 Let's do this. Good morning, everybody. Just wanted to get things started here. My name's Brandon Kennedy. I'm a P.J.Y.3 here. I'll be moderating today for a couple of great cases. First up, we have Dr. Nana Makari presenting Representation and Ophthalmology. Fun fact about Nana Makari is he's been exposed to a concerning amount of new foods here in Utah and he's now considered to have a distinguished palate. I once heard a rumor that the first time he had pancakes was here on a camping trip with Dr. Petty. I don't know if that's true, but possibly so. All right, here you go, Nana. All righty, good morning, everyone. Thank you for the fantastic introduction, Brandon. So today I'll be talking to you guys about retreat I went to about a month ago called Pillar, which was about Representation and Ophthalmology, specifically academic ophthalmology. That didn't work. Can you use the mouse? So this is just a picture from the conference. It was hosted at Byers Eye Institute, Stanford. This is Mubarak and I took as many pictures as possible with Mubarak, he's incredibly photogenic. Here's some additional photos and a photo with Dr. Singh, one of the glaucoma attendings at Stanford, who's there. So Pillar stands for Program and Lasting Leadership in Academic Representation. And why is this important? So there was a paper published by a group called, headed by Miller and Katz, who are, they had a consulting company that deals with Fortune 500 companies, work with companies globally to elevate the quality of interactions, leverage people's differences and really transform workplaces to make it more conclusive in really an environment where you can prosper. And so these were several quotes that were from employees from these organizations, includes the following. Inclusion challenges our thinking, brings in fresh perspectives, raises the bar for our practices and strength as a gene pool. Inclusion fosters engagement and engagement itself increases efficiency. Our decision making is enhanced when people feel included. And so I just wanted to quickly glance at the demographics of the US population. This is from 2018 by race and ethnicity. So about 60% white, 18% Hispanic slash Latino, 13% black, 6% Asian, about 2% identified as multicultural or multiracial. 1% American Indian and about half a percent or less than half a percent native Hawaiian. And then in the child population represented by the bar below, it just shows that there's more diversity amongst that total population. And this is the profile published by the SF match last year from the years 2017-2022 showing residency demographics. And I wanted to draw your attention specifically to the years prior to 2021, whereby black and African Americans were represented one to 3% of the time, about 5% identified as multiracial, 7% Hispanic slash Latino. Many declined to state what they represented as and around 25% Asian and then the rest 45 to 55% white. Then there's a similar representation amongst fellowship demographics as well. So there's a study by Dr. Hanoff Valentine that looked at how the NIH could take a scientific approach to inclusive environments in general. So specifically they analyzed biological and biomedical sciences and medicine amongst medical schools in the year 2017 to 2018. I wanted to draw your attention to the light yellow light blue graph parts of the graph that show underrepresented women and men respectively. And you can see as you advance from associate's degree kind of work your way up all the way up to department chair representation declines. And so one of the first thoughts that I think I have and perhaps many people have is implicit bias at work. And so a group at Stanford, Dr. Pershing Stell and Dr. Caroline Fisher kind of analyze this amongst residency applicants. They redacted name, sex, gender to see if bias was involved in there in the way in which they recruit applicants. And the result of their quality improvement study showed that that was not the case. And so that brings me to one of the questions of, this is a quote by Dr. Caroline Fisher during the pillar conference that really stuck with me. It was, it's one thing to ask for help and another to have the language to ask for it. And oftentimes as physicians we're kind of challenged to really answer questions that patients have before they even know they have it. And it's not to say that a certain group needs help more than another, but perhaps there are many ways in which we need to deeply analyze representation in the way in which we can best represent our patients to provide the best care possible. And so pillar was hosted by the Byers Eye Institute at Stanford, Rad Venable Excellence in Ophthalmology Program and the National Medical Association of Ophthalmology. It targeted underrepresented minorities in medicine, specifically with preference to PGY-2s amongst ophthalmology residents. And once again, it took place last month, September 24th and 25th. The National Medical Association was founded in 1895. It's the largest and oldest organization representing African American physicians and healthcare professionals in the United States. It focuses on health issues related to minorities disadvantaged and medically underserved populations. It's