 So, my job really is to kind of give you the context of the history so that the discussion is preventable for all of us. So, we have a 62 year old woman who originally presented in July of 2014 with some systemic symptoms of thyroid disease, specifically some shortness of breath and an ophthalmology. And this should be presented as some intermittent dystopia and some eye injection. The eye was burned to retropulsion and examination should not have practices at that time. And definitely no optic neuropathy. At that time, we treated the dry eye symptoms and the air to die symptoms with mitified or some high elevation and lubrication. And she was described both Taryn, but systemically and they tore a lot of jobs. And the chronology saw her again in March of 2016 and note that she had pre-to-bill mix edema. And they were wondering whether this was kind of very human and those who versus pre-to-bill mix edema, but they treated our patients with prednisone and tapered that off. Since the visits in April where we started to be concerned about the thyroid disease and its manifestations, the visual acuity had dropped from normal to 27 on the right and 2025 on the left. And as you can see, the pressures in our primary gaze and up gaze are very typical for those that are seen in thyroid patients with elevation in up gaze. And we first initially, for the first time, actually saw an RAPD on the right. There's just some data here to suggest that there are indeed features of thyroid disease and, concerningly, coloration on the right had dropped significantly to 0 to 10. Critical flicker fusion frequency was also asymmetric, again, indicating with the right optomethography, and there was some mild pallor of the optic nerve on the right. This is the volatility here, and you can see that there is an esotopia and a right hypertopia that's seen in primary gaze. And again, very typically up gaze restriction in both eyes. So I think this is probably the most important part of the talk, and this is the visual field representing the significant optomethography that's developed. So the first field is from February of 2016, just a kind of initial presentation to us, which is really reassuring, but as you can see the fields begin to progress. And in May of 2016, especially on the left, you can see the difference if you drop to 215, and you start to notice that there are some people feel deficit on the left as well. This is an MRI that exemplifies the features of those on the axiom cortex, you want to post-galvanium, fat suppression sequences, and these are meant to show you the significant enlargement of the extrafila muscles with compression on the optic nerve, and the same is seen on the other side as well. So just to go back to the fields there, how did we address this and how did we treat this? In April, after the first note of the right gastrointestinal optomethography, we treated the patient with methaloepithelone, mongram, IV, once a week, for three weeks, and it required an orbital decompression, which involved a needle on the lateral walls, as well as some live surgeries at that time. So this story goes on, and we know that later in May still have continued visual field progression, as you can see both right and left are involved. And further on, again, we see further progression of the compressed optic nerve bilaterally, and the middle field there is done in June of 2016. So something clearly needed to be done at that point again, and on July 1st, the patient underwent, again, a repeat bilateral, needle and apical orbital bone decompression, as well as partial echmoidectomy at the time. In addition to that, retrovolver steroid injection was given in both orbits. In July of 2016, in addition to the surgery, radiation was administered to the orbits, and the examination in office of 2016 showed actually improvements in the likelihood in both eyes. The pressures were still a bit normal within the normal range. There was an RFP denoted on the left, color vision had improved, and critical pulver fusion frequency had improved as well. The cover test you could show is a trope of 35 primary case britches and increased from the previous measurements. Now bilateral optic nerves had some potential caliber. So that is kind of a quick run through the history. I have some suggestions for discussion, but I thought maybe we'd get Dr. Bellman to come up and discuss the case from his perspective, offer the suggestions, and we can move on to the discussion questions that are needed. I'm delighted to be here, and it's nice to see a lot of old friends and me to do one. And I hope that some of you were present last night and talked a lot about potential new therapies and some of the frustrations with our current therapies related to thyroid eye disease. One of the things that's most interesting is that the incidence of this severe disease is actually going down. And whether that's due to people who are no longer smoking, or whether it's due to some other environmental factor, or perhaps we're just better treating hyperthyroidism we're detecting earlier, and I think that may also be a factor. The philosophy about thyroid eye disease is our myriad, but the treatments are pretty stereotypical. I think that in patients who are not otherwise at risk of giving radioactive iodine to treat the thyroid condition I think is perfectly reasonable. And this tends to be sort of a local phenomenon. So when I was in Los Angeles, you know, 90% of my hyperthyroid patients were treated with radioactive iodine. Now in Rochester, maybe 5% of people with radioactive iodine. So there's a lot of variation, which means nobody knows exactly what the best treatment is. But I think it's pretty well established that patients that have radioactive iodine do have a slightly increased risk of developing eye-openeramines. I think that's been established in class one type of studies, prospective studies. And also the patients who have thyroid eye disease in the lab tends to get worse when they get the radioactive iodine. So there's been, I think, a pretty much consensus that patients who have high risk factors should be on low-dose corticosteroids for perhaps a week before and perhaps two or three weeks after the time to get radioactive iodine. 20 to 30 milligrams of prednisone per day, and certainly not enough to get all the long-term side effects and not high enough dose to have short-term side effects. And I think that that's a good practice, and I certainly recommend it to my patients. So the question here is, well, were there any risk factors? So our patient today had a history of remote history of smoking in the 70s, so if you're required to say that that is a big risk factor. One minute risk factor is probably eight. And so when you see patients that are in their 20s and 30s, which is the peak for hyperthyroidism, I think that if they're non-smokers, I think you really have no risk factors. But once you start to get into the 50s, then I think that the risk of developing eye disease as the lab and that it may be a little stronger case. Even if somebody has no eye findings at all, for prophylaxis, with particles, photos, particles, steroids during that time. So that's one therapy versus per compressive optic neuropathy versus using decompression. So last night I mentioned that when I first started in practice, in the late 1970s, we had an armamentarium that consisted of hyposporidosteroids, orbital radiation, and orbital decompression. Today we have the same exact things. So we have made, in terms of progress, a lot of new potential treatments coming out of the market, but none that have really displaced the mainstays of therapy. And there's a lot of controversy about the role of radiation, orbital radiation. And there's a very thoughtful group that basically any patient, as soon as they start to develop any kinds of inflammation or peri-orbital inflammation, they're going to go and get radiated. And then there's another group that radiates therapy once every three years when they have peri-orbital optic neuropathy. So there's no consensus. The prospective clinical trials related to orbital radiation for thyroid disease. The one study that came out of the Mayo Clinic showed no effect, but on the other hand it was sort of taking all commerce and it was unclear what degree of information where they were. And that's the problem we have with all of our patients in terms of trying to do studies. No two thyroid patients are the same. And so their end points are all different. And where they are in their disease is different. And what we call severe thyroid eye disease, like our patient today has, is not, we say, well, that's active disease. Well, it's not active. It's progressing in terms of symptoms and signs. But the activity is probably long past. There's probably not acute inflammatory responses going on. What we're seeing is scarring and the effects of increased tissue within the eye socket, the pressure effects that I talked about with a bit last night, as well as the fact that the orbital fibroblasts which are activated are integral disease and either turning the fat tissue or the scar tissue. And then the elaborate phyloronin that breaks in a lot of fluid, which raises the tissue pressure and produces the steam. So as far as radiation, the only real contraindications that I've seen to use normal radiation is patients diabetic or has other severe vascular disease. Those patients do very poorly with radiation and I wouldn't recommend it. But in the absence of that, I think that this is a perfectly reasonable thing to do. The question is, would you use the radiation in spirit rights first or should you have done the math? Decompression, I would have done it the way that you've done it here. Decompression, decompression works to alleviate optic neuropathy somewhere around 90% of the time, especially in terms of color vision and visual acuity. A little bit less so in related visual field about 70%. So that's better than what you get with radiation and steroids which have to be given together. And also patients are already toxic from steroids. You prolong your steroids by giving them radiation as opposed to doing decompression where all the time you can take them off your steroids. So in terms of what the new options are, I did publish one patient who had a course very similar to our patient today who progressed and progressed and progressed to decompression. And finally, I put her on Celebrex which I talked about a little bit yesterday because it's been shown to really inhibit the reactive response, the inflammatory immune response. In fact, actually that patient did better on Celebrex and recovered vision whereas on steroid and losing vision. So there's one other thing, we don't have post-operative CTs or MRIs here so it's hard to know what the first and second oral treatment procedures do. And I use different techniques so where the rich boning walls are decompressed may be slightly different. In the patients where I found that they eventually got better after decompression and then got worse again, what I actually found is that the posterior wall, the maxillary sinus, was kinking the nerve as it was coming into the orbit. And so you have the anterior rectus to look like it's a hammock. It falls down. But it being held up by the posterior wall and so it's kink at that point. So I've gone in and taken out the posterior wall and maxillary sinus and it's then the optic neuropathy got better. And so I think that it's very important for our patient today to really go back and study those scans to make sure that you haven't produced a secondary cause for the optic neuropathy as opposed to just having not enough overall deep compression. It can be very vocal and ten minutes worth of chipping away a little bit of bone and I tend to use a trans-animal root which gives me access to everything with the root and that would be the other option for this patient. Patients who I've had who have failed on free-walled decompression, Dr. Nassager, a neurosurgeon popularized the Nassager procedure and it is a transcramular of decompression. Those patients that I have that have been recounted like this with this kind of optic neuropathy, they have done well with transcramular of decompression and that's the experience of the male cutting root as well. So I think that you don't want to wait too long if you're going to consider this root but getting the entire oral root removed all the way back to the canal is something that might be considered as a root for the patient. Well obviously I could go on and on but I think that this is a very concerning and not that infrequent issue that we deal with. Our patient is still on 30 milligrams per day and that's now you're producing the secondary disease and you're nice to find some sort of acute intervention where you can get off-screen or at least that much of the non-steroid length of time. Any questions? In terms of the order of doing the decompression or the radiation some of the orbital people have said that the tissue in the orbit is just different after radiation treatment and when you're going to be doing a decompression it just doesn't behave the same way. Is that your experience? Well, I think that's sort of true in some cases. I think the problem is when you get really elevated tissue pressure you get fat and croces and that's what you're really seeing. You're seeing the effects of chronic high tissue pressure and you're getting fat and croces and then you get this sort of gritty, fatty, fibrous tissue stop whether it's the radiation that it answers that or not. I really don't know but I prefer surgery before radiation. There are many people who do just the opposite. The real question is how many people didn't need to come to surgery if they had orbital radiation? And the answer is actually none. And the reason is that all those patients end up with normal decompression anyway. The difference is that having it acutely and under all sorts of stress it's not electrically in order to start the respiration process. Any other questions? I just wanted to add that the benefit that you get from radiation really is not immediate. As a matter of fact, you can really kind of stir things up a bit. So you have to prepare for there to be more inflammation with the acute radiation and then hope that over the next six months the things really quiet down from the radiation. So if you're in an acute vision loss type setting I think that what Steve said is very apt that there's going to be a decompression happening. Absolutely. The other thing is that the experience that the Europeans have with IV pulse therapy weekly therapy is very much different from what we have here in the United States. They were talking about complete resolution, reversal of changes, all this stuff. We just don't see it. And in the high dose that they were using, dGrams, there was another stuff that was incidentally adapt from high dose blood blood from this room. I mean, it's not a legal disease, but there was legal treatment that was asked. Now with the lower doses, and the recommendation is about six grams, but the patient's getting worse while you're watching them. Personally, I prefer oral steroids. If you're not going to get better with these two weeks on 100 milligrams of prednisone and I can manage the paper room, they'll offer the operating room and then we'll see what we get after that. So there's no one way to manage these. Our patients here today have been managed duly. I think there's some more to be seen on. Interesting. Thanks, Sarah. I'm going to be presenting a case of neuroglerosis type 2. So this is a 12 year old girl who was originally diagnosed with neuroglerosis type 2 in June of this year. She presented to the neurophthalmology clinic for the 8.9 vaccination. She was referred by NT. She had no subjective visual complaints. Her imaging was reviewed and revealed that a lot of people from the right facial nerve tumor versus an acoustic neuroma, and by a lot of our schools, regionals, or neuromas, is all of a left cervical canal to a neuroma. Her ocular history was significant for her history of myopia of neurosteroism, and it had been noted that in the last two to three years, it was difficult to correct her visual acuity to 2020. She had the surgical history of a right cochlear implant and a left-brain-automate version of the acoustic neuroma. Her family history is negative for her fibrosis or for hearing loss, but her father does have hearing problems. Her best corrected visual acuity was 2040 on the right and a hole in 2025 on the left. There was no APD in either eye, her obstrofluousness was full. Her right optic nerve was like elevation superiorly amazing, and then all quadrants in the left eye. Her vessels were noted to be tortuous in the left eye. There was no right desaturation of an either eye, and there was full-colored vision of both. Her cartel measured 22 millimeters in both eyes. She had an aesophoria that was worse than right gaze. She was also noted to have a right head tilt in the hand, which was not consistent with the photos that were reviewed two years ago. She had a left-peaking eye diagnosis in primary gaze, which was a small amplitude of oral frequency, and she had an up-peaking and left-peaking eye diagnosis in the patient. Because of the abnormal appearance of the optic nerve, ultrasound recognition was obtained to show the osteoporosis improvement in both eyes. This is the vaccine T1 post-contrast with that, which shows bilateral vestibular chornoma here. This is T1 pre-contrast, and you can see the abnormal here, the left lateral rectus muscle here. This is again a post-contrast. This is the enhancement of the left lateral rectus muscle. And then also, as well as enhancement of the soft tissue surrounding the left lateral rectus. This is an example. She has a cranial nerve-free chornoma here. This is a diffusion, which again shows some enhancement in the area of the left lateral rectus and ADC. And this is T1 post-contrast. This is a CT coronal. Unfortunately, if it were to know the coronal cuts of the MRI scan, but you can see here that the left lateral rectus is enlarged, especially compared to the left lateral rectus. So our questions are, what's the next step in her case? What's the reason that she has been seen 2020 as it's because she has neck diagnosis, which she possibly would have an osteoporosis? And is the left lateral rectus mass concerning and should a biopsy be pursued? And then there was originally some concerns with the radiologists that maybe she had an optic nerve treatment in GMO on her right. Subsequent review, I think that they saw it, but it's going to be on the other side. And then I'll just quickly talk about neurofragments. So there's type 1 and type 2. Type 1 is much more common. It's associated with capital late class neurofragments that's where you're struggling after capillate glioma, leach nodules, and then neurofragments that's type 2. It's associated with meningioma, short-normous cataracts, heavy regal membranes, and so on. So Nf2 is the multiple main pages of neurofragments on mutations of Nf2 suppressor gene. Bilateral vestibular nerves, guanomas, are patented on it for Nf2, but guanomas of cranial nerves, spinal nerves, peripheral nerves are also associated with Nf2. meningiomas, appendinomas, and astrocytoma can occur, but neurofragments are actually very rare in Nf2. Several studies have noted that the first doctorial manifestation of Nf2 in the younger population is visual loss or blovia. Closterior sub-pastler cataracts or peripheral cataracts are common, but these may or may not be particularly significant. Epiretinal membranes, optic nerve treatment and genomas, retinal hemartomas, can all occur in Nf2, as well as optic dysplomas that just we saw at heart, can occur as a result of tumor growth, and then a peripheral fetal nerve resulting in an exposure of keratophobies can occur, and it can either be from involvement of cranial nerve 7 or in learning of a vestibular schwanel by our cerebellum. And then here you can see this is anterior posterior sub-pastler cataract, retinal hemartomas, combined treatment of epithelial and retinal hemartoma, and then an optic nerve treatment. This is a very unfortunate case obviously for this young girl. So in terms of what the next step is, I think that in terms, there's really no urgency about getting related to the lives right now. This patient has multiple lesions and they're large and they're producing issues all of their own. So the nystagmus, of course, is probably cerebellum, and it is rather than related to diencephalic diastreminal seesaw or something like that, and probably not due to lack of treatment. So I think we're probably looking at the nystagmus. The nystagmus can blur the vision depending on how much of the primary and whether there's any development. It can certainly cause blurred vision in 2020, 2020, 2020, or even have a perfectly normal after a pathway. So it's hard to know what the 2030 mean without actually examining the moment or detail. We know that she has optic nerve urethane and I'm not aware of any relationship between that to an optic nerve bruisin but it is curious that they're occurring. The things that I've seen in optic nerve bruisin that are of course concerning is that you're the patient who could have or may have had or be in the future have increased intranet pressure. And I think the combination of bruisin with increased intranet pressure and increased intranet critical pressure does have a high risk for vision loss. More so than either one alone. So I think that's something to keep in mind that early shunting gets the pressures or whether it be high or something we want to be considering. So is the left lateral rectus mask concerning? Well, yes, all the masks that she has are concerning. If you're asking me what do we think the tissue type is I think that's probably less important because it's probably an old live tumor so it's going and we know that meningiomes occur preferentially in NF2. So is this an orbital meningiome? I didn't even see any bone hypostasis or urethane. It looked like it was mostly contiguous with the lateral rectus muscle. You wonder if it may be some sort of lexiform neurofibromin involved in the lateral rectus and so if you went into biops it could actually be biops in the muscle and that might be reasonable if you were concerned about the diatosis or whether this could be considered a malignancy but I think it's mostly it's a matter of curiosity that's not for major issues right now and if you needed to she stabilized and then she doesn't have she has no deviation, I believe in primary age showing as a problem of eccentricity so she'll use a slight head turn if she were to develop a bupia or start to a tool to think about some sort of amniopia that would be that would be significant I think you would do muscle surgery in this particular remediation or perhaps do a fund procedure that arrives in some way trying to mitigate the eccentric implosion but I personally don't think it's necessarily biops at this time and certainly if you excise it can be excised in the lateral rectus or the rectum is there an optic nerve sheet meningioma? there certainly didn't seem to be an obvious optic nerve sheet meningioma and optic nerve sheet meningiomas don't usually be associated with optic nerve tourism so I don't think that's the relationship sometimes in optic nerve sheet meningiomas you'll get swelling in the optic nerve and you'll get these cytoid bodies which have been calcified not actually primary or secondary and so I don't know what to do. The problem that I wanted to and a couple of these patients as they age is that they have de novo tumors. This is not watching an optic nerve sheet the asprocytoma that's getting a little bit bigger over time this is new lesions occurring all over and of all the lesions that were mentioned there were several others in the imaging that they or weren't mentioned there's a little problem to not keep up with this as you have your growth factors that are still active and haven't been shut down from causal damage that they caused so it's a very concerning it's certainly unique as many of these cases can be, they are unique presentations but I don't have too much in terms of management any questions about? and that too always shows up on the OCAPs and always shows up on the boards Thank you Dr. William. That discussion was just excellent it was a great patient so we're going to go ahead and get started with our actual interview. Well Randy is filling this out, it's my great pleasure to go ahead and introduce our next speaker our chairman Dr. Randy Olson and we'll go ahead and maybe Dr. Olson can do some of his introductory comments that he didn't have a chance to give while we're working on getting his exposure out. So I apologize I had an interview I had to do it was one of those things that they said you've got to take care of at least one part of it here so I missed my good friend Steve Bellarmine and everybody does so well on Steve it's a pleasure to have you here and Steve and I have worked together at AUPO for many many years he continues in that role in fact we traded each other when we were presidents and the person who is amazing in this for your inventor and great neurologist it's just so yeah we get on the screen so let's see that's my advancement alright so first of all let me just talk a little bit about why we have this today