 Okay, so our next presenter is also a rotating medical student from Virginia Commonwealth, and his name is Dane Stewart. He'll be speaking about infrared imaging as a tool to detect glaucomatous changes of the optic nerve. Okay, good morning everyone. I'd like to start off with my thanks. Thank you for everyone I worked with. Thank you, Dr. Bernstein, Dr. Petty, Nick, and Ron and all of the residents. Alicia Doxson, and of course my colleagues at VCU who helped me with my presentation. And just to start off with, I'd like to take 30 seconds to kind of go over my experience here at the Moran. I've thoroughly enjoyed every second, so thank you for everyone who helped. This is, I guess, how I felt when I found out I got accepted to the Moran for an away rotation. So, we can get this, oh no, it didn't work. In any case, I was very happy. We'll see if the next one works. Dr. Taven gave a lecture on corneal infections, and that included fungal bacterial and parasitic. No, alright, this is not going to work. We're going to try this again. I swear they are very funny jokes. Oh, there's no audio, yeah. So, yeah, if not, it's fine. Dr. Bernstein once told me good work, and Dr. Petty introduced me to the simulator, and he started with the prelude of, this is pretty easy, it wasn't. So my project is infrared imaging as a tool to detect glaucomanous changes of the optic nerve. The purpose is to determine if there's an imperfect correlation between the standard color photos that we get, and then we're going to use, or we're looking at IR imaging to see if they're any different. As we all know, glaucoma is the second leading cause of blindness in the world. It results in visual field loss. In short, it's bad. Currently it is the clinical standard that we assess patients with glaucoma using slit lamp exam, and then we measure cup to disc, and then we also get stereoscopic disc photos. However, as we know, there's a high amount of intra and inter-observer variability in measuring cup to disc, which has led to dependence on OCT and visual field. However, OCT is off-times subject to aberration, and visual field is off-times unreliable. So a quick comparison of infrared imaging versus color imaging. Color imaging is polychromatic light, so that's every wavelength. You have a higher illuminating power, so you have more light inside of the retina, but that doesn't necessarily translate into a higher resolution. In IR imaging, you use what's called a confocal scanning laser ophthalmoscope, and a couple of properties of that are, first of all, it has higher reflectivity. So less light is absorbed by the tissue, which gives two things. First of all, it's a little more comfortable for the patient, because it has a lower total quantity of light. And second, since more light is reflected, you get a clearer image. Second, it penetrates deeper into the fundus, so it allows you to view structures within the retina that you otherwise wouldn't see, for example, the coroid. And finally, polychromatic light has been noted to produce a higher amount of aberration just due to the fact that you have more light. So the conventional microscope visualizes essentially just what is on the surface, whereas in the confocal microscope, what you see is you can actually go to different depths within the retina, so that is known as optical sectioning. Infrared imaging has already been extensively studied, and several studies have shown that it has, with much greater clarity, you can see these structures listed here, pseudo-reticular drusen, angioids, streaks, coroidal vasculature, retinal pigment, epithelial abnormalities, laser scars. In one very interesting study, they actually looked at Stargardt disease, and not only were they able to view the abnormalities within this disease much clearer, but they then correlated it to disease progression with a greater specificity than other modalities of imaging. It's also been used. There's one study where it looks at the internal lamina crebrosa and has been able to produce morphometric measurements of the pores, pore area, lamina area, surface depth variability. Now there's a plethora of images out there. I just chose one just kind of to demonstrate what IR imaging looks like. So here we have a color photo, and this one is IR. So you can set it to different wavelengths. This particular one, one advantage of the IR is that it's a very discrete wavelength, but you can actually change it, and depending on the wavelength you use, you can get different depths into the back, into the fundus. So this one is 670 nanometers, and you can see this pigment epithelial abnormality right here is much greater clarity on IR imaging. And in this final picture at a different wavelength, 830 nanometers, you can actually see the caroidal vasculature. So CSLO has never been used to generate stereoscopic photos for the purpose of measuring cup to disk in glaucoma. Now one thing I have found in my clinical experience is that in clinic you want things to run smoothly and efficiently, and I guess one added benefit of using the CSLO over standard color imaging is that the Heidelberg Spectralis OCT actually has an IR setting on it. So it literally takes 10 seconds, 10 extra seconds to get the IR image as compared to when you use color photos, you have to send them to a separate machine entirely. And we hope obviously that it will show disease sooner. So the study that I'm working on at VCU, it's an observational prospective study. The goal is 100 eyes of 50 patients. Inclusion criteria is essentially glaucoma or glaucoma suspect. Exclusion criteria is essentially any other ocular pathology. And the design is that these patients with glaucoma or glaucoma suspect, they receive red-free standard color and IR imaging, along with their regularly scheduled OCT. And then the images are de-identified, they're viewed in groups to help eliminate, or help eliminate bias if we want to eliminate it entirely. But then they're viewed by a single ophthalmologist. So my program director at VCU is looking at them. And then we measure cup to disk. So I submitted the IRB for this project about two months ago. We don't have a whole lot of eyes yet, but step one, or phase one, is simply just to prove that there's a difference. And I called on Monday to my friend over at VCU, and I got the measurements that they'd had by that point. And just to establish that there is a difference between the two imaging modalities, as you see with a p-value of .005, the cup to disk is indeed larger in IR imaging. Phase two then is to correlate it to visual field loss. And last night I got a call from one of the residents at VCU, and he was pretty excited, and he told me that they'd had two patients that day who had come in. And keep in mind, we've only got about 14 patients so far. But two patients that day had come in, and on color photo the cup to disk was read as the exact same as their previous appointment. But then when they did the IR image directly underneath the vessel, they found two fairly impressive notches. So it was a theoretical assumption that we had made due to the fact that you can look deeper into the nerve because you get due to optical sectioning. But it was just nice to see that confirmed. And I said, please, I'll pay you $1,000 if you can give me those images before eight o'clock this morning when it didn't happen. In any case, a future direction is, hopefully I can get this viewed by more than one ophthalmologist and then get them to observe or to measure cup to disk multiple times to assess intra and inter-observer variability. There's a couple other directions, but that's where we're headed for the moment. Here are my references, and are there any questions? Okay, thank you for your time.