 Good morning. We're going to go ahead and get this show on the road. Dr. Fleckenstein, I want to welcome you here. We're your moderators for today. You're sort of stuck with us. We're going to do the best we can to get everybody through this in one piece and on time. We want to start by having our chairman, Dr. Olson, come up and see a few words. Dr. Olson. I'm not sure if that is plausible for me or for the fact that you get Dr. Fleckenstein and Dr. Hoffman to run the meeting today. So the residents are all spiffed up, ready to stretch their stuff. We're already excited to hear what they have to present on this day. It's interesting. It's kind of part of the ritual of the residency that people have to go through. And for the seniors, this is the last time they have to do this particular event as they get ready to fly off into different areas. And so it's a lot of fun to have you all here. So appreciate your attendance. And we're looking forward to an excellent day. And with that, I'll, without further ado, turn it over to Bob, Dr. Hoffman, have at it. Thanks, Dr. Olson. We're going to start with one of our departing senior residents, Sean Collin. Now, Sean, very fitting with his talk about assessing a combined live and cloud based tele-ophthalmology system for rural Nepal is in Nepal. So we are hearing his talk recorded. And, you know, one of the things that Dr. Fleckenstein came up with last year, we, you know, wanted to know about things that we knew about the residents that, or that they knew that people wouldn't know about them that were exciting. That was good. And this year she put another twist in it. We wanted to know what the residents wanted to do when they were very small, when they grew up. And asked them that. And we've got responses from just about everybody and those that didn't respond will make something up. Sean basically wanted to either be a professional hockey player or a dinosaur. Both very similar occupations. Anyway, Ethan, are you ready to roll with that talk? We'll hear from, from Dr. Collin. Good morning, everyone. My name is Sean Collin. I'm a PGY 4 resident here at the Moran and I'm going to be talking today about my project to assess a standardized tele-ophthalmology system for rural Nepal. The faculty mentor for this project is Dr. Hansen and the principal investigator is Dr. Rabatapa of Tilganga Institute of Ophthalmology. This project is just beginning. The IRB is being reviewed by the Nepal Health Research Committee and we're in the process of purchasing the necessary tools for the study. Consequently, this presentation will cover quite a bit of background information as we have no data yet to report. I'm currently in Nepal, in fact, in large part to work on this project and I regret that I'm not able to be present in person with you all today. I want to start by acknowledging and thinking the ARCS Foundation, whose funding is making this project possible. Aside from this, I have no financial disclosures. Most people here are familiar with Tilganga Institute of Ophthalmology. It's a tertiary eye hospital in Kathmandu with a greater network that includes a community eye hospital in Hatta, a bit to the south, and several community eye centers staffed by ophthalmic technician throughout the rest of the country, creating a kind of hub and spoke model. In this model, the majority of patients outside of Kathmandu receive their care from these technicians and receive some surgeries, especially cataract, in their hometown by Tilganga surgeons during outreach camps organized by the technicians. It is worth noting that Tilganga is the implementing body of the Nepal Eye Program, which is one of two major entities in Nepal's eye care system. The other is Nepal Netra Jyotsang, which has greater influence in the west and south. The perspectives in this presentation will be admittedly Nepal Eye Program centric only because of this is who I've spent time with and am working with on this project. Nepal is a beautiful country. This is an image of Pokhara, where I spent last weekend, and the photos cannot do it justice. The flip side of this coin, though, is that the reality of moving through the country often looks more like this. Any technology or process that allows patients to receive the most and best care possible close to home is hugely advantageous in a country like Nepal. Further, Nepal has a disproportionately high rate of blindness and a disproportionately low number of ophthalmologists. This is actually an American ophthalmologist, only for reference. In Nepal, the ratio of ophthalmologists to population is 1 to 200,000. For reference, the University of Michigan football stadium holds just over 100,000. That's a lot for those chicken legs to support. And again, any technology or process that can leverage that limited physician power is very advantageous here. When it comes to teleophthalmology, though, Nepal came quite late to the table. The first report of teleophthalmology, if we could call it that, was a joint American Nepali Thai initiative that involved two rural screening camps using a large tabletop fundus camera that required an external portable power source to assess macular degeneration and diabetic retinopathy presence in rural Nepal. In 2012, Dr. Sumantapa published many papers as part of his PhD in the Bhaktipur Glaucoma study, and in 2017, Dr. Rabatapa similarly began publishing papers for his PhD in the Bhaktipur Retina study. These studies really were not examining what we would currently call teleophthalmology, but I include them because they were directed toward a similar goal of expanding knowledge of Nepal's needs beyond the patients coming to Tilganga's main hospital. Between 2014 and 2019, several U.S. institutions partnered with Tilganga on a number of studies that were really aimed at establishing teleophthalmology in Nepal that is assessing the feasibility of systems that might actually be implemented to better serve patients in more remote areas. I was involved in a couple of these studies, and while they all showed promise, none ultimately had any staying power. Finally, in 2019, Tilganga established a dedicated teleophthalmology unit. To some extent, this has had the most staying power of any of the efforts, but in truth, its effectiveness has been significantly limited. So, having been involved in these efforts in the pre-COVID era, in 2022, Dr. Hansen and I began talking with Dr. Rabatapa at Tilganga about how we might continue to be involved in improving teleophthalmology capabilities in Nepal. We visited in September of 2022 and spoke with staff, faculty, and residents at Tilganga and traveled to community eye centers to see the teleophthalmology system in use for ourselves and talk with the technicians. We learned that there's a high degree of variability in resources at community eye centers. Some have real-time conferencing capabilities, some have good fundus cameras, and most have desk drawers full of cameras or phone attachments that were momentarily exciting. Some have incredibly skilled and motivated technicians. Others are run by more novice technicians. They're funded by the Fred Hollows Foundation, the Himalayan Cataract Project, the Lions Club International, and others, and so receive different amounts of funding and are involved in different initiatives. Overall, nobody was pleased with the current system. It cost every person involved, including patients, far too much time. There's effectively no anterior segment imaging capabilities, and the fundus photo capabilities are mostly very poor. Further, nobody seemed very convinced of the program's efficacy. There were anecdotal reports of cases where patients received vision-saving referrals and treatment, but there were more anecdotes of patients who made long and arduous journeys due to an unnecessary referral. Despite all of this across the board, I'll acknowledge the potential value of a system that actually works. Unfortunately, little consensus exists on why all of the prior initiatives have failed. There seems to be relatively limited lines of communication between technicians, physicians, and administrative staff when it comes to this issue. In summary, though several systems have been shown to have the potential to work, it's not clear to what extent they have or do, because there's no real data on patient referrals or outcomes. It's also not clear where exactly the prior initiatives have fallen short in their ability to be sustained over time. Our hypothesis, therefore, is that a protocolized teleophthalmology system utilizing both real-time and cloud-based, that is, stored forward imaging capabilities will improve disease detection, staff and physician satisfaction, and patient referrals compared to the current non-standardized teleophthalmology program in place at Tilganga Institute of Ophthalmology. Given the gaps in our knowledge previously described, our study objectives are to, one, evaluate incidents and types of pathology present in communities, and even more so, to formally assess staff and provider opinions on the teleophthalmology system, and then to assess referral follow-up and outcomes for patients identified as needing a referral. We have two study sites where we'll be implementing this system, DATING and NUACOTE. And of course, physicians at Tilganga