 Hello, everyone, and thank you for joining us for today's Grand Rounds. We have a wonderful list of medical students who are going to present their various projects, presentations. Our first one, Anna Mueller, she's from Florida International University. And a fun fact about her is she's a black belt in karate. She also once took someone down with one finger. I don't know if that's true, it probably is. The title of her project is Serious Retinal Detachment and a patient with a port wine birthmark associated with prostaglandin analog therapy. Thank you so much. And so, yes, I'm Anna, and I'm going to present a case from the pediatric glaucoma clinic at Bascom Palmer. I have no financial disclosures. So this is a case of an 11-year-old girl who presented for a glaucoma follow-up secondary to her port wine birthmark. She was diagnosed with a condition called figmentosis pigmentovascularis. It's a rare condition that is characterized by Mongolian spots, which have blue discoloration of the skin, extensive dermal melanocytosis, and port wine birthmarks. She was diagnosed with glaucoma at the age of eight, and so far she has been on various drops, and all of them she has tolerated poorly with localized side effects. On that visit, her visual acuity was 2020 bilaterally, and her IOP was elevated in her affected eye. Her fundus showed intact foveal reflex and glaucomatoscopin, so I was decided to change her to bematopros at that visit. She returned four months later. Her visual acuity was slightly reduced to 2030 in her affected eye, and her IOP remained elevated. So she was changed to vasalto, latinoblastin butanod, and four months later she returned to clinic. Her visual acuity was still reduced to 2030 in her affected eye, and her IOP was still elevated. Visual fields and RNA file showed minimal progression from her baseline two years ago. Her fundus showed this. So the white arrows outlined serious retinal detachment that extend all the way to the phobia, and then OCT confirmed the diagnosis. So vasalto was discontinued at this point, and two months later her visual acuity was 2020, and the serious retinal detachment has significantly improved. So we did a literature review of all the cases of serious retinal detachment in port wine birthmark, and it turns out that there were 35 cases worldwide, pretty rare condition. 33 of these cases were of Sturgeweber syndrome patients, two were of fecomatosis pigment ovascularis. 100% of the cases had diffuse choroidal hemangioma, and 63% of the cases had glaucoma, which is probably secondary to the port wine birthmark. So how do all these conditions relate? It turns out that port wine birthmark, diffuse choroidal hemangioma, fecomatosis pigment ovascularis, and Sturgeweber syndrome all have the same activated mutations in the GNAQ gene that essentially cause aberrant gene transcription and cellular proliferation. So we went back to these patients' charts, earlier charts, and we found that she indeed had hyperopic shift on cycloplegic withinoscopy, which indicates choroidal expansion. And her ultrasound showed thickened ocular coat in her affected eye, which likely indicates diffuse choroidal hemangioma. So what is diffuse choroidal hemangioma? It's a congenital benign vascular tumor characterized by tomato catch-up appearance of the fundus thickening of the coroid and ill-defined borders. And it turns out that it is an independent risk factor for serious retinal detachment. And how so? We put all the mechanisms into a cartoon. So I'm not sure if my, yeah, OK, perfect. So hemangioma is a vascular tumor, and it has abnormal leaky vessels. And it has a mass effect that puts a lot of mechanical structure, mechanical stress on the retinal structure and function deforming it. Retinal vessels that are not shown in this cartoon that drain the retina to the coroid cannot drain it properly. And over time, the RPE degenerates. And RPE is, of course, the part of the outer blood retinal barrier. But it also has an important function of pumping fluid from the retina to the coroid. And once the RPE degenerates, these pumps can no longer pump this fluid and fluid can accumulate in this space. So we went back to the 35 cases that we reviewed. And we asked whether there were any preceding events to the serious retinal detachment. And just to make it super clear, any trigger events or preceding events do not imply causations. Those are simply observation. So it turns out that most of the cases did not have any preceding events. 20% of the cases occurred after surgery, particularly glaucoma surgery. 