good candidate for these phakic IOLs, which are, as most of you know, inserted through the anterior chamber, clipped to the iris. Here in the US, it's also marketed as verisice, although abroad, it's marketed as artisan, simply reflecting the difference in manufacturers. And so these patients were found to be contact lens intolerant or simply did not like wearing the strong prescription glasses that they needed. And so in these 16 eyes, 14 received just the standard phakic IOL and two actually received Toric IOLs. And it's important to note that Toric, artisan, phakic IOLs are not available yet in the US, and the study was conducted in Iran, which was nice to sort of start off with an international collaboration. And so here, looking at our data, you can sort of see the range that these patients experience. I mean, the vision, visual acuity was on the order of correctable to 2020, usually 2022 about 2040, but the range of power ranged from minus nine all the way up to a minus 22 and a half. And so clearly these are patients who really benefited from insertion of these lenses, and you can see postoperatively, their uncorrected visual acuity ranged from the 2020 to 2060 range. Although even the 2060 patient could be correctable with relatively low residual refraction postoperatively. So all in all, all the patients had a final visual acuity of 2040 or better, and about 85% had a final corrected visual acuity of 2032 or better. So in this paper, we concluded that phakic IOL implantation is effective for treating these patients with stable keratoconus who are usually contact lens intolerant. All right, moving on to paper number two. So what we had the opportunity to do was review a prospective contralateral study, which was done here at the University of Utah, looking at patients who received PRK, photorefractive care tectomy, versus patients who received thin flap lasik. And in this study, thin flap lasik was defined as creating a flap with the intralase laser of approximately 90 microns. And so in this paper, we were able to compare and contrast the visual outcomes. And so overall, there were 52 eyes that we looked at. 26 had PRK and 26 had thin flap lasik. In looking at the postoperative data, as to be expected, there was a visually, there was a statistically significant outcome in the visual acuity at the postoperative month one, namely with the lasik patients doing better compared to the PRK patients. That in and of itself is hardly a surprise. However, as we continue looking at postoperative months three and six, the difference no longer statistically significant. And we see that the outcomes were great between the two groups. As far as predictability and safety, the outcomes were similar. We looked at contrast sensitivity as one of the factors as far as outcomes. And you can see here graphically that the contrast sensitivity was similar between the two groups. An interesting thing that we looked at were higher order aberrations. Most people consider higher order aberrations to increase after laser treatment. And we can see that that generally was the case. It's consistently with PRK and lasik. And most notably, the total higher order aberration in the spheres increased postoperatively, whereas threefold is pretty much consistent, both pre and postoperatively as well. Any questions so far? Okay. So moving on to project number three, I think I'm going to finish very quickly because I seem to be speaking in dictation mode. So the next project we looked at was a series of patients who had iris-fixated faking intraocular lenses. And it was interesting because these patients presented with decomposition of their cornea. And so taking a step back, Dr. Moschfar has a lot of experience with these faking IOLs that are clipped to the iris. And in general, in his experience, which reflects sort of the FDA experience, corneal decomposition is not common. However, these were cases that were done by outside ophthalmologists that presented to us. And as far as the management was concerned, as far as the cases that we looked at, there were two cases at that time of patients who had had iris-fixated intraocular lenses. And they were noted to have corneal decomposition at 22 and 36 months, which are pretty far out from initial implantation. At presentation, their visual acuity was approximately count fingers or 2400 in each patient. And one patient underwent faking IOL explantation with concurrent DSEC at the time of surgery. And another patient underwent explantation with faking IOL of their lens because of cataractus changes that were noted with a concurrent DSEC surgery. And post-operative, both patients were actually noted to have vision of 2050. And so this just sort of highlights how we're able to efficiently treat endothelial disease when we sort of bring it on with our surgical treatment. Okay, yes, please. You know, Dr. Moslin? No, it wasn't dislocated. They're actually on Dr. Mosfar's service. We did see a patient on whom Dr. Mosfar had operated who was lost to follow-up and he had to change in insurance. And so when he finally decided to come in because his vision was a little bit blurry, we were able to see that inferiorly he did have some decompensation. And that was more when the lens was being placed sort of clipped inferior or superiorly. And so it wasn't dislocated as far as removal from the actual iris. But you could see that there was