one of the leading voices for parity and disparity amongst, or parities in health and justice medicine and with the goals of elimination disparities in health. The Rad Venable Excellence in Ophthalmology Program was named for Dr. Maurice Rad, Drs. Maurice Rad and Dr. Howard P. Venable, both of whom were nationally recognized amongst their respective fields but also for what they did in terms of how they helped the next man forward. They both combated the inequities of their time by selling as a, almost as a form of protest. The Rad Venable Excellence in Ophthalmology Program was founded in 2000 as a research competition in Washington, D.C. by 2007, gained national recognition by the NEI and NIH. And then as a result of COVID, kind of had a migration to a more virtual format. That helped third and fourth year medical students who were interested in ophthalmology kind of provide an opportunity for career development, mentorship, navigating the application process. And this was just a random photo from the Pillar Conference last month. And then I wanted to draw your attention to the article listed below. This was analyzing the contributions of Rad Venable over the years, specifically with attention to the year 2020 to 2021 and how Rad Venable has contributed to some of the changes that we've experienced in the demographics of ophthalmology. And so I wanted to take another look at this graph here again, a little bit closer of a look here. I have no comments for this, but you've been closer than that. From the year 2020 to 2021, black, and people who identify as black and African-American, there was a substantial increase from 1.3 to 5.4%, which is about a 300% increase. And that was sustained for increase even further to 7% in the subsequent year. Upnoted, Hispanic and Latino represented by the dark green did decline during that period from 7.4 to 5% and then back up to 8%. And so the Rad Venable program saw this as a resounding success. So that was a really pivotal year in the way in which they combated how they can help students of color really get into ophthalmology and succeed in it. And so this was a group of us at the pillar or retreat last month. And really, this was a lot of our first times meeting each other in person. We've been through so many conferences together, so many virtual formats, and it was really, really awesome to be able to see one another in person and really share our unique experiences together again. And I just wanted to draw some attention to George from the class of 2021. And then of course, my co-resident, Mubarak, who's also part of the Rad Venable organization. And so Pillar had several different main components, many of which are listed here, but it's not an exhaustive list. The year was the career paths in ophthalmology. There was talking about grants and research funding, fellowships, navigating academic careers, inclusion and diversity, sharing their shared experiences, mentorship and then work-life integration. It was formatted in a way that it had seven different big sessions. There was presentations on each specific topic followed by Q and A and then four 20 minute table sessions afterwards. One of these sessions was career paths in academic ophthalmology, whereby Dr. Amar Ross from UPAN discussed laboratory research as a career path in ophthalmology. Specifically, she shared her joys of lab research, ways in which you can find support, mentorship and institution and really choosing an institution to best promote that path if that's something you're interested in. Then Dr. Nicholas Volpe from Chicago kind of showed a different, I guess a contrasting career path whereby he highlighted a master clinician as a career path that one can pursue and it's important role in academic departments. And then Dr. Roretta from Wilmer discussed residency PD as a career path in ophthalmology and how she has the opportunity to have significant impacts on the lives of others and really a career of mentorship. She discussed scholarship and the creation of knowledge amongst so many as well as the various ways you can take paths to that ultimate goal. Dr. Paul Lee from Michigan discussed negotiating and accepting the first job, what one should prioritize like family and benefits with regards to contractual negotiations. He also discussed sources of assistance, choosing a lawyer, things I didn't even think about with regards to navigating that process. Dr. Dolly Chang discussed industry and academia and how there's kind of hybrid fellowships that exist out there and ongoing collaboration between industry and academia. And then Dr. Mildred Olivier discussed DEI leadership as a career path, specifically Rabbi Venable where she serves as the president and local department school leadership opportunities, importance of representation, increasing recognition for career advancement and promotions. And so along those lines, I thought deeply about diversity, equity, inclusion and ways in which we can really tackle that. Dr. Olivier brought up this paper, Passing the Leaks, Revitalizing and Reimagining the STEM Pipeline. And in summary, it's about early exposure, early and often exposure. So there's exposures to research, exposures to internships, work