 All righty, good morning everyone. Welcome to this morning's Grand Rounds. I'm delighted to introduce to you one of our outstanding fourth year residents here, Lydia Sauer. She, apart from her remarkable dedication to ophthalmology, Lydia has a fascinating hobby that's capturing the beauty of the Milky Way while flying high in the skies. Her passion for both the celestial wonders and the intricacies of ophthalmology truly embies the spirit of her curiosity and exploration. Please join me in giving her a warm welcome as she presents today on her presentation titled Extending Peripheral Retinal Vascularization in Retinopathy of Prematurity, the Regulation of BEDGF Signaling. Lydia Sauer. Thank you, Nana, for that introduction. Yeah, so this data that I'm presenting today, it's the finalized data on our study on extending the vascularization LOP with anti-vegf signaling and we currently have this study as a manuscript submitted to HIO. So why am I starting with a picture of a pomegranate? Because at week 21, your baby is the size of a pomegranate and the youngest born survivor was born at 21 weeks of gestation and was a survivor. And it's just incredible that this is possible to have a baby as big as a pomegranate survive and turn into a full-born human. So premature birth occurs in 11 to 13 percent of pregnancies in the US and it's considered preterm when a child is born before 37 weeks and the survival rates of those very young premature infants is increasing. And so is the retinopathy of prematurity, which is the major cause of preventable vision loss in premature children. It occurs primarily in children born at 30 weeks or less and with a birth rate of 500 gram or less. And the incidence in the United States of premature infants has doubled from 4.1 percent in 2003 to 8.1 percent in 2019. So this is a topic that's very important to address. The treatment of RLP at the moment includes laser ablation of the erascaluretina as well as intravitual injections of anti-vegf agents specifically of vivicism up. Intervitual anti-vegf was found to be beneficial in the randomized control B2OP study trial that was published in 2011, but it is still largely unknown how VGF alters the development of retinobusculature. And there's very little data on the very early prematurely born infants because they are in the ICU and it's very difficult to obtain data in these children. So our research question for this study is how is retinobuscularization affected by anti-vegf injections? And the hypothesis that we started off with is that the vascularization of peripheral retina difference in infants who have received an anti-vegf injection compared to those who were observed and did not receive an injection. And kind of going back to the motivation, we have that increasing incidence of RLP that stems from an increased of survival of prematurely born infants. And it is really poorly understood how an intervitual anti-vegf affects these premature infants and there's no quantitative data available to compare how the vascularization differs between treated and observed patients in this patient population that is in the ICU. And the goal is to quantitatively investigate how the retinal vascularization progresses after one single injection of anti-vegf compared to a control group that was observed. So this is a retrospective analysis of patients treated at Moran from 2019 to 2022. All patients were examined and treated by one retinal specialist. We had RLP requiring treatment for type one that was treated with a single low-dose injection of 0.25 milligram by the SISMA compared to RLP that was closely observed. And patients obtained photographs before and after treatment and those were selected. And the identified photographs were investigated by myself as a blinded reader together with age matched and birth rate matched controls. And I was unaware who was a patient who was treated and who was observed. So we looked at in total 382 patients that were screened for RLP. Of those 34 patients had type one RLP that required treatment. 210 patients had type two RLP or less and 138 patients had no RLP. And of those 34 patients that had treatment requiring RLP, 13 patients received lasers so those were excluded. And of the 21 patients that were treated with bevacism up, 11 were included in the study. One patient had their support withdrawn the same day as the baseline exam. Three patients were treated outside of the facility prior to their screening in Utah and six patients had incomplete records of poor image quality. And I'll talk about the image quality in just a minute. So the analysis that we came up with, we wanted to find a way to reproducibly measure the vascular extent in one area at baseline and follow up. So we decided to come up with a marking line that is kind of a reference line for us. It is set based on vascular bifurcations. And we wanted to see those vascular bifurcations at baseline, at the posterior pole and the periphery, as well as at baseline and follow up. And that was the inclusion criteria for those photographs that were able to be measured. The reason to do that and not to do any overlays in a single picture is that any overlay that we tried to do was obscuring the measurements. And we wanted to be as accurate as possible and as reproducible as possible. And we took a line from the optic nerve to the marking line and measured the angles and extended that same line to the periphery and did the same thing at baseline and follow up. So we have the posterior line from the optic nerve to the marking line that we measured and then from the marking line to the peripheral extent of the vasculature. And we looked at the complete line as well as at both lines individually. Poor image quality that was excluded were pictures like this where it was impossible to find a marking line or reliably see the peripheral vascular extent or images where there was no optic nerve in the picture so we could not obtain those measurements. For our patients, we included, as I mentioned, 11 patients and 