9% of the cases occurred during pregnancy where there is a significant hemodynamic shift. And 11% of the cases, four cases in total, had to do with pharmacological agents. Three out of the four cases had to do with prostaglandin analogs, specifically prostaglandin F2-alpha. One case happened in a 26-year-old male who took an arginine containing erectile dysfunction supplement and developed a serious retinal detachment right away. An arginine, once ingested, it is metabolized by nitric oxide synthesis to nitric oxide, which is a potent vasodilator. And interestingly, an interesting observation is that vasolta is both prostaglandin F2-alpha and a nitric oxide donor. So we put together all the possible mechanisms by which prostaglandin analog with or without nitric oxide may cause serious retinal detachment. And obviously, those drugs are generally safe. But in an eye with a diffuse caroidal hemangioma, they are more susceptible to the adverse effects of the medication. So prostaglandin analogs acts as it can stimulate pro-inflammatory mediators and increase the disruption of blood-burning barrier. It also stimulates the vascular endothelium and the RPE permeability, which increase how licky those cells become. Interestingly, prostaglandin analogs and nitric oxide can induce angiogenesis via VEGF. And in a vascular tumor with torturous vessels, it's probably not a desirable outcome. Finally, nitric oxide is a potent vasodilator, and it can exacerbate exudation. And it leads to fluid accumulation between the RPE and the neurosensory retina. And that's the definition for serious retinal detachment. This is the entire figure. And in conclusion, patients with port wine birthmarks are likely to have diffuse caroidal hemangioma and glaucoma. Diffuse caroidal hemangioma is an independent risk factor for serious retinal detachment. Some glaucoma drugs may increase the risk of serious retinal detachment. And therefore, we recommend a regular surveillance for serious retinal detachment in these patients. And something that I personally learned working on this case is that in medical school, when we learn about turdwebber, we learn about port wine stain. And stain is not a nice word. Nobody likes stains on their clothes. So why would a patient like a stain on their bodies? So port wine birthmark is a much more positive, neutral, and accurate word to use. Those are my references. And finally, I want to thank to my amazing mentors in Boston Polymer, Dr. Peter Chang mentor on this case and my mentor in my research here at Boston Polymer, Dr. Betacharia. Also special thanks to Chandler, who made it happen for me and all the wonderful people in Admaran that I worked during this rotation. Thank you so much. I'm happy to take any questions and try to answer to the best of my ability. Thanks. The Hebrew word got messed up. Alrighty, thank you so much. Hey, so for our next presentation, we have Tara Gallant. She is a fourth year from California Northern University College of Medicine and she'll be presenting the wholesome foods approach to trabeculectomy training. A fun fact about her is she is a wicked mountain biker from Tahoe and once rode a double black diamond with two flat tires. I don't know if that's true. Hi everybody, my name's Tara Gallant. And again, today I'm going to present the wholesome foods approach to trabeculectomy training. So this presentation is going to describe a wet lab approach to helping residents and training physicians practice trabeculectomy surgery. And I thought this would be an exciting presentation to do here because Utah does so much outreach into underserved areas as well as focuses a lot on making sure their residents are excellent surgeons upon graduation. So first, why do we care about trabeculectomy training? So trabeculectomy surgery like most surgeries is less effective in the hands of surgeons in training than when performed by experienced surgeons. And it does require a relatively unique skill set. Additionally, the number of trabeculectomy surgeries performed in the US is on the decline. In 2005 most residents were only narrowly achieving the surgical numbers required to graduate. And although now there is no specific requirement for trabeculectomy surgeries or surgical training numbers, the number of cases is going down from 6.0 to 4.8 on average for 2009 to 2016. While the number of primary glaucoma drainage procedures is going up and it's still an important skill set to learn. So the importance of wet labs was really enforced by the COVID-19 pandemic when a lot of elective surgery such as ophthalmology procedures were canceled and postponed and wet labs became an important way for surgeons in training to keep up their skills. Additionally, the United Nations Sustainable Development Goals recently adopted its first resolution to develop eye care in emerging nations. And it was noted that simulation training would be an important part of this. So surgical simulators obviously exist, but they're very expensive. And animal eyes are another method that people can use to practice surgeries. However, they often take a long time to attain and they might cause you to come into contact with infectious diseases. In contrast, wet labs are generally very accessible and inexpensive. So for this wet lab, all of the materials you need are either available at a local grocery store or they're materials that most surgeons would have on hand. You need a fresh lime, any chicken part with skin, styrofoam border head form, four steps, a blade of your choice, surgical scissors, a needle driver, suture material, a marking pin and a vegetable material or a vegetable peeler. All right, so for preparation, it takes about 10 to 15 minutes. You just need to peel