experiences, et cetera, et cetera. And then that got me thinking a lot about my own personal journey. From when I was 13, I've had the opportunity to be a part of various different pipeline experiences. I think specifically to my very first one, it was called the White Foundation. It's a program for individuals in Newark, New Jersey who specifically underrepresented individuals in Newark, New Jersey, who there's a ton of research supporting the fact that there are plenty of people qualified but didn't necessarily get the, I guess opportunity to obtain college scholarships. And this program started really, really young. I actually had us going to class after school, every Wednesday and Friday and then on Saturdays as well. So it was exhausting, it was exhausting and really, really rewarding because it ultimately provided a pathway for us to obtain scholarships to boarding schools at the time and then actually assisted us with college as well. So it was a really transformative experience for me and so many of my peers who were fortunate enough to be a part of this program with me and I listed some other programs that have helped me along the way as well. And that brings me to some of my most rewarding experiences, kind of things I've been a part of or founded that have similarly looked at goals of influencing others along the way. And of course, I'd be remiss if I didn't discuss possible challenges that exist when you're kind of thrusting these environments whereby maybe not everyone looks like you or comes from environments with which you came from. Some of the challenges of that include, you know, like you have to be more than competent to do the job, you know, like you have to be able to fit into the organization and its culture, willingness to accept the spotlight and being the only one of your kind, able to represent an entire identity group sometimes on your own, capable of disproving colleagues preconceptions about members of your identity group, able to deal with constant questioning as to whether the job was obtained as a result of your merits or your differences, serving on committees, task forces, public appearances related to your identity, none of which is necessarily your job responsibility or considered in your performance appraisal. And then of course assisting as needed with recruiting and outreach. And this is also listed in the article I previously mentioned from Miller and Katz. And so what can we do? In addition to the just generalized support that we do a great job of here, there's a variety of different programs that we can kind of expose students underrepresented in medicine too, if they have an interest specifically with ophthalmology. That includes the aforementioned RAV-Venable program, but also the Minority in Ophthalmology Mentorship Program, which is a similar program that helps students become ophthalmology applicants and competitive ones at that. It's headed by the AO, provides a similar one-on-one mentorship, another opportunity for networking and educational resources as well. And then more recently, I've been exposed to a group called the Black Physicians of Utah, which is really, really fascinating because they target high school and as early as middle school students in the Utah area, get them exposure to medicine in general. I know the other day they helped introduce how to put in IVs and they're asking for some medical health and honestly, I wasn't very much help at all, but I thought it was really cool to at least show these individuals, get them some type of exposure to that health pathway. And for me, the most rewarding aspect is both the exposure that we can assist with, but also the sense of community that exists here because being underrepresented in medicine is kind of a US issue, but also more prominent in the state of Utah as well. It's one of my good friends and longtime mentors from high school, Dr. Mike Quiss. He's an ophthalmologist at Cleveland Clinic now. He was at the Polar Conference and he stayed this quote that has really, really stuck with me and I think it's just a fantastic quote. It's actually originally from his father, but kind of passed along the way. And he said that when life gives you the opportunity to take the stairs out, make sure you send the elevator back down. And it's something I personally wanna continue to live by and promote the rest of my life, but also I'm hoping to inspire others to do so as well. So I wanted to give a quick thank you to the Buyer's Eye Institute for hosting as well as the RAP Venable and NMA program. To Dr. Petty for letting us, me and Mubarak know of this retreat. And then my colleagues at Iowa, Dr. Sy Lewis and Arnaful Garza who helped me with the collaboration of this presentation. And then here are some pictures from our own mini retreat about a month ago as well. We went camping at Buckeye Lake and it was an awesome experience. And in addition to my distinguished palette, I now have a distinguished sense of sight. We used binoculars, it was really fun and really cool. Unique experience for me and super rewarding. So I now will take any questions, comments, ideas, happy to entertain. Thank you so much for your attention. I think when people are first coming and looking at the