perhaps some contact that was happening. And then he did later admit that he did rub his eyes a bit. And it didn't require any surgical intervention. We just monitored him and he was able to sort of overcome that localized decompensation. Okay, so we'll slow down a little bit and talk about this project, which was sort of one of the highlights of my fellowship. Ultra-thin decimates stripping endothelial care toplasty donor tissue preparation and profile analysis. So basically the principle here is everyone is sort of seeking to make a donor tissue for endothelial care toplasty. And of course the endpoint marker for that is decimates membrane endothelial care toplasty where you're simply transplanting decimates membrane and the endothelium. This of course in principle sounds wonderful and practice is quite challenging. And so in order to sort of approach the benefits of DMEX surgery which are believed to be transplanting thinner tissue which allows for less interface issues as far as stromal-stromal interaction. And theoretically just transplanting the tissue that needs to be transplanted. We looked at trying to create ultra-thin desect donor tissue whereby we minimize the amount of overlying stroma to sort of approach the visual outcomes associated with DMEX surgery but still have the sort of ease of desect surgery. And so in this project basically what we did is modify our standard approach which is to use a microkeratome in preparation of donor tissue. And usually using the microkeratome we take the full thickness cornea which is mounted in an artificial anterior chamber past the microkeratome over and basically leave behind stromal bed with underlying decimates membrane endothelium. Typically our stromal bed approaches the thickness of approximately 150 microns. But with the double pass technique our idea is to basically shave down a second time in order to permit minimal stromal tissue overlying decimates membrane. And so this was a fun project to do mainly because we were able to collect the data in one relatively long afternoon but it was very satisfying to sort of see this project be completed from start to finish. And what we were able to do is look at 11 human corneas glow rims donated by our eye bank and mounted in the artificial anterior chamber I mentioned and use a microkeratome in order to produce this ultra-thin tissue. So the way that our study was designed we had access to several different depths of microkeratome hence. Typically in the ORM practice we have access to a 300 or a 350 micron cutting head. But in collaborating with Moria we were able to get access to different cutting heads and so for the superficial free cap that we created as demonstrated here we were able to use four different cutting heads and then we basically created a second pass which resulted in this in Drillameller stroma lenticule and in order for that pass we were able to use either 110 or 130 micron cutting head and basically we would be left with the donor residual stromal bed very thin layer of stroma with decimates membrane and endothelium. So in doing this you can see the histology that beautifully demonstrates epithelium with stroma alone and then finally a thin bit of stroma with decimates membrane and endothelium. When we tried to compare the depth of the microcaratome cutting head with the thickness we saw that generally as you can imagine the thicker the cutting head the thicker the cut but what's interesting to note is there was a little bit of variability between the cut that was anticipated in the depth of the cutting head namely when it was a thinner cutting head you were a little bit closer although here so the numbers were varied but as you generally increase you can see here using a 350 micron cutting head our average cut was actually 467 whereas using a 200 micron cutting head our average cut was 210 keeping in mind the numbers were very low and so clearly you'd need more data in order to have a stronger claim as to the consistency of the depth of the microcaratome cutting head. The other important factor to notice is that when you pass the microcaratome the pressure of the artificial anterior chamber is very important because any changes of fluctuation in the pressure definitely affect the thickness of cut that we are able to produce and we see that clinically when preparing our donor tissue and so in a series of OCT imaging we can see here that this is the virgin cornea with its relatively uniform profile that we expect as it grows thicker as we move to the periphery and here is the residual stromal bed after the first microcaratome cutting head pass and you can see that it's largely maintaining the same sort of contour and consistency namely that the center is the thinnest and sort of grows thicker and outwards and that trend is maintained as we perform the second microcaratome cutting pass and so looking at residual stromal bed thickness as far as actual quantitation you can see that as the various residual stromal thicknesses arise there's uniformity across and there's more variation that thicker the residual stromal bed thickness you might also notice here that we're pretty high up in the numbers and this is the reflection of the fact that the donor tissue that we used wasn't quite necessarily the freshest and so it became a demodus with time but I still think that there's value in learning that because certainly our colleagues