and what's ongoing as you know this was a meeting that essentially we call the clinical faculty day we certainly have good people we have some people who are here today they're going to do that but my thought is we have so many great researchers here we've got so many people on the clinical side are doing great clinical research and what we often have lacking is communication between both sides all here people say that so-and-so got on the board and they'll say I've never heard anything that they've done before I don't know what's ongoing what's happening that's a mistake and there is a general thought that oftentimes that things have become so specialized in the area that there is no ability to communicate and I think often what's really happening is there's a dearth of interest and desire to communicate and then therefore becomes a de facto truism that we lose the ability to understand each other and so we want to have this very even mix we want people to sit down and talk and I do know in some cases in some of these areas it may be a little difficult to understand the core concept but I think that if we all try to make sure we're speaking in the lingo that is more every day and we work hard at this I think this can become a very important that so that we can understand a bit of the breadth of what's happening because I have that opportunity to see and understand that and feel it and I'm so proud of all that's going on here but you know we miss opportunities because oftentimes I'll hear about something and I'll say well you don't want to see Alan Crabb, well Alan Crabb is working in that area we're so and so on and so on well I didn't know that but we're not going to get the collaboration that are necessary until people do understand so this is our first and I'd like to see this expand and move forward and hopefully everybody will have a great time so I'm going to talk about really a fairly simple easy way of moving forward and something that's actually been incredibly productive I want to start out first of all that we talk about this that I've got a lot of colleagues here that are extremely important. Jeff Petty sitting up here he's been very involved in this moving forward frankly Jeff Petty and Bill Barrow I'm assuming and the plan is they're going to take over the leadership and all of this as we move forward Brian Zog's been very involved Brian Stagg, a lot of other residents Ashley is now taking over the leadership to move this on the resident side but it's an example of how it could be a lot of fun and it can be very straightforward and frankly I think it's been the most important body of knowledge that's occurred in this area certainly that I've been aware of during my career so cataract surgery what's the past been a cataract surgery? it's been a bunch of talking heads talking to each other each of them saying this is better than that with no scientific basis whatsoever for what they're saying and if you're in the know like Nick is and Alan is and I am we know who's being paid by A or B or C or D and we can essentially guess what their opinion is can be what they even say and that's been the state of the art of this field here for a very long period of time so what happened Griffin here Griffin Jardine did he make he's one of our newer faculty members Griffin I'm giving you a shout out he's not here he's at the he was a medical student and I told him how frustrated I was when working on a project and I said we need something that will sit down and tell us what works and what doesn't work in regards to cataract surgery and I've got a lot and I've got to give him 100% credit because I'm a pretty good idea guys and those of you know me I don't have a lot of time and so he just wouldn't give up and I said let's try this let's try that and he came up with what is affectionately known as the Cuban and it's really really high tech so on this pointing this doesn't have to be something you don't need to get a million dollar piece of equipment so what exactly does the Cuban there's a point so the idea is is that we need to determine relatively equal size chunks of cataract material relatively equal size density of cataract material and then by having that and looking at it we can determine two very important facts for fragment removal this is the fragment removal department and that is how long does it take to remove a certain size piece of material and how often does it bounce off the tip of what we call a fragment two very important clinical questions does that answer the whole issue and I get that in reviews all the time no but the perfect standing being is good right you start out with something and we'll talk about where we're moving now in regards to this but at least for the first time we can start debunking looking and seeing what makes sense in this field and where there's not so again you take a nucleus and we'll start out with the human cataract with your jet tape and also a shout out to jet where they could get us a bunch of you know hard fresh human nuclei you cut them into slices and you cut them again and then you cut them again and you throw out the smaller ones and you essentially get a two millimeter on a side cube now are those exactly two months they're not exactly are they exactly the same hardness no but by mixing them up together and randomly selecting them we can do 20 controlled experiments have enough power to be able to analyze and compare and talk about some of this work that's happening testing is simple you just bring them up in your regular mode testing chamber we all have bring it to the tip how long is it there if it bounces off you stop the timer and put it on again and every time it bounces off it's a chatter this is not again it's amazing that none of this had ever been done before but this is the overall scenario moving forward so the power of this as you can see on these this work that was done with human nuclei is that we can sit down now and we can do the equivalent of thousands of surgeries in a controlled fashion something you cannot do clinically too many variables there's no really we've eliminated everything other than the variable we're looking at and we're doing it and this first big study that we had and came out by the bell I think the most powerful thing that we found out that we didn't realize is how important parameters were a lot of people always wanted to talk about what was the mode what was the echo or the models or sound they were using and if you look at the efficiency in regards to time here is an example we could go from 31 seconds to 5 seconds just based on the parameters so if you don't know what your parameters are I can show you anything is better than anything else and you have to know what are optimal parameters for you to compare it so this was our first landmark study and I think very powerful but the first step was how critical parameters and a lot of time tried to optimize those and understand it the next step was as much surgery as Jeff does he's so busy these days he probably almost couldn't supply it but it's not that easy getting human nuclei in a third world and so we needed to get another model and so this particular group we found a pig model pig lenses we get plenty of that were equivalent to these human lenses so what do we do here same thing, you're just a cubinator putting it in place we soak them in the balance solution for 24 hours this is neat after formal and soak different times we talk about that then you cut it and you mix it and then you compare it what did we find out well the density test is very precise and you can say well 2 hours looks like it's pretty close to the human nuclei a pig solution available for what about Kalman tip here's one that just shows me I actually some of the some of the people here were back when I gave my the worst lecture, I love that the worst lecture when I first told Susan you know Jan Versta is the triple IC has one other big lecture and I talked about this we have been taught by Charlie Kelman from time immemorial that the most way to do efficient way to what actually doubles the time it takes to remove a tip and it doubles the chatter I see and question what's happening all kinds of errors crop up and nobody knows about it another one I'll just talk about the worst lecture, I love that anyway and he has standing close right here like 42 he says you'll be dead before you turn 30 Teddy Roosevelt famously said sir I'd rather die with all my running around well he was doing the right thing it's not super healthy person so what finally changed that diagnosis World War II we had all these elite troops they were diagnosing them one after another with athletes part when somebody finally said we can't do this we're eliminating our entire cadre of people and the elite troops maybe it's okay and it was really not World War II until finally this diagnosis started like we may have more athlete parts helping them in real life tipped I am, again big discussion going on real short 0.9 seems to be the sweet spot we've run into some smaller size tips to do quite well with interesting design then you're looking at other features but as far as just the core regular round trip going on that combination of wanting to make sure that you totally seal to get vacuum but you're losing efficiency by the size of the tune you're trying to ram it down 20 games seems to be the magic part MicroPulse was the best fluidity parameters a lot of interesting work you look at low flow that it turns out it doesn't make any sense to go higher than 300 millimeters of mercury because you don't get anything look at that why is it? because it turns out that if your flow is only 20 millimeters a minute you can't generate more than 300 millimeters of mercury you can't pull enough to generate additional vacuum above that well a lot of people didn't know that it does make a difference when you start getting up at higher flow because you can get that full vacuum realize and put in place get new information, nice paper Venturi we know a lot about Venturi a lot of people say that there isn't really what happens with it indeed as you can see that 20 millimeters a minute consistently is two to three times better than peristaltic as far as it's overall efficiency the same time though is that if you look at 20 this is looking at transverse as far as chatter, Venturi is automatically better you start getting up at 50 millimeters a minute it makes a difference that lower vacuum is good time to get the high vacuum they were statistically the same but here's the big one how much flow are you getting with Venturi remember Venturi is vacuum based you don't control how much flow it's inherent inside the system well turns out your flow rate when your vacuum base is sitting up here at 70 to 100 millimeters per minute that's a lot that's why a lot of people have been weary about how fast the flow is at the price turns out from a physical standpoint that if you were to take peristaltic flow to the same level you should have the same overall flow so if you engage and you judge there's no question here's one I love Steve Dewey made a proposition that if you round the edge of the tip and you touch the capsule are you more likely to break it so this is the regular tip the idea is if you touch the capsule over sound you're breaking tarot if you round the tip and you touch it that's something that we talked about for a long period of time it wasn't the facts and association with it so we started with some fresh human lenses we took a look at it and wow it's like maybe there is something to this it turns out that you've got one shot at a fresh human lens once you break the capsule you can't do it anymore but at least with the number we had this is the number of taps to break them to 4 versus 47 that was a significant difference so again we said we need to come up with some way we can duplicate these results that happen to go through a human lens every time that's not that easy to do solution so ram rap over a coffee can attack and it works we've got several good papers in association with that go on as a very busy slide and not go into all the details is he looked at me, sharpened all it was significantly better every step of the way these comparisons are highly significant Steve knew he was right that it indeed is very protective of the capsule often by the tenfold less likely to break it but is there a price to pay as a person who is an old physics major I'm telling you physics is a two-edged sword you rarely get something from it it's almost always a price to pay so again very protective as mentioned we published that American drill about homology we've now recently done a similar one thing out in H.O. 2015 and we showed that in comparison to a linear approach same energy that transfers and torsion won't increase the capsule break and drain I think if you touch the capsule you move from side to side it's easier to shear something than going straight in and out but yes we can decide and look at that and you can see that if you're looking over all say at an Osso type approach torsional that we about double the time so when you're talking about pure torsional yes, do we chip it's going to cut your efficiency but if you're looking at a transversal it wasn't consistently different those are the same what about micro pulse ultrasound those are the same now when we first admitted in this particular article in regards to this using a radius tip and I'm a radius tip the questions that came back to us on this well you're just looking at a really really soft moving idea is this really going to hold on something that's harder and these things probably don't work on harder and so we said fine we can make harder we can make as hard as you want how long they're going to soak in formalin so we repeated it there you are double the time again significant in regards to torsional transversal the same so for those who don't know torsional is the motion in milliseconds the nap of that little thing there's an ellipsoid I think it's a football shape overall or as linear it's very simple going straight forward and back difficult that there's not a good animal model generation there's never likely will be a good disease and if you're going to look at human disease let's get to the real source so we currently have a repository now of somewhere over 700 pairs of eyes produced in an identical fashion and you can see that one of the messages here is it takes large numbers to do good science so it sounds like a lot of lives but I want to show you the process patient cohorts on the other hand have been incredibly valuable as we move forward and we have access to about 70-80 thousand so those of you that are familiar with activity generation I think you agree with this comment that there are there's a huge diversity of phenotypes both for early stage disease, Jerusalem there's all kinds of Jerusalem if you get to the histological level you'll realize that there's even more phenotypes in Jerusalem and certainly you're familiar with lots of different forms of late stage disease particularly neurovascular disease and I think we're starting to lose the plot here clinically in identifying some of the subtypes of neurovascular disease polyvoidal, rap legions colloidal, et cetera but we thought one of the most important things we could contribute is asking a question are there true genotype phenotype associations ok and so to get us to that point became really important to understand the background genetics of the disease in my particular group we've been looking at genetics in that kind of regeneration group somewhere over 20 years now but I want to leave you with an important message and that is there are two major low side that are associated with developing this disease in complications ok, one on chromosome 1 and that that locus contains complement factor H and the factor H related genes and a second major locus on chromosome 10 contains a pair of genomes on its genomes to your one and to make the point again that over 95% of all risk is associated with these two most ok so it really is a gigantic gift but I think on the scientific side we've kind of whitewashed that a bit by wanting to go out and find more and more genes and yes there are a lot of minor gene associations but if you're really going to dig into the disease and understand the pathways you need to work on the two big ones put another way clinically if you look at my combined patient cohorts only 5% of our amd cases braids 1B to 4C is in the broader dance field only 5% of those cases don't carry in the risk of leos and chromosome 1 and chromosome 10 or C3 and I recently went through these 161 cases and there's a lot of mystic I know it's going to be in those cases stargardian species that have a lot of elastics and probably the remaining that is associated with some of these minor gene associations so the strategy we've used from day one is we know we needed a really robust understanding of the genetics before we could do anything again we're lucky two major genes resources became critical and this is the piece that the pharmaceutical industry just doesn't have access to they don't have access to these human tissues in fact none of my colleagues in Europe have access to these kinds of tissues and patient resources and this has been really important we can do lots and lots of good science but without the knowledge of genetics and the resources I don't think we'll ever get to this place where we're really finding true drugable targets for these genes so just a little bit about the genetics chromosome 10 as I said contains these two genes arms 2HTRI1 it's been a real enigma as to which of those genes or perhaps both of these genes play a role in actually causing the risk for the disease it's very interesting genetic block strong like each disequilibrium but it becomes quite simple after you make your early complex and there's a single variant there's a 69S variant tags all the risk for the disease at least in the populations and so that makes things a bit simpler the chromosome 1 locus is a little bit rougher 360 kilobases contains complement factor H and a truncated isoformal of factor H called truncated and 5 would be so called factor H related to this number of course one group 5 if you look at haplotypes across the smoke list a couple of really important points to review there are two major risk haplotypes not a single risk haplotype more importantly two major protective haplotypes and those protective haplotypes are the most significantly associated haplotypes with animal being but skewed towards the protection and that's really very prominently in our thinking about developing therapeutic risk for disease in addition to things we're talking about there's a neutral so and I'll leave you with one clinical product if you're doing genotyping we say oh my patients carrying one risk that we don't fact rate so he or she is at increased risk for developing the disease it actually turns out that that's not true if this major risk is present with the second way of its protection that this locus rules the day every time so we spent a lot of time in Iowa looking for biological relationships between chromosome 1 and 10 biology and we were never able to identify a direct biological interaction between those two pathways and that has held true we should have thought about this a long time ago as I've gone around looking at patients in Africa, Asia and Easter Island one striking observation is that the Africans are mostly characterized by tourism in fact we've seen maybe one promoting neobascular mentioned that's due to indeed our African cohort from Asia on the other hand the disease is primarily neobascular and very little in the way of cruising about preceding disease development and it turns out that the African genetics all skewed towards chromosome 1 and the Asian genetics all skewed towards chromosome 10 more recently we've seen a lot of skewing towards chromosome 10 in the Native American population in others so it turns out Caucasians are a mixture of the two and it makes an interesting sense but we thought at that time wow this is probably two very different diseases so we need to really dig in and look at what is chromosome 1 doing all by itself in the absence of 10 and the reverse and so we've done a lot of that and I don't have time to show you today but we've addressed this like the ocular level genetic mechanistic gene expression that goes on and systemically through blood biomarkers through blood cell composition, post-sacridating disease and the message that I really want to leave you with today is that we strongly believe that macular degeneration is at least two major diseases and it means that those diseases that a lot of patients will carry both diseases and here's one example one of the early examples with genetics if we reach into these comoras that we have from Iowa, Melbourne and Utah and we look at the association of what I call pure chromosome 1 which are homozygous risk at 1 with no background risk at chromosome 10 and pure chromosome 10 risk at 10, no risk at 1 and you look at the association with AMD, you see that strong association of both genes they're both driving geographic heterogene and colloidal male vascular disease but the striking observation is chromosome 10 does not associate with early stage disease and that means basically drusen that doesn't associate with drusen formation and if you dig in clinically and start pulling out these groups, these pure chromosome 1s and 10s but you'll find that the chromosome 1 group is driven by the formation of drusen drusen are much less prominent in the chromosome 10s and you can see a lot of other clinical features that are different between the two there's this obvious of the nerve issue that's used with chromosome 10 we've been chasing that a long time and there's a whole plethora of differences between chromosome 1 patients and chromosome 10 patients I'm going to go through this very quickly since most of the audience is clinical but if you just look of course this drusen observation comes springing out chromosome 1 patients are strongly associated with the development of large macular A-rats grade 3 drusen and the macular pigment epithelial attachments 55% of our chromosome 1 patients over the age of 60 show this phenotype in contrast to about 8% of our chromosome 10 patients histologically you can see there's a crowd donor that had large soft macular drusen, you can see the phenotype very nicely again chromosome 1 very much characterised by these sub-RPP deposits pigment epithelial attachments and interestingly in the donor eyes very often the separation between the RPP and the gross family which I think is important from a biological reference chromosome 10 patients very little in the way of drusen, you can see there's a little drusen, they tend to have these particular drusen that don't move or change shape ageing and the retinas, I think you all appreciate it, if you look at these on Mars like this, the retinas seem better than the chromosome 1 patients chromosome 10 patients histologically if they do separate, they separate between the retina and the RPP, so a very different separation Phil Luthert, a very good pathologist from Marfields was here in the last few weeks looking at this, he's looked dodgy and then you remember they're all fixed in the same period of time, so we're working hard to quantify what the differences are but one interesting clinical observation is the chromosome 10 retinas are thinner across the board, it'll incubate to about 40 or 50 years above the age the retinal and paroidal vasculature is far less dense in the chromosome 10s than it is in the ones, you can see that here, on average about 30 to 40% lower vascular density, we thought we could really dig into this heavily with OCT endiography and it's just not quite very much, so we'll have to go through it on our way. Fluid distribution in neobascular phenotype are very different from the chromosome 1s and 10s, the chromosome 1 patients strongly characterized by the accumulation of sub-rep and the E-fluid in comparison to the chromatone's chromosome 10 patients characterized primarily by intra-retinal fluid. Phenotype, you can see this was grading, it was done I think Al said in the back, Al helped us a lot with this early on. Chromosome 10 patients varies much towards a classic patient with classic CNB as compared to chromosome 1s which are graded primarily as classics probably speaking to the type that we invest in this issue and we think that 10 is largely associated with that patients and it's certainly shown that to be true in Japanese. The response to anti-vegeta agents varies dramatically between the chromosome 1 and 10 patients basically your patients that take injection after injection and kind of maintain vision are your chromosome 1 patients. I don't have a lot of time to talk about the biology but the biological manifestations of these two disease are also different. We've seen incredible associations of histological features with 1 and 10 basal laminar deposits for example strongly driven by chromosome 10, compared to chromosome 1. Serum biomarkers blood composition are dramatically different in the two groups and I'm going to show you one example gene expression which is really getting down to the nitty gritty of what pathways are chromosomes 1 and 10. And we've been very fortunate this relationship without again the one thing