underrepresentation of medicine, it just looks like a pipeline problem entirely, right? Although what could we do if there's just not enough medical students in the pipeline? And while those are essential and fundamental, over time you start to see the challenges of the graph you showed with the trends in biology, right? So as you've come in much more diverse and by the time you're getting down to full professor, it's really push those underrepresented groups to a significant minority in the group. And so that's the part that to me seems less just simple, right? It's like, okay, we can put more effort in the pipeline. But this kind of systemic structural challenge, how would you assess this? I mean, how much of this is mentorship? How much is this culture? You were to advise a department, a school, what would you recommend to address this particular issue of attrition? Yeah, thank you for the question. So I think I'm clear in my experience first and foremost with that. There were so many things I was just really oblivious to before that retreat in general. So Dr. Roretta talked about the path of GD, for instance, had no idea what was the typical, same with associate deans at the typical pathway to that or a whole variety of different mechanisms to do that. Really it's both explaining that course but also promoting excellence. So it's one thing to kind of rush people into positions they're not ready for. It's another thing to prepare them for it. And so I really think it does start really with pipeline and getting more and more people interested in medicine in general first and foremost, and then eventually ophthalmology as well. But we really have to make sure that the people who do come through, become the best they can be. And that's the only way that this would be a sustainable habit between if we were to, both of these people, it's a variety of different positions. It really needs to excel. I look back at, from, like you used to do some of the, Dr. Roretta, and so many other different people. And you really have to excel in positions to inspire people that want to continue that and put those people forward in the future. Thank you. Thank you. Question. So I just had a couple of thoughts and I was curious to hear your perspective about a lot of the programs that you were involved in early on. I'm familiar with a couple and I know it's still an application process that is overall somewhat competitive. And amongst the under-representative students are still unequal distribution, like allocated resources. So how do you think we can better tackle the individuals who aren't even aware of these programs early on or those who do apply and don't get into these pipeline programs maybe because they don't have similar backgrounds or access to resources as others that are considered under-representative? Yeah, and that's another fantastic question. So a lot of people in RAV Venable did not obtain this admission to the Minority Alphamology Mentorship Program, like the AEO. They just had such a limited supply of resources. They couldn't accept everyone into that program. And then there's another half of people who just never heard of it. Despite having interested alphamology for four years of medical school for a longer. The resource thing is a top endeavor. I guess we can obviously put more resources into it, but I don't know, I couldn't tell you from that standpoint of what we really can afford and can't afford. But in terms of the exposure, I think it's almost a shame if someone was in medical school and from an underserved background and didn't hear about it. Because it's such a nationally recognized, a lot of these programs were very nationally recognized. So someone just needs to show that care to really bring it to their attention. But then also it's, you don't have to necessarily tell them these programs just invoke curiosity. So there's, in my opinion, there's minimal excuse to not know what things are out there if you're interested enough for it. And sometimes it's just asking them how bad they want or putting forward the question of what have they done to seek or obtain that goal that they're assigned for. Because there are many ways that we live in the world of Google whereby a lot of these things will pop up. So we just have to be curious enough to find them. Thank you. Yeah, thank you. Not just one more question, comment, talking about systemic structural issues related to this. I remember applying to medical school and if you didn't have a certain amount of volunteer hours, you wouldn't even get an interview at certain medical schools. And in hindsight, we are trying to move more toward what's called holistic review and look at this thing called distance travel. And seeing someone who worked full time as a waiter or waitress through all four years of undergrad, my goodness, like what is showing more grid and commitment than that, even if they didn't have the financial freedom to volunteer or research is the same way research volunteers positions are largely volunteer. And that, you know, this doesn't necessarily directly correlate with race, but you know those with resources and ability to volunteer for a summer and not worry about, you know, making ends meet. Again, that