11 age and birth rate rate matched controls. And there was really no significant difference in any of the baseline characteristics in these patients, including the week that they were born, the days between visits and the optic disc size, which was something that we measured independently as a separate comparison method. And the baseline zones of our P differed a little bit because the treatment group was obviously a little bit more affected. So we had one patient in the treatment group that was in zone one, eight patients that were in zone two compared to two controls and then the mid to end here zone two included nine controls and two treatment patients. And this table is a little confusing, but this is our first analysis and I want to walk you through this. So let's focus first on how changes happened within each group. So both the patients that were observed as well as the patients that were treated increased in vascular extension from the baseline visit to the second visit. And this was highly significant in both of the groups. When we are comparing observation to treatment, there was a non-significant difference in the vascular extension at baseline, but that completely disappeared at follow up. And when we looked at the difference in vascular extent between visits, there was a highly significant difference in vascular extension. So in the difference, how far the vasculature extended from baseline to follow up between those two groups. Also when we looked at that divided by the days in between visits. So what does this tell us? It tells us that the vascular extension increases both with observation and with treatment, but that there's a significant increased vascular extension with anti-VGF injections compared to observation. So what we can see here is that both in the observation group as well as in the treatment group, the vascularization extended. But it was really when we look at the difference, we see a very big difference that the treatment group extended a lot more compared to the observation group. And this is the second part of the analysis where we looked at the different areas of the retina to really figure out where does this vascular extension happen. So looking at the posterior area versus the peripheral area. And going through this slide a little bit more, the first thing that we're doing again is looking at the first thing is looking within the groups. So the observed patients and the treatment patients, there was no significant difference in these groups in the peripheral area. So this area that's marked as B here stayed pretty much the same in the patients and controls from baseline to follow-up. Whereas the marking line to the peripheral area, that's where the vascular growth happened in both of these groups with high significance. Secondly, we looked at the comparison between observed patients and treatment patients. So we see that from the marking line, from the optic nerve to the marking line, so this area did not have any significant differences between the observed and treated patients. But the peripheral line did have a non-significant trend at the first visit and then not at the second visit. And again looking at the differences, we see that there is no significant difference in the vascular extension from the optic nerve, from the area B, so the posterior area. But there was a significant difference in vascular extension in the peripheral area. So to conclude this, the vascular extension is greater in the periphery. And if we look at this graph here, so this represents the optic nerve to the marking line, so the growth in that area, and then the marking line to the periphery. And we see that there's a much greater vascular extension in treated patients. And this just kind of highlights the same findings, how the treatment and the control groups increased from baseline here depicted in blue to follow up depicted in red. And here we also see some in all of our individual patients. And we see that the treatment group depicted in black here had much greater vascular extension from baseline to follow up compared to the treatment group, to the observation group, which also increased, but just not as much. So to discuss these findings, in laboratory studies, ENTIV-JF has favorable effects on vessel elongation. And because it causes a favorable orientation of endothelial mitosis cleavage planes. In clinical studies, it was found that the temporal vascular, retinal vascularization after bivisism up is greatest at short term compared to long term. That was the only clinical study that was done looking at vascular extension. And in long term follow up, we know now that there are no long term side effects, both medical and neurodevelopmentally in patients who received ENTIV-JF. The peripheral vascular retina is frequently found both in patients, but the patients and patients often require additional treatment, but we simply don't know if this is also found in observed individuals. And 91% of patients screened for ROP that did not receive treatment also showed this peripheral vascular retina. So overall further studies are needed to investigate the long term effects of ENTIV-JF. But we know that the vascular length increases with ENTIV-JF injections, and that there's an increase in healthy retinal vascular that is accelerated with interritorial 0.25 milligram bivisism up. And it seems like patients catch up with the controls with one single ENTIV-JF injection. It seems that there's a regulation of abnormally increased VGF signaling that may promote the physiologic vascular development and further prospective studies are needed to quantify this effect on longer follow up intervals. And I want to conclude with this sentence, which was the conclusion of our paper, that this study provides a quantification of clinically measured fundus images in support of experimental proof of concept that the regulation of VGF receptor pathway in endothelial cells not only inhibits pathologic angiogenesis, but also extends the peripheral retinal vascularization