 Okay, so I'm Brian Zog, I think I know everybody pretty much in here. I just joined the cornea faculty in July, finished my fellowship in residency here. So we're going to be talking mostly about cornea, and if we have a little bit of time we'll talk a little bit about refractive surgery as well. So we're going to start out with our two cornea fellows, so Brent Betts is going to start. He's going to talk about acanthamoeba keratitis. He comes to us from Wake Forest, and he's going to be joining a private practice up in Boise, at Intermountain, it's kind of the name of the main practice up there, that he'll be helping us out with for Northern Cornea. So we'll start with Brent, and then we'll move to Severin. And Severin Poli comes to us from UT Southwestern where he did his residency. And he's going to be joining Grant Morcetti in private practice in Arkansas, one of our past glaucoma fellows in residence. So we'll go to that point for now. So this is kind of a follow-up to, we already talked about acanthamoeba the last time Severin did, and just kind of the general management ideas and kind of updates on treatment, but I just wanted to show, mainly I'm going to show a surgical video, kind of the what ultimately can happen to these acanthamoeba patients. So I don't have a PowerPoint, but I'll just kind of give a little clinical history, it's a patient we saw starting in September 2015. He had already been treated for a month for kind of an unusual keratitis, history contact lens where he had had fibroplastic about 10 years previously. So they kind of had like a suspicious viral appearance. So he started on acycovir. He was on fourth generation fluoroclonaline. And just didn't really improve, and he was seen over multiple weeks. And he had a straightening done about two weeks after we saw him. Finally, out of a month, it came back positive for acanthamoeba. So he's put on PHNB and chlorhexidine, which is kind of our standard treatment. And over the next six months, he kind of waxed a wing. He had a really persistent on him, and he had a little defect. But about in the springtime, we had got him down to just using both chlorhexidine and PHNB just twice a day. And then he got a lot worse, and he developed a huge hypopoean. And we were really, because of the rapid onset and just the appearance, it really looked fungal. So he was taking the OR for an ac washout. And the washout, the hypopoean didn't grow anything. And about six days later, his cornea just blew up again. And so he was taking the OR for emergent PK. In general, if you suspect canthamoeba, the stand room is not to do an emergent PK because it can recur in the graph really quickly. The canthamoeba bugs can get right back in the graph and you get a worse inflammatory reaction. But it really looked fungal. So he had this emergent PK and there's pus everywhere. And he kind of had a mushy host cornea, so they had to do a conch flap in one area. And anyways, it came back as a canthamoeba. So that was in April. And then we nursed him through the summer and up until two weeks ago. And had a completely scarred cornea and looked like his anterior chamber was flat. Throughout all this time, he was seeing Dr. Carey for kind of serial B scans just to look at the posterior pole, which looked normal. He dealt with some pressure issues because we could tell in the summer that he really didn't have much in the anterior chamber, but we were able to control him on topical therapy. Even during that time in the late spring, things were looking pretty bad. And after his cornea transplant, so he actually got eye drops from Europe, a different type of canthamoeba treatment that's not available in the US called desmatidine, which is just another kind of chlorhexidine type antiseptic, like hexamidine. So we were fairly confident, we would do, in the fall, we were doing kind of these times where we would have him off steroid and let his eye get a little more inflamed with the idea that when you take people off steroid, maybe the cysts kind of wake up and that way he can kill more of the bug. And then we'd put him back on steroid and we slowly tapered him off of his pH and being chlorhexidine. Once he was off for about a month, things were looking good. We started to take him to the operating room. So this is our case and just like it was a, we did general anesthesia, because you can see we were pregnant a lot of work, can't really see into the anterior chamber, but you'll see what it looks like when we take this cornea off. But one of the first things we did is we kind of marked out the limbus, because it's so scarred and we want to make sure that we sat in the graft well. Put on a flaring green because we knew that there's gonna be an open eye for quite a while. I think we used a 8 millimeter tree find and then 825 graft. So you can see, we tried to go down 90% thickness and kind of perforated a little bit. So one thing the anesthesia really helped us with is they hyperventilated him to help with kind of paralysation and also gave him medication so that he wouldn't buck it all during the surgery. But you can kind of appreciate here, in Jack Visco elastic that there's a lot of resistance and you can