structurally just keeps this pipeline of privilege into medicine. It's something that we need to acknowledge as well in the process. I think very much related to that is the application process itself doesn't allow you to highlight something like that. So if you look at some of the application, they'll be, you know, like previous career experience, one bar and a waiter. There's really nowhere else for them to highlight, like unless they choose to talk about in their personal statement. So I think structurally it's recognizing that that's an issue, but then also changing the rubric by which you're evaluating people in a much, you're thinking much more outside of the box and allowing people to highlight that as a part of the standardized application instead of recognizing that we as reviewers need to, you know, need to dig for it, it should be able to be much more, you know, I think it should be able to highlight it much easier. And I think that's interesting, one, because it's a college application that you would have not to list how many hours you put in or are dedicated to a certain activity or work. So I do think it would be more ideal to be able to expose just how burdensome a certain job might have been for you or how passionate you are about certain activities with the hours you put in. One of the things that I think speaks to what Brand was talking about was the outreach in middle school and elementary school. And that's a lot of the middle school students being introduced to STEM and coming up to the university. If it isn't even an idea, then you won't go looking, Googling for how do I be a doctor? If it doesn't even cross your consciousness, that could be possible. It relies so much on your teachers, your counselors, saying, hey, you know, there's this career you could do because I think that people are aware of the things that are around them. Yeah, I think that's one of the more important points, too, as well, I think about where I came from and how really medicine was not in the courage pathway just because no one around us were really in that. And I was fortunate enough to have a carriage to pursue it during my own pursuit as well. But there are so many individuals who are kind of pushed towards other things as a result of the lack of role models to really think about medicine or STEM in general. So it really is something that we have to be more dedicated for attacking early. And I see so many, even the paper I showed, it started at the undergraduate level. It really starts far earlier than that. I think at the undergraduate level, it's almost too late to make a significant impact because especially nowadays with the minerals, we have to have such a robust application. Some of you were working experiences, volunteering, opportunities like that, that you talked about, and it starts early. And you have to do a better job at attacking them. Thank you, Mr. President. Thank you very much. You're a great presentation and really a topic that I think we can agree on that we had all discussed for over 30 minutes. So we have Dr. Ashley Polsky. She comes to us from the great, great, great state of Michigan. She will be presenting, Don't Go Chasing Waterfalls, Minimally Invasive Manipune of a Bleeding Iron Factor Puff. And a fun fact about Dr. Polsky is she wants to do a Seabird Ecology Research on a Protected Island in Puget, us, Phil and Sarah, near Seattle, for summers and college shows. Now she knows an unusual amount of seals. So welcome back. I have a pigeon at the sea. Hi, good morning, everyone. I'm Ashley, and we need you to answer the question. As many of you know, part of our responsibilities as an intern in this program is to run the Ophthalmology Walk-In Clinic at the VA Hospital. And the case that I'll be presenting today is actually one of the first patients that I saw in that intern clinic last year. So I'm really excited to share it with you. There we go. I have no conflicts of interest to disclose. And this case begins with a 74-year-old man who presented to our VA Walk-In Clinic with painless generalized blurry vision that developed in his left eye about five hours earlier. He denied any flashes or floaters in his vision and he had no recent history of eye trauma, prior eye surgery or any history of anticoagulant use. His past medical history included hypertension, which was reportedly well-controlled on amlodipine and his ocular history was significant for a branch retinal vein occlusion of the left eye that occurred in 2013 and was complicated by neovascularization of the iris and retina. He did undergo intravitral Avastin injections for that in 2013, as well as PRP treatment in 2015 and 2017. He briefly followed with our VA glaucoma service for neovascular glaucoma, but this had remained quiescent since 2017. For his ocular medications, he was using Bremonidine drops daily in his left eye. He had no relevant family or social history and specifically he had no personal or family history of bleeding disorders. His visual acuity on initial presentation was 2025-2 in the right eye and 2020 in the left eye. He had full color vision, normal pupillary responses and full extraocular motility and visual fields to confrontation. His intraocular