who use this tissue internationally or may not have access to the freshest tissue can still work with tissue using two microcaratome passes in order to produce a relatively thin end product so in the data that we collected we developed an algorithm that basically looks at the thickness of the tissue and so what we propose is if the initial picimetry measures between 500 and 600 microns you're probably best to use a 250 micron cutting head whereas if it's thicker you're better off using a deeper microcaratome cutting head and then subsequently regardless of which you use in this range it's best to be conservative with 110 micron cutting head but the 130 micron cutting head might be most appropriate when the residual stromal bed after the first pass is still microns. Any questions? Yes. We didn't. We didn't but that definitely would be the next step. Obtaining fresher tissue and being able to do not only vital staining but I think it's specular microscopy would be advantageous as well. So more or less we basically tried to use a tonal pen between passes to make sure that we were sort of in the same range although when we did the experiment it seemed like a good idea to make it nice and firm so we were actually aiming for pressures of 560 but one could make the argument that maybe you should be a little bit more physiologic when making your passes just to maintain the health of endothelium. We actually were we did get one perforation and in that case it was because the residual stromal bed was still so thick that we were a little bit on the greedy side and still wanted to pass one more time and it was the third pass that resulted in perforation. So we're going to switch gears a little bit and talk about some case report of CTK or central toxic care top of the after LASIK and so this was an interesting case of a 58 year old woman who presented with not too unusual of a myopic correction and so she underwent LASIK which by all means was considered pretty standard and post-operative week one she was noted to be hyper-opic with a plus 1 and 25 on the right and a plus 250 on the left and clinically she presented with this sort of haze across the linear pattern on the front of the eye where the underneath the LASIK flap and so as we followed her over time she had the diagnosis of central toxic care top of the and we noted that pre-operatively she had pichimetry that sort of dipped down and then slowly gradually made its way back up both in the left and the right eye and as far as her refraction was concerned she definitely had a hyper-opic shift that slowly came back and you can see that her vision was correctable sort of after the first month and so gathering data with this patient we tried to clean more information about understanding what is really going on in this principle of central toxic care top of the and so here looking at some of the pentakam data we can see that if we look at the posterior curvature as to be expected it's pretty constant and that makes sense because certainly we're doing refractive surgery on the anterior portion of the cornea we wouldn't expect changes on the posterior curvature but as we looked at the anterior tangential curvature we can see that there was this swift change where at week one it definitely became more flat and then gradually increased in curvature this we tried to correlate with looking at the pichimetry and so we can see that the thickness dropped down immediately and then slowly had this increase in thickness of cornea over time looking at OCT imaging we can see here this was sort of in the initial first week period you can see there's this hyper-reflective area underneath the flap that results with time this is sort of at month three where you can see that not only is this hyper-reflective area gone but this sort of delineation between where the underlying stroma in the flap is sort of decreased as well and so our hypothesis is that this may have reflected localized inflammation associated yes question yes so here you can see here yep yeah that was supposed to stop particularly no problem so it was that haze that was underneath the laser flap and so we see these images that changed unfortunately we weren't able to obtain very good specular microscopy images because it would have been very interesting to see if we could actually see the inflammatory cells located within the stroma since publishing this paper there has been another paper that's come out in the French literature that does talk about this case of CTK where they are able to do specular imaging so if you look at the image it's black splotch with like these teeny white punctate spots which they propose are inflammatory cells like macrophages that are in that area and so from looking at this patient we concluded that the majority of the corneal tissue loss occurred mainly in the first post-operative week however in order to fully understand the disease mechanism it's important that we had important to have more post-operative data especially early on and it would have been helpful had we obtained an OCT image of this patient before the onset of this disease process of course con focal microscopy would have been helpful as well and ultra very high frequency ultrasound would be something that would be interesting as well to sort of delineate where that information is and how it changes over time yes please I personally think it's within a spectrum