the outer green layer of the lime with the vegetable peeler, leaving the white rind in place. And then once that has dried, you can just pin that into a styrofoam folder and use the marking pin to draw a 12 millimeter circle representing the corneal limbis. And the line rind itself will represent the sclera. So then the next step is practicing the creation of a scleral flap. And you wanna create a flap that is about three quarters the depth of the sclera. If the dissection is too deep, you can see a darkening of the color created by the green fruit much in the way that intraoperatively you would see a change if you're getting too close to the UVA in a human eye. And then some flap shapes are rectangular trapezoidal or triangular and this is up to the discretion of the surgeon. Next, you can practice suturing the flap with Nino or Tenno suture. You can place one suture in each corner of the flap and practice additional sutures if you want. Here's a picture of this step of the wet lab. So you can see in figure or images A through D they are creating a scleral flap and in images E and F they're practicing suturing down the corners. The other part of this wet lab is practicing conjunctival sewing on the chicken skin. So again, you can draw a 12 millimeter circle on the chicken skin to represent the corneal limbis. If you're doing a fornic space trabeculectomy, you're gonna create an incision right at the edge of the limbis and sew that shut at either end using interrupted sutures. If you're performing a limbis-based trabeculectomy, you're gonna cut a line in the chicken skin about eight millimeters posterior to the limbis and sew that together using a running suture pattern. So here you can see images of the fornic-based incision. So you can see they create an incision and then suture it closed using interrupted sutures. And then in these images, you can see the limbis-based incision and the running suture format. So this is a project I developed with some of the ophthalmologists at UC Davis and after they implemented this web lab, we sent all of the participants a survey to see how effective this was at helping them perform trabeculectomy surgery. So you can see the responses are the same across the board, whether it was performed by an experienced glaucoma surgeon or a trainee who went on to specialize in a field other than glaucoma. So everyone said that they felt the simulation overall prepared them very well for glaucoma or trabeculectomy surgery. And that the lime rind was a good simulation of human sclera and helped them feel more confident suturing on human sclera. Similarly, they felt the chicken skin was a good representation of human conjunctiva and that's the simulation prepared them for suturing human conjunctiva. Additionally, they said it was very easy to acquire all the procedures and set up this web lab. So I would like to thank my mentor, Dr. Michelle Lim at UC Davis for helping me with this web lab. And if you would like to read more about it, we recently published a paper about this a few months ago. All right, and here are my references. And does anyone have any questions? Careful. I've had personal experience where we used to teach intraosseous line placement, to pediatrics residents in developing countries with one of my pediatrics colleagues getting salmonella that required massive IV rehydration. I had to reinvent my IV skills to get him functional. So urge some caution. Rot chicken can be contaminated and could be another thing like the other animal specimens as a cause of infectious diseases. Salmonella's not good. This is great. I think this looks like a really good idea. I did this web lab when I was at UC Davis and now I'm a glaucoma specialist, so. And you didn't get salmonella? And I did not get salmonella. You would have. All right, well, thank you very much. All right, our next speaker is Greg O'Yuaknen. He's coming to us from Chicago Medical School and his fun fact is that he lived in the Caribbean for two years and the title of his talk is Merging PRK and Collagen Cross-Linking. Thank you, Lydia, for the introduction. Like she said, my name is Gregory Rodnan. I'm a Fortune Medical student visiting from Chicago Medical School at Roslyn Franklin University. Today I'll be presenting on a recent literature review I was participant in with Dr. Mosifar about merging PRK and Collagen Cross-Linking. Grateful for the opportunity to do so. As a brief introduction, care to colonists is the leading cause of idiopathic corneal ectasia. It is characterized by thinning and bulging of the inferior cornea and has a large spectrum of severity ranging from subclinical with no visual symptoms, but with very subtle findings on shine flu imaging to very serious stages requiring full thickness corneal transplant. It remains one of the leading independent factors for developing postoperative ectasia and in any stage of the disease, it can be a risk factor. As such, detecting these very subtle patients in form-fruits care to colonists is of great interest and has been the focus of a lot of research recently. Most of these studies focus on comparing a normal fellow eye of a parent