will be reviewing photos and participating in real-time consultation in the Tilganga teleophthalmology unit. One thing that's different about this study from prior ones is that it was designed specifically based on input from Tilganga physicians and staff about things that have worked well in the past. The fundist camera pictured here is made in India, easy to use, affordable, and easily serviced in the event of breakage in Nepal. It's being used currently in a couple of community eye centers, and the technicians who have used it reported it working well in that setting. While most previous studies in collaboration with the U.S. have used iOS-based devices, which are used by very few in Nepal, we'll be using Android-based cell phones for real-time anterior segment imaging. These will integrate seamlessly with the pre-existing system that we saw when we visited the community eye centers in September. Finally, while looking for mechanisms to acquire real-time slit lamp imaging, a technician pointed out that he did great success using $10 binocular adapters to attach a cell phone to a slit lamp, which is at least one-twentieth as costly as other alternatives we were considering. Our plan is to collect data from 500 teleophthalmology encounters from these two sites prior to implementation and then 500 encounters post-implementation. We'll use staff and physician surveys about their satisfaction with the system pre- and post-intervention, and we'll do chart reviews for referral follow-ups for all of the encounters, which has made much easier by the fact that in the past several years, Tilganga has integrated its EMR with all of its community eye centers. We have a broad set of inclusion criteria, with an eye toward including as many patients as possible who may have disease that warrants referral or at least remote consultation with a physician. All patients' post-intervention will receive fundus imaging at a minimum with real-time conferencing to be utilized at the technician's discretion. Ultimately though, this is still very early on in the process of developing a functional teleophthalmology model for Tilganga's network. I don't think any of us are under the impression that this protocol will be the magic bullet to solve all of the major problems, but hopefully this can serve as a helpful starting point for ongoing improvement. Perhaps most importantly for Tilganga will be ongoing quality improvement initiatives to improve staff and physician buy-in, without which no program can succeed. Another important factor in the sustainability of this project and others like it is patient buy-in. Will patients see value in this service and be willing to pay for it? If so, will it be enough to recover hardware costs and additional incurred operational costs? And if not, why not? Of course, we hope that any successes realized as a result of this project can be used to lobby for increased support for ongoing investigation into and expansion of teleophthalmology at Tilganga. And lastly, this is definitely a time where there is great enthusiasm in teleophthalmology worldwide. I'm personally involved in our project here in Utah. This project in Nepal, an almost identical program in Ghana, and I've been discussing plans for similar initiatives in Bhutan, Ethiopia, and a number of other places. Each of these places is unique and no one model will fit two places perfectly. But my hope is that projects like this can help create a framework that can be used to help in successfully developing teleophthalmology systems anywhere in the world. These are my references. And that's all. Thank you all for listening. If anyone has any thoughts. Thanks, Dr. Khan. Realize, we don't have him available either in person or on Zoom. I checked he has not joined us to answer questions. Feel free to email Sean or you could get those to Dr. Fleckenstein or myself, and we will get them answered for you. Moving on our next speaker is another of our senior residents. This is Ali Simpson and Ali is actually staying here with us as a cornea fellow and we're thrilled about that. Now when asked about what she was going to do or wanted to do when she was very small, she wanted to be a meteorologist. There's still hope. She's going to talk to us about measuring intraoperative cataract surgery complications. What is lost in the billing data. Thank you. All right, so this is kind of another part of the study if you were here last year that I kind of discussed some yellow sheet data and this is the next part. It's no surprise to anyone that tracking intraoperative complications, particularly yet academic institutions is important. And there are even some institutions where they publish the rate of their complications the Moran being one of them and you can see here I've included mass ironier and also coal I where they show not only the rate of complications and cataracts are drew by how this breaks down. What is difficult about this data is that it's not well discussed in the literature as to how they arrive at these numbers. Of course here at the Moran we rely on physician reporting hopefully if any of you have operated downstairs you recognize these yellow sheets. For those of you who don't know this is the sheet that's filled out at the end of every case for the attending surgeon is supposed to report a complication yes no and then of course that there is a complication right down the nature of that complication. This year we've been really focused on how we can identify intraoperative cataract surgery complications that results in vitreous loss. And you know we all have our yellow sheets and physician reporting here at the Moran, but there's also avenues in the billing and in chart review. For this aspect of our study we decided to focus in on the billing data. And so we collected cataract cases from March of 2014 to February of 2020 to avoid COVID that built for the anterior vitrector pack at the time of cataract surgery so the physical equipment was built that was built for during cataract surgery, and we did not do any combined cases with retina in this case. We also took all positive cataract surgery yellow sheets from the same time period and just to note when I say positive from the rest of this talk. I'm talking about a cataract case in which the yellow sheet reported a posterior capsular tear posterior capsule tear with vitreous loss or drops nucleus. And then I did a chart review of all the opera opera ports of the cases that we found these two ways. So there were 19,258 cataract cases without billing data or yellow sheets during this time and you can quickly see why doing chart review on all of our cases is not feasible. Out of those cases there were 308 that either had a positive yellow sheet or had anterior vitrector billing at the time of surgery. And then I did a chart review of those cases and found that 198 cases had a complication reported in the chart review. When we look at the billing results, there were 279 cases with an anterior retrector build at the time of cataract surgery. Out of those 177 cases confirmed the complication on chart review, which is 63%. Out of the total 198 complications that I found through chart review, the billing identified 86% of these. For some of you, you might be wondering 63%. That seems like there's a lot of anterior retrector is running around that aren't used for posterior capsular tears. And it's true, especially in an academic institution, we use anterior vitrectomy or the anterior retrector for a lot of different reasons. You can see here that the most common time we use it was to create a PI, but also in cases where there was a secondary lens or squirrel fixated, we were using a vitrector. Surprisingly, there was 18 cases where an anterior retrector was billed, but the off report did not describe using an anterior retrector or having a complication. And then there were 10, 10 cases where there was a posterior capsular tear where they did not describe anterior retrectomy in the off note, but there was one billed. So what did the cases missed by billing and the yellow sheets identified 28 cases where there was a complication in the operative report, but no anterior retrector bills. Seven of these cases there was a posterior capsular tear that did not require vitrectomy so that makes sense. But there were 21 cases where there was a posterior capsular tear that described ventrectomy, but there was not one billed. When we move on to how the yellow sheets performed, there were 109 cases with a positive yellow sheet during this time 100% of those cases with a positive yellow sheet describe the complication in the off report. However, what did the yellow sheet miss billing identified 96 cases where there was a complication noted in the off report, but was not reported in the yellow sheet. So out of the 198 total complications identified during that time, there was 102 identified by the yellow sheet, which is 52%. For a lot of you I know you're probably surprised by this data. There are a few reasons for that, I think, but obviously our complication rate is likely higher than what was reported during this time. First thing is that if you are at M&M on Wednesday, Steve reported, you know, the years of our compliance and particularly during 20 from the 2014 to 2020 time. There were a high