in treated type one ROP patients compared to a natural history of a suitable comparison control group. These are my references. And with that, I would like to thank especially Amy Hartnett and Melissa Chandler, who both have been very helpful with the study, also Maria Margarita Parra and Rachel Jacobi. And with that, I'm going to conclude with a picture that I took out of an airplane from the Milky Way. So yeah, thank you very much. And I'm happy to take questions. So when you I know this is submitted now, I think your conclusion is going to run into problems when you say it's a suitable control, when you have when your controls are type one versus type two, when it's type two controls versus type one, which they're just going to hit on that. So I think going forward, you have to think about how you can get get past that without doing a randomized prospective trial, you know, that's going to be that's millions of dollars and takes forever. Are there any data sets that you can go back to from the trials where you can at least have where there was randomization somewhere to get data? The issue is that there's very little data on those extremely premature infants because most studies are done, or most studies where patient where groups looked at any of this were done in patients that received fluorescent angiography. And that is much later in the course. And I think that at least from the patients that we had here, patients who had more zone one, our zone one, our P were more likely to receive anti VGF injections. And that's just the way that they are. But type one and type two are different diseases. So that's that's by definition. So I think you may run into some. No, it was all type one, but it was different zones. So zone one and zone two for this study. Yeah. Yeah. So all this type one, our P, but some it's the different zones that I thought you said differently. Okay. All right. Thanks again, Lydia. It's with great pleasure that I get to introduce to you another talented chief resident. We have Tony Mai. In addition to his dedication to the field of ophthalmology or learning it, he's truly an adventure at heart. True dare devil. He's not only running with the bulls once, but twice at the exhilarating festival, San Thurman. Tony's fearlessness and spirit of adventure makes him a unique and inspiring member of our team. Please join me in giving him a warm round of applause as he presents on a presentation titled re-envisioning the Moran surgical curriculum. Tony Mai. All right. Good morning, everyone. What I'm presenting today will be nearly as exciting, but not as risky as running with the bulls. So what I'm excited to tell everyone about is just our Moran surgical curriculum, what we've been doing about it and what we're envisioning for the future. So first off, I have no financial disclosures. And then we are going to jump into just a brief history of surgical training in general and how that is, how ophthalmology has fit into that. And so in the past, there's something that's been labeled as the discovery method. And this is the traditional apprenticeship model that's been done in medicine for hundreds of years, where you have a preceptor, you see what they do, you try to replicate yourself, and then you're able to teach it yourself in the future. So basically trainees observe the procedures. And in the past, they would then mostly perform these procedures a lot of times individually by themselves without a lot of oversight. And they would learn the repetition and then eventually achieve proficiency. Nowadays, this has become a little bit more of an issue. And this is because there's lower tolerance for medical error. And that is really related to the increased litiginous nature of medicine. It's a lot harder to say, we're just going to do trial and error on a bunch of patients through surgeries, and hopefully over time you learn. We still do that, but nowadays we have a different model for helping speed up that learning curve. And then lastly, especially in ophthalmology, patients nowadays also expect, especially for cataract surgery, that there is some visual improvement, perhaps more so than in the past, there's just more of an ask nowadays for a better result. And so now comes in a new method over the past couple of decades. And this is what we call the guided discovery method. And so like we've touched on in the past, the pure discovery is no longer as acceptable anymore. And so now there's a shift to this guided discovery method where the mentor supervises the learning. And this allows the trainee to go through stepwise learning and have graded autonomy while under this preceptor. And so the pure discovery is in the past, we've arrived at guided discovery. And now we're moving past that and do something that perhaps will be better as I'm showing you the next couple of slides. And so the question is where do we go from here, especially for ophthalmology? And so we're going to look at three examples first. The first one I'm taking from the University of Iowa, and this is where I went to medical school. The next one from Massachusetts Eye and Ear, and then the last one from Penn State. So first looking at the University of Iowa, when I was there, I was made known to the ophthalmology wet lab curriculum. And this was actually published a long time ago, I believe around 2009. And there's a lot of people here that you might recognize from Keith Carter, Dr. Olson, Dr. Lee, and Tom Odding. And here, their wet lab curriculum, in short, has a predefined curriculum. There's tests both pre and post after they're doing this curriculum. There's mandatory pre-work material, but then they really come in and work in the wet lab. And this is mandatory required. And there is someone supervising them the whole time, giving them feedback, especially through a form, and they are graded on this. And there are mechanisms for them to track their progress through this wet lab. This is just a snippet of what this looks like online. This is actually on the Iowa website, on their