unilateral care to chronic patients to the eyes of controlled postoperative healthy eyes. Just some recent examples. In 2013, Dr. Smadja and company developed a decision tree based system to screen for FFKC. The sensitivity and specificity were pretty promising. In 2018, Dr. Wing also and company introduced a system using 13 different parameters of OCT epithelium mapping and Pentacam reporting perfect sensitivity and specificity. The main takeaway is that the detection of form-fruits care to colonists is very difficult. It's very subtle and there's no one parameter that would be useful in detecting this disease. However, in clinical practice, these systems, unfortunately, are a little bit lackluster. They have great utility in the reported populations. But for example, Dr. Smadja's system seemed to air on the side of false negatives and Dr. Wing's on the side of false positives. So this leads into a potential application of this combined form of FFK and crosslinking to reduce further the postoperative risk of ectasia, though the incidence of this ectasia extremely low already between two and hundreds and six tenths of a percent. However, this can also be applied to care to chronic patients undergoing crosslinking generally. The initial venture into a combined, excuse me, PRK and crosslinking procedure was first began in 2009 by Dr. Cannonopoulos named the Athens protocol. Previously in 2007, he suggested that a PRK procedure should be delayed 12 months after crosslinking. But in this 2009 paper, he found that to be inferior. And since that, many other papers have been published about different protocols in combining different forms of PRK and crosslinking. In 2020, Dr. Kankaria and Kim Jonas said in a review article that despite the promising results of this case report referring to the delayed procedure, there were several limitations with this two-step approach. The ablation rate might be different in a crosslinks than in a non-operated virgin cornea leading to unpredictable refractive results and possible limited effectiveness of PRK. The risk of post-PRK haze formation is higher as the anterior stroma is repopulated by new care to sites six months after crosslinking. Lastly, and probably the most significant limitation of this approach is that the second step PRK removes part of the crosslinked corneal tissue, thereby potentially decreasing the stiffening effect of crosslinking. This delayed versus simultaneous procedure is certainly under debate currently and the jury is still out as to whether the simultaneous approach is superior. However, there is promising results so far. These are taken from the submitted article, the manuscripts. The figure on the left shows a general overview of the most popular protocols, the Athens protocols, the Cretan Plus and Tel Aviv. The original Cretan was excluded in the review because it did not use PRK with crosslinking, just PTK. As you can see, some of the differences range from the type of PRK, the use of PTK, the order of both the use of mitomycin C, the riboflavin soap procedure or the corneal crosslinking UVA radiation protocol. For example, in the enhanced Athens protocol they use a customized profile for crosslinking as demonstrated in the figure on the right. They focus a larger amount of irradiance over the thinnest and steepest portion of the cornea giving promising results in disease stabilization but also refractive benefit. These are some graphs and figures from the paper. The top left is showing the improvements in visual acuity across the paper studied. It is reported in logmar and the standard deviation because of the logarithmic scale is quite large. However, there was significance because of the large amount of eyes analyzed. Respectively in UDVA, it was an average improvement from 2250 to 2050 was found and in spectacle corrected vision 2040 to 2025. We also did a random effects analysis to see if the combined effect was reasonable. The combined effect size is represented by the diamond on the very bottom with a 95% interval confidence interval showing that though the heterogeneity is large across the papers, there is a combined effect size that the treatment would be beneficial for the patient. Charitometric parameters also showed promising results namely in K1, K2, mean K and Kmax. The forest plots for those are also shown here all showing combined effects that are consistent with improvement postoperatively. Manifest refraction was also analyzed showing really promising improvements in spherical equivalent especially but also in sphere and cylinder and all the papers that we analyzed in these parameters were also showed a combined effect of a positive improvement postoperatively. So the question remains certainly of which of these approaches is best. At this point, we cannot say because of a large amount of variables between the papers and different protocols. However, we can see with moderate certainty that a combined approach would likely be of net benefit for the patient both from a safety profile, convenience and a refractive benefit and disease stabilization postoperatively to assess more carefully if a combined versus