kind of see the cornea open up a little bit. We did a really slow dissection of the cornea from the underlying iris and just, this is sped up some, so this case total took about two hours. And we weren't really sure, we couldn't really tell anything about his lens status. When we had done his original cornea transplant, sometimes it was actually fairly clear. Just lots of dissection and, like I said, document from this nice, slow and methodical. And you can kind of appreciate there's a lot of fibrosis and scar tissue on the iris, it's distorted. Really, it was really hard to tell where his natural pupil was and we thought it was right in this spot. You can appreciate that he does have this white lens too, so we basically tried to see if we could open up his pupil and expand his iris, see if we could do heart surgery without distorting or cutting it like we're doing right now. But ultimately, we had to cut it inferiorly, which is right there and then also superiorly too. There was about 30 minutes between the first cut and the next cut. But something else Dr. Mifflin did was he wanted to make sure that there was some space in the entire chamber. And so we spent a lot of time kind of dissecting out to the angle with blunt west cuts, which I skipped a lot of that because it took quite a while. But you can see as this big white lens and Dr. Mifflin did an open sky cataract extraction. So me, division blue and me to tried to suck out some of the cortex after making a small nick in the anterior capsule. She'll see coming up here. And there really not much came out, but it's really difficult to do open sky cataract because there's really, there's no viscoelastic keeping the anterior capsule flat. It tends to want to go out, and it looks like it's kind of going out here, but we were able to do a continuous curvilinear capsular axis. And we could actually, once the lens is prolapsed out, you could actually, under the scope, you could actually see the inferior edge of the capsular axis. So it kind of helped us stay oriented as we did this part and also removal of cortex. But when it's open sky, the lens typically comes out pretty easy. And it's pretty rewarding watching this come out. So we're really careful at the end because we didn't know if it was still attached to the posterior capsule or wasn't. But at this point, you can do, there are different ways. You can use bi-manual INA. You can use a SIMCO if you have one available. But we tried to get as much cortex as we could gently. And then viscoelastic can put a three-piece MA-60 in the capsule or bag, which is also difficult to do in the open sky. And one thing that I won't show here, but we had already cut the donor tissue at this time because we really wanted to decrease the amount of time that the eye was actually open. But here we did some, we tried to make a pupil and ended up with about a, I don't know, two, probably three millimeter opening. But just use nano-prolune sutures to kind of close the two ends. Mainly could, probably reason-wise, because if he was gonna have some vision potential, we wanted not to have crazy glare, but also we wanted to keep the lens in the back, in the posterior chamber. Yeah, so that's kind of what it looked like. You can kind of see the pupil-like aperture here. And then just did like a standard penetrating care in plastic. We used 16 interrupted sutures. He had a little suture leak superiorly at the end of the case that we checked before seeing. And so we actually put an advanced contact lens, but took it off at week one. So I'll kind of just skip and kind of see the, I showed the four caramel sutures, but as I didn't really get to put in the first four sutures and kind of a little less stress at that time because I wasn't opening any more. But you can kind of see here, this is interoperatively what he ended up looking like. His chamber was deep and we tried to get as much viscose as he could. And then we patched him overnight and he had been like perception for the last few weeks, but there's no relative effort, pupil area defect by reverse. So about, this is two weeks post-op right here. And he used calc fingers. We were able to look at his nerve and see that he didn't really have any pallor in his macular, it was kind of grossly normal. But it just kind of shows that what the damage this can do. There are reported cases where people have lost their eye because they can't think of a spread to the sclera. Luckily we haven't had a case like that, but we have had some of our cases where it's gotten into the eye, eating up the lens and cause ticis. But we're hoping that he can make a good recovery. He's, his big issue, we're kind of concerned that his pressure may be an issue because his chamber is so flat for so long. So we just don't know ultimately how that's gonna end up, but we just want to show the case because it was interesting, it took a long time. Probably the longest cornea case we've done in a while. But just slow, methodical, the section of all the scar tissue I think really helped us in also getting anesthesia on board to really discuss the importance of helping decrease the risk for expulsion. So if there are any questions I can take those.