irons. And then this is public for everyone to see. So everyone can go on here, take a look at what these residents are doing, and even model their own learning off of this. So they did a study and they looked at the residence complication rates before the curriculum was implemented, as well as after the curriculum was implemented. And they saw that there was a pretty significant decrease in what they called sentinel events. So these sentinel events, they termed as posterior capsular tears and or vitreous loss. And before, they were about 7.17% within one year for the sentinel events. And that dropped down to 3.77%. Yeah. And then I'll show you the next study from Master's Dioneer. They also had around 7.7%, 7% before too. And so now we're going to move on to Master's Dioneer and they also did a study where they implemented a cataract curriculum and tried to see how that affected their residence complication rate. So for theirs, they looked at doing interventions in the pre-op period, in the intra-op, as well as in the post-op period. In the pre-op period, we're not going to really get into the details as much, but they really worked on getting a full wet lab curriculum up for the residence so they could be practicing these skills before they ever entered the eye. During intra-op, there was stepwise learning, very similar to what we are doing right now to with a very immediate feedback. And then in the post-op period, there was review of the residence of videos and then as well as giving feedback based on a particular form. And then this would be documented and tracked over time. So just some highlights from their curriculum here. Out of the many other details is that they had four one and a half hour sessions with faculty in the wet lab and this was required. Every resident got this and this was even before they started doing intraoperative surgery or intraocular surgery. And several clinical rotations would have blocked out time for the residents to be in the wet lab so that they did not have to try to schedule time by themselves or go after clinic. There was protected time for this learning. The form that I had alluded to, the Grace's form, this is a form used by many institutions to just grade how surgeons, ophthalmology residents are doing on their surgery. And so it's a pretty standardized and validated form. And then lastly, these residents were given their complication rates bi-annually so they can see how they were doing. And so their study showed that there also, again, was a huge drop in their complication rate, which they define as posterior capsular tear, vitreous loss, or having to use anterior retractomy, again from about 7.7% all the way down to 1.4%. And this was statistically significant. Now, last one, we're going to look at Penn State, and this one I'm a little excited about. So this program had a really cool way of approaching the curriculum in that they tied it to their didactics. So they made a curriculum where they would have the residents do some didactics, traditional learning, but then they would all then move into the wet lab immediately after that learning session, and then have a two-hour block with the faculty. And then after they do that, there was a homework assignment to send a video to the faculty by the end of the week with their perfected skill that they were learning that week, say capsule erexus or to Biden conquer. And then that would be later reviewed. During that week, the chief resident or the senior resident there would be helping the junior resident work on those skills, get feedback informally. And then by the end of the week, they would send the videos off, then that would be graded and discussed. And so they also looked at their complication rates before and after before 3% going down to about 1.13%. And so overall, the common theme out of all of these is that they seem to have this curriculum for residents to learn cataract. And they were all able to show that there was a significant decrease in their complication rates after they implemented the curriculum. And so now we move into our modern what is modern teaching for ophthalmology is that typically we'll have a standardized curriculum and that there is not just learning in the OR with patients with your preceptor, but there's also learning in didactics, the wet lab and using simulators too. And I'm not going to go to some of these other studies, but they have shown that this shortens learning curve for residents, it decreases their operation time and overall decreases their complication rate. And if you feel like this person looks familiar, this is our old Dr. Murray here working on the help me see simulator, which we used to have here at the Moran. So now we're going to go to the Moran searchable curriculum. What do we have right now? What's working? What's not working? And what we're going to do moving forward. And so we have proctored or planned proctored sessions for the residents to be in the wet lab learning certain skills. There's a lot of self directed learning to that we have planned for them. And there are also industry sessions where reps will come by show us devices and help us learn some new techniques. We also have these just in time lectures done at the end of the year to help the residents gear up for the upcoming year in terms of like what they'll be doing for surgery. So the first three here have been consolidated into pretty much a checklist. And this is our surgical curriculum checklist where there are certain items that the residents will have to complete by the end of the year. And this is pretty much done on our own learning. So they cover a wide variety of skills, especially for cataract. We also have some in there for plastics, pediatrics, retina, cornea. So pretty comprehensive. And then just looking at what the checklist, the format it is, the resident is really responsible for the self directed learning. They have to schedule these one on one sessions with the faculty, another chief resident, or the fellow. So it's really incumbent