pressure was 14 in the right eye and slightly elevated at 22 in the left eye. His anterior segment examination of the right eye was within normal limits, aside from an age-related cataract and his left eye demonstrated diffuse conjunctival injection. And before I kind of further discuss his slit lamp examination, I'd like to show you a few examples of what we saw in clinic. So this is what I saw on my very initial external examination of the left eye. You can imagine that my heart started racing a little bit when I saw this as a brand new ophthalmology intern. I think I called Brandon like two seconds after seeing this. And then this video hopefully will play here. This is what we saw on slit lamp exam. Yeah, very cool video. Thank you to Brandon for taking this. Okay, so that was what we saw on slit lamp exam. So as you can see in that video, this patient had a four millimeter layering hyphaema inferiorly in the left eye that was being fed by this continuous philiform hemorrhage originating from what appeared to be a small vascular tuft at around one o'clock on the pupillary margin. There was no observable neovascularization of the anterior surface of the iris. However, we did see very subtle vessels suggestive of NBA temporally in the ear to corneal angle on gonoscopy. Dilated examination was unremarkable in the right eye and in the left eye demonstrated findings consistent with this patient's prior known BRVO including some superior shunt vessels and a sclerotic vessel that was branching from the superior arcade. There was no neovascularization of the disc or the retina and he had stable dense PRP scars superiorly consistent with his prior laser treatments. We did obtain a blood pressure measurement while the patient was in our clinic as well and that measured 141 over 83. So this list represents some of the major differential diagnoses that we were considering for the etiology of this patient's hyphaema. Some sort of iris vascular lesion was really at the top of our list given that the bleed appeared to be originating from a tuft-like structure at the pupillary margin. Iris neovascularization was also a very important consideration given this patient's prior history of a BRVO and previous need for anti-vegeta therapy. However, he did not have obvious NVI and the NVA that we saw on gonoscopy was not actively bleeding. Traumatic hyphaema and UG syndrome seemed less likely in this case given his lack of previous eye trauma or any prior surgeries. And systemically he had no history of constitutional symptoms or easy bleeding or bruising to suggest a systemic coagulopathy. So at this point in our workup a bleeding iris vascular tuft was our leading diagnosis. Throughout our slit lamp and dilated exam the iris continued to bleed just like what you saw in that video. So our primary goal at this point was to stop this bleeding and hopefully prevent any adverse sequelae such as corneal blood staining or prolonged increases in this patient's intraocular pressure. Given our concern for possible subtle NVA on gonoscopy and given this patient's previous success with anti-vegeta therapy we did decide to proceed with in a bastion injection in his left eye. We monitored this patient's intraocular pressure very closely after this injection and measured a pressure of 48 immediately after the procedure followed by a pressure of 35, about 10 minutes later. We had hoped that this pressure elevation that occurred as a result of the intravitral injection would have a tamponade like effect to promote hemostasis of that iris bleed. Unfortunately on re-evaluation of the slit lamp that hemorrhage continued to really steadily flow into the anterior chamber. So our next course of action was to pressure patch the eye. And as illustrated in these photographs here we developed a pressure patch by placing two iPads over his closed left eye and applying tape really firmly over the patches to hold them in place. We kept that pressure patch on for 30 minutes and when the patch was removed the active hemorrhage had completely resolved. After achieving hemostasis we discussed standard hyphema precautions with the patient and sent him home on pred forte, atropine and cosop drops in the left eye. The patient returned to clinic the following day and was found to have a visual acuity of 20, 30 minus one in the left eye with an intraocular pressure of 10. And as you can see here that inferior layering hyphema had decreased in height to about one millimeter. And that arrow there is pointing to a quiescent vascular tuft that was noted at the location of the previous hemorrhage on the pupillary margin. It's a little tough to see I think but it's kind of a whitish tuft-like structure there. We followed this patient really closely over the following weeks and by week three his hyphema had completely resolved. His intraocular pressure remained normal on cosopt and he had no recurrent episodes of bleeding. So we were able to discontinue his atropine and taper off the prednisolone. At one month after his initial presentation we were able to obtain an iris fluorescein angiogram here at the Moran Eye Center. And interestingly we saw irregular hyper fluorescence and staining bilaterally at the pupillary margins consistent