that it did do is it gave us the opportunity to run this huge gene expression study and basically without going into details we used 7 pure gene type groups with about 50 donors and 50 patients per group 1400 total samples and this platform is particular platform we used was called the Dioxon Hip Platform 6 million probes for 23,000 genes and we generated about 8 billion data points. But more than any other experiment this has really started to teach us about pathways that are driven specifically by 1 and 10. There's no good way to show that of course so this is actually this is real data and you can see that there are dramatic differences in gene expression profile between 1s and 10s and we looked at macular extra macular RPE corloid retina so four pieces of tissue were each done. What we have learned we've learned a ton about ocular sites of gene expression and that becomes particularly important on chromosome 1 where is component factor H actually being made and we've had some surprises on that front. We've learned a ton about biological mechanisms and we've been able to use that data to go back into the SAM lines and show that yes indeed those mechanisms truly are active. And we've learned a lot about potential targets for drug development. So I'll give you one example the complement system is of course comprised of about 85-90 different proteins and for the first time we have a very robust understanding of what's happening in the back of the eye with the complement system and that becomes very important when we start thinking about is factor D antibody treatment really the right way to go? Do we have any data whatsoever that factor D is up-regulated or down-regulated in the back of the eye that we need to inhibit it? And that story goes on. We've had a lot of surprises here and we've been able to take that gene expression data and combine it with RNA sequence data and functional data and protein distribution data etc etc and really show that the pathways that we think are good candidates for drug development truly are that. And I'll leave you with the message that really these are just examples of haplotypes across that chromosome 1 locus and their association with the presence or absence of macular degeneration no AMD being the brown bar, the AMD being the blue bar and we can certainly see in the case of chromosome 1 our therapies need to mimic this highly protective haplotype in the form of the disease. I think we would have probably had drugs with patients sometime in 2017 that we would have been able to maintain the allergen relationship but we are ready to treat chromosome 1 and we're ready to do it in the right patients. Chromosome 10 I would have stood up six months ago and said it's a difficult locus, we're not making much progress but the team has really made some important discoveries and I think this very complicated locus that I described early we are now in a place where we think we have really found a region of frank causality within that locus and that knowledge is really quickly pointing us to the mechanisms that are active in chromosome 10 disease and hopefully next year I'll really be telling you the story. So I'll leave you with a few messages hopefully that all of you will take on is that AMD is very very likely two distinct biological diseases. Do these minor genes play a role probably modulating to some degree but we've looked at that a lot using the same strategies and we don't see a lot of these actually being causal from every challenge. We've learned a lot about the entertaining biology of both chromosome 1 and 10 directly disease. We've identified critical pathways and mechanisms and targets we're really at the place where I think of chromosome 1. We're ready for developing treatments of chromosome 10 a little farther behind. And I think I hate seeing this situation out there where I think potentially good drugs and failing trials because of lack of this and so certainly one thing that we'll do here at the Moran is group our patients appropriately for trials. I envision the first trial with the chromosome 1 directed drug to be directed towards chromosome 1 patients not with the chromosome 10 in the background. Two very different pathways and I think it's obvious why some complement inhibitors have failed with trials because they have a huge amount of chromosome 10 so let's not lose potentially effective drugs for the long distance. So with that I'll stop happy to take any questions. Great. Fantastic. Here's a chance for me to talk about commissions here in the room. This is an example where we very much need to be involved. He's got a group ready to look at patients but who's seeing the patients? We are. And the groups they need to look at they want to look at people with macular degeneration the more we can get the more robust and it's hard to look at them with a different shape but that can be young. Also interested in people who are younger but the family has been macular degeneration and frankly probably one of the shortages of people who are older who really don't have any changes in the retina at all. Those people who are 7 you seem to have been losing what I call a super normal and if you're not sure that's fine but if I found all you need to do you can say listen we're really working hard on macular degeneration and often these people who have a family history or they're older they don't want people to say could you give us a few minutes? You have your clinic coordinator they'll talk to Jim and her team everything else is taken care of and I can't complain about it but all of us seeing patients here can help dramatically expanding those cohorts to help us to where we can further understand this disease and remember the future treatment is going to be pure wants pure 10s and there's no place in the country that has large groups of these and we have large groups in the party so just a shout out in regards to that all of us can be involved I think it's going to be really important yes they hit the ground running we do want to move this and the new core treatment is getting at the basis of the disease Thanks Brandy, I appreciate that I also want to you know remiss not thanking those of you that are out here as you know in the last month a new in-day has been approved which is on raindrops last year and camera in-day was approved so we know that these in-days are coming down like and we want to know if we can offer them recommendations and I would like to acknowledge my colleagues who have helped me throughout these last six months working on this project and I do not have any financial interest in any of the products I have mentioned here in terms of lasers and I also want you to know that most of my co-authors also want financial interest except Dr. Jerry who does not stock in the actual focus is a small aperture corner in-day which is 3.8mm around the outside diameter 1.6 in the central pinhole area the size of it is almost the size of a red blot cell which is about 5 in mine comes and the material is very similar to the material that we see in the haptics of the big piece lenses the concept is very simple the concept of pinhole effect it simply increases your depth of field the power it does not have a 1-doubter add or 2-doubter add it simply uses the pinhole concept that we are familiar with in order to increase the depth of field theoretically it should not impact the distance and this is a good demonstration of that how we can increase the depth of field by using the control effect the way it is inserted is with the assistance of the anti-second machine it creates a pocket not a flap it creates a pocket along a certain area and then it inserts a special insert in the box the FDA approved this technology in 2015 by April based on a 6-year result primarily on the safety issues the labeling of this primary populations were between 45 and 60 and these patients need to be amateur that means they shouldn't be wearing any glasses for the distance they should be wearing in the range of 2020 to 2015 depending on the type of glasses now let's face it in the artifacted world most of the patients knock on our doors and ask for vision correction surgery it's hard to find someone who is purely electrocuted with a very small refracted arrow many of our patients can have one of the outages of refracted arrow in terms of sphere they may have some stigmatism which is more than 1-doubter add or 2-doubter add so when the patient comes to us and they ask us with enthusiasm for in-days of some form they tell us that you are not in this window of population what can we do for them and this is where a lot of the European office have looked and said can we amateurize these patients can we take their myopia down can we take their stigmatism to this level bring them to this sort of refractive error and then put it in their eyes when I looked at the data that has been provided to us by the FDA and we look at the bar graph 91.9% 92% of the patients who are slightly myopic that means their rotations would be minus 0.75 and zero these patients did a lot better when it came to near visual acuity compared to the other borrowers 76% of patients were slightly hyperbolic so when it comes to the camera in a specifically I personally think it works better on patients who are slightly myopic but when it comes to range drop if anything is better for patients who are slightly hyperbolic and based on this and based on the a lot of the European experience many of us who are interested to use inlays in our population mean to word the camera pinhole aperture inlays for patients who are slightly myopic and this is nicely shown here so how does this help us this helps us to understand that the patient who is minus eight or minus four and has two or three doctors of schismatism and if you're trying to bring this patient to a level that can be affected from the camera in they bring their non-dominant eye and leave them approximately minus 0.5 to minus 0.75 myopic in their non-dominant eye and many of these patients could be 57 or 58 years old and then impact the camera in they in them either consecutively or in their non-dominant eye this is a de-focused curve which is simply showing that if you shift the focus from planar to minus 0.75 it can actually increase the amplitude of the patient's capability of seeing by 2.75 doctors in terms of depth of focus so the two questions that many of us have can we combine this, can we mishmash it and is it going to be safe or should we do basic which one is better and this is simply a preliminary result based on about 42 to 45 patients in which are not studying that we have had for the three months and six months, the six months data actually has an attribution and goes to this time 10 patients in the basic on and about 36 patients in the PRKR but before I go there I think that it's important to talk about centeration, centeration has always been a challenge in the practice surgery from the time that the country case here was teaching us the RKs and from the time that we went to use X-ray lasers and this first generation X-ray lasers where we didn't have an eye tracker we really don't know where is the right place to place the application or where was the right place to put the RK incision, is it the prematurely flexed one, is it the center of the pupil this dilemma has been with us but when it came to eye trackers we simply learned that we should just focus on the pupil area aperture and we should simply update with respect to the pupil area aperture and even now that we have gotten sophisticated with the femtosecond assisted cataract surgery and we see all this multiple focal lenses, many of us have learned that when it comes to a large angle cap on sometimes between 0.5 and 0.7 the multiple focal lenses are not placed with respect to the angle cap on and the prematurely flexed one you may not have a big result so now we realize that centrations become even bigger issue than ever before and that also applies to high probability laser with long large angle cap so when it comes to the camera index where are we going to put it are we going to put it with respect to the pupil are we going to put it to with respect to the prematurely flexed one and it's been shown that there are some studies that it's better if you actually places with respect to the prematurely flexed one, but many of us that still feel uncomfortable to do that try to center this in somewhere between the pupil as well as the prematurely flexed one goes back to intact span high probability laser in the same concept applies centration is primarily done somewhere between those two spots and there are different techniques for that there are different diagnostic devices many people have an opn scan some people have a ray tracing technique by Sherry's principle so you can use these machines in your practices I don't have any financial interest in any one of these things but you can use this in order to see where the angle cap is and where is the entrance pupil and where is the reflex and by using that you can actually have the data shot, take it to the operating room and use it for your mounted focal use it for your camera angle and this is a good example of topography guided centration of the barrio and it actually shows both in the optical and photovoltaic and also the percange movements so this is another device that people use which is called the active target again another device that helps us to have a numerical understanding of where the center of the pupil will be with respect to this is the center of that and this is the center of the pupil and in this area we are lucky because these two are very close but if somebody had a more nasal angle the percange movements would have been here and then the center of the pupil entrance is here and where would you put that and it would come between them and the beauty of such more diagnostic devices is for example active target for the others when you put the camera in there later on you can go back and actually see how often you are with respect to the pupil and how often you are with respect to the percange and where it becomes significant and again you can take a snapshot of these things if you are operating you know whether you sit temporarily and superiorly you can use this for your mounted focal implantation your in-day whatever I love the mastel, personally it's a very simple device it's a huge diagnostic machine an expensive one but it gives you a fixation point that you can use throughout the procedure and you can fixate on that and can give you an idea in terms of this there are machines, the X-immer laser that some people use in order to tell them where the center of the sight is this is another one where the patient is looking in there, they are fixating this is the Visex laser you can use what we have at hand to help us in terms of saturation I simply want to show that what we are doing here is I am placing some ink mark trying to have where the limb is so that they are not interfering to second arm I know exactly where the limb is because you want the incision to be as temporal as possible so you do not induce the stigmatism and then the centration is done with a heavy mark because you do want this heavy mark to be on the right place for the duration of the surgery so it does not dissipate so you know exactly where it is there are three different platforms that can create pockets for the innate insertions and this one is the most common one used by the intralase or AMO company has it again it creates the pocket for us the other one is the FS200 FS200 has the capability of creating your pocket at 180 meridian 9 meridian, 75 meridian and the beauty of that is that if somebody has 0.75 or 1 dot of stigmatism you can actually place FS200 along the meridian that you like so that is one advantage for the Alcon FS200 because it gives you the ability to create your pocket in whichever meridian you want and that can also help with the stigmatism as well insertion again you do have your heavy mark from before hopefully it has anticipated and then you simply place your in-day and the reason here you cannot rely on the patient is because at this point the vision is quite distorted the patient cannot see that's why the original centration becomes critical so in my study design we had one at the in-day at the same time in the non-dominant eye aiming for minus 0.75 and in the group 2 they had LASIK and the in-day in the non-dominant eye aiming for minus 0.75 in fact in aerobic the LASIK part of it the dominant eye of course is on the LASIK accordingly 44 patients in each arm are 45 in the other and 10 patients in my LASIK group 42 in the six months after the PRK demographically these patients overall are very similar preoperatively in terms of cylinder and myopia or hyperopia and in terms of PRK technique very simple centration you create the pocket you insert your in-day and then go to your laser and you do your PRK and I'll try to show that here this video has been already shown on an eye tube website under the in-day section the centration is done based on the information you gather preoperatively based on whatever diagnostic device you prepare the pocket is being created using whatever kind of second but that is what you'd like to have the pocket size is approximately 4.7 because you need to have enough real room in order to place this because if you don't then you won't be able to center it after the placement of the in-day patient is being taken to the X-ray we do not need the places underneath the X-ray laser we use the microscope, the surgical microscope that we use for the cataract or the other procedure we didn't use so much better in order to place the in-day and have the fixation so after the in-day is placed you have to actually physically move the patient so that he can use that optics for the PRP treatment aiming for your under correction of 1.75 diopters the 20% ethanol is used here in order to remove the epithelium and then subsequently the adhesion is being applied the challenges that we have when you are in simultaneous surgery especially in the beginning is if for any reason your X-ray coordinates of your camera in-day implantation is not perfectly centered with respect to the protein G or the pupil your adlation is going to be centered so if I was not careful and I did not put this in the right place the eye tracker is not going to track the pupil the eye tracker is going to actually track this in-lay so you can see that the adlation can become centered if you don't know where to put the in-lay that is why many people advocate you do the PRK you aim for minus 0.75 diopters you come back 3 months later and you put the in-lay because you don't want to do the centered in-lay and have the adlation also be centered that can be very problematic and this is where some people believe it is better to do them consecutively first the adlation pattern and then 3 months later the in-lay and we do have a small supplement for that to see what the data is available to know whether consecutive is better than simultaneous the rest of the procedure is very similar in terms of the scuricosteroids treatment I will briefly talk about that momentarily after we finish with the LASIK product procedure when it comes to the LASIK part initially we all thought well that's not a problem we create our LASIK flap we do our LASIK and then we put the in-lay and close the flap why we don't even need to have a pocket well studies after studies as shown over time that if you do that you actually cause hyperbolic shift because the flaps are only 100 microns or 125 microns whereas the pockets are usually placed at 200 or 250 microns if we place these pockets underneath the flap that we usually do for LASIK you will have some optimal result and you create huge hyperbolic shift over course of time this is the way that has been described in Europe and many places will do and it's quite simple you lift the flap and do your ablation and then there you go you put that at the same time but this has been abandoned over time because it has been taught as well as Europe so we are now placing the pockets deeper as long as the residual strength of bed is more than 250 microns and then the pocket is at that depth then you actually go back and you make the flap either simultaneously or consecutively at a different time here this is the technique that has been described by others and we don't advocate this but I would like to show you one of the first who does simultaneously flap creation and pocket creation within a matter of a minute with their femtosecond device places the camera in a underneath that 250 microns pocket then lifts the flap does the treatment underneath the 100 microns flap so there is only 100 microns of space between the two planes and places the treatments over the camera the problem I had with this technique and we did this on some cannabinoids is that bed is not regular if you create two cuts one after the other and also again the challenge is what if your centration of the intake is not proper your adhesion is also going to be centered because that's how the machine understands although they have shown some good results with that we believe that it should be done differently first the pocket is created then we wait for five to ten minutes to make sure all the pockets are gone whether they are OVOs or not then we go to the contralarrow eye we make the flap in the contralarrow eye we come back to the eye of interest almost 10-15 minutes later and then we make your lumbar cut I'm hoping that this will come this will we'll figure it out it's okay usually it takes a few seconds for some reason it's not doing good but if I get it I'll throw it to Les going back to this so I'll try to see if I can get that shown but getting back to the results if you look at the FDA results and this is the communication that people are back to do when they're talking to the prescribed patients when you look at the FDA results with the camera in rate 91 to 92% of the patients achieve visual IQ about 20, 40 or near or something called a J5 then arguably most of the time both eyes open in terms of J2 or better which is 20, 25 or better only about 50 to 60% achieve that that's the communication that as a surgeon we need to have with the patient because when you look at the data that the FDA has provided that is the reality 91 to 92% of the patients see J5 which is 20, 40 and about 50 to 60 see J2 and if you communicate with the patients that and explain to them this is the outcome some patients may say well I don't want this this is not what I was expecting and that's the FDA enabling the results that we got for both of our groups whether it was for distance or near is quite comparable to what the FDA has right now for the entropic patients and we show that of course the LACI patients always start better than the PRK patients but then they eventually reach almost the same end point even though we had 10 patients in the LACI and about 36 patients for the PRK but here they were more comparable and that is the binocular uncorrected near vision that means both eyes open looking to the in-date and non-dominant eye and this is the monocular distance vision and it shows that the distance vision is not compromised at the end and majority of these patients still in their non-dominant eye still maintaining distance vision despite the fact that they had an in-date that close them with their near in terms of safety none of our patients lost two lines of vision and as you know FDA says 5% or less can lose not two lines of best corrective vision 11% of our patients lost one line of corrective distance vision and that is still what they call it with parameters 58% saw J2 and 89% saw 20 body of what people call J5 and when we look at the LACI camera group again 91% saw 20 40 at near 62% saw 20 25 at near and in terms of safety again nobody lost two lines or more but there were 12% that lost one line of potential vision in J5 that means if there were 20 20 another 20 25 or if there were 20 15 another 20 20 in my opinion as long as this communication takes place there are some patients that have been done the concept of doing them simultaneously if some of these experienced maybe they can do it but consecutive within three months of one another is a very just far-over way of approaching this PRK is always a slow evening but that's the case whether you're doing a pure PRK or you're doing PRK with another modality so whether you do PRK camera or basic camera that in a time is still the same but thank you for your attention Questions for Dr. Marshall Of course it has to be adjusted the question is what about the depth of the camera you have to understand if you have something that is minus 8.2 and the patient has 550 micron hornia and you create a flap of 100 micron for the flap part and do that minus 8 diopters minus 8 diopters is almost going to be another 96 100 micron so you have 100 micron another 100 micron so you really need to put your inlet as a depth of 340 micron that is beyond the 250 micron reserve so some of these minus 8 and they want to get camera and even if their corner is 550 micron you cannot do it with the basic you have to do it with PRK on the other hand if somebody is 550 micron and they are minus 4 diopters you can do it so you have to respect the residual storm of death based on the level of myopia there are some patients that if they want to get their inlet