 We'll wait to introduce Dr. Furbuck. OK, good morning, everyone. Thank you very much for coming. I hope all of you or some of you had a chance to see the patient upstairs. So it'll just be a kind of a quick sharing of a history of an interesting patient. And I'd love to hear what you all have to say as far as possible intervention if it wants to work. So basically, our patient is a 70-year-old gentleman who had presented initially saying that his vision had been blurry over the past year. And his past medical history is unremarkable. Just to give you a little bit of an idea of where he started. In 2007, he presented with vision of 2020 and 2050. And at that time, it was deemed that he had a cataract. And so he was approached with the idea of using a multifocal resume lens, which he thought would be a good option. Even though at the time, by keratometry, he was noted to have about a diopter and a half of the stigmatism. Sorry, two and a half diopters was stigmatism. He still went ahead and had a resume lens put in. The plan was to put in a 17-diopter lens, which would allow for a final refraction of minus 0.1. Well, with regards to his post-operative course, at post-up month one, his vision was in the 2025-2030 range. And as you can see, he started off with three-quarters of a diopter of a stigmatism. As he was continued to be followed, his vision actually worsened. And he was noted to have some SPK. And he was told that his vision will continue to improve if he's compliant with his tears and uses some ointment at bedtime. And actually, doing so did make his vision 2020. But you'll notice that he now has a diopter and a half of the stigmatism. And he's noted to have some tiny filaments as well. At that point, his road of many, many drops in medicine started. And he was placed on Muro, FML, and Rostasis. So now, by post-up month seven, he presents with vision in the 2070-2080 range. And he's described as having this inferior epitheliopathy with about two-thirds of the cornea staining with irregular epithelium. At that point, his ophthalmologist decides to put him on acyclovir. And then is seen a month later and, unfortunately, noted to have no improvement. And he's given feedback along the lines of, wear sunglasses. Maybe that's why your cornea is not healing. So by post-up month nine, interestingly enough, his vision improves. However, he now has two and a half diopters of the stigmatism. And he's taken off the acyclovir. Punctile plugs are placed and he's recommended to have aggressive lubrication. So now, by post-up month 11, his vision is 2020 with two diopters of the stigmatism. So just taking a moment here. If you had a patient like this, what would sort of be your next course? Any thoughts? Bashful group? Okay, so what they ended up doing is they offered him PRK. They offered him PRK to sort of treat this residual stigmatism and improve the quality of his vision. Well, interestingly enough, even though the notes say PRK was offered, he actually ended up having lasik. So keep in mind, this is while he's noted to have some sort of inferior epitheliopathy, he's offered lasik and the treatment plans to treat minus one plus two. And it actually ended up being a nine micron treatment. So first day after lasik, his vision is 2020, which is great. Post-up month three, he's described as having some photophobia and watering. Post-up month five, his vision is now back to 2080, 2070, although needing a plus one correction with not a significant improvement. He started on doxycycline as far as efforts to help improve the state of his cornea. Now he's about two and a half years out from his original surgery and he's finally referred to the Maran. So he comes in to see us. Approximately one month ago, and his vision is noted to be 2100 in the left eye. Keep in mind, the right eye has a little cataract that he's not interested in touching anytime soon. And so the vision in the left eye is about three quarters of a diopter of astigmatism noted. And on his hand, really the big things is he has some dermatoscial aces, he has the resume lens in place and he has some malchillicula. So these are photos from his visit approximately a month ago and you can see his right eye looks healthy. And as far as his left eye initially looks great, but if you zoom in, and if we can adjust the lights a bit perhaps, if you can see there's sort of this ring here, it almost looks like a little shield. And if we zoom in, you can see that there's the sort of punctate, heat epithelium. So on initial examination, my first thought was, is this epithelial downgrowth? But on closer examination, you can actually appreciate that it's sitting on the surface of the cornea. Dr. Moshfar suggested that we get an OCT, which actually wasn't particularly helpful in this case. So thoughts at this time. The patient sort of has this long history, it's not necessarily certain that this is related to the LASIK, though in retrospect I wonder why PRK wasn't necessarily followed up with. Yes, no, there was no comment. No, they just said that there was some SPK. That was sort of the extent of the description. Yes, I'm sorry, epithelial maladherence? Non-adherence. I think that's a possibility because why clinically would it present with sort of that heaped appearance? Clearly, it's not laying down flat. Would it have been appropriate to maybe scrape the area or do a polishing or use a burr to sort of allow that epithelium, a fresh chance to re-adher. Yes, that's the thing, exactly. So he's actually been on tears up to this time and he says that he uses the tears maybe once at night and the lesion itself before was about four by three millimeters in area and today it's measuring about one and a half by three. So it's improving spontaneity. His vision today actually pin-hold to 2025. So it's possible that with a new pair of glasses his vision may improve. And I think this is just a slide of some of the thoughts that sort of crossed our mind. But sort of something along the lines of a persistent epithelial defect, though he didn't have a history of a defect, but certainly unhealthy epithelium. So at this point, as far as recommendations, I mean certainly it seems reasonable to recommend aggressive lubrication. He himself says that, or rather, his wife offers up that he hasn't been golfing with this weather over the last month or so. He's been home a lot. And so I think that there is a role for an environment perhaps in this case where simply being outside and being exposed to the elements didn't necessarily help. So aggressive lubrication certainly seems like an easy option to pursue. But does anyone feel strongly that at this point we should offer him some type of scraping or necessarily discontinue observation? Let's do this. Sure.