with the presence of bilateral iris vascular tufts. And there in the close up of the left eye where the arrow is pointing you can see the culprit of this patient's previous hemorrhage with that little tuft-like structure there. As of two weeks ago this patient has had no recurrence of an iris vascular tuft bleed or hyphema. He was able to actually successfully undergo cataract surgery in both eyes last month with Dr. Swiston, Dr. Petty and Dr. Laura Shell and he is now seeing 2020 in both eyes. So for the rest of this talk I'd like to just further discuss iris vascular tufts as well as some of the various approaches to their management. Iris vascular tufts also known as cob tufts or iris microhemigieomatosis are relatively rare benign vascular lesions that form along the pupillary border just like we saw in our patient. These small tufts can range anywhere from 15 to 150 microns in size and they account for less than 5% of all iris vascular tumors. They're typically found in elderly patients and they have no known sex or racial predisposition. Interestingly for largely unknown reasons they are found at an increased frequency in patients with myotonic dystrophy and diabetes. And in terms of clinical presentation typically patients with iris vascular tufts are actually completely asymptomatic. And so I think it's very possible that these go unrecognized a majority of the time. Often the initial presenting symptom is a sudden onset of blurry vision due to the development of a high fever similar to what we saw in our patient. And this bleeding often occurs in the absence of any preceding ocular trauma or systemic vasculopathic conditions. Iris vascular tufts are generally considered an idiopathic acquired vascular anomaly. In our patient the fact that he had bilateral iris vascular tufts really suggests against any sort of causal relationship between his previous BRVO and his iris vascular tuft development. However, interestingly some papers have suggested that the ischemic and hemodynamic changes promoted by vascular occlusions might actually contribute to alterations in vascular tufts structure making them more prone to spontaneous bleeding. So one question that we had regarding our patient was whether his prior BRVO may have somehow contributed to a heightened bleeding risk in that eye through maybe up regulation of VEGF or through some other mechanism that led to increased vascular permeability. And that was partly why we had a low threshold to treat him with intravitral avastin on that day. The diagnosis of iris vascular tufts is primarily made by slit lamp examination along with fluorescing angiography of the iris. And as you can see in these photos here the classic appearance of vascular tufts on an iris FA is rapid hyper fluorescence along the pupillary margin along with often late staining or leakage at the margin there. And in these patients it's actually common for iris FA to identify multiple additional small vascular tufts that were not readily visible on slit lamp exam alone. The Shields group at Wills Eye Institute also suggested anterior segment optical coherence tomography and geography or OCTA as a potential imaging modality to further characterize these tufts. On OCTA the appearance of iris microhenangiomatosis consists of non dilated normal appearing iris vessels that then coalesce into these tightly coiled vascular tufts at the pupillary margin. When they used cross sectional anterior segment OCT with an angio overlay which is pictured at the bottom of this figure they were able to localize these vascular tufts to the posterior iris stroma rather than superficially on the iris where neobascularization typically occurs. Additionally studies of OCTA and iris vascular lesions are somewhat limited. And so at the moment anterior segment FA really remains the supplemental imaging modality of choice for iris vascular tufts. Most commonly iris vascular tufts can be observed without any additional intervention. Topical steroids and atropine with or without IOP lowering drops can be initiated in the event of a high FEMA. And for more definitive management argon laser photo coagulation has been described for the treatment of iris vascular tufts. In this approach the laser is directed often both at the tuft itself as well as the feeder vessel leading to that tuft in order to either stop or prevent active bleeding. And I've just listed here some of the laser settings that have been reported in previous studies that used argon laser to treat actively bleeding iris vascular tufts. This table is from a 2010 literature review of laser photo coagulation for iris vascular tufts. Of the eight cases included here five patients were treated with laser photo coagulation either for an active iris vascular tufts bleed or for a history of recurrent high FEMA. Two patients with a history of recurrent high FEMA were actually treated prophylactically prior to cataract surgery in order to reduce the risk of intraoperative bleeding. And one patient required repeated treatment with argon laser due to recurrent bleeding. But as you can see in the outcome column to the right, the majority of patients had no additional bleeding episodes within their follow-up period. Here's an example