it has to be done with PRK not this G that is always it would seem to me that just trying to kind of physics all I can say is that it is always a downside and do these people notice that potentially their mesopic vision is quite good you are blocking a certain amount of comparison both light and dark there is this really subconflict you really don't see patients noticing that there is a difference in that lower light in some ways in order to answer that question I would just say something would be in all of this business long enough to see how LTK came by and CK came by NTAX came by for many things and many of them are gone and dead and let's look at Hyperion LTK is not here anymore CK is here but we use it for a different thing we don't see you for what we are using it for in chemical concentrations NTAX we are not using it for myops anymore we are using it so I use that disclaimer to say that PRM discussing camera camera is the best thing after the discovery of other things the answer to your question is definitely the best as a matter of fact that is different so if something goes by they can actually get effect from that so my opinion is that if someone says less photons are getting through that area absolutely and I think there is definition of quality of vision in mesopic and then of course we will know that they issue the contrast sensitivity monocularly and there is no impact but if you monocularly there is definitely definition contrast sensitivity not only in mesopic but also in photopic environment but the thing is the camera despite all of the stuff that it has and despite the fact that it can affect the night vision for some patients who have learned to have a suppressed image for whatever non-efficient they have in the past other than as much with regard to the distance vision I was surprised to see that many of these patients unlike the monovision that we do when we do monovision patients call in their non-dominant type of 2040, 2050 or 2060 these patients still maintain that 2025, 2030 even though they have their J2, J3 range which I tell my patients are J4 and J3 there are some that are J1 and J2 maybe because they are younger they have some accommodation reserve but as I said this is a technology for people who want to go after Saturday morning vision for reading their paper this is not for somebody who wants to see not only the war on this novel let me ask you a question and speak as one of our clinical faculty members he now has a very busy private practice at the Black Hills Centenary in Rampant City, South Dakota and he's going to talk to us a little bit about co-managing cataract surgery so that's your answer I'm very grateful to be back here where I trained actually not in this building but in the whole Marine building it's really great to see old friends in the morning people who are helpful and responsible for me having a fun and successful career so it's nice to be able to come back and try and get some information back and this is the information that I never got as a resident because there's really no residency you don't get involved in the building and certainly not in co-managing it's really not a thing that's necessary here but where I am it is so when I told Nick I could get this back in like February or March so it was still clinical faculty day and I didn't have any research to translate for you so sorry about that I'm not gay I don't have any interest in having a talk That's a financial disclosure That is it so I'm right on this trip to come out here and see my son in New York but it is true we get out there in private practices pharmacists and ophthalmologists do have to work together and I'll show you why in a moment but co-management is a relationship where the surgeon can do the case and the patient's regular eye doctor can see them and take care of their follow-up care the surgeon is ultimately responsible for anybody that has a surgery but they can share care involved that's different than a transfer of care which is when a different circumstance stays over to another person you no longer have responsibility and co-managing the surgeon does have responsibility and there are a lot of optometrists out there that want to co-manage their patients there's different reasons and there's even some controversy in the medical world but there are situations where it is totally appropriate for cataract surgery patients so what I wanted to do is tell you how you do it what is ethical what are the rules and how to build for it so I live in the Black Hill which is this little hilly mountainous area in the middle of a great big area of plains and this little symbol represents there in our town in Rapid City we have ophthalmologists and optometrists and the next closest ophthalmologists are like 250 miles in any direction so there is a lot of space out there where they're just optometrists it's a little different than the setting you guys have right here in this valley but what happens when a patient in Eagle View means cataract surgery or a patient in the middle of nowhere these people literally drive a couple of hours just for their appointment so this is an indication where co-managing is a situation that can be helpful and is in the patient's best interest they don't want to come to Black Hills anyway because it's so beautiful this is a picture I took in the Black Hills 25 miles from my house where you can drive through the town and look right at Mount Rushmore and so in Rapid City has 11 ophthalmologists it's only a population of 70,000 but they're all way more busy than what you would expect in normally say 20,000 population of ophthalmologists so let's talk a little bit about the co-managing in my practice the patients have been going to their optometrists for all their routine care for a long time and then those are the ones who typically diagnose them I don't have a practice full of people who come to me for routine care I don't even do my practice is so busy with medical and surgical problems I don't even do contacts and glasses it's not part of what you have to be efficient and so we have to divide and conquer these tests so the optometrists is deciding when that rancher needs to come in and have their surgery and the treatment for their cataract initially might be observation maybe some guy comes in off the farm hasn't seen a doctor for 10 years whatever the situation might be but they decide when a cataract is advanced enough to refer it's the ophthalmologist who makes the decision for surgery so when a patient is referred it's for an evaluation and that comes from the recently updated ASPR's position paper the ophthalmologist is responsible for all surgical care including post-op care and that starts with the determination of the need for surgery so I'll say a sample of what I'm talking about here a woman might be referred by her optometrists for cataracts she comes in with you see the referral note maybe 2 plus nuclear sclerosis vision might be not 2020 and she complains that my vision gets blurry after reading for a while otherwise I see just fine and so in this case it might not be that you need to treat what she was referred for you know during your normal evaluations you're going to find out what their complaints are what are their effects on their daily visual activities but in someone like that you know that cataracts don't cause vision to fluctuate the way that the dry eyes do and you saw from that little picture that she had dry eye syndrome so here's a patient that was referred for a cataract surgery that ends up being treated for dry eyes and in a situation like that you might recommend some treatments maybe send a letter back we might sometimes you end up doing that you might follow up on the patient or have the optometrist see them back but not every patient that was referred for cataracts can or does necessarily need cataract surgery and so I had many patients that get sent back and what we do is we give lectures to the optometrist once a year so they kind of know how to work with the optometrist routinely you know which ones kind of know what to do and you can teach them and so they don't take it personally but when you have a patient like that it's easier to have everyone happy in the long run when you treat them right and when they have real cataract complaints another picture in the black hills I always thought this was school they have this highway where they kind of wrap around in order to get up to the mills last month they had the usual Sturgis Valley where there's 500,000 people on their harleys it's right there one place to come in August if you want to like people watching so when is surgical treatment indicated I adapted this talk from a talk that I went into optometrists but most of the medical stuff I was going to take it out of this talk except I left this slide in just because you should know when cataract surgery is indicated and it's based on visual function and or lens-induced diseases like epimorphic glaucoma or it's necessary to visualize the fundus and then I that otherwise still has visual potential but my optometrist thinks they need a multi focal IOL if not an indication for surgery if patients can see well with their glasses or contacts and their activities of daily living are not affected and they don't necessarily need surgery and surgery won't improve visual function the asterisk there is because there are some other situations like the epimorphic glaucoma type stuff if they can't undergo surgery because of co-existing medical conditions and if appropriate post-operative care can't be obtained so if there are patients who say you know what, I'm going to be out in the middle of nowhere on my ranch and I'm not going to come for follow-ups they don't get surgery some Medicare carriers require more specific when it comes to reduced visual acuity and such so we have to follow those guidelines as well and inducement for surgical referrals coercion by recurring practitioner are not factors that should influence your decision to do cataract surgery you know the optometrist who wants to go out and find which doctor is going to pay him the most money the surgeons who want to give gifts or kickbacks that's not allowable that's not why co-managing is done when an optometrist refers a patient they need to inform that patient that the ophthalmologist is going to see them in clinic so many people come in and think, okay now I'm having my surgery today and you know, sorry you're not having it today and they might discuss options optometrist might know that a patient has used multi-global contact lenses for example or they have used contact lenses for mono vision and when they refer patients that's the kind of information that needs to be communicated back and forth the options for expensive premium lenses or upgrades should not be a factor on who they refer patients to optometrist know the patient so when an OD sends me a referral note and says call me and I call him up and he says, man this this is the guy who is the engineer type that is always complaining every year he comes back his glasses aren't right he's never made him happy that's another important piece of information because that might help you decide if this patient is a candidate for something like an upgrade option the ophthalmologist in a co-managing situation is responsible for the consent the the plan, the options the expectations and to inform the patient or discuss the options for co-managing post-operative care arrangements co-management cannot be done as a matter of routine policy on all patients it's unethical to share the care for economic reasons patients have to consent they have to sign a form that says that they understand what the arrangement is and that they have access back to the surgeon if needed and there's no fixed time you can't have a policy that says I always am going to see the one day follow and my ophthalmatist is always going to see the one week follow you have to wait and see what the patients look like and make sure that they're in a stable condition to go back the patient has to have access to the surgeon now when they're seeing somebody way off in the middle of nowhere and the ophthalmatist is there there can be situations where maybe they can't get back right away if you've got a patient that's a far ways away and has some kind of post-operative problem you really have to have a way to perhaps travel is arranged things like that this is where an ophthalmatist tried to lower the eye pressure and instead of trying to make a little tap on that small paracentesis incision they pushed on the big temporal pericornal incision until the iris came out and you got another surgery coming up you want to make sure you communicate and educate your ophthalmatist in full managing situations and it should not be done against the patient's interest it's not done because it helps the ophthalmatist and it helps the ophthalmologist get more referrals than the ophthalmatist so let's talk about what that's worth the value of the post-operative care is 20% it's 20% of the global package which includes the surgery and the post-operative care if you're doing a cataract surgery and you're co-managing the surgery portion that you bill for is this modifier 54 and automatically the surgeon gets only 80% of that surgery and the 20% is shared between the ophthalmologist and the ophthalmatist if an ophthalmatist sees all of the post-op care they would get that entire 20% so here's an example case cataract surgery on May 1st, the surgeon bills with the modifier B54 for the surgery and Medicare gives them 80% of the total global fee the rest of it is going to be divided up so for the post-operative care the surgeon who sees them will be billing that patient for a portion of that 20% so if the optometrist takes over care on May 12th which is 10 days after the surgery they bill for 80 out of 90 of the days and so that 20% the optometrist will collect whatever percentage that is you have to follow proper Medicare billing guidelines and use the appropriate codes and I think you have most of the private insurances follow the same rules and if your surgery code is upgraded to a complex surgery you have to let the optometrist know because they have to build their co-managing post-op under that same code Medicare requirements do not apply to the refractive or upgraded portions so there's lots of different ways that this might be done and to tell you the truth I don't know what is lawful in the situation but what we do is try to make it so if there's an upgrade cost on a patient then the OD can actually get part of that cost but it has to be at a fair market value for example if they're billing for a total of 10% of the follow-up care then 10% of that upgrade might be something that seems as a fair market value as well so when it comes to the premium lenses I think optometrists are very helpful like I was saying they know the patient they're happy to see them back they're excited to see new technologies but they should be familiar with the options and they should not get kicked out and like I said before I think there are places where surgeons kind of require or incentivize ODs with premium IOLs and that's not ethical communication is really important pick up the phone call your optometrist you're working with if it's somebody new or you haven't worked with them before make sure you find out if they're comfortable with that have they done an optometry fellowship where they've seen postdoctoral care have they been in a situation where they see a lot of that invite them to come and watch surgery so they know exactly what's going on I've had a lot of optometrists come into the operating room and watch cases with them make sure you send notes back and forth especially if there's anything unusual if a patient had a high fall of intraocular pressure and he added an equisopressent drop to their post-op regimen and they're in a situation where they're maybe following up next time with the optometrist make sure they know what your plan is what pressure expectations are and what to do with the drops and that's it a little bit different but I do some research too but like what I do is those kind of FDA trials where there's multi-center things and I need sites to do cases for a phase 3 approval but sorry I know nothing to translate Brett? Terri, I think you know especially in a place like Rapid City where like you said, access to care is so difficult for people that live next to each other this model is really effective and I think the fact that you also combine the education piece by giving lectures for the optometrist to go to for bringing their level of expertise up is a really important part of that Thank you, thanks Dr. Spencer It's good to see a little bit of an idea of what goes on in the real world and so as much as we don't like to admit that we're not in the real world here at the Moran Iset we're all in the real world for residents we're going to go on So the change of the topic is quite a bit I'm a biochemist molecular biologist and I think I was invited to present here because I do some sort of translation My topic is seriopathy and my body or my chin is called AQC1 or AQC5 and it's very complicated it stands for AQ domain containing protein B1 or an ever-systemed R This protein when mutated causes seriopathy syndrome in patients and we are producing mouse models to replicate or see differences in the model in which the mouse uses applications in the same chain So seriopathy syndrome is an autosomal excessive disorder developed twice by metamorphosis worldwide prevalence is estimated to be non-linear, so relatively rare The disease was discovered like more than 50 years ago and here it was published in 1961 at Dr. Seymour Dr. Wilken who gave it to me There are only 6 genes involved in seriopathy syndrome that are called MP8P1 4, 5, 6 and 10 1 is still unknown and I have 2 students who are known as genes 1 is the first and 1 is the 4th and 1 is the 2nd and 1 is the 3rd and 1 is the 4th and 1 is the 2nd and 1 is the 4th and 1 is the 4th so receive the survey and for that of which the mice you see within kidneys becomes smaller, which I'm here. They don't get it. And with all these studies, I insist on which of the mice we see. So it's fine. On mouse, the form of Jesus, not generally, it's not a gene, which does not cause rapid interrelation just in the form of Jesus. So the high diseases, like mice, pigmentosa, or LCD, we have a congenital analysis in the world. It's pretty long to look at you, or concussion, or inflammation, concussion, abnormalities, abnormalities, and comets, and eventually, they don't have problems. So I just, I made this picture to show you the complexity of the form of T-sync in the first 16 genes, going from 1 to 19, and all those different colors of different domains. Proteins, CTC, gets virtually no relation to the one model of those proteins. There's no sequence similarity in the function of all those proteins. The proteins cause signal form, causing signal differences from in the yellow, and in other proteins, in other mutations in those genes, cause negative syndrome by the real syndrome at all, and the real syndrome, which are synoptisms, synoptic synoptisms. So I'll just give you a very short introduction to the photos of the nomenclature sitting on the same page in the rest of my presentation. Photosurface, and other segments, and other segments, they're connected by those places we call the connecting cell. And it's known in transitions, in transitions of only a few seconds. And you see all the lots of bases continuing forward to social cascade. There's an axonene, which is basically the backbone of the other segments. And, you know, they're made in the advancement of the axonene to give you all the language that we use in the next few slides. The axonene is one of the single microtunnel dimensions. The transition zone is a double microtunnel. And there's a basal body, which is one of the two central nodes in the cell. The basal body, which is important for general transitions of the axonene. And then there's a total center. So, also important is what we said about the second development. We have to look at this from the two of the series of pages. We see that it's one of the main nodes. And basically, it's one of the projects of the cell. And in P3, it pushes a little bit from the main basal body which will be a transition zone shown here. And eventually, it's important and also important solution in here. So, this takes by three years from birth in Mars. And we are mostly in the state in locations that change this arrangement of the length of the second foundation. So, the basal body, as I said, is very important for the basal body and axonene. Very important for the basal body and axonene. Without that, the basal body will be well-instated. So, this shows you a state problem in the final paper. It shows you that all of the subsistence are closely connected. These are directly or indirectly on the molecular axonene cell. This will be a result of transitions from the basal body to the axonene cell. So, now we get to my protein and you see that it has several components. One is for the maturity which is a kind of rewind type. The CC is a very region for protein interaction. And the CP is the site for interactions in the system. So, molecular migrations are associated in the same way as in the original axonene cell. But, we don't know exactly. So, since the disease is recessive, we were planning to make the knock-out mouse. And for knock-out mouse, we built in a certain gene type and now we have the gene type based on the influence translation of the molecule shown here. So, this top side is the gene type based on how the protein cannot be made. And the evidence in the knock-out gene is shown here in the control. You see the inconsistent part of the gene type. So, look to the ethnography we have P14 with multiple isopropyl. We see that the mouse is blind as the response is in the protein. This is photopic for hearts and photopic for bones and bones are not active. And the mouse is the gene type of the gene type of the gene generation of bones. Now, this gives you an idea of how what opsemin is and how other segments are developing with what opsemin is and what opsemin is to which pigment will be produced in other segments. We see slowly developing other segments in the form of very strong. In the one opsemin address we see more of the segments developing and opsemin is focused on the inner segments and eventually about the gene generation and we see essentially one robot working by a still person at G30 which also happens with our corresponding structures and we see there is relatively rich generation in the first two weeks of age and after I'm opening up a team that's a very rich generation and I'm a teacher and a teacher and a teacher. So to all surprise we give this a completely normal this is a intersection and a long year of age where we get the result so that's normally from thesis in our model so it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not as it is not Now looking at mechanisms, why do we have a future innovation? We decided to do force conceptions in an assay, in that manner. And you see the force conception here, in all the other segments, in the other segments, in the other segments, and you see something really new here. This is what a model for each year of P-center to a passive body of proteins is acting very strongly with the transition zone in the second century. So it goes a lot in the environment, and you see the transition zone is formed using the user body and the valid center of these other segments. In the layout, we don't see, we see a passive body in the fourth century and we don't see transitions on the experience body on the second century. In this seventh experiment, there is a protein called pomegranate. Pomegranate pomegranate is located in this pomegranate segment, and it's responsible for formation of disks, and you see in the layout that this protein is localized, it doesn't form this pomegranate, approximately this, and it consists in this lack of basic formation. On the brutal structural level, we confirm that the control of the pomegranate forms the years of the zero body, forms a very nice transition zone, and really the lack of membranes, which you actually want to see in the fourth century, and the control of the pomegranate is the base body and the very bit of the extension which resembles this pomegranate transition zone, which is a solid pomegranate transition zone, and at an age of 10, you see all the second formation in the control, basic pomegranate transition is found in the excellent pomegranate segment and in the same pomegranate segment. So what we have learned is that in the age of 5, pomegranate was made during the phenotype of this LCA in non-syltonics utilizing the generation of mutant blood photo-services completed at one month. Mutant in this to not develop the form of fuses, no silver or pomegranate pomegranates are known for this type of transition zones and abstinence in larger segments of our absence. So we would like to know more details about the pomegranates. Pomegranates are important for the alive vision which we can think of as a way to last three pomegranates in this mind's revolution and restore it. So the way to go for pomegranates is to make non-normal pomegranates using another transcription method, another similar method which we can see