of DLK and this sort of represents the endpoint I think we don't have enough information as far as on a cellular level to be able to differentiate why is this not just an extreme form of DLK which I kind of think it is and in order to get that information I think if we had more data we'd probably have a better understanding as far as what the inciting factor is I think once upon a time when we were using blades to make flaps it certainly made sense that perhaps the mechanical chatter of the blade itself was causing a lot of local information but now that we're using interlays I'm not really clear as to why the mechanical separation would be pro-inflammatory do you have any comments? we looked at the OCT imaging to us it seemed like well first it seemed like most people thought that this was just an issue that was happening underneath the flap but our feeling was that looking at the imaging it actually involved the flap itself and that there was stromal changes going on that the thickening wasn't just at the epithelial level but in the stroma itself I think that's a valid concern actually you can do hopefully spectacular microscopy to sort of see what the state of the endothelium is I think that circumstance is sort of unusual because most standard tissue that you receive from the iBank at the time of transportation is not going to be that thick however there was a case the first six months of my fellowship where the tissue that we received from the iBank actually had de-epithelialized and so there was market thickening certainly not to the extent of 800 microns but that is the circumstance where perhaps the tissue that you receive is a bit thicker than you expected it's good to know how to handle that tissue as well yes that was documented but I'm not sure that it was necessarily reflective of what the cell account may have been at the time of using the tissue so we're going to switch gears a little bit more clinically instead of experimental and this paper looked at the use of desec for treating endothelial patient endothelial failure in patients who had penetrating keratoplasty and if you were to do a literature search you would see that there was a flurry of papers that were published at the same time regarding this topic so definitely a lot of institutions were thinking along same lines and so in our study we were able to evaluate 22 consecutive eyes in 19 patients who had undergone previous penetrating keratoplasty and then had desec following that mean preoperative vision visual acuity was 2180 and there were actually eight cases that received best corrected visual acuity of better than 2040 and I think it's important to take a moment just to step back and look at that and say well are we really doing a service to these patients if only 36 about a third of these patients are having vision that's better than 2040 and I think it's important to note that these patients are not your standard like oh they had a little bit of flukes and now they're having desec and they're expecting vision to be 2020 or 2025 these are patients who've had likely several surgeries with different amounts of scarring may have retinal diseases as well and so in some cases the reason for us to do the desec was more therapeutic simply for comfort to treat bolus changes that were causing patients a lot of pain and so this was not a study that was meant to try and highlight great visual outcomes it was meant to sort of reflect our experience which was dealing with very complicated patients who had failed PKPs and of the patients that we evaluated only one was noted to have a partial dislocation which is a dislocation rate of 4.5% which is excellent when compared to similar results in the literature of note and if you were to review sort of the papers that were published at the same time noteworthy changes or differences in our paper were the fact that the graphs were designed as to be the same size as the failed PKP whereas some papers proposed that may be having a larger desec graft would be advantageous because if you're avoiding that sort of graft host junction then you might limit the amount or the possibility of that graft dislocating because of an uneven edge against which it's placed in our patients we did not remove or scrape desec membrane and there's definitely some controversy in the literature as to the benefit of scraping there are some people who really swear that scraping the base stroma really helps as far as making adherence of the donor tissue improved however in our experience we don't do that and didn't do that with these cases however all of our patients had paracentral venting incisions and this is something that is part of our standard clinical practice and we believe allows us to ensure that the graft is in good position and while other techniques involve using forceps to introduce the tissue we used a glide pulling technique using a 4.5 millimeter incision at the limb this and so here is an example of one of our patients who had successful desec after penetrating care to plasticine here you can see on the OCT how beautiful the images where you can see the actual graft host interface of the desec tissue as it nicely opposes to where the PKP is and you can see the margin of sutures here a little bit over here yes okay so now we are going to change gears a little bit moving from the FAKIC IOLs which of course we know are FDA approved to these