on the resident to do that. And then they have to keep track of this log. And then this log is supposed to be reviewed by the CCC committee by annually. So I'm going to go over just some quick examples of what this log looks like currently. This is what the PGY one log looks like. You can see there's proctor sessions on the top. These are the items they have to do. There's a place for the faculty to sign off and then put the date that's completed. And at the bottom, this is self directed learning for the resident. I'm just going to look at some interesting skills that we're supposed to be learning there. So suturing for the PGY one, then for the PGY two, we add on things like working on model eyes and pig eyes. And then for the PGY three, we're adding on things like pediatrics and retina skills. And then for the PGY four, we're moving on to more complex techniques like anti-retractomy using capsular support devices, suturing, iris, yamanis, and then perhaps even doing M6. So looking at the pros and cons of what we currently have, the strengths is that our curriculum really covers a wide variety. There's a lot of subspecialties that's represented here. And there is this greater difficulty as they go along this curriculum. And now this is what I found to be more expanded than the other curriculums that were discussed before. So not just cataract, but we also involve other specialties too. The weaknesses currently is that's a very self driven curriculum. It's not really integrated into our didactics. And there's variable learning because the residents have to be reaching out themselves to faculty, fellow. And so there's not one person teaching, but they could be getting multiple residents to be giving sources from multiple people. And lastly, I feel that like the scheduling and comment on the resin can be a little difficult for them to try to find time with faculty, with fellows, and then with their own busy schedule too. So currently, the reality is that this checklist is not really being used as much as we had hoped, as well as the wet lab is not being used that much too. And so kind of going classic QI style, looking at a fishbone diagram, looking at the root cause analysis, why is this happening? Our intent and goal is to have the residents go through this curriculum, which is very comprehensive actually in what they're supposed to be doing. But why are we not reaching that? And so looking at some of the causes, two things I came up with talking to some of the residents talking to other people is that there's just a lot of difficulty scheduling with their own busy schedules and trying to reach out to faculty, fellows, and finding a time that works. That's just really hard to do on the resident side, as well as it's there. A lot of times are unfamiliar with the wet lab. It's hard to walk to the wet lab. And if it's messy, you don't know where the supplies are, you don't know how to work the materials. It's very hard to try to start doing things yourself and complete some of those assignments that you have. I remember myself being a PGY to walking in, not knowing where the model eyes were, or even when I found them, finding out that there were missing pieces, the instruments weren't there that I needed to use, and so there's just a very high barrier of entry. So for the current workload we're talking about for the Moran residents, there's a lot on our plate in general. This is just some of the things I'm bringing up here. And this is a beautiful picture of our resident. I'm actually very happy here that he wasn't on call as he has thought, but this is just a perfect picture. And so there's just a lot of items for us to be thinking about completing, doing over the course of the year, and trying to schedule these sessions with faculty, with fellows can be just another added factor of this complex net of things that we have to be doing. So it can be very difficult. As well as these barest wet lab, like where are the instruments? How do I even set up the machine? How do I fold a lens if I want to be doing cataract surgery myself? What if we don't have enough sutures? How do I get more? How do I even use the model eyes? So these were questions that I myself had over the past couple years that I have found difficult answers to get, and that had prevented me and some other people from really utilizing the wet lab to our capacity. And so I really like this quote that I found in just some of my studies. Every system is perfectly designed to produce the result it is producing. And so we're looking at our result right now. And that is that we're not really using using the wet lab. Our curriculum is not really being utilized as much as it should. And so we need to be looking at the system itself to see what we can do better and changing the system so that we can get that result that we want. And so the question really is here is, let's focus on instead of the resident responsibility of pushing them harder of trying to make them do all these other things. How do we change a system to actually get this learning in place? And so this is just a picture of flattening the curve. But I wanted to show that these are the barriers here in red. And classically, our instinct is that if there's a barrier, we should push harder to go over it to achieve our result. But we've been shown through business strategy and, you know, other studies that it is a lot better and a lot more efficient to just lower the barriers so you can get to the same result with the same energy that you had before. And it's a lot more efficient to do it this way. And instead of like I was saying earlier of trying to punish the residents or trying to be on top of them more for completing these tasks, perhaps we can perhaps we can change the system so that we can get all this learning done without more stress. So my thought is what if we shifted this responsibility from here to here, our academic curriculum and make it an integrated structure where we can have this learning be more autonomous. So for the academic