that is written better. It is required to watch the volume. If you get rid of this gene while you're not out, you will make the mouse that has 10 pomegranates in the pomegranates. So that's, of course, one of their most experimentary parts in the vital pomegranates, where the pomegranates have 10 pomegranates and 97 pomegranates are once. So we can now, with this mouse, focus on this. And you see here the volume of the pomegranates comes from 15 to three months into the pomegranate mouse. And you see again the center of the transition zone and the volume of the second pomegranates are performing. And the volume that we will receive is this pomegranate pomegranate and the control we will receive are the two centrioles from normal transition zone. And surprisingly, at three months, we have essentially a voltage generation of pomegranates. So we have a speedless integration of at least three months of that pomegranate generation is basically very, very slow. And we have a window of three months or longer for gene therapy, for gene therapy, for placement therapy, paying to a specific cost. So this will show you again, pomegranate thickness, it doesn't change for pomegranate pomegranates and that's what we will be able to do. So in this part of the experiments to come up with the virus for gene therapy, on the left is the vector for transcription and tissue processing. And this will be the result of the people producing the virus that can be injected into the software from space. It's passing that persistent call and hopefully we will be sure that we can see the changes in our second convention in the last six months to visit. So I mentioned at the beginning that we have time to do a similar experiment that's in the age of 10. And the age of 10 is known to our senior workers that are in human relations. And so far we have produced a moth and received a moth that produces a moth and it seems to me that in the future time it's like six stitches and unfortunately the moths does not survive. It's a new moth, just a moth. So the future of this kind of experiment is to make the tissues fit for that most specific outcome and maybe in five, in the second, in the second, or in the case of therapies with an age of 10 months. So this is the summary slide and the age of five moth we will see when it comes to senior workers in time and the number of years and months to keep on the right amount in this time order and with the rest of the time we will see the number of moths that forms the best for them and survive up to three months or even six months in the long term. This might be satisfied by two or three months each month but the research of the time is still going on in the foundation and the research foundation is still going on Thank you So Wolfgang, obviously fascinating and indeed if we could figure out how to do a couple broad generations of moth make that disease The chances are very good in moths but I can't guarantee you that in humans does that make because for most of you it's a large step a large channel it is a dog model for senior workers which we find so if we can do it in a dog model we have modifications of the shuttle vector and the virus we may be able to make it So I don't know if you've mentioned but Wolfgang's our record research and as well as all of the other workers he's doing and we're very proud of the outstanding work he has and Nico who he's talking about is one of the workers I think he's on call He's not on call He shows you about there's this interesting foundation of the people working together I actually wanted Nico to present but he said he's on call We do that too and he's probably going to run and anyway it's very exciting how you've gone through this and the potential to change the home side but it's a great experience for us to keep going So your mouse follow of the H5 most of the LCA type but in humans it's not quite that bad but you've got a great record so it's interesting to see what you're doing So this is a model of human to want to know where to come I have many genes which cause LCA and human are not dog we have some people having dogs So and there's a dog model it's the same potential it's eventually a potential in the future and this dog has a link on that so there is an axon in one the NPHP5 mouse knock out why do you think that that gene is not required for baby development or do you think that there's another gene that rescues the fetus the short answer is the tongue and the Z or the nervous system the tongue and Z have so many nervous systems and some of them can be used to function so it's really depending on the tissue so another possibility in human life would be to stimulate another one of those proteins to kind of step in well thank you Wolfgang and thank you to all the morning speakers we'll break for lunch now please try to come back so we can get back on time at 12.50 and then we'll go ahead and we'll get started with our guest speaker next just one I don't know how many of you know the wrong one I don't know I don't know let's get a photo well it's total we might do a transcranial orbitotomy well we did some transcranial work Dr. Bell is one of those rare individuals who can combine basic and clinical research clinical care, surgical care teaching and administration and it's happened with us last night we had a fantastic talk kind of bringing together the clinical care and basic science research around thyroid eye disease and we're so glad you could be with us that this is really bringing cold to the loop house because your neurophymology group are much more expert in the transcranial hypertension than I am and usually what happens is that like the residents beg me to give them lectures on thyroid eye disease so I never talk to them about thyroid eye disease so I'm assuming that there's maybe a little room for a sort of getting caught up on neurophymology hypertension even though that should be great work to really come out of this institution and then sort of the mother institution University of Iowa that sort of gave rise to the interest in neurophymology hypertension so I hope that I'll get corrected for any misstatements I'll go on so it turns out that if you have intracranial hypertension it had a few other names in its history cytotermic cerebride really nobody liked that term because it's had a word tumor and people forgot about cytotermin and then the residents would always get confused between orbital cytotermin and cytotermin cerebride to use them sort of interchangeably which would be great except the diseases are different and then benign intracranial hypertension was actually popular until the Iowa group said you know it's not so benign patients are going blind and we really shouldn't color bias the outcome of these patients in the series by calling it benign so now we call it IIH which is a mouthful and so someone in the audience came for it, I'm sure there's room to change yet once again I'm going to start out with a case this patient is a 27 year old 5 foot 3 woman which in my house is tall but in most places it's short and overweight and she had a history of a renal stone actually she was treated with IV antibiotics including vancomycin but wasn't going to be treated with hepatocytes or anything like that and within 9 days she developed blurred vision and her vision as you cannot see was really reduced 2400 to the right eye, 27 in the left eye and this is like you know the grand fuba of papillodema this is about as bad as papillodema again so this was not your usual case there's a lot of hemorrhage a lot of this swelling in both eyes and the blind spot as you might expect was it was increased to real or simple scatomas in both eyes and here you can see on goldmong fields, yes we still do goldmong fields again you can see that there's a bilateral synchrocentric syndrome a bit about the criteria of endocrinal hypertension so up until very recently it's been modified dandy criteria that we have used and so we have to have the right symptoms headache, nausea, vomiting, visual aspirations or papillodema with no localizing sign but you're allowed to have dyplopia from a non-localized and a 60-degree periscous patient is otherwise in good shape or awakened alert so there's evidence of thrombosis on CT MRI and the LP was supposed to be greater than 250 25 centimeters of water I used 25 250 millimeters and 25 centimeters interchangeably so if I slip it's about 10 times the amount of hypertension and there's no other explanation for the range of endocrine pressure so this is the criteria that we traditionally use and then it got a little bit more complicated and I won't bring you through all this but this is a new classification with Kathleen being involved in this with Doug Friedman who was my fellow and with my institute for a long time before moving to Southwestern and things began to change in terms of what's included and I just like to call attention to the fact that there is such a thing as tumor cerebral syndrome without papillodema and this is kind of a new concept people had intermittently reported well you can high pressure no papillodema I always had a little saying I have a number of sort of maxims that I use for optic nerve disease and the maximum that corresponds to this is that the optic discs are not the monometer of the central nervous system and so you don't have like a gauge sitting there at 260 turns into papillodema and at 240 it goes and you have the papillodema so different people have different tolerances for different pressures in terms of the papillodema but there are other things that have to be present to make sure this isn't a different kind of headache for instance the Bicella that you can have as opposed to your glow and that you can now transfer so these are things just to be aware of that still in evolution exactly what we mean by elevated intercranial pressure so what are the hypotheses well because we don't know everything to say is possible so Dr. Shugerman did a bunch of studies where he said these patients are heavy and they have weight on their inferior vena cava and superior vena cava and so they just can't circulate their blood and you get high vena's pressure and this is what the underlying problem is but really it doesn't really fit for most people that this is a logical extension sleep apnea is regularly associated with patients who have IIH but it's not the other way around if you go to sleep clinic you can examine thousands of patients who don't have IIH nor do they have the ILN or all the other things I think that having sleep apnea just means you're more susceptible to chest about everything including IIH for modal influences again patients are women why should that be so maybe there's some hormonal influences but no one should be identified what those hormonal influences might be of course you can increase CSF production and in certain papillomas that involve the core influxes you can actually get increased CSF production and overcome the absorption system this is a perfect term to increase CSF absorption and that's probably what's going on most of the time but we don't know exactly why I didn't see one interesting article just recently we haven't had time to read in detail yet talking about or four defects of being associated with IIH so it would be interesting to follow up to see whether that has validity we often said about functional or mechanical destruction of venous organisms so if you raise some of these into cranial pressure you put the tissue pressure collapses or can collapse segment of the venous system on the other hand if you collapse a segment of the venous system then you get higher venous pressure which you actually do higher into cranial pressure so these are these are some of the ideas but the fact of the matter is that we just don't know and we were hoping that the study I'm going to talk to you about today was going to give us some more clues and it has not been satisfying this one way so the clinical presentation as I've already alluded to is no BCO on women usually with a recent weight gain and headaches that are often constant in the distance because they have abducting empiricis transient oscurations of vision which are usually posture induced in the last seconds of the time they can be in one eye or both some patients do get nausea and vomiting in association with it which really makes it confusing for patients who may be treated for migraine for periods of time because they have nausea, vomiting, and headache and there's another syndrome with pulsopial tinnitus there's a noise in here this is not the high pitched sort of line that is common but rather it's a whooshing sound that is sometimes pulsing a mild stiff neck because the increase in the pressure but they roll worldwide so of course you always want to see if we can find a cause so if you eat polar bear liver then you are in fact at some risk of developing hypervitinosis A I think at least all the third year residents know all about Naladix Acacid and I've never seen Naladix Acacid used in antibiotics in my entire career but SIFRO is an analog of Naladix Acacid and can cause the syndrome so that's a good point you're coming on or coming off so it's really complicated it's also used by some people in the treatment of IA so it really becomes complicated when we try not to use corticosteroid head trauma probably from venous obstinosis or temporary venous obstinosis and then this would be a quite a lot of these again we think about venous obstinosis associated with the signs so the the vision can be fine and often is fine as a matter of fact the IA treatment trial had patients who didn't have much vision loss and that's one of the strengths and one of the weaknesses of that study and we'll get to that they definitely have effect, visual field effects of any type and as I said they can have the paracetopathlodema that's used in bilateral and symmetric and I'll show you some evidence of that later the neurologic exam there has been some thought about you know with all that elevated venous pressure the arterial circulation must be affected in some way and perhaps the confusion of the compromise but very few patients would see or confuse your son melin or anything like that so we want to do some tests the first thing we do is to get an imaging test so we obviously imaging first then L.P. you wouldn't want to image something you'd find that the pseudo tumor was really not pseudo and then you end up causing complications by doing L.P. so we get MRIs and MRVs in our institution if the patient is the typical onset we usually don't get MRVs we just get MRIs some places do both all the time because they typically should have an MRV or now I guess they're getting CPVs as well lumbar puncture I mean so I used to do them all myself and the problem was that about four hours a week I was doing L.P.s and then they found out I didn't have hospital privileges to do L.P.s because I'm an ophthalmologist so I had to go back and get privileges improved I actually didn't paralyze anybody or anything in doing L.P.s but now we have a PA who does them under fluoroscopy and I can tell you it's just a wonderful thing to have when you know that person is doing them right because doing them wrong is a real problem you can't say anything about what that patient's opening pressure is if they're sitting up squeezing you know there's a hundred ways to do it wrong they're all equally easy as doing it right but if you do it right you'll get a pressure you can rely on and I'm going to task in those cases having it from both of us we'd like to make sure that there's no underlying cause for this so artist for Eugen who happened to be a fellow with Bill White when I was a medical student and got to know him an individual who is truly brilliant and has done a lot to help us with our understanding of optic nerve he was sort of the premier disc-gazer for decades and he came up with a system of haphalodema that allowed us all to talk about the same thing and so this was what was used in the IHGT study and so just to review and briefly basically stage zero is a normal disc or a not normal disc but with no C-shaped halo that's very confusing it causes a lot of contra-nation amongst all of us and I'll show you why when we get to the results of the trial stage one is the C-shaped halo and I don't always project well but basically what it is is a white fuzzy area that doesn't include the macular-papilla bundle so if you see white around the disc but it doesn't include the macular-papilla bundle then that is stage one stage two is that the halo goes all the way around there's elevation near the border there's no major vessel observation so zero, one, two all depends upon what the nerve fiber layer around the disc looks like three, four and five talk about vessels and so in three there has to be at least partial obfuration of one vessel and four you have to have some obfuration of all vessels and in five you have to have complete obfuration of at least one vessel on the disc and again there's room for interpretation with all these things in general it turned out to be fairly reliable and in the study they were both judged by the principal investigator at the site as well as by photography where Mike came in and so this is what we did in addition to looking at the qualitative classification we actually we can stereo the disc, we can blow them up to the size of beach balls or the disc of the beach ball side which allows you to see a lot of detail and we stereo it we can do a lot of things that help us to actually calculate the area that is involved and when we do that we came up with two different areas so we came up with what we call the area of white which is the halo so the halo goes all the way around and we looked at the vertical and the horizontal and we would calculate the area of the halo and then we calculate the area which we call the dark zone and you can see that on the hill of the papillodema outside the white zone it's still elevated off the surface of the retina and so it comes out as a dark shadow and it also is the inflection point of the vessel and so you can then get an area of dark and we looked at both of these separately as well as together and so what happens when you try to do a treatment trial but here we actually here's an example from a patient in the IHDP and here's what they look like at baseline so this is pretty much all the way around and I think there's a vessel so this there are several vessels obscured this was called a level 4 so there's a presion 4 and then one month into the study you can see that it's still got halo all the way around but now you can see the vessel you couldn't see well before and now it's a 2 and you look back at month 8 there was still a 2 and then 2 into a 1 and then it went to 0 at 9 months so this was a really nice case study of how you can follow Pavlodema look at response to treatment and if you now look at it from the standpoint of the area of white you can see the area of white goes down mostly at the beginning and then it slows down and similarly the total area also continues to go down and then flatten and so in other words this this size is not very much different than this so we have a nice correlation between the qualitative and the quantitative then we took this quantitative assessment and we started looking at it against other parameters and the point of doing this is that first of all it's published if you're really interested in the data it's all there but the really there are a lot of things that really didn't help us very much and so you can see that the curves really are not too exciting there's a lot of scatter when you're trying to correlate it to what you wanted to do so what are the management principles of IAH traditionally we have a few things available to us we have medical therapy which weight loss is the mainstay and we all recommend the patients lose weight of course it's easier said than done in the IAH TT we actually had an obesity specialist crew with each individual's role to lose weight and you'll see they actually lost a lot of weight and then dimoxiracy has always been the mainstay of treatment for 40-50 years but never shown in a class 1 medical study no prospective study that demonstrated that it was useful but everybody tended to use it a lesser known drug so I find very useful for patients who are not tolerant to dimox is neptazine so if you're doing 25 250 milligrams of dimox twice a day you'd be doing 25 milligrams of neptazine twice a day so it has 10 times the potency but it seems to have less side effects so I use it patients who seem to be sensitive to pyramid there are no clinical studies but it is a mild chromatic inhibitor it's really good it gets rid of their headache it helps their headache and it's also a positive present so it really decreases people's appetite and so they lose weight so a lot of people they don't tolerate dimox to pyramid it can cause swelling and closure of the angle so every once in a while you can compound your difficulty Lasix is interesting Lasix is sort of a fallback drug they can't tolerate dimox oh they're pregnant, oh they're this and so we put them on Lasix it really knows good studies that demonstrate that Lasix is really effective patients really don't like it it makes them feel all the time and you have to watch their potassium more in general than using W2O1 so as I mentioned before we want to avoid steroids if at all possible because of rebound on tapering and because the side effects include weight gain and we know that steroids can either start with the onset of using corticosteroids where IH can start if you discontinue it it's avoidable patients who have severe vision loss you can sometimes rescue their vision for a period of time with a short course of stela so surgery is generally used when medical therapy fails and the surgical therapies that have come about have been usually optic nerve venestration and there is one eye primarily for vision loss not for the headache LP shunts which we're trying not to use anymore because even though they work about 50 to 60% will have some complication soon after they have the LP shunt put in they get infected, they get disconnected your lower back is just never made to hold the shunt so ventricular perineal shunting it takes a little bit more skill you have to stereo tactically place the catheter you can get hemorrhages, you can get swelling so it's not completely without problem it has the same effectiveness in all these shunts and even though the initial success rate is high they also have substantial failure rate so it's certainly not a panacea and we and the neurosurgeons hate doing them so it's not like you have to convince them you want to do an optic hernia venestration they're sending them to us to say won't you please do an optic hernia venestration we have to tell them no it's not indicated you really need to do the shunt so optic hernia venestration there are really two ways to approach it I still use the medial approach that was first standardized in the ischemic optic moroccan deep compression trial I think you're looking at it under as much power as you want in a microscope and this is very early on I think John Keltner and in the 70s published this shunt that occurs between the subarachnoid space and the interorbital space demonstrating fluid but there's also been some demonstrations the scarring takes place and some people feel that the scarring takes place may protect the nerve from swelling but also cause further vision loss down the line cause the pressure on the nerve back of the disc is still there and you haven't really done anything for the pressure so I don't know if this is going to it was just a 10 second showing a gush of CSF from a super sharp blade so a long time ago now I guess almost 10 years ago I wanted to look at what the effectiveness of surgery for IH was not done in any systematic research and literature there's much more data on looking at optic nerve chief demonstration because ophthalmologists were seeing those patients in visual fields but if you're being referred from a neurologist to a neurosurgeon or to a neuro radiologist they somehow never stopped in the ophthalmologist's office and so most of them just had subjective my vision's better because they had a visual acuity on them which is a very good measure but basically what it demonstrated is that we really don't have too much data on many of the surgical procedures except optic nerve chief demonstration which has like an 80% effectiveness so this is in terms of vision improvement 80% so it's pretty good pretty good thing to do if the patient's playing a vision law there's not that much to say about it so it's a headache because of course ophthalmologists never send their patients to a neurologist so they can ask about whether their headache is better and so we don't really know much about the effect of optic nerve chief demonstration on it so let me go through this is a Michael Wall slide so these are part of the official slide set of the IHGP and this has all been published now and I'm going to show you a few things that haven't been published in subsequent in the initial so here's the steering committee and you can see that we have really good representation from Jim Corbett the treatment and Mark Coopersmith, Michael Wall all people who have really invested interest in IH over their entire careers and here was the study it was diet plus placebo or diet plus I