rates of non compliance, some greater than 10% definitely approaching some to closer to 15% during these time. There's a similar discussion to what we had last year when I presented some yellow sheet data. We always have to ask yourself who is filling this out. It should be the surgeon but is it a nurse who doesn't necessarily know the full aspect of what happened during the case. Are they thinking that it was an uncomplicated case so we really have to kind of ask ourselves how we're doing and who is filling out the sheet. What does the billing data lose? It loses a lot of accuracy. I really only found that I trusted the billing data after I had done a chart review and filtered out all of those cases where the vatrector was used for not anterior vatrectomy during post-ear capsular tear. Non-compliance with yellow sheets causes under-reporting of complication rates, which is not really surprising to anyone. The systems when we use them together were quite accurate, meaning if they both had positive billing and a yellow sheet, the opera port 100% of the time described the complication. However, this was only 81 cases of the 189. And lastly, we have to remind ourselves that this is a very specific subset of complications. So we're really focusing only on cataract surgery and we're focusing on complications of post-ear capsular tear with vitreous loss. We don't report these yellow sheets for retina cases, for pediatric cases. So it's not like this billing opportunity could be widespread throughout the Moran. In conclusion, neither system is perfect, but I don't feel that billing is a good proxy without chart review. And for that reason, physician reporting remains important at the Moran. We are kind of surprised by some of this data. It's good to think about that our reports are only as good as what our physicians are reporting and to really look and make sure that we're being compliant with our yellow sheets. And we're going to continue to look for the standard, as I kind of mentioned before, there's this aspect of chart review. And while looking at every chart seems very difficult, we kind of started laying the groundwork for a keyword or phrase search of operative reports. And you can imagine there actually are some hurdles with that and you have to be very specific. So if you write no post-ear capsular tear in an op report is a different result than if you write post-ear capsular tear. So there will definitely be some challenges with that, but we're hopeful we can catch maybe some more complications. Thank you to Dr. Warner and Dr. Stagg. Of course, the Marshall Henry is a medical student who worked on this and then several of our statisticians and I'm happy to take any questions or comments. So I saw Dr. Warner. It's part of this. So I'd be very curious if we look at the this overall discrepancy between the yellow sheets and the complications over time. The reason I state that is, is that for those who've been around a little longer, there was a very real period when resident reported issues with one faculty member and then things were thoroughly reviewed. And it was quite obvious in that very thorough review of everything that complications were not reported or essentially ever. And that's when, you know, we worked on trying to tighten things up and improve them. So I think it'd be important to see if maybe there's a period when we really did quite poorly. And I think that there were reasons because it was an honor system and sadly this person was not honorable. And then since then, you know, are we doing a lot better. And I think if we, if we could understand that it would help us feel a little better about where we are now, because there was that transition and Judith any thoughts about that. So I just want to clarify one thing which is the non compliance is the non compliance is not that the yellow sheet is not filled out ever. It's that it isn't filled out immediately. Which of course, if it's not filled out immediately right in the OR when some, you know, when the case happens then you might lose some accuracy and you're reporting but the yellow sheets, such as they are all sort of cracked back and they chase the surgeon down, and they turn up on their desk and they eventually have to fill them in and Steve could provide the numbers but we do have a pretty good rate of yellow sheets for all of the cases so you can track the number of cases that occurred and the number of yellow sheets that you have per month or per year. So, although there have been instances like a change of staff etc downstairs where things kind of go oddly awry for a minute or two. The other thing that, you know, we try to do every year and it's very labor intensive obviously as you've discovered is review all of the times that a protractor is pulled, and then read the opera port and see if it was a complicated cataract versus a complication of a simple cataract. And Jeff and I were just discussing that I mean there are some cases where you can guess that things are not going to be a simple case and you can identify those not only by the entering diagnosis but the exiting diagnosis and reading the opera port. And that sometimes it's hard to tell whether this was some very loose zonules that became revealed during the course of the surgery, or if the zonules were ripped during the course, I don't know the right words for it. The data is very large, there are so many cases as you as you as you remarked, and if we could do really good real language searching, as you say, no vitreous loss versus vitreous loss, you still have to go back and look at it. But I think that, you know, as, as I say, this is a really good start. And I think it is a really interesting way of looking at the data and trying to improve the process of improvement. Allie and team congratulations I'm really, really interested in this and that was excellent. Publications are actually really interesting when you start to think about them and how they're defined, you know, for instance, most commonly, you know, common complication according to I wiki is PCO after cataract surgery. And then you can have a subcontractable hemorrhage after surgery, you can have corneal abrasion, some chemosis, all the way through what is clear posterior capsule tear. And then, if I do cataract surgery after a retina surgery where they've already violated the capsule and it's a complex case as Judith points out and I'm using a tractor and there's a posterior capsule tear I might even do something that really makes the situation worse. And so, again, it's just kind of this interesting kind of, you know, gray and so as far as my question, do you think that there's an issue of surgeons understanding a common definition, and that could be contributing to some of the discrepancy or in your estimate is that a non issue. Oh, and I think that's what Mark, Mark's also saying. In cataract surgery specifically when we're thinking about posterior capsule or tear I assume and I, I suspect that every cataract surgeon knows that this is a complication that should be reported was this kind of a paper that came out last year talking about these gray area complications. And that it is an interesting aspect of how we report. But we are just really just focused on kind of the most basic and probably the most significant or worse complications in cataract surgery. Yeah. Yes. Yeah, I found myself and I didn't discuss it in my chart review, having to read extensively into the opera port, and then going back in the chart and seeing you know, did we know that there was trauma was this a pseudo ex patient. It wasn't as simple and it was definitely more nuanced than I expected it to be, which is why I still have some concerns about using the billing data exclusively going forward because you really have to have someone that has that knowledge base to be able to read these opera ports and glean that information because it can be quite subtle and difficult. Dr. Stagg had a Santa. Yeah, just a quick question so I understood we're just focused on the posterior capsule tears right that was the only complication we were considering. And then I thought it was really interesting you went through. It's awesome you went through all those op notes, and you found that they actually said there was a posterior capsule tear. And part on the op note where you say like complication yes or no. Yeah, had they said yes in that place. It was it was hit or miss actually but then they would below they would describe there were definitely a few I should have kept track where it said no, and then you'd read the body of the report and it would go on to discuss how they use the they needed to track to me. It wasn't a lot but it was definitely. I think templates might explain that. All right now housekeeping item realize there are people on zoom. That's why we're passing the microphone so if you have a comment or a question. You want to use the mic so that they can hear it if you're on zoom you have a question. Use the chat we are monitoring it now moving on. Bob I interrupt for one sec sorry Brian sorry the mic from the back. Brian stag made a perfect comment about templates. Yes. If your template automatically puts in complication no. I think it should be changed. Yeah, so mine has those little three asterisks, so that when I go