delayed approach would be best. Standardized control trials would need to be done first to assess the simultaneous versus delayed and if there is a benefit in a controlled setting that the simultaneous procedure is better than comparing the different protocols between each other. It could be said at this point that a combined procedure that combines the latest technology in PRK and cross-thinking would be best. For example, the Athens Enhance uses topography-guided CTA-adjusted and high-speed eye-tracking PRK with a customized PRK profile with really good results postoperatively. Thank you for your attention. I'm happy to take any questions. Thank you. All right, if there are no other questions, then we move on to Wyatt Corbin who's visiting us from Loyola School of Medicine. And his fun fact is that he has an identical twin and he's gonna speak to us about the effect and implications of diabetes on fully-dilated pupil size before and after cataract surgery. Okay, thank you so much for having me. Really grateful to be here. Another fun fact is that I am experiencing like migraine aura right now, so forgive me if I'm a little, you know, need to find my place. I'm really excited to present this research I've been working on with Dr. Felipe de Alba, retina specialist at Loyola. We received a grant from the Illinois Society for the Prevention of Blindness for this project, which I wanted to point out. And it's been a great opportunity to work on it with. With him and with that team that, and so just some background, there's as many of us know, there's an increasing global prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy. In 2020, there was about 100 million people with diabetic retinopathy and about almost 30 million people with vision-threatening diabetic retinopathy. And by 2045, that's expected to increase by about 50%, if not more for both categories. As we're aware, these must, these conditions must be addressed by annual dilated fundus exams, injections and relevant to our study, PRP, lasers and parts plan of atrectomy. So background tying this into cataract surgery at baseline and all patients cataract surgery leads to decreased fully dilated pupil sizes post-operatively. Diabetes compounds this through a variety of mechanisms. One, people with diabetes have smaller pupils at baseline compared correlated with smaller pupils post-operatively. As Hayashi and Hayashi here shows, the smaller the preoperative pupil area, the smaller the postoperative pupil area compound this with the fact that people with diabetes have a greater risk of cataract formation and they experience greater reductions in size due to cataract surgery than people without diabetes. Then we can get a more significant problem. Some proposed mechanisms for this include neuropathy of the ocular sympathetic innervation, degenerative changes of the iris muscle, higher concentrations of substance P and calcitonin G related peptide due to surgical trauma as well as inflammation might play a minor role but it still does play a role. So why is this clinically relevant? How is it clinically relevant? For cataract surgeons, there are some increased risk of intraoperative complications with smaller pupil sizes. You have increased surgically induced meiosis as well as just a smaller window for operating necessitating the use of maliugin rings and other medication, medication interventions which come with their own risks and benefits. This also has an increased risk for post-operative complications such as limited view when you're performing parts plan of atrectomy in these diabetic patients with retinopathy or limited view when performing pan-retinal photocoagulation laser therapy as well as perhaps you're not gonna be able to get as dilated of a fundus exam when you have smaller pupil sizes. So building off the previous research, again based off of the slide I touched on a few slides ago that people with diabetes have smaller pupil sizes preoperatively. It hasn't yet been shown if what the effect is between or what the difference is or if there is a difference between non-proliferative diabetic retinopathy patients and proliferative diabetic retinopathy patients. We hypothesize that there will be a greater reduction between these two groups mainly in the proliferative diabetic retinopathy group. We also hypothesize that the reductions will remain beyond three months postoperatively. That has not yet been shown. The largest study was done or the longest study postoperatively was taken by Totsuka at all in 2012. But we're gonna take it out further six months and possibly a year to see what the pupil sizes are postoperatively in these patients. And finally, for this last one I'll just explain the pluses mean that there's a greater reduction the minus is a smaller reduction. These reductions vary based on the duration since diabetes diagnosis. So there'll be greater reductions over time. The A1C, if there's greater A1C you have greater reduction. If they're on insulin treatment then I'll be greater reduction than patients on oral medications, non-insulin medications for diabetes and that will be greater than patients only