see the zolomide and the zolomide could go up to four grams so the deal was if they could drag themselves in the office and they weren't complaining too much you increase the dose you kept increasing the dose and normally I would say the clinical idea was you got to two grams and you pretty much stopped but now we feel much more comfortable with the two grams in order to get that effectiveness and so and then you monitored them in the chronometry with the outcome measure and the output to dispose was taken at regular intervals and at six months there was a statistical comparison of these two groups here are the centers and you can see that I don't think you're that far north north north north okay well you can see that it's heavily east coast based I guess we have more patients that have the disease or something but Rochester was one of the centers than there was another center but there was involvement across the country and actually in Canada what was then what was the the EMI and this cohort and it was hefty you know so I think the definitions of obesity is more crazy than 25 correct so these people were obese, obeser and obesist the initial symptoms of IH headache and vision loss was the first two and then there were a few there were a few that were asymptomatic look how what a small percentage actually had leukemia so I think it's overemphasized that you should have leukemia and the frequency of symptoms again headache and PBOs are the most frequent interestingly back pain we don't know if it's back pain before or after the LP but certainly one of the complaints also about tinnitus dizziness which is interesting because one wouldn't expect necessarily to be busy photophobia perhaps but related to headache and again neck pain vision loss so you can see the relative frequency above many symptoms that occur some expected and some unexpected so John Kalbner tells us that this is the most common fielding effect of experience which looks kind of like an arcuit interestingly the lower field seems to be more susceptible than the upper field how about the severity of papillodema well this is a nice bell shaped curve remember that these patients really didn't have more than a couple of dBs of depression on their visual field and so we are seeing only a mild IIH cases and it's interesting that it's sort of a bell shaped curve around grade 2 to grade 3 and almost no grade 5 and of course there are virtually no grade 0s and in the study there were some in the non-study one of the things that I wasn't published is what was the symmetry between the eyes so this is a calculation that I performed in my lab looking at symmetry and because unilateral papillodema is always a differential diagnosis so could you know is this ischemicopic neuropathy or papillopathy of some sort or is it optic neuritis or is this IIH and so it turns out that virtually almost all but 5% had within one grade the inner direction of the study on and that's really helpful to us I think because more advanced IIH patients have bilateral disease but even in the milder disease bilateral is certainly the rule and again you know we looked at the relationship of papillodema to visual loss we really like to say well the less edema you have the better your pressure and the better your vision didn't work out that way at all and similarly we said well you know if the denominator of centromerosis really is the optic dose there should be a really good relationship with the PSF pressure and with immunization and that didn't work out too however what did work out is that we found to .05 level exactly that there was a benefit to using a C-to-Zolamon and in doing it by increasing the doses in the way that I've described and most of the effect took place in the first three months and so after that you can see that these lines are almost parallel between the placebo group and the C-to-Zolamon group but what you see is that as soon as you've got an improvement immediately in the C-to-Zolamon group within a month and then but not in the placebo group and that accounts for most of the difference what about symptoms well you can see here that the C-to-Zolamon plus diet seem to improve PBOs Fulclopenditis Phobia, Neck Mane and visual loss very nicely the diet seem to improve the cognitive the diet alone with placebo seem to improve some more major symptoms like cognitive dysfunction that will be announced at a particular time so that's not too unexpected percent improvement different over six months you can see that with the C-to-Zolamon that you've got tremendous improvement in trans-individual obsturations some improvement in headache severity and some improvement in the frequency of headache so what was the average dose of medication well it turns out that if you you needed a lot more placebo to get an effect if there was one but so that's not too surprising what was surprising I think to most of us is that people tolerated 2.5 on average and many people were actually on the ground today and the effect of C-to-Zolamon on freezing grade was fairly significant the effect of placebo so how many treatment failures were there there were seven treatment failures in this whole study which basically says you can leave most of these patients alone on the other hand since we wanted to find out if C-to-Zolamon would actually help it turns out there is a significant difference between the treatment evidence oh by the way I guess I should point out that all the patients who failed on freezing on freezing scale this is just shows you the change in applevene grade in the worst on over time and you can see that even the placebo did pretty well it gradually got better but they never kind of got down to where the C-to-Zolamon group is and this is just reminding you again the progression of grade 0 what's interesting is to look at baseline in six months so here's the baseline up here and you can see the sort of distribution normal distribution in both the baseline study group but then when you look at six months you can see that the lower number of 0 and 1 are predominant in the C-to-Zolamon group but you're still somewhat normally distributed in the C-to-Zolamon group this is again something that isn't in the study it's just a little study I did which says well what are all those disc hemorrhages being and what you find out is that patients who failed have a lot more disc hemorrhage but on the other hand they were also higher grades of applevene mode and so when you have high-grade you might need to have a disc hemorrhage I'm not quite sure what it means but I now know that disc hemorrhage is not a good thing to see one of the sub-studies was to look at OCT and to look at OCT volumes of the NERD very interesting study so here you see papillodema grades from 0 to grade 4 they didn't have any grade 5s in the sub-group you couldn't measure them and you can see that it's a pretty good correlation that as you go up in papillodema grade you get more and more volume and this is the three-dimensional reconstruction of those so it's very pretty and it may allow us to be more quantitative moving forward and here you can see over time this is volume over time you can see the zoolomite group and you can again see that you can use volumes of disc volumes of measurement to demonstrate the differences between the zoolomite and the different people there's also a very interesting phenomena where so this is getting back to umbilical science so we have the RTE that comes in in papillodema and then as it gets better you can treat them then it reflects posterior way to become out of these so this may be assigned to tell you whether the papillodema is a progressing orbit we did look at disc area versus disc volume and it is an amazingly good correlation which I guess one would expect but what it really means is that the z axis doesn't add much in terms of understanding if you can quantitate the differences OCTs might be easier to quantitate than taking measurements using a big screen but the correlation is just amazing between total area and OCT volume and baseline study eye baseline non-study eye and in six months study eye I guess reassuring but stay tuned because we didn't address a whole bunch of problems especially we didn't address patients that really worry us with more severe symptoms and signs by age and we didn't look at any of the surgical arms so we started two other studies the light study which I think has come to a conclusion now and the light study was just to continue those same patients and we were going to see what happened to them long term and the symptoms got bored and didn't show up for the follow-up point and in the surgical side we now have the site and the site is we'll find out probably within a few weeks whenever council meets in October we'll find out whether they're going to fund this project which is the natural extension and the site study is looking again at peremacrine and alleviation but these are patients who have from minus 8 to minus 30 to be lost on the big fields at a light 0 to 6 and they're going to be randomized into a system volumizing medical treatment op-ignition frustration or CSF shunting technique so we're going to try to figure out by what maximal medical therapy does versus the same thing that we just talked about versus doing surgery we're going to be monitoring the visual field and now OCP is the other outcome manager and then we're going to look at the results and see how they bear so we really need to get back to that patient I showed you so what do we do with this patient I'm giving you all this data I'm all about this disease but here you have this patient in front of you has 20 terrible vision of both eyes and is probably the clock is really ticking so what do we do the patient has already been taking 1.5 grams per day of dialogue in the time she was referred so I really didn't think we had a whole lot of time to figure out whether or not maybe going to 2 grams or 2.5 grams is going to be infected so she went and had a write-off of emergency penetration so this is great 2040 vision remember that was a really bad 2400 vision pre-operatively she comes back first post-operative visit 2040 and left eye which we didn't touch hand motion so does anybody have an idea of what happened so what happened here's the visual field so in the right eye there's just this big blind spot but overall pretty good and this is the left eye I mean just disasters well you know that was one of my thoughts my thought was is the residents fall obviously the residents is the medical students fall is there an APD there is an APD but not the one you think about so here's what happened this patient had a vitreous hemorrhage probably because of hypervaluations during the time of surgery and it's one of the very few patients I've seen with IIH developed a breakthrough hemorrhage into the vitreous and when I last saw the patient after one of my retina colleagues cleaned all this up this was through his 2030 ride, 2100 on the left side there was no APD at that time and the color plates were back to the normal so just to show you when you think you've seen everything then you get to see one more so thank you very much for the opportunity actually I may have missed this when you were going through there did they follow weight loss compared to the placebo or are they different? it wasn't due to the use of the diamont it was a very sophisticated system because the patient's on diamont lost more weight because it takes away your appetite because they make the color taste bad and your tongue is vibrating all the time so when you took away the dependent variable and looked at it as a dependent variable there was no difference due to the weight of the bone so the first question if I heard it correctly was just about how do I describe the build is that correct? 250 vs. 500 that's how it was for 6,000 so of course they went in 250mg increments for the purposes of the study but I used the long-release 500mg and as I increased it what I do is I ask the patient for the diamonts in the morning and as I build up I'll give them more when they're less symptomatic from their diamont related facts but I don't know there's no study that shows that it's better than the other but you can almost depend upon patients trying to take the medication 4 times they aren't going to take it 4 times today so you're very fortunate to take it twice a day and the other question in terms of you're asking about your kidney stones you have somebody with a history of kidney stones so we had one patient who had kidney stones the patient here who had the history of kidney stones it turns out even if it had a kidney stone you can put them back on and they probably do fine you have to make sure that they're looking at their urine from time to time make sure they're on much more more crystal clear point but in general you can put them back on this patient tolerated and the diamont's fine without any improvement so I noticed in your review from 2007 you had the stent placements as a treatment but you didn't mention that it's been kind of hot in that press in the last 5 years are you guys doing stenting a lot so we're not doing stenting not because they don't want to do stenting but I have serious concerns about stenting and the stents at the time that I published this back in 2007 there were only about 30 published cases of stents now of course there are probably 100 and the stenting these are venous stents so they go right into the transverse sign that's funny so it's like taking a nail and sticking it into the transverse sign and a hollowing there were initially a lot of complications and there were serious complications, hemorrhages and all sorts of things I think the procedure thought it was safer over the years and people were more skilled at putting them in and the shunts are better but the problem is that most centers are not making a really good differentiation between stenosis, true stenosis and secondary narrowing and so because they're all going to get better if you take care of the narrowing then you've taken care of part of the circle, the vicious cycle so it's going to help it get better but if they truly have stenosis it's not going to get better until you do that or until you have a permanent stenting solution so I didn't emphasize it in this talk and it's not part of the cycle so there wasn't a lot of them who we have but what's your experience here we don't do it very often rarely there are certain centers Australia likes to do you know if you're south of the equator there's a different fluid dynamic any other questions thanks again co-chair that has been able most of the time sorry about that I made this slide a couple of hours ago literally after I saw that I looked at the preceding talk and the question is what do these conditions have in common they look pretty different in a way but basically if you look at this what they do have in common is some kind of a pathological stretching or swelling or pushing so there is some kind of mechanical thing so what I would like to sort of address in this talk is can we find maybe unifying principles in all kinds of diseases that are affecting the human bodies and can we find this through understanding a process that is called the counter evolution taking account that pretty much every cell in our body really cares about mechanical forces if we look at the eye for example it is a highly mechanically active environment so I went to Arbault this year and there was a poster showing that just rubbing our eye or blinking or getting up from the bed increases our interoperable pressure with hundreds of millimeters so there is swelling going on activity dependence swelling there is pushing there is stretching so what I would like to leave you with is this idea of this being a highly mechanically active environment pushing can cause coronal obfuscation and so on so there are all kinds of pathological phenomena that have a very very strong mechanical component and what we are interested in many of them perhaps most but what I will focus on is Vakoma basically when we think about Vakoma we think about two things first of all first is how is IOP regulated in the front of the eye and the second thing is what is actually going on in the back of the eye how do these cells sense pressure do they sense pressure or do they sense stretch or what is actually going on this has been a million dollar question thousands of papers have been published and really we have gotten no closer to the answer and this answer is what we are looking for so how we do this connects the front and the back of the eye the likelihood of developing Vakoma it is exponentially related to the pressure that patients have so there is something going on with the pressure and indeed we can increase pressure artificially in the monkey and look at the retinas and you see that the retinas looks look pretty good except here there is this huge loss of retina organism so these guys look at the sensitivity of the monkey for like a base found that the sensitivity loss was actually pretty minimal until the monkey is lost about 50% of cancer cells which is what we see in humans in other words by the time we realize we are getting blind it is over so we really need a mechanism we need to understand how this loss called the IOP occurs what is the molecular magnitude because that is really the only way for us to die most early and that allows us to treat those patients before this so the question here is what is actually going on in the Ganges and the hypothesis in the field I actually all over the place some people believe that retinal Ganges are intrinsically sensitive to pressure other people say no it is actually the glia and it is the inflammation that kills the Ganges there is a strong strain of thoughts suggesting there is an excitadoxic stress too much for some and some people say no it is actually the fetus acid some kind of metabolic disorder and this is definitely the case for higher IOPs another really a Cremonius debate that is going on is whether the first effect of increased pressure is the optic nerve head or is it the dendrons and this is a very important question that still needs to be so how do we put all of this together the hypothesis that I will be talking about today is that all of these things are happening because these cells express higher channels that are sensitive to pressure or to all kinds of mechanical stimuli we can take the glaucoma fewer types simply by activating these channels and we can protect the retina from hypertension by lung or by eliminating them so this is what we will be looking for we are looking at several types of these channels what I will be focusing on today is a channel called Transcent Receptive Potential another device for which is a member of a large super family also called Transcent Receptive Potential it's a non-selective kind of channel and what is interesting about it is it's activated by all kinds of mechanical stimuli from swelling, from stretch but it's also sensitive to temperature and lipids such as our hedonic acid it's expressed all over the body, especially in tissues that are still low bearing stretch sensitive the bladder, it regulates uterine, vascular bladder contractions contractions and it's being associated with mechanical hyper-orgiesia something is going on with this channel and mechanical stretch and another device we're shown to be less sensitive to painful stimuli and we show less effective responses during mechanical injuries so it's a very interesting candidate to evaluate in a mechanical force-related such as the colon so when we started nothing was known about it so we looked at it we find mRNA, we find protein and when we immunostain we find it's very strong expressed in reticulitis so the red here is a transgenic marker in reticulitis cells in Taiwan and you see very strong reticulitis and the red here is another gangness cell marker and you see transcription factor so you see the only neuron in associated preparation that it's expressed during the war you also see this green fuss here these are the endospeed or retinal mylargia so we confirmed this by immunolabelling with mylargia and why is this interesting because liver cells and retinal gangness cells are in fact the most susceptible to sort of blood clot so we can take a chemical that selectively activates to before channels and we can look and we can load these cells with calcium dye and then we look what is going on with calcium signals and what we see is huge calcium increases in response to this channel and what is amazing to us and really interesting is that the parent of the calcium response in the neuron the gangness cell in the middle cell is extremely different so here it is sensitized very quickly and in the glial cell the signal is huge and stays on for a long time now what happens to the life response of these cells when you stimulate this fugitive in the channel channel adenis so this we are recording an intact retina home out this is a cell that responds to life with spiking and it turns off during light off and you see in the presence of adenis the cell has great excitability more like it is turbo charged we also see increasing spiking in a cell type that goes on with the light and then goes off with the light as well so there are also more spikes and when we actually look at the excitability which we test by injecting tiny amounts of current in the cell getting spikes we see that we need much less current in these spikes in the presence of the adenis in other words what this adenis is doing it is increasing the excitability making them much more susceptible to any kind of glutamate or any kind of life stimuli these cells are going to experience so producing an excitable dose of stress now this is the case for all adenis cells because when you take the retina we block them to a microelected array and we stimulate the adenis we see a huge increase over unfolding in spiking that shows a similar type of adenis so we are pretty sure that this channel activates the excitability what about swelling which is another mechanical stimulus when we induce swelling there is a huge increase in calcium as well and we don't see it so this is an increase in calcium when we swell and we don't see it in the long run now our retinal gland self intrinsic sensitivity here we record single channels and so-called patches and we can stimulate the very very defined calibrated pulse of the pressure and we can induce swelling and this is really very reliable when we do longer pulse stimuli we see again inward currents which are much smaller in knockout channels or knockout retinal gland cells or much smaller when in the presence of highly selected different adenis in other words, trickly form is a pressure sensor in retinal gland cells and we can take it out of the adolescence now can we mimic glaucoma or can we mimic sort of pressure induced retinal cell death simply by activating the mechanosense the channel the answer is yes so when we inject the adenis this is the control this is the the adenis, there is a huge loss of retinal adenis so we can actually reproduce the mechanical phenotype simply by stimulating chemically stimulating mechanosense so what about this question about dendrites versus of your head I would like to say that this is something that we are still investigating right now we don't have an answer to this but we have culture cells and we can see the dendrites and we can get localized increase in the dendritic calcium level so we are pretty sure that this is the way to regulate the synapsylation in the inner quest format and the newest studies published in journal neuroscience assuring that indeed the first changes in response to elevated type may affect the synapse so if you look at the optic nerve head the immunostanding is also extremely strong so it's very likely that by stretching the lamecarvosa or the lamecarvosa one would be the activated channel so we we stretch the substrate we have a machine that allows us to do that very specifically we can see huge calcium increases in retinal dendrocell which are missing in about 70% of cells in 30 we still see some calcium now so the knockouts show less calcium increases trypsi1 knockouts this is another type of macanocentric channel don't are not susceptible in trypsi1 knockouts but all of them are susceptible to the selective anxiety so in other words we propose that trypsi4 is actually a macanocentric channel that is sensitive to pressure and that is sensitive to stretch and that might extensively mediate the effect of hydrostatic pressure both and of the optic nerve head so this is kind of a very simplistic model of what we do over activation of the channel leads to overloaded calcium and this activates calcium depending on what it is and so on and we have proved that as well and really so so what about the second part what about the glial so the muller cells in particular develop every single retinal neuron they are absolutely essential for every aspect and what is interesting is that the first thing that one sees following IOV increase is glial activation together with the individual so what goes on with muller I will skip over a long period of time of work a lot of work I will just show that how incredibly strongly expressed present are muller cells in the retinal development you see these little holes this is where the cell processes are so the strongly expressed trick before and to just