through it, I have to think about it. Right. And obviously like somebody like Nick Nick here. There is who never uses a template. You're not going to run into those issues but if you have a template you've got to have that asterisk by the complication yes or no it shouldn't be defaulting to yes, or no, obviously default to no but that's how I kind of remember to put something there. Good comment right. Here's an advantage and I feel vindicated dictating all of my own operables. So, Abigail Jabra she is leaving us to join the faculty in Madison, Wisconsin University of Wisconsin, and we're very pleased that she is doing that and she is going to talk to us about the use of color duplex sonography in the evaluation of giant cell arthritis when she was asked what she wanted to do and she grew up. She knew all along she wanted to be a physician. How about that. That's great. Thanks Dr Hoffman. What that doesn't capture is the one brief day where I thought I wanted to be a dolphin trainer but then I remembered. I can't swim number two I'm the daughter of immigrants so that's an option plus ethical concerns which I didn't know at that time. All right, well it's, I'm really excited to talk to you about this project passed on by Dr Mike Burrow to me, and it's been a really great learning experience not only in this field of using ultrasound to diagnose giant cell arthritis, but also how to quality improve within a project that was something that we had to retool a lot during this project. It's called panartritis it is a disease that many of us are familiar with here as segmental and focal panartritis that involves large to medium arteries, preferentially affects the branches of the external carotid, and the temporal artery which is the most effective is a great target for our diagnostic purposes but in our realm of things, it affects the ophthalmic artery as well, and has a large risk of permanent vision loss from an AIO and our current diagnostic model is number one, the clinical suspicion really guides things from the beginning so being able to screen symptomatically, whether a person has transient vision loss episodes, dyplopia, temporal tenderness, the headaches, the jaw claudication, weight loss or the proximal limb weakness and soreness really guides our flag in the first place, along with their age. Typically here we look according to the guidelines is over 50 years but we kind of use a threshold of 65 as a general tool with some exceptions but of course the whole clinical picture comes into play. In addition to that we look for thrombocytosis and screen for inflammatory markers like ESR and CRP to screen these patients as well. Our current gold standard is temporal artery biopsy which has a sensitivity of a large range reported in literature is 39% to 77%, but a bilateral biopsy certainly increases this to 87%. It is however invasive requires a pathology read and it is a segment of the whole artery, so you may miss it if there are, if it's a skip lesion area, if a patient has been on steroids, or the anatomic variability of a patient, you may just miss it in the biopsy which has happened in some cases. So our ultrasound in reported literature thus far it has a sensitivity of 54 to 77%, which is overall quite similar to what's reported in literature for the temporal artery biopsy, but it has been reported as high as 95%. The specificity is listed as 81 to 96%. And just like with the temporal artery biopsy, the bilateral doppler increases the sensitivity quite a bit into the 90% tile. Signs that we look at which I'll show you in the next couple of slides are the halo sign and the compression sign. This paper that I listed here is a great overview for those of you are interested in kind of learning more about where we have come from where we're going in this field of diagnostics. So this here is a halo sign characterized as you can see here on the Doppler, you have the blood flow centrally marked by that red and little bit of blue which shows the velocity of blood flow. But surrounding the lumen which is filled with the blood there, you can see this hypo echogenic region around the artery, which is called the halo sign. What that indicates is a thickening of the blood vessel due to inflammation. The other sign that we can look for here is if you compress the artery with the transducer, you can still see that thickened blood vessel wall, and that in addition to the halo sign will improve the sensitivity and specificity of this diagnostic measure. So pros and cons of this, it is non invasive which is quite nice. It is quick so you don't have to schedule a surgery, you don't have to coordinate all of that, and then send off the pathology, you can have a Doppler ultrasound, and the expert to run this. It is Doppler, the Doppler ultrasound is operator dependent however so that's important to realize not all institutions have who we have the fantastic Dr. Harry. Exactly Dr Wilson said our secret open and I completely agree. So Dr. Harry were very lucky to have him here as he was able to run this project and screen all of these patients. And the last consideration that we need to consider in healthcare as a whole is the cost to not only the patient but also the healthcare system. And so this is much more inexpensive when compared to a biopsy or when looking at other vessel imaging such as a CTA or MRI and Dr. Harry again wrote actually the book on ophthalmology ultrasound so very lucky to have him. So the effects of steroid therapy I think it's important to note that no matter what it does affect either it will affect pathology, and it will affect the ultrasound. As of current data the halo sign can disappear within two to four weeks but can as early as two days so that's important to note. It's about 69% loss of the halo sign at two weeks and 100% scone at four weeks of studies done thus far. So biopsy typically around we think 10 to 14 days. The reliability of it decreases the sensitivity of the biopsy, but it's still able to use around 14 days or so so kind of similar overall in the effect of steroid therapy. So our data so far it like I mentioned earlier it was kind of a challenge of quality improvement because something called the pandemic the COVID-19 pandemic happened in the midst of it. And because of that we had to shut down all quote unquote non intentional non essential diagnostic things. So the project was shut down for that time period. In addition for a while our Doppler ultrasound had to be borrowed from the main hospital and sometimes it'd be shifted off to another city and we didn't have access to it. However, now Dr. Harry has his own Doppler ultrasound that we're able to use so please do send patients our way. We did have 26 qualifying patients. And of those patients who qualify they have to be giant cell arthritis suspect and the plan must be the temple artery biopsy is going to be performed so the two results can be compared of those 26 patients for had positive biopsies. Our data for the Doppler ultrasound had a sensitivity of 75%. I put an asterisk by that because we had those patients where one of them had a false negative on the Doppler ultrasound but she was on steroids beforehand so that's important to know I believe it was for two days. And even that could throw off the data quite a bit so that's important to know. And something that's still evolving in this field is how much does steroid use affect the results of these patients and our specificity was 100% given Dr. Harry that's not surprising. So I'll delve into an interesting case here of a 76 year old male who had kind of all of the symptoms that you asked for every box was checked yet a normal exam normal appearing optic nerves elevated inflammatory markers and was started on prednisone. I think the day of his Doppler and a few days or one day sorry before his biopsy. So here are our patients image and then a negative halo sign. So the color Doppler had that shadow sign or that halo sign where you can see that hypo echogenic region around with lighting up with the blood flow there indicating that thickened artery. And next to it's kind of an example also from our study of where you don't really have that region of hypo echogenic around the artery and these images are from Dr. Harry. So again here's another picture of the same patient compared to that picture that I had before that had a negative halo sign, and you can clearly see that region of hailing around the artery. So the next day this is from the pathology report for the first one, essentially to summarize this it said that there was a few inflammatory cells but really couldn't definitively say that was temporal artery biopsy, based off of the pathology. And because of this he had a repeat biopsy one week later, which was reviewed by Dr. Mamois and his team. And while there were some markers such as a thickened artery with a markedly narrowed lumen, a few inflammatory cell reactions, there was no giant cell reaction. And so again this was a very difficult call when it came to when it came to the pathology in terms of it had to do with there were it was inflammation but of course a lot of different factors went into it. So this was a case where the pathology wasn't necessarily straightforward, although it's still pointed to a temporary biopsy. So it was a good