new color iris implants in FAKIC guys which are actual plastic discs which are inserted into the anterior chamber in order to produce a cosmetic change this is not FDA approved as you can imagine actually has been proposed by an ophthalmologist in Panama and so we had a little bit of experience in management of patients who had this implant placed and then unfortunately experienced decompensation in particular we had a 19 year old who presented with a place of subjective vision decrease and he had had bilateral blue color iris implants done in Panama the week before this vision was 20 30 at the time presentation as pressures were normal however on gonioscopy there were evidence there was evidence of early PAS and several quadrants and the implants basically looked like they were lodged in the angle and given the fact that flair and pigment itself were present we had a long discussion with the patient and proposed taking out the implant so this is the schematic of the surgical technique that we use the plastic is basically like a flimsy floppy plastic but there is still some rigidity to it and so what we proposed and what we did was basically make clear corneal wound and then basically cut through the implant approximately 180 degrees away and then after doing so continue rotating the graft within the anterior chamber in order to create third sections which could then be removed through the clear corneal incision and the idea of course doing this under viscoelastic is to try and minimize trauma to the anterior segment and the cornea while removing this implant and this is a sample of what it looked like and you can see here it's pretty flimsy looking and more importantly you can see that maybe this is where we cut it and we can be responsible for some jaggedness but this is the actual edge of the implant and unfortunately in reviewing sort of experiences in what's published and that's more published in the late literature apparently the surgeons who do this sometimes pardon exactly customize yes oh the new color iris implant okay what is the consistency of this compared to that silicone I thought this one is silicone too the one that you showed us before sort of has like a rubbery silicone feel to it and have you used the other one because my impression is that this one is a little bit more plasticky is that incorrect no this does not look like a tree fine at all unfortunately yeah I actually had a patient when I was in residency she came and she had this form and she asked that I fill it out and basically said that she was going to have this implant done and I said did they tell you to come here to Wilmer she's like no they told me to come go to Walmart to get an eye exam but she ended up at Wilmer and so we had a long discussion about how it was just not a good idea to have this done and she was upset because she came and she wanted her form filled out so she could have this done and it was just I mean you try rationalizing and the response you'll get my friend did it and that's sort of the end of the discussion because you're dealing with someone who's like 19 and really is interested in having their eye color changed so it's definitely frustrating yes yes right yes yes okay okay yeah yes right good no I think it's several thousand yeah like five thousand con doctor con yes okay so that being said this is just a little sort of pearl for the residents so we wrote this beautiful paper and we included what was pretty scanned but what was the review in the literature and when we submitted it the feedback we received this is great but you have too much literature review so basically we just took the paper and reformatted it into two and so that's how I was able to get another paper out of this year and so here's the picture actually doctor candle of the patient yeah right and you can tell how stunningly handsome he looks with those implants wow I would totally understand why someone would want to pay five thousand dollars that's crazy absolutely crazy it looks ghoulish and not only that you can see that the placement here the light reflex is centered in the people and you can see where it is here so I mean it's just it's atrocious to think that these things are being implanted and it's very sad to think that people think that this is attractive enough to risk their vision for so basically if you do look at the literature looking at patients who had different implants put in available in blue and green the onset of symptoms range from anywhere from a week to six months and you can see at the time endothelial cell density was measured in some patients I mean some people dropped down 19 and 21 year olds dropping down to less than a thousand it's just it's really really sad this is going on this is a pentakam image demonstrating basically that this is a shoved into the angle you can see that it's just sitting on the iris shoved there yeah right so this is not paper number nine this was a little review article on soft tech lens which I think is worthwhile sharing because we do actually have access to it now in the operating room and basically this is designed as a aspheric lens that is acrylic the idea is that there would be less dysphotopsia and the biocompatibility and clarity is good and that hopefully it's resistant to damage during insertion actually I had a chance to implant one of these couple weeks ago and it is a very very very gummy lens I