managing their diabetes through lifestyle management. And finally, if they have a presence of prior PRP treatment, we hypothesize not as great reductions. And that's because of the potential damage the short ciliary nerves perform during PRP treatment which can cause increased myosis when you try to dilate the fundus. Try to dilate the iris. So for our study protocol we are getting 20 patients into four patient groups. So 80 patients total. One will have a control group, patients without diabetes. Two, patients with diabetes without ranopathy. Three patients with non-proliferative diabetic ranopathy. And four patients with proliferative diabetic ranopathy. So again, 20 in each group, 80 total. And each of these patients are scheduled for cataract surgery. And then we measure their pupil sizes before and after cataract surgery ideally at one month, three months and six months postoperatively using the right and right no max K plus three device. And of course patients must not meet any exclusion criteria. So currently where are we at in our project? We've been at this project for about a year and data collection can be difficult but we have collected a decent amount of preoperative measurements. We mainly have patients in the preoperative in the control group and diabetic group without ranopathy. Although we do have measurements for the non-proliferative and proliferative diabetic ranopathy groups. Because we're still collecting data we still need to perform our final statistical analysis. We haven't determined significance yet but we do have results, preliminary results that we find are interesting that I would like to present because it can help us to project what our final results may be based on previous research. So these preliminary results we have, it is encouraging in terms of our hypotheses that we do see a decrease in pupil size between patients with diabetes without retinopathy and then to non-proliferative diabetic retinopathy and the proliferative retinopathy. It starts at 5.8 as you see about five and then to about 3.3. Of course, we need greater sample sizes to determine significance but this is interesting. Finally, patients with diabetic treatment, patients with no, on no treatment with diabetes have an average size of 6.45 millimeters, patients on oral medications only 5.3 millimeters and then patients on insulin only five. Some data we have based on the A1C value. We have a slight negative correlation for increased A1C value and average preoperative pupil size. The correlation is actually stronger and negative for the duration of diabetes since prior surgery. They're both not incredibly strong but it is perhaps significant and it is encouraging to know. So based on these data, we can make certain kind of hypotheses, guess is what we think will be the outcome. We do expect to find greater reductions but we need to finish our patient recruitment, data collection and data analysis but it'll be similar to the analysis I just showed you but more based on the reductions between preoperative and postoperative pupil size. Finally, after we do that, we'll identify some trends, draw some conclusions and then highlight some future research directions. A few studies that you could do are the effect of small pupils on diabetic retinopathy screening, diagnosis, disease monitoring, the effectiveness or extent of limitation of small pupils on PRP, PPV and other interventional retinal treatments and ultimately the prognosis of diabetic retinopathy. Interestingly, Dr. De Alba observed that administering cyclopensylate three times per day and his patients, one most postoperatively, did restore, he believed anecdotes some pupil size but we need to have some official data to back that up and encourage some other clinical trials of this issue. These are my references. So thank you for your time, any questions? Any questions? Okay, thank you. All right and then the last speaker of the day is Brianna Banashevsky who's coming from Aikon School of Medicine at Mount Sinai and her fun fact is that she qualified for the Nigerian Olympic team in gymnastics and the title of her talk today is Technology Guided Central Atina Adory Occlusion Intervention Reverses Vision Loss, a 24 month pilot study. Thank you for that introduction, Lydia. Let me just pull up my slide. Good morning. My name is Brianna Banashevsky and I'm a fourth year medical student at the Aikon School of Medicine in New York City. Thank you for the podium time today. I'm excited to speak with you all about a project that I've been involved with in Mount Sinai where we have used technology to reduce time to treatment for our CRAO patients. First, I'd like to acknowledge my mentor and the lead of this project, Dr. Gareth Lima, a retina specialist at Sinai, as well as all the other physicians listed on the screen who've made this project possible. Also, I'd like to mention that we will be discussing off-label use of TPA throughout the presentation. So by way of backgrounds, CRAO has recently been identified in the literature as a treatable medical emergency. This is akin to stroke, however, unlike stroke, there aren't widespread systems in