curriculum, our current schedule is that we have a lot of learning directed towards OCAPs. And then once that is done, we have these just in time lectures at the end of our academic year that are focused more on surgery. So what if we change those and then made a didactic plus wet lab structure similar to what Penn State was doing. And so our vision for this right now is that perhaps we can do a flipped classroom style, where there is some learning to do pre work beforehand, but then the residents would all come into the wet lab and have proctored sessions by the faculty in there. And we actually have enough room in there for an entire class all at once so that they can learn particular skills. And these sessions will be led by faculty or fellows. And it might add to these sessions that we had before even replace the just in time lectures, we'll see how that goes. And then we'll really use our current checklist, which is a great foundation already to use content creation for the future. So just the vision for what we have coming forward for the PGY to as they're starting, we'd really like to get them into suturing so that they can get prepared call and plastic surgery. And then after OCAPs is where we're really going to ramp up and start our crash course for cataract surgery. And hopefully by the end of PGY to your coming into PGY three, they will have done pretty much a full case by themselves in the wet lab on a model eye. And they'll be familiar with how to set up the microscope, use instruments, set up the centurion machine folder lens, all these basic skills. And then through PGY three and four, we're continuing them doing more advanced techniques as they go on throughout the year. So the next steps right now, we're going to be discussing the curriculum with the mole committee, see what's viable, what's not, what can we change? What are some of the other barriers that we have? And then outside of the curriculum side, increasing the wet lab's capacity itself to do these training sessions. And so that's kind of what I've been doing. And I've been excited to show you guys what's been going on here. And so some of these questions, where do we find things, how to use things, how to replace things? These are all items that need to be addressed to lower the barrier to use. And so the first step is to actually just clean up the wet lab. And the wet lab before had been a pretty unorganized place, because there wasn't really one person that was in charge. It was just like a common area where everyone went, came in and use things. And so on my elective time, I came by and with help with some other people, we really cleaned up the wet lab and reorganized everything. So we know where things were. And so right here in the middle that you can see that there's a central teaching station. It's hooked up to the TV right behind it. And then on the right and the left, there are microscope stations. So there are four of them on either they're two on either side. So four total, which fit a single class. And then that one teaching station in the middle for faculty. Here are some of the cabinets that we have on the right. We have sutures, blades, gloves, aprons on the left. It's our full cataract cabinet where we have like the packs for the centurion system, as well as other tools that you would need. And here is our IC that's in the room right next door. So the wet lab right now we have six stations. There is a central teaching scope connected to the TV. We have one fake over machine. We have a bunch of things from cataract surgery supplies, Iowa lenses, model eyes, instruments, sutures, as well as the IC. So we have a lot of materials. It's just not currently being used to the capacity that we would like it to be. So looking at the instruments, we were partnering with the Corsa, which is a device or a instrument company. And the kind of the reps came by cataloged all of our current instruments found the ones that were broken. And then we are working with them to replace those and get new ones for our residents to use. We have also been working with certain eye model companies, one of the ones more recently is the Bionico ones where they have a great line of products that you could do cataract surgeries, strabismus surgeries, retina surgeries, even some glaucoma surgeries too. And then these right now we're talking with the reps to see what is something that we can use in the future. And then if this works out, perhaps we can have these model eyes integrated into our curriculum. So things that I'm looking for more into the future too to see how we can lower this barrier of entry is also having a map of supply so people know where to find stuff, keeping things organized. And then another idea I had is using QR codes with links to videos that we can have piece it up in the wet lab area so that when residents come in, they can just take a picture of that on their phone, find instructions on videos and how to set up the Faco machine. What do I do for this technique? How do I position myself so that there can really be learning right there instead of them coming in not knowing what to do. And then that being a barrier of entry. And so really I'm trying to find ways to make it as easy as possible for someone coming in without knowing how to do anything and just getting started right there from the ground. So if anyone else has any ideas, please let me know. We're all just in the brainstorming stage right now. So this is something that we're very excited to get rolling in the next year or two. And any feedback is welcome. So acknowledgments here for Dr. Simpson and Dr. Petty, as well as Dr. Hu, who's heading our surgical curriculum right now. And people from outreach, including Lori and Abby. There are my citations and welcome to take any questions. Great job, Tony. So I know that AUPO and Jeff pees around with no more about this as well has that score curriculum. They have a big wet lab at AO and otherwise and they've got the an online kind of set of videos that I guess all residents could