mean it almost doesn't want to stay rolled for that short time that you're inserting it and it just flops and unfolds immediately and so the theory behind zero aberration is that an average the mean corneal spherical of aberration is about a quarter micron and so most patients have positive corneal spherical aberration and so if you implant a zero aberration lens you don't necessarily have to worry about alignment errors which can be a factor in a placement of other lenses and the other interesting thing about this lens is it comes in quarter diopter increments in this 18 to 25 range and then half diopter increments in that broader range in one diopter even in the higher ranges extremes and so that allows a little bit more custom tuning as far as providing optimized visual outcomes to our patients and so okay ooh that was nine papers and there are a few more that are in review so I didn't want to jinx it and put it up here because you never know but I think it's been out on the market probably about two years so not that long I don't no sorry just wanted to take a moment I mean this has been a phenomenal year so you can see I've had a chance to do amazing surgery work with amazing people and participate in a lot of really nice research projects and I think what I want to share is obviously it's been a busy year and as all of the faculty know balancing academics definitely is a challenge it requires time management and what I found most wonderful is the opportunity to collaborate and to delegate because it really does make a tremendous help in trying to get these projects done I think the joke among the fellows has been if only we could get a fellow to help us with some of our work we'd be we'd be in good shape and so what I wanted to share with the residents as far as my experience over the past year I think every project sort of has a different scope and the easiest way or I think the most efficient way is to sort of frame a question what is it that you want this paper to share with your scientific colleagues but more importantly I think it's important to have a modest goal I definitely know that we all are aware of certain projects that you may get involved in and they become sort of bigger and bigger and more ominous as time goes by but I think the projects that sort of have modest goals to begin with are definitely the ones that sort of have the best chance of being successful that's something that you can be proud of because you feel like you've worked on it from start to finish and I think sometimes what gets overlooked is actually taking the time to review what's in the literature because there is so much out there and I think keeping up with scientific proceedings is not what it used to be I mean there are so many ophthalmology journals and there's so many papers and now there's online publishing and it's hard to keep up but when you set your mind to a certain task it's important to know what's out there, know the audience and that way you can sort of focus your efforts so I'd like to take a moment to share some acknowledgments I mean clearly this year could not have been possible without the support of Dr. Mifflin and Dr. Moschvar and Dr. Newfer was a tremendous co-fellow that I really do appreciate having the Moran faculty staff have been amazing I wish I could take all of you back with me in particular Monette if you know Monette in the laser suite in the OR she's phenomenal the Moran residents have been wonderful to work with I really have not dreaded being on call because it's been delightful working with all of you in particular Chris, Tom, Derek and Lloyd have participated in some research projects with me and I really do appreciate their contributions Jeff Petty is about to be mentioned because he's working on something now but I'll see what his turnaround time is and then as far as medical students are concerned I've been really lucky that I've had a chance to work with some really intelligent medical students Lisa I'm sorry I forgot to put your name up there but Lisa Leishman is one of the incoming path fellows and so you'll have a chance to get to know her over the year and she's phenomenal as well my female fellows that's what we kind of call ourselves and Mark it's been great to have such a wonderful group to sort of survive the year with and also my family has been tremendously supportive so I'd be happy to answer any questions and this would be a chance for anyone to make an escape because I'm going to show some wedding pictures I've already seen them 10 times minimum 10 times okay so you had your chance Dr. Mifflin here you go round 17 so as some of you may know I got married on April 9th this year and it was wonderful in particular because Dr. Mifflin let me have some time off and that was much appreciated and so here I am with my family, my parents and my sister and we actually had as you can imagine several events and this was the one the day before the wedding which actually took place at our house and so this is me being escorted out by my cousins everyone's matching, here we are up on stage that's my groom and you can see he's pretty happy which is good, a good sign and then this is actually the day of the wedding the next day, the wedding ceremony where we're exchanging rings and then there we are for the reception and here is a photo we had this stage set up and so everyone as is custom in the evening comes up