place to accelerate the diagnosis and accelerate treatment for our CRAO patients. Here's a couple of examples identifying this challenge in the literature. In 2021, the American Heart Association released a scientific statement calling on hospitals to prioritize early recognition and triage of the CRAO patients. In addition, later in 2021, a group of physicians at Emory did a retrospective review over a decade of their CRAO patients, and they found that only three out of 181 patients were eligible for treatment. And this was because a long time from last known well to presentation, as well as a long time between presentation to diagnosis. So again, we see the publication in 2021 calling on hospitals and health systems to accelerate diagnostic pathways for CRAO. So the problem has been well-established in the literature. It's simply taking too much time to diagnose CRAO. Therefore, fewer patients are eligible for treatment. This problem was also identified at Mount Sinai. Actually, in late 2020, we had our stroke team approach the Department of Ophthalmology and they asked us if we'd like to collaborate with them on a updated clinical protocol that would help reduce the time to diagnosis so more patients could be eligible for treatment. So an interdisciplinary team came together and this team had two goals. The first goal is to reduce time to treatment for CRAO patients. The second goal is to integrate into existing stroke team pathways as much as possible. And the second goal is all about uptake. We wanted this new process to be seamlessly integrated into the stroke team pathway. So if you try to identify pain points in a process, the first step is to understand what you're dealing with. So here is the protocol prior to the update. On the top left-hand side of your screen, the patient presents at an ED at one of Mount Sinai's several emergency departments across New York. A stroke code is activated. The stroke team conducts their exam and they get CT or CTA imaging. Then the ophthalmology team is consulted and depending on what emergency department they're in, ophthalmology might not be in-house. So oftentimes you're waiting for ophthalmology to travel to that hospital. Then the ophthalmology team conducts a non-dilated exam. We wait for dilation, then we conduct the dilated exam and only then can we share with the stroke team whether it's a confirmed CRAO and the stroke team makes the ultimate decision on if this patient is eligible for TPA. The team, this interdisciplinary team put their heads together and said, where is this process taking the most amount of time? And the areas that we're taking the most amount of time are highlighted on the screen. And all of these boxes that are highlighted are related to the in-person ophthalmology consults. It was simply taking too much time for the ophthalmology team to arrive in person and conduct their exam. So the solution that we developed was to completely eliminate the in-person portion of CRAO diagnosis and instead, replace it with remote consultation with a group of retina specialists because we have now implemented OCT imaging devices within emergency departments across Mount Sinai. So here's what that updated protocol looks like. We start out the same, the patient presents with symptoms that are suspicious of CRAO, stroke code is activated and then we start to differ. The stroke team immediately after activation of the code contacts that group of retina specialists who have joined the CRAO remote diagnosis team and they give that group a heads up that data will be coming soon on a potential CRAO. Then the stroke team conducts a regular exam as before and in addition, they use the local OCT machine that's in that emergency department to get an OCT image and that image along with all the history and other exam components are sent in real time digitally to that group of retina specialists. That group of retina specialists within five minutes confirms receipt of the data and they can quickly analyze the history, the exam data and the OCT imaging and let the stroke team know if it's a CRAO or not. Importantly, I do wanna call out that there are certain criteria if a patient meets, they automatically switch over to an inpatient consult. Those criteria are listed on the screen and the stroke team is thoroughly trained on these criteria. So the novel part of this pathway is elimination of the in-person consult and replacing that with OCT imaging devices within the emergency departments. When we were choosing which OCT device to use, we wanted one that was easily usable. That was the primary factor of choosing a machine because the stroke team was getting trained on how to use this and the last thing we wanted was to have technology complicate the integration of this new protocol. So the one that we selected is pretty much point and shoot and it automatically focuses. In addition, we liked this device because the screen is embedded in the machine itself. Several OCT machines require a monitor and that just takes up too much room in emergency departments at least in New York City simply don't have the room to store many devices. In the middle of