comparison here of where the Doppler ultrasound was very strongly positive. And the pathology was weekly positive, and that kind of helps solidify the diagnosis for this patient who's currently being treated. So here are so a few of the images this is from the first biopsy, and you have some scattered inflammatory cells here. And then the one, the second one shows that markedly narrowed lumen, you have some discontinuous intima, as well as thinned media. And all of that pointed to temporal arthritis, however, it wasn't as strongly positive as the halo sign in the Doppler ultrasound. So some conclusions here is we in our study had similar overall to the bigger picture of published data thus far, it is affected by steroid use so perhaps this modality is best before you even induce that but it is a quick enough and efficient enough that you can do it safely without having to wait for surgery. It is operator dependent. It's fast, low risk and inexpensive. I think this very well could replace temporal artery biopsy in the future but of course we're all appropriately hesitant as this is something relatively new since the early 2000s it's been in use. And until then it can be an excellent screening tool something that I would propose is you do a Doppler in every suspected patient, if it's positive then no need to proceed to biopsy, but if negative you proceed with a biopsy at this point, perhaps someday it could replace a temporal artery biopsy. So future steps we just need more patients. I think that was where a lot of our strength will come from being able to power our data more appropriately to generalize it to patients. Having a streamlined direct recruitment process is something that we've been active in trying to figure out. It's not something that naturally fits into the flow of patients here. And so being able to insert that has been a good challenge for us. And then overall in this area of research continued study to really nail down that sensitivity and specificity, working on the relationship of when this should interplay with a temporal artery biopsy. Optimizing Doppler settings and protocols things are getting more refined but trying to get that standardized is something that will be important. And then something that is very early is using AI deep learning models to detect GCA through these ultrasounds and so that's all very exciting. Thank you for your time versus and thank you for your time. I would like to thank Dr Burrow who was the original investigator. Dr Harry Dr come and our pathology fellows for contributing some images for me. All right, I can't get up. Thank you. Thank you. You know, you and Dr Harry should be complimented because we do a lot of temporary biopsies here as we're a tertiary care referral center and so in a normal setting people say in the laboratory you should have 20 to 30% negative biopsies so that you don't miss anything. And here we are 95% negative, which means literally 19 of every 20 biopsies are negative they probably did not need to be done and so we can get good data from this so that we can eliminate those unnecessary biopsies I think this is a really critical study. My last comment is Dr Harry, you can never retire and as the Eagles said you can check out anytime you'd like but you can never leave. I'll make make comments so thank you Nick for those kind words and Abigail great presentation. We need to clone Abigail because when she leaves we need to have the baton passes somebody else to carry this study. Mike Burrow started it we're trying to get 50 to 100 patients so it's just a slow process but again just be aware that Doppler is available and anybody that's going to have a biopsy we'd be happy to do the test. It's about the expertise required to do it. You know I read all these and I do a lot of ultrasound so I, you know, I know what I'm doing but at the VA hospital. We've seen several patients there that we suspected Johnson larger right as we take them down to the vascular lab at the VA. It's not part of the study, but yet the technician there is really is pretty easy for them to be able to do the test so anybody that does ultrasound vascular ultrasound especially can be taught to do this. Readly they the Halo sign they know about this from other parts of the body. So residents are going to other places you know other facilities and doing things. If you want to do an over Doppler to rule out GCA. The advanced or technicians can usually do that pretty easily so just a caveat there so again thanks Abigail for excellent presentation. Thank you Dr Harry. Great job Abigail so my question is about you kind of touched on it the specificity and sensitivity after steroids started now for like TAB we talked about like two weeks after that kind of falls off the table. Is there any data or literature on when ultrasound kind of isn't useful anymore. Yeah, so about 66 69% of them drop off after two weeks, and then 100% in the data that of that one study dropped off after four weeks. So very similar to temporary biopsy in terms of the effect of steroids on the results. Thank you. So what about using the fact that the findings disappeared after steroids to confirm that. Yeah those changes were real. And marker that they respond to steroid treatment. There is some work on that we haven't done that in our study itself but there is some thought that the ultrasound can be used to track disease process whether that correlates directly with the response is, I guess assumed at this point, but it is a good marker that again is effective to be able to to track, as you said, the results. Absolutely. We have other questions. Now, moving on. Our next speaker is called Swiss and Dr Swiss and is one of our senior residents he's staying with us as a law coma fellows so we're not done with him yet. When asked what he wanted to be when he grew up. He said, Firefighter but really didn't have a lot of ambition to do anything when he grew up and what has changed. Well, Dr petty still might agree with that. Well, here you go. So we're going to hear about comparing have internal viscose, canoplasties to a chagras micro step, combined with this go canoplasties for treatment of law coma. This is the biggest time. Yeah, that's a that's a mouthful. So, last year I was able to give some preliminary data on comparing these two miggs cohorts so I have some updated data to share with you today and this was just presented as a poster as Chris so fresh fresh in my mind. So, this case today, it's kind of all the rage in the past few years. As a minimally invasive your corneal incision based glaucoma surgery that is congenital sparing and then compared to traditional incisional glaucoma surgery that you have less complications, still with efficacious and long term IOP lowering. There's a recent interest in these complimentary makes procedures that you can combine during the same surgery. We're going to talk today about ab internal canal plastic or a big which can be combined then with a trabecular mesh work bypassed in. And so, just kind of getting into what these surgeries actually do. So, this is a small micro catheter or ab internal canal plastic here shown with the eye track device is a small micro catheter that's inserted through a clear corneal incision, and then threaded through slums canal 360 degrees. And as it is withdrawn it ejects visco elastic which then kind of serves as like a rotor router for slums canal dilating the now itself and then the district or channels. And then the omni device. Omni devices similar, but it's built into a handheld device. And so, the micro catheter is blue and is inserted through kind of a self made goniotomy, 180 degrees, and then as the devices with tracted it automatically ejects visco elastic I think it's 5.5 micro liters per 180 degrees. And so that's abic. The thought of combining this with a micro send or a hydrous is advantageous for two reasons. Number one, having performed the canal plastic you've dilated slums canal then created more room which can help facilitate an easier hydrous placement. And number two, the thought is that by performing both procedures that you're going to lower IOP more. The question has never really been answered. So, that is our question today is does adding abic in these hydrous patients, give you a lower IOP or reduce your medication burden. And so to answer that question we have two cohorts right so it's hydrous alone or hydrous plus abic and in this case these are all combined with simultaneous cataract surgery. This was a retrospective study at the Moran for five years up until 2021 where we identify these cohorts with CP T codes. And this was among our six different glaucoma surgeons. We included anyone who had hydrous alone or the abic plus hydrous procedure along with cataract surgery. You can see there were 279 eyes, 205 in the hydrous group and then 74 in the abic plus hydrous group. You can exclude anyone with prior incisional IOP lowering surgery or anyone who had SLT within six months, or some sort of strange IOP confounding diagnosis during the follow up such as intravitial steroid use, or development of a new glaucoma diagnosis like one patient developing the abascular glaucoma. And so our primary endpoints then were comparative IOP values at each of these follow up periods through 12 months, which we