have access to. So I don't know if we have a way of getting that access to all residents, but it has like I know Jeff made videos on how to set up like each of the fake machines. So knowing how to set up a centurion and they've got videos on how to set up those bionic eyes and I think maybe one other model. So maybe having access to that for all the residents would be really helpful. Great lead in because I just went through the whole score curriculum curriculum myself right now, just the past month. And we did talk about this. We are planning to include the score curriculum into the PGY 3 to PGY 4 section of this curriculum. And they do give access to all the residents. It has to be renewed every year though. And so that will be Dr. Simpson who will be giving access to say that PGY in coming in coming to PGY 4. They'll have the access. They will be reviewing that and they will be going through the modules before they get to the PGY 4 year and they'll be practicing some of those things they learned in those modules in the wet lab too. So that will definitely be integrated. That's one of our core things. I think you probably already know this, but since Catherine's on the committee, I know she knows this, but Catherine did a really great QI project video on all of the surgical instruments and what they're called and how they're laid out in trays. So obviously you want to keep that. That will actually be displayed in the wet lab too, and we are using that as our starting point for getting the instruments from Corsa. So we are heavily using that right now. So this could be a question as much for Judith, it's for you. What is our average vitreous loss slash caps or breakage rate now for the residents? Do you know what our numbers are? I know overall for faculty it's been like three tenths of a percent, but until now, but hopefully changing going forward with the electronic yellow sheet, the reporting on in quotes who did the complication rather than just who was in the room has not been available. So a resident who wanted to go through all of the surgical logs for all the residents and look at their complications could track that back, numerically speaking, but we don't have that information as part of just the general QI information. So what we've got is everybody who's operated Moran for the complication, as I remember that's about three per thousand as we're running right now, but that would include residents we haven't so we do need to be able to break that out. We also unfortunately don't have a great way of tracking it at the VA. So if you really want to look at resident publication rate, you have to include the VA and we just don't have a really robust way of tracking complication. There's nothing like a number, you know, to help people and see how we're following and moving forward. So I highly recommend we work hard on getting those specific numbers in place. I have a feeling and I remember we did one study it's been a few years ago where we did track it down and look at it and the resident caps or breakage rate was running right around one percent or a little bit less on average, but we should have that updated and that was literally having to go through charts back in those days. And I think unfortunately that still is the case. There's no easy system. And so yes, someone can do like a big push and then get all the numbers crunch it, but then we'll have it for like just that time. If we ever wanted to get it again, it'll have to be that huge effort once again. So I think that's kind of the rate limiting step there. So Tony, it's great presentation. One thing that may help in addition to your wonderful organizational efforts is to also make the faculty's availability known to the residents as far as I would imagine there are faculty that aren't actively involved now that would love to be and maybe a list with what they're comfortable teaching and if they have general time that they're usually available for somebody to contact them and set something up, you know, create a list, you know, for that to take advantage of those opportunities. That's a great idea. Thank you. Tony, who's currently in charge of keeping the wet lab clean? That's a great question. And the answer is no one. So while now I'm now me. So traditionally it is in the outreach space. So it does kind of fall under their purview, but it is really what they say in no man's land. There's no one really in charge of like keeping track of supplies, restocking, replenishing, cleaning. And so that is one of the things that we will also be working on to find how do we keep this place organized, replenished and stocked because right now there's not really one person oversight. So in discussion. Yeah, are you volunteering? Well, I think to start with, that's at a baseline. I mean, it's assigned someone a PGY2, PUI1. That's what I did at my residency. And it's really good learning because you start to learn the instruments and where all of the equipment's supposed to be, how the foot pedals are set up, all of those kinds of things. It's true. It's true by all kinds of people including industry and even research. But I think you can assign someone and it does not be one person the whole year. You can rotate it every three months or whatever it used to. As long as it's under sort of someone's responsibility that someone can take ownership. Also really good idea too, on the ceiling. I know there are some in the, there's some in the chat here also. I'm just going to say while you're pulling up the chat, this is a very similar presentation in field to the one that Swab gave us back in 2019 when she initially talked to us about flip classroom and what that looks like. And of course from that came the whole more curriculum. So hopefully we can follow up this presentation with the same inertia that followed that presentation and take what we've done with our didactics and apply it to our surgical curriculum. Was there anything else in the chat, Megan? No. Okay. All right. Thanks, everyone. Have an early day off.