 good morning. I appreciate the opportunity to speak with you this morning about the use of serum biomarkers in neobascular age-related macular degeneration, excuse me, poor timing. Macular degeneration is a disease that affects immaculate, primarily primarily change and loss of central vision. And as we can see from this Amphler grid, as the disease progresses, this loss of central vision can be can be quite dramatic and devastating for the patient. It's the leading cause of irreversible blindness in patients over the age of 50 in the Western world. There are two primary sub-subs types of macular degeneration. First the dry subtype, which is usually not associated with visual loss. And then this can progress to wet or neobascular macular degeneration, which is essentially associated with formation of new blood vessels and can cause loss of vision. Roughly a quarter of all patients over the age of 75 have some features of AMD and 80% of those individuals do have, looks like it's cutting off just the bottom of my slide here, but 80% have to neobascular disease. Now how does this disease progress? Degenerative changes that are again usually not associated with visual loss begin with the accumulation of extracellular protein and lipids called drusen that that form within the retina in different layers. At BRUCC's membrane, the RP, and also at photoreceptor interfaces. And as this is a disease of progression, about 50% of individuals with extensive macular drusen by years, and these are considered late changes in the disease and can be vision-threatening. So the characteristic of the onset of neobascular age-related macular degeneration, it's associated with an acute vision loss that can be permanent if left untreated. NV AMD represents 90% of all blindness caused by AMD and as we see in this graphic, dry AMD begins with drusen formation causing thinning of the retina and this can progress to abnormal blood vessel formation which can break through membrane causing vision loss. In terms of risk factors for the disease, it's all in the name. Age-related. Age is the most prominent demographic risk factor, whereas environmental risk factors, the most prominent of which is cigarette smoking, which represents a two to three-fold increase in risk compared with non-smokers. This is related to dry and wet macular degeneration with a stronger correlation to wet. High blood pressure as well as overexposure to sunlight are also risk factors, as well as diet, diets that are high in fats, monounsaturated, polyunsaturated, as well as hyalinolic acid, can double the risk of wet AMD, whereas, in contrast, low linoleic acid and diets high in omega-3 fatty acids. Another reason to choose the fish at lunch today rather than the Twinkie or other snack foods. Genetics has also been found to play an important role in AMD. There have been 19 loci that have been identified to date and these genes regulate a number of different physiologic processes from complement activity, metabolism, matrix remodeling as well as angiogenesis. And one of the most prominent and strongly associated genes is the ARMS2, also called the HTRA1 locus, which is thought to be involved in matrix stability. Additionally, a strong correlation between genetic locus and AMD is the mutational change of the CFH molecule involved in innate immunity. There are two VEGFA polymorphisms that are thought to contribute to AMD susceptibility, as well as the KDR gene, the VEGF receptor 2, that may also correlate with an increased risk of AMD. But this relationship is unclear at this time. In comparison with genetic risk factors, serum biomarkers are less well categorized. There are numerous different serologic biomarkers that have been identified to name a few. Elevations in inducible co-stimulator, MDA, superoxide dismutase, LDLEO2. The most well understood and well studied serum biomarker by far and away is CRP, which can be a non-specific biomarker elevated in a number of different conditions, including temporal arthritis. But a recent meta-analysis has shown that high levels of CRP are associated with a two-fold increase in the likelihood of having late AMD. Now, this here says elevated serum VEGF receptor 2 is also a potential serum biomarker, but this relationship is not well understood at this point, as this is a monomeric molecule and does not have a high opinion for VEGFA. So, VEGF is well understood to have a very important role in the pathogenesis as well as the treatment of NDA. SFLT1 is a molecule that binds and sequesters VEGF, thus reducing its angiogenic activity. So, SFLT1 is anti-angiogenic. SFLT1 is the subject of what my group studied, and it was found that the RP in the RPE SFLT1 is required for sub-retinal vascular demarcation, as well as in patients with NVAMD. SFLT1 is decreased. A knockout, a recent study showed that knockout of SFLT1 in the RPE did show spontaneous coroidal neobascularization. Now, SFLT1 can be found in the serum, it can be measured in the serum. So, that brought the question, if it can be measured in the serum, does SFLT1 also decrease in patients with NVAMD, as was previously seen in the RPE, as well as in the serum, as either a byproduct or a cause of the condition. And so, we performed a study in which 205 patients from Belfast, Ireland had their serum SFLT1 measured, and it was found that SFLT1 was significantly decreased in these patients compared with early AMD and their controls. Also, of clinical importance, there's a step-wise correlation between SFLT1 levels and the risk of developing AMD. For each 10-point increase in SFLT1, the odds of having NVAMD decreases by 27%. We also found that in patients over 73 with SFLT1 levels less than 80, there's a six-fold higher risk of developing NVAMD. And we see here in this box line-in-box graph that, in fact, SFLT1 level concentration is significantly decreased when compared with non-AMD and early AMD. Also, this graphic that indicates an estimation of probability of risk of progression to NVAMD from early AMD. This finding in reduced AMD does have a pathophysiological link that makes quite a lot of sense. In terms of, SFLT1 is the highest affinity receptor for VEGSA, and it has two different isomers. There's SFLT1 or soluble FLT1 and membrane-bound FLT1. The unique characteristics of FLT1 in that it has six rather than seven extracellular IgG-like domains, no transmembrane domain as well as no tyrosine kinase, allows it to be soluble and free to interact with VEGF, thus blocking VEGF's interaction with the receptor and preventing angiogenesis. Whereas when SFLT1 is reduced or absent, VEGF is free to interact with the receptor and angiogenesis progresses. So in summary, SFLT1 in neovascular AMD patients here was found to be reduced compared to early controls. And so we understand that SFLT1 is likely to be associated with the development of neovascular AMD. Although I have to say that we can't necessarily determine causality in regard to SFLT1 because it's uncertain whether or not the decrease in SFLT1 is, it proceeds or is a consequence of neovascular AMD. However, there is a, there does seem to be a very strong correlation in patients over the age of 73 with SFLT1. They have a dramatically increased risk of neovascular AMD. The observed effect was not affected by age, gender, or smoking history. And the sample of 205 patients was not large enough to look at interaction with different gene loci. So as we look forward to the future, there will be serologic panels that will be designed, including CRP, EOTaxin-2, and Homo-cysteine, and possibly SFLT1. And these could be very, very important tools clinically to be able to, whether it be home monitoring or more close clinical observation to have earlier detection, earlier diagnosis, leading to earlier intervention, and possibly preventing vision loss from the onset of NBAMD. I'd like to thank Dr. Hiro Uehara for his significant contribution to this work, as well as Dr. Chikvarthi from Belfast Ireland for helping with samples, and Dr. Bala on body. Any questions?