summarize our findings we nailed down the signaling cascade that is associated with trigger for activation basically we think that 4 channels which are the water channels for activating trigger 4 channels by increasing the rate of swelling during kind of automatic shocks but the trigger channels intrinsically sensitive to stretch and the kind of stress as well so we are 100% certain that trigger 4 channels are developing stress sensors now what about glaucoma when we induce chronic glaucoma in certain genetic mouse models or a hugely elevated IOP by injecting microbeads in front of the eye we can get reactive gliosis so the question is can we reproduce this by activating this pubic injecting this agonist induces huge reactive gliosis so basically in other words we can reproduce the key as retinal element of glaucoma simply by stimulating a mechanosensitive reaction now what about treatment can we protect by systemically treating mice with antagonists or by eliminating the gene and the answer is yes so this is a normal eye treated because this is the eye that has experienced elevated IOP you see there was a very significant degeneration about 20% loss of RGC switches in here in mice that were systematically treated twice a day with high dose of the trigger for antagonism there was no degeneration we did this many many times and we think this is a fairly solid result so somehow blocking the mechanosensitive channel blocks the degeneration of this disease now when we got this result we were very thrilled but we started to worry that maybe the effect is actually not at the end of the cell what if we are regulating pressure itself as well so we tested this so this is injection of micro-VPC elements IOP in mice and when we systemically inject the antagonist you see that the IOP drops like a rock and stays down as long as we treat them with antagonism every couple of days so in other words not only is true before expressed in retina it is also expressed in the front of the eye and it's regulating why is this fascinating because this would be a way to treat both at the same time so we can get even a stronger effect when we intra-ocularly eject eject the antagonist and you see this lowering last for days we also designed eye drops here at the University of Utah and these are also effective lasting for day or two so better than current eye drops so the important question now is where is this channel in front of the eye is it in the center body which produces the fluid or is it in the trapeco-measured or the mucillary muscle where that mediated outflow and you see that trapeco-measured is much more important because higher you go with IOP and the more low is going through the trapeco-measured unfortunately most of the current glaucoma drops are targeting the uvelovera component so there has been a very strong push of looking at trapeco-measured so we published two papers this year showing that it's expressing both very strongly and we localized the non-pigment of the uvelocells and we did a huge amount of molecular, physiological genetic kind of methods that I would skip over today just to make it more fresh and bold but we were more for various reasons we think the trapeco-measured component is more important so when we do so-called pressure clamp studies we see that pressure that trapeco-measured cells are highly account sensitive so the ramps of pressure are actually in use currents inward currents and when we stretch the cells we see calcium increases that are blocked by the 24 antagonists these increases are non-dependent this is the statistics but what is really beautiful and here we were saved by a collaborator who can mimic the conventional outflow in nanopibrated devices that we populated with the trapeco-measured cells you can confuse through that and this has been shown exclusively to be perhaps one of the best in vitro models for conventional outflow so basically when we do that we find that the antagonist is highly effective in increasing the conventional outflow of the cell so this would be really one of the first drugs that might be if you look at the pressure perfusion pressure on the other hand the antagonist increases it a lot so this means that the force in this nanodivise are much smaller because of activation of this channel this is exactly what happens in humans when you increase the pressure the regular mesh work cell becomes stiffer the cytoskeleton extra cell metrics become upregulated this increases the power which further increases the power so is this the case in terms of 34 channels the answer is yes because we can stretch the regular mesh work and you see that actin cytoskeleton and the coca-lutus get upregulated like this so we can mimic how it can be shown in humans finally in the end of the coma so we also looked at these nanodivise nanodivise conventional outflow models and we see that the agonist 24 agonist itself can reproduce the upregulation of actin and upregulation of the cell and this is highly suppressed in the presence of these 4 agonist so the bottom here is that increased pressure in front of the eye imposes some kind of a mechanical stress that activates the 4 channels leading to increased stiffening of the cells and conductivity which increases outflow resistance and maintains or increases other types so what we are doing currently is we are nailing down the very specific components of the cytoskeleton mechanism that link the internal cell cytoskeleton to the vocal effusion and to extracellular matrix something to allow the pressure to go down and another fascinating approach that we are using is we use fret probes so fluorescent probes that function as force sensors so basically they are stretch sensitive and changing fluorescence we can tell how much load it employs on the cell as we are pressing or as we are in any kind of manipulation as you can see here the load or the strain is many of the vocal effusions so nobody has done really before that in the eye or the brain so this is really an exciting way to go forward and I won't go into this but this is what we are thinking is the mechanism that regulates the ultra-resistance at the level of the clinical pressure cell it involves 6 or 50 enzymes it involves calcium and gene expression and we have data for pretty much all of these now to conclude we think that the 24 channels regulates IOP at both input and output levels although we think that output components are probably more important we think that he also regulates the remodeling that happens during mechanical stress in glaucoma at the level of gander cells, the neurons and here, I didn't talk about microdia they are also having for channels and they also are very stretch sensitive so, and combine these events together function to induce the phenotype that we call the glaucoma industry what is very interesting if you look at this, this has very interesting parallels to the neuropathic pain paradigm in CPC and other sort of force over the chemical-dependent paradigm we see across the body but they have different names so we think they are different so if I have just one couple more minutes, I will tell you about some of our unpublished work which I think is very fascinating as well because I told you about the inferior cells that may be involved in glaucoma but they also form the blood-red nerve area and are critical for all kinds of other diseases from diabetes to ischemia and for macroligination so we found they expressed you before oh, yeah, first of all just to show you, this is an inferior cell it is enveloped by a pterocyte not a vascular cell or a smooth muscle cell in arteries and that is shadowed by the entity so this is called a cliovascular unit then it is really responsible for the brain to be able to function in any way and when we we have been saying before, we see that inferior cells are very, very strong and in fact what is interesting is that they expressed in the macrobascular, in the retinal in the inferior cells, but not in cordial arteries so different macrobascular vascular have very different calcium or ion channel signatures which we have explored one thing which is interesting is that the calcium increases in these cells are enormous they are tenfold more sensitive to any other cells that we have ever investigated when we look at the currents when we look at the calcium so they really, really, really care about the cannibals so we in collaboration with and indeed here at the University of Utah we can look at now a model of blood-retinal barrier by using high-profile impedance studies in monolayers of this macrobascular cell you see when we use the adenis there is an enormous increase in cannibality in vascular just like crazy so again suggesting that these cells really care about mechanical and the 2D4 channel is a potentially major regulator of permeability now we nail down we believe the molecular mechanism of this so the permeability of blood-retinal barrier or the brain barrier is mediated by via catenine complexes including complexes and we found that 2D4 adenis triggers a retraction and this is a retraction of these complexes towards the inferior of the cell which is directly correlated so again this is something we are exploring very actively and this is kind of the model of this vascular unit because the interesting thing here is that 2D4 is very strongly expressed in the lower end state and in the vast culture and we believe it's regulating and controlling the flow of metabolites in swelling as well as pressure sensitivity now when we treat any disease we don't want to treat just any target we want to choose the targets where many signaling pathways converge so as to treat several symptoms at the same time so I propose that in terms of treating glaucoma 2D4 is a very convenient and reasonable target because first of all it's expressed exactly in cell types that are most effective in glaucoma it is associated with transductional mechanical forces and stimuli with a highly relevant glaucoma and by treating this or targeting this channel we believe we could alleviate a lot of the type that is associated with glaucoma here I would just like to mention that most of these diseases that I plotted here are important because I already knew they are associated with 2D4 dysfunction some of them with 2D4 mutations which are associated with pathological load bearing and sensory vulnerability with neuropathic pain I don't know about intracranial hypertension but I would not be surprised especially because they threaten glaucoma is very strong so basically we think glaucoma is just an ocular version of neuropathic pain it's a kind of a semantic switch that perhaps we made especially once we better characterize what's going on in terms of synonym and synhthalmology so TEM form was involved in pretty much all the aspects of the work that I was talking about today and she is really stereotyping in the field of project and writing these ideas everything was started by Dan Briskamp who was a graduate in the lab and he started this train rolling Sarah is working on microgeo Oleg and Maxime are electrophysiologists who have done absolute spectacular work on mechanical production I think this is really in terms of neuronal stuff something that no one has done even if you bring neurons to it we are doing it right now Andrea is doing phenomenal work now on spherical but I didn't talk about it Andrea where are you here so and Andrea had been working on aquaforins and swelling and stretch assays and I have to mention here Dr. Olson because I am a photoreceptor guy and I wouldn't be talking about the coma if it was the conversations and support from Randy so who basically said go ahead to some of the crazier ideas that I had and without that those crazy ideas would go to nothing so I had no support when I started my studies and the support from Randy so thank you thank you so David obviously I am extremely excited about your discoveries and what's ongoing and I also want to point out this is an example why we need videos like this all too often when we are in a silo and we only talk to each other we go on about that politically as well we just start with the science and it turned out that David picked this up and a calcium channel and so we've got to be more what's going to understand outside of our normal fields this whole line I think you know now we have a really important partnership working on better understanding all the work that we do on this Sunday exciting things our next speaker is Brian Jones he's a research associate professor if you think that was cool so I'm not going to talk we don't do a lot of translational work per se Cheryl, pull up with your above what is going on so we study the retina what is that for this view we're interested in what happens in two diseases so we're going to evaluate the macular duration the classic view of the RQ we're going to sort of look at the storage a bit more sort of zoom in let's say the backward view from the kind of load sort of illuminating the retina in the spignts and spicules this is sort of another view of close another patient for RQ And if you look at these pigments, you have to start wondering about the histology. So there are some tools that we can use clinically, OCT in this case, and we can give you a view of what's going on in the retina, but really the gold standard is histology. So the important thing with histology is we're going to look at what receptors are sticking up in the samples. It looks obvious now, but in a minute it'll get a little more complicated. So the important thing to remember is a million has about 70 kinds of cells. And so if you start making changes to the numbers of cells and their connections, Trindad has a lot of implications into how information is actually processed. So light comes through, it flows up to the back, it flows up to the infection, and it transduces those signals through a set of circuitries that do ruin its infection, contrast infection with infection. A lot of sort of visual primitives before sending those data out to higher structures and cortexes or cortexes for further analysis. The problem is, in diseases like archaeology, these photoreceptors become compromised. And a lot of the communities for a long time presume that when these die, this structure, these structures, romantically have to be rescued. And so we've been feeding the storm for about a decade and using animal models. And so we can do with animal models that can't be very well with humans, identify the gene, feed them, the disease gene, and then track the disease, and progress it to animal model. This is a mouse record for over 700 days of the tumor. So the photoreceptors get stressed, the photoreceptor gets shrinked, the photoreceptor cell bodies start to die. Bipolar cells and amicron cells start to die. And the wound can be wired, ganglion cells migrate into the amicron cell layer. And the whole pathology of the record changes. So this happens in every single animal model that we look at. Rats, mice, eggs, there's a very expensive concern. It's available from Louisville. The last egg that I handled, it took the eyes from about $100,000 from birth to where we harvest the eyes. We have a rabbit model now. It's very affordable, smaller, it's still a large-time model. It's about two criticize of human eye. And it turned out it's a perfect mimic for a somatoma. But regardless, all of those animal models do this. And we've been hammering on this for years and are distressed by the number of human clinical trials that are going forward in biotics and biologics and generics and object genetics that aren't taking this real biology into account. So we started collecting human tissues. This is a normal human retina. Actually, it's probably early A&B. It did not have a diagnosis when we got it. But the reason I say it's normal probably early A&B is this is one of the first things you can see in A&B. So this is the retinal treatment up here. And in normal healthy retinal treatment up here, you can see what color variability in this particular label. So this DL label is actually read separately as it's touring the somatoma that we're touring, the somatoma that we're looting, the somatoma that we were finding that are assigned to red, blue, and blue color channels. And that gives us this sort of view where we can visualize in ourselves the goal and the photoreceptors and see themselves. But it also allows us to see nicely what we have to do here. And we'll show you in a minute in the normal healthy tissue that we don't see any variability there. And we think this is actually the first indication of the dry end. Here's another view where we change the labels. This is Gavacin retina, Glycine retina, blue retina, blue retina. This allows us to see excitatory and inhibitory enzymes. So the important thing with this normal human retina is even though there are some indications of disease, the overall apology is the tact, the photoreceptor therapy, the tone photoreceptor storm up here. If you have a new layer layer, you can have plexiform layers and inhibitory enzymes themselves in the on-cone bipolar cells here and the ganglion cells down there, this is vascular illness. Using normal patented primate retina, it turns out we can get primate tissues, non-human primate tissues faster than we can get them in tissues. This was collected about 20 months ago somewhere and a lot of the signals are a little fresher, but the important thing here is to look at the RPV. So this signature, this fingerprint is what normal RPV is. All the RPV cells in a normal human retina can really get absolutely to this. So if you keep this in mind, normal healthy retina, ganglion cells down here, you've got to fight the layer. Again, you can switch it. This is the view that allows us to see excitatory and inhibitory neurons. But again, normal lamination is really important. This is central retina from a person with RPV, about 74 years old. No visual presets. The interesting thing is the IPL in this particular guy was rightly packed. There are almost no, there's no rod photoreceptors. There are a few cone photoreceptors. And this is actually important. We'll come back to that in a minute. We get the tissue freshener up. It's still alive. And we can do some experiments. We have a molecule of 1.4-minor retina. It's a non-selective rudiment channel marker. So basically put the retina in which it can stimulate the retina with light. In this case, light wouldn't do much. And the rudiment channel goes up and it should be closed in these channels. And so we can get a visual picture for which neurons have been activated. So we basically recorded from every single bone in this tissue the more green in a particular cell. We want you to do this again. So we can do this AGD labeling in addition to our other small ones like markers. And what we can do is we can generate a classification task. And so what we can do is we can find all the horizontal cells. We can find all the genuine cells in the inventory. And we can lessen the average amicron cells in the different bipolar cell classes here. And so the interesting thing here is in the normal labeling when the bipolar cell classes, your on-come bipolar, your off-line and the raw bipolar, you should have about 33% of each. There should be equal numbers of equal ratios of proposed bipolar cells. The first thing that starts happening in RT when you see this in animal models and in humans, is that these ratios change. And what you see is you see on-come bipolar cells chromatically reduce the number. And the off bipolar cells chromatically increase the number. So in this particular case, they are actively doubled. And that's interesting. Even though the retina, even though the topology of the retina is intact, there's still some symptoms up here. But it turns out as long as comes or present, you will have all the topology of the retina. It will soon come to the secure that sort of the strength that secures. So there's another region of retina. And this is the YGP, and then the T2E. Just to slide that down. So again, the cori ingredient, glutata, glycogen, glutathylate, so these are the same cells we're just visualizing them differently so that we can see different things. And the first thing we look at is we're starting to get, so here's a retina thing that's killing itself its diet. We can look down here. And this is actually very interesting. She's chasing this problem aggressively. So normally the newer cells should all be the same color to it. They all have the same small molecule. Interestingly, this is the case across species. So birds, turtles, fish, mammoths, this sort of signature of this mammalian, the newer cell signature, the metabolites, they're very robustly across evolution. But what starts happening when retinas get stressed is we start seeing this very word in the newer cells. So the metabolism in the newer cells starts stretching that sort of metabolite around the world. And we start doing some very different things. And we can start visualizing that here. So we need particular newer cell problems. There's more tooring in them than the newer cells here. This is also true on the structural level. We look at the structural data that I'm not going to show here. There's lots of protein changes that start happening as well. You can see that with the electron microscopy. We look at these boxes. So this one is just to show you if there are some common colors of these newer sort of heavens, the other side is still left, but it's helping to maintain the overall quality of the retina. This box we're going to sort of zoom in on right here. And the important thing here is to look at sort of these finding processes that are coming up from glycerinage-gallon cells. So normally glycerinage-gallon cells cell volume is here and the processes come down and take them back to the center where they're starting to project up in their own direction. We actually saw this in animal models first, but what they start doing is when you effectively de-affirm the retina in the orders of their input all the cells downstream have two choices. They can either die, which is a lot of them do, or they start spreading. And they start spreading these processes and they start talking to other neurons and they can send thousands of signals and they just order mechanisms for that. But this is a very common finding that's sort of spreading. To look at the ultrastructure, there are synapses in the spreads, so these are not sort of quiet processes, they're active processes where these cells are finding other partners that they shouldn't be talking to. Things can get really weird. These are amicron cells in the sub-retinal space. So these are cells that are migrated up from where they normally live and they're now taking out those in the dark here. So in addition to sort of the sprouts, the cell bodies can migrate and go into their places. And then we've taken a punch here with a three millimeter punch between our key and look at the red stripe here. We basically put that histologic slide right out of there and we want to look at far more infrared retina. So the idea is that the data that I showed you before was sort of more central retina because our key is sort of more central in the new influence of how bad you get. So we looked at OCT, not a whole lot of OCT signal, not a whole lot to see. But if you look at the YGP, it's basically a lot of vascular components, the vascular components of certain type of trophic. There's almost nothing left of the normal retina. There is nothing to see which is quite good signal in OCT. There are some neuroglia elements here. It turns out there's some astrocytic elements and some other work that affect the fight against the OCT. But almost all the ganglions cells are gone. A lot of the inhibitory neurons are gone. Glycineers ganglions cells are still left. Most of the bipolar cell population is gone. And all of the disease problems and surfaces are dead retina. And there's no resting. These are other mapings. This is 20 million per unit. I'll show you sort of the allele components that are still there. There's some proteins that are just that. So you're able to see the argument which proteins are still left. So small molecules change much more rapidly than the proteins do. And this is about appropriately with opsoons. So there are no... So normally you should be able to see that's pretty photoreceptors up here. The only opsoons that could consider sort of a crack around these vascular elements that are probably sucked down in the field. So this is another sort of stretch out in peripheral retina. Just to show you how bad things can get. So this is a little distance away from that red stripe that we showed you earlier. And again, this is what a normal retina and a normal retina thing should look like. So to sort of take this bottom of this visceral retina up here and sort of go up. This is where the disease retina stops and that's how much further it should go. So the idea is that an archaea is this is sort of a if you took a horizontal section through the mirror section into the screen just a little bit more. This is just before we use the vitreous. So these are all the mirrors. The normal happy and healthy tissue you should see this nice sort of mosaic tile. It should all be the single signal. This is clearly disruptive. There's a lot of stretching going on and there's some vascular aerolines that are sort of pushing in and the signatures are all different. So