the screen, you see a couple examples of images that have been sent to the retina team throughout this protocol. The top image, I am by no means a retina expert, but the top image does represent a patient with CRAO and we can see that because we have foveal glow right here in the middle. We have lack of differentiation between the retina fiber layers and we have hyperreflectivity of the internal retina layers. So once the retina team receives OCT imaging and the other exam components, they can let the stroke team know digitally whether it's a CRAO. So this new clinical protocol has been live since May 2021 and in the first 24 months, 86 patients were evaluated, 33 had confirmed CRAOs and 15 were eligible for treatment. We did see a reduced time to treatment overall. Prior to this protocol update, we were at about four hours from when that patient came into the ED to when they were being treated. Now we're down to 2.5. In addition, we've seen vision recovery. So visual acuity increased on average from counting fingers to 2,100 and 60% of our patients who received TPA improved vision from worse than 2,200 to better than 2,100 and this metric has been used in the literature to define vision recovery. Importantly, we have had no intracranial bleeds or systemic complications and for folks who are familiar with TPA use for CRAO in the literature, these results are very similar to the Hopkins trial that was conducted in 2008. So the key takeaways here are that improving CRAO diagnosis times can increase eligibility for potential vision saving treatment. This type of solution does require interdisciplinary collaboration and cross department stakeholder buy-in but from our experience, we do believe that the time consuming inpatient ophthalmology consults can be replaced by using OCT imaging devices and a remote retina group that can remotely review and diagnose CRAO. Thank you for your time and I'm open for questions. Hi, thank you to all the students for the presentations, they've been excellent and I have lots of questions for all of you later. Would you know what the positive predictive value of OCT is in this setting considering that the treatment has significant risks? So it was a good question. I don't have that number up top of my head but we did recently publish a paper it's under review right now and I believe that number is in there so I can get back to you with that. Thank you. I guess it's a similar question. Why did you, or I guess you didn't make the decision but why did they opt for OCT versus non-medriatic camera? Yes, this was a case in which we were approached with the idea of OCT and we had a relationship with an OCT company that we had a grant to get these three machines and so it was trying to evaluate if those OCT machines were as effective as other diagnostic tools and we did a review before this pilot was implemented. We ran a review this was before my time at the school and we ran a study to see if those OCT machines were as effective in diagnosis and we found that OCT imaging was and therefore we went forward with the OCT line. We had a Eminem very recently on a very acute CRAO where the patient got TPA and had a tremendous recovery of his vision. So we've also had an opportunity to review the literature recently and we've long had a protocol but it has the same issues that you described. Fortunately for us we're mainly dealing with one emergency room but what that means is that all the other emergency rooms are not. Right, and to that point we're excited about this remote ability because CRAOs aren't that common and when you go to rural community clinics I don't see it very often and they have to travel multiple hours patients have to travel multiple hours to cities to get treatments. This is a way where you could in the future see a remote diagnostic capability where all you need is a machine you don't necessarily need on-call ophthalmologists to make that call. So we are excited about the potential for rural support here. I would just make one other comment which is that that's a lot of CRAOs in two years. We, I don't know our number we probably average three or four a year at the most. You think so? Or that actually would come in within the window. So meet the protocol. Yeah, it's pretty rare. Yeah, and so this intervention only helps from presentation to treatment and that's a big limitation because the treatment eligibility has last known well to presentation. So we think pairing this with the public health education campaign to have patients understand what symptoms to look out for to present earlier that would help us really dramatically improve eligibility for patients. And there was just a question on the chat if fundus photography would work as well. Yeah, so we would like to incorporate that actually at Arvo. I was with my mentor Dr. Lima and we went around testing out all the new technologies for fundus photos. That's where we wanna take this. We all know that new fundus photo technology is rather expensive but that's absolutely the future. We wanna use, we wanna get as much data as possible within the emergency department. So short answer is yes. Thank you.