compared with a linear mixed effects model, counting for within I correlation. And then we also stratified, like I showed the two different abic devices we just stratified by that. I won't go into detail on that but I do have the supplementary figure at the end for anyone interested. The secondary endpoints we looked at medication use at 12 months comparing with a Wilcoxon rank sum test surgical complications and any need for additional surgery. So like I mentioned all patients receive simultaneous cataract surgery by FACO abic was performed with either the eye track or omni, and then the number of degrees cannulated for abic was surgeon dependent, but also dictated by patient anatomy for example if there's a large limbs canal that prohibited insertion of the micro catheter any further. That was where the abic was stopped. We also use the linear mixed effect model to stratify by the number of degrees cannulated and it did not end up making any difference in results. And importantly there's no goniotomy or gap performed at the time of abic you can perform goniotomy with these devices but this was strictly a canal plastic procedure. The first column here is the hydrosolone second column is abic hydros. Overall they were similar you can see this is kind of a heterogeneous glaucoma population, most common is primary open angle but there are some secondary open angle types as well as some chronic angle closure patients. If you can see the abic hydros group was statistically different in that there were more severe patients in this group, and they were on statistically more medications. I think that makes sense in a surgeon picking a mixed procedure. If the patient has severe glaucoma they may be more prone to pick the procedures of which they think will give the most IOP lowering benefit. So that's how they were different preoperatively. And then so our results so for either procedure at each follow up visit up to a year, both led to significantly lower IOP compared to baseline, and like we saw on the other table there was no difference in baseline IOP. And when you compare the two procedures, the abic plus hydros group lowered IOP by an additional 1.4 2.1.8 2.0 and 1.3 millimeters mercury at each of these follow up periods respectively. And if that doesn't make any sense here's the graph of it. You can see baseline IOP for each was similar right around 17. And then these blue bars represent the abic plus hydros cohort. So there's trends towards lower IOP at each follow up period, reaching statistical significance here at three months and then very close to at nine months. In regards to the secondary endpoint so medication use. While there was no statistically different lower medication burden among the cohorts. There was a trend towards more medications drops in the abic plus hydros group. The complications were very rare in both cohorts. A little bit higher in the abic plus hydros, but again, you know, two versus one complications among these cohorts need for additional IOP lowering surgery in the hydros alone group. There were two hydroses that needed to be removed for malposition, all they were none in the abic plus hydros group, and then to tube chunks in that group and then just one Zen hydros alone. So in conclusion, both of these procedures are safe and effective and lowering IOP in this particular cohort of glaucoma patients compared to hydros alone when you add abic. There was a consistent trend towards larger reductions in IOP among that cohort over 12 months, and that additional IOP lowering benefit range from about 0.8 to 2.1 millimeters of mercury. And like we saw the comparative medication burn was not reduced. I acknowledge that this was a retrospective study and kind of a heterogeneous glaucoma population so there may have been some confounding variables that we weren't able to identify. This also was a relatively small sample size, particularly among the abic hydros cohort. And as this procedure becomes more popular and this cohort continues to mature I think the data will also grow. The relevance for this is that to our knowledge this is the first study to compare these two procedures. There have been several landmark glaucoma trials that show that, you know, each, even one millimeter of IOP reduction can lead to lower rates of glaucoma progression so it may be worth doing this in the long run, but we do need more study to prove that. Special thanks to Dr. Chia, our current and past glaucoma fellows or pathology fellows, Dr. Muser, Dr. Balls, our medical students, Bryce and Christian and then Ben Brins for helping us with the stats. Happy to answer any questions. I'll leave this up here. This is the graph stratified by my track versus on me. Are there questions? This is awesome work, Cole. Have you, did you think about or have you looked at, do you have any idea on how this would compare to the abic alone? Like why did you, like you did the one, the one plus the two and then not the third by itself? In the process of that, I think there's about 100 abic alone patients over the past five years. We chose this because the data was a little bit cleaner. With just abic alone, it kind of gets more complicated because oftentimes there's a gap throwing in with that so it's not pure canal aplasty. And among that patient that cohort of 100 abic alone, a lot of them were not combined with cataract surgery. So it's just got to be a bunch of different variables but eventually yeah we're going to try to compare all three. See where things line up. All right, we're going to move on to our second year residents and the first up is Tyler ethrich. Dr. ethrich when he was asked what he wanted to do when he grew up he wanted to be Sean Collins. And good luck with that. He's going to talk to us about left digit bias in glaucoma. I didn't have the heart to say that I didn't want to bail hey and clean Barnes anymore. I have no conflicts of interest. Today clinicians are faced with a challenging task of accurately and efficiently incorporating large amounts of data to make critical decisions that impact patient health. And just to care for patients with glaucoma face this challenge daily, synthesizing information from multiple different data sources, including patients, IOP measurements, that chemistry, perimetry, OCTR NFL disc photography, and the list goes on. This data is collected from multiple visits over long periods of time. And these data are obviously complex and must be interpreted in the context of patient specific circumstances. Furthermore, the data must be evaluated and integrated quickly and efficiently to make medical decisions amidst a busy clinic. Unfortunately, research has consistently shown that human working memory is limited to four constructs or data points, which can be synthesized to make a medical decision highlighting our cognitive limitations. This is where cognitive heuristics come into play. Cognitive heuristics are mental shortcuts that facilitate problem solving. These are mental shortcuts that allow us to make probability judgments accurately and efficiently. Although these strategies are generalizations or rules of thumb that can be utilized to reduce cognitive load and allow us to make decisions and judgments immediately, they are often, they can often result in irrational or inaccurate conclusions. One such cognitive heuristic is left digit bias, where in the left most digit of a continuous variable disproportionately influences our perceptions and evaluations. Left digit bias is well known in marketing. Have you ever noticed that the prices of consumables such as clothing, groceries and gas always seem to end in 99 cents? Such pricing strategies have been effectively leveraged to increase sales by taking advantage of our inherent left digit bias. The impact of left digit bias on medical decision making has been published in two papers, both of which are outside of ophthalmology. A study by Hussein et al demonstrated the presence of left digit bias impacting the utilization of deceased donor kidneys. Kidneys from donors age 70 years were significantly more likely to be discarded than those from donors age 69 years, as were kidneys from donors with a creatinine level of two compared to 1.9. A study by Olinsky et al studied patients with acute myocardial infarctions who were admitted two weeks after their 80th birthday. Those individuals were significantly less likely to undergo coronary artery bypass grafting than individuals admitted two weeks prior to their 80th birthday. This was as compared to individuals in their 77 through 79th and 81st through 83rd birthdays, there were no corresponding differences. As left digit bias has never been studied in ophthalmology, we thought that we would evaluate the impact of left digit bias on the escalation or initiation of intraocular pressure lowering therapy with medications, laser procedures and intraocular surgery. Data for this study were derived from the site outcomes research collaborative ophthalmology data repository or source, which captures electronic health record data of all patients receiving eye care at any of the 11 academic medical centers participating in this consortium. Source captures patient demographics diagnoses based on ICD billing codes, structured and unstructured data from all clinical encounters and