of a case from 2013 in which a patient had active bleeding from an iris vascular tuft that was treated with argon laser photo coagulation. This particular iris was treated with just a single spot of argon laser at the pupillary margin. And hemostasis was successfully achieved immediately afterwards. Due to the rarity of iris vascular tufts, there is somewhat sparse literature regarding its treatment, particularly as it relates to actively bleeding tufts. And while argon laser has been shown to successfully arrest active hemorrhage just like what we saw on the previous slide, it does entail its own set of risks, including damage to the iris or other ocular structures, further exacerbating anterior chamber bleeding or causing corneal endothelial decompensation. So because of these potential risks, argon laser is typically reserved for patients who have had recurrent hemorrhage from vascular tufts or as a prophylactic measure to prevent bleeding during intraocular surgery like we saw with that previous literature review. Additionally, a really good point that Brandon discussed when this case initially came in is that timely access to an argon laser may be really difficult, especially in settings with limited resources. So what other options might we consider when faced with an actively bleeding iris vascular tuft? And based on our case, we would suggest that a pressure patch is a very accessible minimally invasive first line approach to stop active bleeding of an iris vascular tuft. This approach does require an extended period of observation in the clinic. Like I said, we were patching this patient for 30 minutes and also monitoring him really closely before and afterwards. But the benefit is that it can be performed in a variety of settings, including in really low resource areas without significant risk of damage to intraocular structures. If active bleeding continues despite pressure patching, then additional more invasive modalities such as argon lasers should be considered. And although there's limited literature regarding the benefit of anti-vegeta therapy for iris vascular tufts, intravitral abastin, for example, is another reasonable consideration, particularly in the rare setting of iris vascular tufts and vascular occlusion as we saw in our patient. So in conclusion, iris vascular tufts are a rare but known cause of spontaneous hyphema, particularly in elderly patients. Pressure patching is a safe and very accessible option to successfully achieve hemostasis in the setting of an active tuft bleed. And for the rare scenario of a recurrent or persistent iris vascular tuft bleed, additional modalities such as argon laser treatment can be pursued for more definitive management. I'd like to, again, thank Brandon Kennedy who saw this patient with me at the VA back when he was a PGY2 resident. As you can see here, I repaid him with a free refraction. And also many thanks to Dr. Bear and Dr. Simpson for providing really valuable clinical guidance in managing this case. And we actually recently submitted this case for publication as a case report along with that really cool video. And it's currently undergoing peer review. Here's a list of my references. And I'm happy to take any questions at this time. With the patching, obviously the key thing that we're trying to do with pressure patches raise the pressure high enough to have a lot of bleeding. Where you have a combination where you've already got an active pre-pneum. And you've already got pressures that could be elevated. And then a pressure patch all at the same time just gotta be careful that you could actually raise the pressure above the arterial pressure. And we can do that short term. I mean, that's what's one of the stoppin meetings that plays about 30 minutes could be a problem. And a way that you could do the same thing that I know can be quite effective is that you can sit there and you can actually just kind of put your finger on the eye and you can push it and you push hard enough and you'll watch it stop. You're probably at the arterial pressure at that point. And then hold it there for a couple of minutes and just gently lift off. And often it's in place but you're monitoring it and you're not doing it for a long period of time. So that's just, that's a very simple way. I know with Gonioscopy, they can do the same thing where they know there's bleeding by just by holding the pressure, but you're watching it. And it's not something where you're not sure what that pressure is for how long. Yeah, that's a really, really good point. And I shouldn't mention we tried kind of compression. Gonioscopy as well when we were looking at his AC. And I believe just that persisting. Just the finger up to the upper lip, you're watching it and you hold and you push, push, push. You'll get to a point where it'll stop. I'm sure that's arterial pressure. Yeah. Just give it enough time so that something can start, that little fiber can start to crack when you get that thing started. Yeah. And it would be interesting to see too, with more like limited trials of pressure patching for maybe 10 minutes or something could achieve the same effect as opposed to 30 minutes. But yeah, thank you. That's a really, really good point.