results from ocular diagnostic testing. Our inclusion criteria were all patients diet with a diagnosis of glaucoma. Our primary outcome variable was the initiation or escalation of IOP lowering therapy, laser procedures such as selective laser trabeculoplasty and incisional surgery. We plan to evaluate the impact of left digit bias and clinical decision making, comparing the initiation or escalation of IOP lowering therapies at an IOP of 19 compared to 20 as compared to IOPs of 18 versus 19 and 20 versus 21. Our analysis includes 61,858 patients with a median time in the database of 2,686 days or approximately seven years and four months with a median number of IOP lowering medications being two per patient. We just have preliminary data, descriptive data. So this that's shown in this table. So as displayed, the median IOP of our population is approximately 10 and most patients have not received a laser, laser procedures or surgery for their glaucoma. Obviously, we plan to continue forward with our current analysis. We also plan to assess in separate papers the influence of provider variability on the initiation or escalation of IOP lowering therapy, as well as the influence of clinic visit time such as day of week, time of day and and time of year on the initiation or escalation of IOP lowering therapy. I'll leave you today with a quote from William James. He is a prominent ethicist and regarded as the founder of American psychology and stating a great many people think they're thinking when they are merely rearranging their prejudices. Here are my references. There are many people to acknowledge listed here Deborah Harrison, Elizabeth Newtall, Ben Brince, Rachel Simpson, and Brian Stagg. A special thanks to Brian Stagg for allowing me to pursue this project. And I would be remiss without acknowledging Dr. Bapu Jena, who is a hospitalist at Harvard and also a PhD in economics and hosts the podcast MD for economics who inspired this project. What questions do folks have. You know, Tyler just congratulations, you know, kind of in keeping with you coming up with really interesting ideas and thoughts. It's hard sometimes as a resident to, you know, think outside of survival mode and one thing that I've really been proud of all of our residents over time is always trying to find the the additional what else or what what else is it that I can do can I find a solution between this and then your, you know, ongoing study on cognitive enhancing medications those are two really, really innovative ideas and just leave this with a final comment. There's a book by Arthur Brooks that Teresa long gave me it basically the first chapter talks about how now that you're over the hill how do you be successful in your life. At any rate, and I do thank you Teresa for giving me to, because they do talk about this idea of early on we're really excellent at fluid intelligence creativity that's where Nobel Prize winning innovations come from that's where tech startups come from it really does come from it's kind of early 30s, and then later there are different sets of kind of intelligence the skills that you can really parlay and I, I, I'm grateful to be at a place where we do empower residents and then young new faculty Carol and others coming in. You have the innovative ideas to help change things and we happen to be at a place where the way we've always done it is in the hindrance to that so anyway congratulations. So you raise an excellent issue and one that we all need to consider and I want to point out that one of the problems I think we have not recognizing these is that we have a tendency to be defensive about the fact that other people have problems that we don't. So we don't like to recognize that you know maybe there are issues where we are failing so I strongly recommend that it's always important to have a dose of humility and sit back and think well wait a minute. Is that an issue is that a problem is there something here that doesn't quite make sense and recognize you know the own your the failings in your own thinking and it's been shown in people with behavioral problems or drug addiction that you'll never get changed until people recognize. Basically the fault has to lie with them and you are responsible only then are you going to make changes and you're going to have understanding so I think it's important part of all of our careers and sadly as someone has been around a while now. That often doesn't happen and and it's hard for people to therefore make corrections when it would be so much better for them and their lives etc. This is this is Brian stag. Hey just a quick comment to on this database. It's a pretty awesome database that like anyone has access to so if you're interested in using it talk to me. It has it's us combined with about 10 to 12 other academic centers we pulled our HR data and it's it's de identified. It doesn't have notes so like if you needed if you're doing a say that you need to review the progress notes it wouldn't work but otherwise you could do this for like almost anything so it's you know better than a chart review and a lot of situations. Next to the speaker. Is our own Brandon Kennedy. Brandon. Wheeling up here this way around. He's going to talk to us about risk associations surgical outcomes and divergence insufficiency. I'm a trope and that can refresh my memory. What did you want to do when you grew up. Oh I was supposed to be the lead singer of lads up and it's all close but so it didn't work out. You don't want to hear me do that. Thanks Dr. Hoffman. I think I'm the last presenter before the morning break so hang in there with me. Hello financial disclosures, unfortunately. So, starting with some background information divergence insufficiencies of formster business with esotropia so eyes in and associated double vision greater at distance vision the near. So this is kind of the opposite of what we typically see with infantile esotropia which is more common or the eyes are crossed up close. In other graphics this is typically seen more older adults, like many things in ophthalmology it's been coined age related with the average age being 74 years old wide range, and then estimated 10 11% of all adult cases of esotropia fitting this diagnosis. Importantly what we've seen in clinic and also in recent data is that there's been this kind of surge or increase in diagnosis of divergence insufficiency recently the past couple decades. So here on this graph, this is a study done by guidance at all. I'm looking at the incidence and you can see kind of 2020 versus earlier late 90s early 2000s that this is really skyrocketed. In regards to the presentation, this is an inquired condition gradual onset of horizontal double vision it's competent so it's equal in different gazes of Diplopia. It's progressive so it will start intermittently and then become constant and again double vision patients will mainly complain at distance vision situations driving hobbies TV stuff like that. In the initial diagnosis, many other misalignments, more conditions can mimic this, especially in younger individuals or where this isn't as common. So you got to make sure to really roll any diagnosis of exclusion that can be vision or life threatening. Some of the more common ones are listed there. And lastly treatment you can try prisms but ultimately most these patients end up getting surgery, usually bilateral medial rectus recession so taking the medial rectus muscles and weakening them they're looking straight are kind of strengthening the lateral rectus muscles with every section. In regards to the mechanism of the pathogenesis this is somewhat unclear. It's evolving. So to say there's been multiple different theories. One of the first ones is that we have this divergence center in our brains and individuals with this condition that's abnormal, or doesn't function properly. You'll hear people say that you know this is all a big misnomer that everything we see with divergence insufficiency is actually sagging eye syndrome, which is related to age and kind of the generation of orbital connective tissue and the fascial polies, connecting and different recti muscles and they sag over time especially the lateral rectus muscles, their abduction isn't as prominent. Recently there's this theory of increased convergence tone. So as we age and become presbyopic whether we have corrected lenses or not, we're constantly trying to accommodate and get that near triad going and causing this over convergence. And there are studies looking at the histology of medial rectus muscles and actually lose sarcomeres, they become shortened. There's also studies where preoperatively people will kind of do four stuctions on the medial rectus muscles and those are tighter versus the lateral rectus muscles those are looser. And then there's also studies looking at, okay save presbyopia is corrected bifocals or progressive at lenses. A lot of individuals aren't actually looking through the proper distance on those lenses so they're still kind of using that near triad and over converging over time. So things that we noticed in our clinic and kind of why we did this study I'll talk about here in a second is we also notice you know not only in the data but we're seeing a lot more divergence and sufficiency. We're also seeing it at a younger age with our wider range. Then lastly this is a tough one surgically and there's a lot of surgical under correction with need for reoperation or multiple adjustments with adjustable sutures. So we wanted to propose a study to see if these things were true and see if our trends are consistent with the previous literature. So therefore research initiative or purpose is to evaluate the demographics of all patients seen at the Moran ice center with symptomatic divergence and sufficiency. Look at the risk factors risk assessments surgical outcomes and see if there's anything we can do to improve the treatment of this condition. So we did a retrospective review or chart study. We looked at all patients undergoing horizontal business eye surgery between 2013 and 2020. We use CPT codes for single muscle and double muscle horizontal surgery excluded any of that included a vertical component. Looked at the distance near disparity so the prism diopters of esotropia distance versus near surgical outcomes in relation to everything I have listed here. Exclusion criteria was esotropic deviation greater than five prism doctors at distance versus near or symptomatic plopia from this at distance. Exclusion criteria is any prior surgery including strabismus surgery intraocular surgery sclerobuckling or any of those alternate etiologies that we previously talked about as mimicers. So for the results we had a total of 478 patients about 8% of those met criteria for divergence and sufficiency so similar to the previous data that I mentioned. Congrats to the average age of surgery I'm a little bit lower than what's reported in literature but still consistent with it at 66 years old. You can see here a wide range as well. I should say 67. Thank you Dr. effort effort. Results in regards to the surgical approach most commonly we did a BMR is here so bilateral medial rectus recessions about 84% of the time. Also lateral rectus resection so strengthening and then a couple procedures with R and R the resection recess. In regards to results of the surgical outcomes over correction was minimal only three patients. However under correction this was near a third of our population sample size, 27% and then about 11% of these patients end up going re operation within one year. More data looking at adjustable suture rate. So 31 of the 37 patients had adjustable sutures place during the time of surgery. However, only five of those 31 ended up having a just adjustments postoperatively. And then kind of a busy slide here at this chart but real important data here so this looks at the ratio of distance near disparity so the amount of prison doctors of esotropia distance versus near, compared to the total distance at the eyes either recessed move back or respected. And the blues all patients, the orange is patients who had their symptoms resolved after surgery and weren't under over corrected. And then the gray is a patients that were under corrected. So when we looked at the medial recession ratio. The ratio was lower so 2.5 prison doctors to every one millimeter. So a little bit of a stronger dose per millimeter, the symptoms were usually resolved there was no under correction. Versus if the dose wasn't as strong or close to three prism doctors per millimeter recession, then a lot more under correction was seen, which makes sense more surgery more movement less under correction, kind of the same thing with lateral direction strengthening or lateral rectus resection, but the opposite with over correction. And then another graph here, kind of looking at the relationship between number of surgeries and again that distance near disparity, the prism doctors and here, it kind of demonstrates that the smaller the distance near disparity, so the less amounts of difference between distance and near in regards to prism doctors, the more need for number of surgeries which if you think about it, the smaller number of distance near disparity we're probably going to opt for less surgery smaller dose of millimeters in regards to the excess, recessed or resected. And then lastly here, last data point is just the correlation with the progressive ad lenses. This is something that's been seen in recent data, and also kind of going with that convergence tone theory. Use of these progressive ad lenses was statistically significant in regards to the number of surgeries as well. And then last point, kind of reemphasizing that last point I just talked about that our data supports prior work in the role in regard to progressive ad lenses as a risk factor for divergence and sufficiency. And then that our hypothesis of patients being certainly under corrected was also true this was seen in nearly a third of our patients. And then lastly, what can we do to kind of improve that. Well we identified a new optimal target of, at least for bilateral medial rectus recessions of 2.5 between the distance deviation millimeters of recess to help prevent the under correction and this is really interesting I got to present this nationally in New York and this is Dr. Owen and I. A lot of individuals are pediatric ophthalmologists came up to me and they said that they're surprised that we even had that good results that they will even double their dosage or go for the max amount of reduction regardless. So there's a lot of data out there I think this is something you know is very interesting. And I just want to say thank you to Dr young and Dr Owen broader help with this project and next steps where we're gathering more data for 2021 2022 and we're in the process of writing that up as well. Thank you everybody questions. So, there's no reason why I should be commenting in regards to survive this is certainly not my area of strength but it is fascinating that as we look at how our culture has changed. That we're getting this explosion of myopia and we're seeing these kind of issues, I have a feeling they're probably related. But there is clearly something about the eye that wants to conform with what we want it to do. And if we spend most of our time early on and not looking at a distance and near and the most fascinating one that that I ever read had to do with the center at Eskimos, none of whom had myopia. And then their children went to school and started reading and they clearly have a high genetic susceptibility myopia and profound myopia for all our kids. And so I'm wondering we're spending so much time, which is part of the reason why we have myopia. So, looking at our iPhones and near and reading and texting and not having distance is that, frankly, we're encouraging, you know, maybe just as much that media rectus muscle is just getting stronger and bigger because that's what we want it to do is turned in most of the time so that increase probably will continue until we start realizing we got to spend a little more time out in the mountains and looking around and doing other things and not our nose and our iPhones. I think it's more accommodation and things up close but I've noticing this, the old data I mean the initial question I had with this was, do I scan these people like do you need to scan these new people because they're more distance and near and you're just worried that there's some kind of lateral and a lateral rectus component and I started seeing more and more young people with this, and then kind of looked into it that way but yeah I think it's largely related to our culture now of using smartphones and myopia and that's kind of what the thought is but the tricky part of it is, it doesn't respond to the same kind of surgery that we do for everything else so you got to do a lot more surgery or you're going to end up taking them back and I think part of it is that they're controlling a lot of that. At rest they're deviating more and they're actually getting pretty good at divergence to pull it out to get rid of Diplopia and they're controlling a lot more than we know and then only do a little surgery they kind of eat it up and you kind of got to keep going but it's why I like putting these on adjustable because you've got to oftentimes throw a lot more in it. This is a great topic and did a wonderful job with it. You know, I think that everybody's worry when you're operating on a patient with a big distance near disparity is that you're going to over correct them at near if you operate for the distance deviation, but you absolutely have to operate for the distance deviation. They'll deal with things at near. The other question I would ask is, are these progressive ad lenses I mean is some of this disparity because the progressive ad lenses are not fit correctly and you have somebody who's struggling with them. I mean, but they're clearly you know this issue of the myopia, not just myopia which is epidemic now in Asia, where they're forcing school kids to play outside in China, two hours a day. This is one of the most effective interventions, but in our local, you know, regional efforts here in the Navajo Nation, where you see large amounts of myopia, huge amounts of astigmatism. It's now genetic, but how did it come to be that way. You know, those are questions that we don't have answers for. This is this is good work and hopefully this will make a difference and I hope you pursue your interest in strabismus. Thank you very much Brandon.