this is really in its interface toward the green and the red and the blue. And again, this is showing that there's effectively metabolic chaos in this also. And this is sort of another question. At what point, so new cells are really important for the normal human spaces in the retina. How long is the cycle or components for neurotransmitters? The sort of question that arises is how far can you sort of push the metabolism in the U.S. all over the expense of retinas to be able to function normally? This is another map on the trojan, but the diversity is very crazy. So another piece of paper was just published with A&E. So this is sort of a classic view of a lot of you guys look at this sort of pretty cruising on this copy. You can sort of zoom in again and you can see it's nice sort of pretty cruising with the form that's just here. Here's some histology, there's some nice cuts to be able to apologize. But again, in this sort of retina, retina E, again this sort of tile appearance which would be absolutely smooth in the flow of signatures. This is a small screw for a ferrum. This is very early. This is towing the way through the ferrum, I think. And this was just looking at towing. So this is just looking at the RTE here, so here's the vascular foray, and here's some further separate outer segments. This was a cool image that shows you the tiling that goes on. So each one of these is a separate rebel figure that could do it themselves. And normally, they're coupled. So they've got functions between them. And that allows this normal flow between them. And that's why signature is absolutely going to come in all about the issue. What's happened is we've got functions that are uncoupled and each one of these cells is doing their own thing. We suspect that means to dysfunction. And so what we're starting to see we don't quite know what they are but these reporting rich deposits, sub-retinals, sub-cruising components. Who knows actually there's some argument when we published this paper there was actually an argument in terms of what the receptor or neurotransmitter all of those were. So the translational component comes because a lot of people are looking at ways to sort of renew. Bionics is one of the big sort of approaches. So there's a couple of ways to do biotics. One, you can sort of put a biot, you can leave the retina to slip the biotinum by hand with the idea of stimulating the surviving retina. The more diverse more successful in terms of sort of market and the creation in terms of the every retinal implants they're looking down there is to stimulate the dangling cells. The problem is there's no effect and so you have to sort of ask yourself which cell population should be stimulated even if you say there's no way to stimulate the dangling cells. It's still a problem. There are also 12 to 20 channels that outgrow the dangling cells so it just doesn't go to the visual cortex the sub-cortical areas there's a superior cordular cell gene and a lot of these places. So you're sort of stimulating the dangling cells in a different way. There are some other approaches that we've done in some of these studies where you can take a virus engineered in an opsin basically orders up to this period to put an opsin in the surviving cells and then the light comes in the retina so it can be genetically transduced to express the opsin and then the closing of the cell and stimulate the surviving retina. The massive assumption here is that once you do this the retina will stop de-generating and it turns out in some early experiments in retina modeling this process that we call this sort of plasticity it's a freight train and because you put a little bicycle in front of the freight train it doesn't stop the freight train it's still going down the track so we intervened without the genetics and tracked the animals for a couple of years and that was just what they helped even with the optogenetics. But the assumption is that you can stimulate bipolar cells you can stimulate amyconcells you can stimulate two amyconcells or you can put an optogenetics in one of the cells and there's a lot of very cool elements that this works in fact the first guy that did it really got kind of this bad hand that Women's State University was the first to actually show that you could do optogenetics there actually was the retinas and he largely got ignored he presented that at Artville in 2005 it was the single coolest thing I saw that year at Artville and Stanford is a little better at promoting their people there's some great talented people actually, Ed Boyden is wonderful and Carl Disaroff really got most of the fame for actually doing this optogenetically and there are a lot of reasons why that happened so the problem with all this is even if you do successfully transduce some cells the cells die and the cells rewire and this circuit results in great changes so then the question is how bad is the change the other main mission is how much was that you studied how and how was it tiring and it turns out there is a very specific structure there are very specific synapses and gap junctions that follow the cells and there are other populations of cells in the retina it's very tight that you can see the cell pattern it turns out you can identify this actually and you can pick synapses and gap junctions and actually visualize them from across the field and you can start this and you can do beautiful sort of figures and then you can sort of do these connection diagrams so here's one of those H2N-princell sphere and you can start mapping out rod-like force that one put onto it and you can sort of sort of start mapping it out so the trick is it's really complicated so this is just two synaptic hops away from that H2N-princell and so you start asking yourself in retinal regeneration which one of these connections is broken and how many of them can be break and still expect normal retinas to occur that's kind of where we're at now we're trying to figure out where, how bad can we get it's up real quick so we've done some bionic work we've done some optogenetics work and we've done some cell-based work it turns out underneath bionics, remodeling and accelerating in a lot of these cases and optogenetics, like I told you remodeling progress just proceeds just each going down the track we've done some cell transplants it turns out remodeling, accelerating and transplanting so we haven't done a lot of genetics yet there's some other experiments we've done so far the basic take-home message is there's a lot of rules that are happening in remodeling and then there's a couple clinical things coming along the idea seems to persist it's like a light socket and you've got to plug it in and you issue how many points of contact you can make and if your work is so overwhelming and it's not the others that'll follow to confirm with a couple of companies and I apologize I can't really disclose much about them because they still haven't some of their children in college yet so I can't talk about it I'll have to kill you first but there are some ways that are not quite as complicated as that so the idea is you put this base unit in the capsule bag and you can take the optic out and adjust it now in children that would be very good especially infants that you can have a surgery on you can put it in there and as the child's eyes grows and you have to change it you can just change the optic without disturbing one's capsule bag so I think that's a pretty exciting technology for the future now I just wanted to show somebody there's some wild ideas these guys have basically a little piston system here that you screw in and screw out and so if you want to adjust it you go with the micro instrument and basically screw it down and screw it back up and so interesting way of adjusting an IOL power and they actually did some initial human studies on this lens and you know they said they could adjust it without any kind of damage to the eye itself so interesting idea now this one is repeatedly adjustable and the idea is that you actually screw the optic in and then unscrew it and so again these are all invasive man that's the problem they're all very invasive techniques and lastly these guys actually hook the magnet to it so they magnetize the material and then the idea is you can use the magnet to unscrew it and you can change the power when you do it that way so wild idea now what's getting more exciting now is the application of using the femto-second laser to change the surface of the IOL and we're just starting now to do some work with this particular company it doesn't take much to change the power on the surface of an IOL in fact we're talking micro level changes and the idea is if you use the femto-second laser and Dr. Beal is the doctor who talked about this and Aaron Scientific is the company who's doing this and the idea is is you change the molecular structure on the very surface and you can actually change the power and the idea with this is you can actually change your multiple times and you can change it in a lens that's already in the eye this is not a particular lens you put in the eye this technology would be something that you could use in all impact materials so what's exciting about this is you could have a lens already in the eye and change the power now if you wanted to think a little bit outside the box there's all kinds of ideas that you could do and you could put a multiple pattern on there and then if the patient dislikes it and has dysphagopsis and you don't like it you just erase it exactly and I know I'm exaggerating here but this is something that can really be done it's pretty fascinating technology and so we're just beginning to do some early studies and locations on this particular technology but I thought this is very exciting to be sure because how many people do we have that we like to do that fine-tuning of their own plant power once it's already in the eye and here they could take it again use some phase warping technology put a multiple pattern on there try to get people to have some near vision and some distance vision well what is there that's available now phase three and so it's almost available now the light adjustable lens and this is an IOL that you can actually again change the power of the lens once it's inside the eye but the problem is you can't just apply this to a lens that's already in there it has to be a specialized lens that goes in in the first place now it's a very interesting idea and if you're going to try to change the power and add power in the center of the lens you can get a high profit correction here and you shine it in the periphery of the lens let me show you how this works so this has a partially polymerized silicone with some little moieties that join to the side-chain when you shine UV light on there they will then further cross-link and so you shine the light in the center these little side-chains will then cross-link and then this creates a diffusion gradiness over about 24 hours the unprolimerized material from the periphery will then flow into the center of the lens and as that flows in that will change the curvature on the surface if that flows in that the issue makes this room will happen in about 24 hours you can change it then once you're happy with the change that you've got you lock it in and you shine the UV light on the entire IOL and when you do that that locks everything but they're working on trying to make it change with time now this is now in phase three and we're hoping to have it out this is again one of these technologies where we started doing work with them in 2002 and the idea was this is going to be ready always the third quarter like the next year and so this is there for 14 years now but they basically these studies are almost done so we may have this available sometime soon so this is potentially exciting again in that group of patients who have had previous refractive surgery where you've had some refractive surprises but the other thing that you can do with this technology is you can change the delivery of how the laser puts the pattern on that so you can actually get a stigmatism correction and we've done that again in the limitations you can even go ahead and make it so that it does some wavefront corrections on it but just for fun we did a tetrafoil pattern on here it looks kind of like the stiffened burrito that you have during the supermold and so the idea is that you can do all kinds of things on it so you can measure the refractive error within the patient's entire visual system and then put that something that's going to neutralize that right on the IOL and so you can do wavefront correction astigmatic corrections again the idea of the tetrafoil is you can theoretically put a multiple fold pattern on here just the other picture doesn't look before you lock it in and then just erase it when it's done so again pretty good potential for things that you can do with this particular technology with the adjustments that are made so in conclusion when we look at adjustable IOLs I think that these are very exciting until our measurements get perfect but also even when our measurements are perfect sometimes patients are just never happy you can have so many maybe you made them and just kind of get students very unhappy so the idea with some of these adjustable lens technologies you can change that later or in the ones where you actually have a patient in a place and remove the update for example children if they grow you can go ahead and you can change it or people grow you can change it so I think this is very exciting technology and of course the calendar for this one along with the several others that will already move to this is hopefully where I'm going to be tomorrow morning so thank you for your attention I'll be happy to take any questions so the word I'm hearing from Calhoun is either 4th quarter this year or 1st quarter this year but I do think it's it's real close so I think it'd be that that may happen but it's interesting they waited so long I didn't think that we were after rather than that shaking that's a problem if you've got a technology that doesn't get out there soon enough it's more than a big problem than that and they can work in any material that you've mentioned and it looks like direction of film three and a half years across the line it covers most of the year we're talking about cylinder the same amount you know multi-pogal and you can also do hyper-expiring you've got multiple shots on the same blend if you look like me you need to do five times in a lifetime so you can imagine you go in and you're buying your third glasses you've got any shots you've left and you sit there and you say now we've got to get it cured up and you get the treatment down just for a few seconds and it's instantaneous as well and you have to get approval process maybe it's a practical meaning because this is really a laser treatment in the ideal it's not a new lens it's not a polymer, it's not a new material and it's not a new laser it's going to happen pretty fast I think it's one of the truly some of all changing technologies which is really important to all of us in the field where you come in and get your free practice procedure it's in order to get the eyes to move you're going to have to use a perfection which we do not like either doing a second flat cut or a laser or a shampoo used to be that way once you have it and you've got it locked in the whole image now it's instantaneous well if my fellows are still here at this stage it's not quite instantaneous and so as the fellows will attest our first attempt at doing these took what, nine hours? so I mean it's not quite instantaneous but the actual laser part is pretty fast not even that it took a while to get caught still got a few little procedures to work out but I think it's a work in progress and I think it's pretty exciting theoretically they can get it downward for like 7, 8, 9 seconds exactly, so I think it's pretty exciting to come on so it's just taking you ahead alright so next we're going to have Nick and I need to research so I'm going to show you a thumb for any results we got for our laser research so so our research has been focused on the retina gang itself for most of you I guess I understand that retina gang itself is the only cell that connects the eye to the brain so it's the only part of the neuron and the retina gang is very alive by many diseases and also like a brain injury so if someone has a high extended and they're going to get a head down that's forward and they'll act up to nerve when you're there bone fracturing behind the eye can cause a lot of nerve injury and the big study of the project was supported by the V-8 grant because a lot of soldiers were in a battle together and they had both sides in the bottom of the basket in the hospital to bring and cause the option of injury to the company so the question we're interested in is that when you look at those any other disease problem the retina gang is an injury there are many types of some kind of retina gang itself they respond to those that have not your insulgeness some cells are much easier to be injured or damaged or killed and some cells are much tougher and more resistant to those diseases so we're trying to figure out what are the reasons or the mechanisms which can show the vulnerability of the retina gang itself hopefully by the way actually enhance the resistance so so this is just a show of the event so when we try to study how gang itself dies we don't want to figure out the process of their death so these are the pictures from the life and moments or from nights so we use the transgenic amount we can express voice and focus in the gang itself so we can actually watch the cell to morphology every day for a long time period so this is the example when we put those bruises injected into the eye of the bruise into a commonly excited neurotransmitter natural so in our brain and our retinas, most of the excited cells actually release bruises as a neurotransmitter but when they release too much of it it can't talk to them we call it enzygno-practice so those happen if someone has a brain injury you have the primary cell death and those bad cells release a lot of bruises to the adjacent cells that cause those cells secondary death of the cell around the primary injury so gloomy toxicity is a very, very common cause so in the hospital emergency room about 40% of the patients are in injury patients die due to the secondary death not a primary injury so gloomy toxicity is a very, very important issue but in some people you can believe that gloomy toxicity is the cause or partially of the aspect of the cause of the genus of death and sometimes in particular years the annual cost of coma means that IOP cause a lot of cell death and it can't speak to the cells so when we inject it we look at how the cell died so you can start before you inject the genus of death and then 10 minutes after that the death started to become a signal and about 3 hours after that it reduced to maybe 90% of the death the cell lose all the dentures become a signal so when we look at the cell death process what we found and we use the capillary it's a cell death when we use the capillary which means the cell in the process of dying and then we compare the time of course of the fever of the forest in the process of death that we found the genus of death always lose their dentures completely before they started the cell death process so it sounds like the genus of the dentures is a condition for the cell to die or it's an earlier stage of the cell death but with some of the cell dentures completely we can see people alive for several days in this condition so what actually keep them dying without dentures or can we actually promote them because they're not saving them from dying so it's a question where time is starting so that's one example this is actually often a crash in the life and also we identify these cells and then we go back to the eye and use the process just mechanical crash often a life animal and then we watch the cells and how far they can die well you can see it's like a 31 hours after they have a crash and the four days later the cells die so again mechanical injury or after the nerve even if you injure the axon of the young cell the cells don't lose their axon actually they lose their dentures first before they die the third example is this this is a light induced cell death so we look at a bunch of cells we use a relatively high intensive laser scanning of these particular cells and then we wait for 13 days and those cells start to actually lose their dentures then they become sick and 14 days later or one day after that another two days after that the cell is dead so it doesn't matter what kind of injury you use when you injure getting yourself they lose their dentures first and then they die so then as I said before so you look at a mouse there are multiple types of getting yourself morphologically and vitologically and those cells actually respond so first we want to know we know the cell response to these can easily be very different from some cell types and then we want to know so what are the control methods for the quality so that's one goal we want to look at so to characterize the gingers that's one goal the second goal we want to look at is do we lose gangrene cells in a retina is that going to affect other cells even if they are not directly injured is there any secondary cell death after gangrene is affected and then because that's very important because we want to say do the stem cell transplantation and you don't have the normal cell morphology or well-being of other cells you get the redness they are not going to respond to the normal because the whole retina has to function a network so that's the second so the second the third purpose where we have some candidates have a neuroprotective kidney so we want to try those in your those can definitely be neuroprotective for a protective kidney while they actually protect themselves from that just the model where it comes of course but the fourth purpose we are trying to figure out if there is any genetic approach we have to protect ourselves by over-expressing or non-regularism gene-expressing to change the cell morphology or commodity so agri-model where we are using as I said when we have two common models one is often nerve injury and the second is by injected into the eye to cause the movement inside the mechanism and then we use the transgenic which expresses the process of the ganglion cell so we can actually very precisely monitor the structure change so we so we choose three ganglion cell models and another animal a mouth model with the amyquid cell specifically the spasitia so we basically have four animal models and this is the arba ganglion cell we use one model specifically for arba type cells and then those two are ganglion cells which are either B ganglion cell and D ganglion cell and then there is an amyquid cell which are spasitia ganglion cell so we just take it with four type models to test if there are model B and then there are responses to disease or if there are type models so the the technique we are using just is the amyquid cell model and this is the example of our three dimensional treatment of a single ganglion cell bandage so by looking at it by looking at it right now we can actually precisely identify every small branches of ganglion cell to look at how it changes or if we change the gene we can see how it changes the form so so this is the result of the ganglion cell and if we take it right now we can put it in bloomings and watch the individual cells how fast they can lose their ganglion what we found is from those three sub-type of ganglion cells what the two types of sub-type of ganglion are actually lose their ganglion very quickly but another type which is a BD cell they actually then this can last much longer in a higher group type of cells so prove that on the common course of cell there is a ganglion toxicity and the ganglion cell is very different from the BD cell and this is the one point I'm going to talk about later if when you look at the gene in transfiguration of the gene the ganglion cell that changes that cell quality from there to the other cell so there is some gene actually control the cell more but I will get back to that so the second model we are using is if you often work fresh you can find the ganglion cell and the family cells so this is the way we do the surgery we just anesthetize the mouse and cut the skin a little bit and then push to the altium nerve put a little 4,000 behind you and crush it for 10 seconds and then when we put a dye into the ganglion cell and then look at how the dye can be transferred around the altium nerve they can say from the fresh side the dye cannot ask that and the surgery is that so we now have the axon then we look at it so we use the new thing in dye to label all the cells the cell new thing in the ganglion cell and the ganglion number of the cells so the dye comes back so this is the red nerve this is the red nerve and this is the red nerve after the altium nerve is fresh you can see the bruised out and you can put the cell dye so we remember the cells from the years now so when we look at the time of the cell dye as you can see before the crash and after the crash about seven days before the crash we can look at the bruised out and we crush hard enough so that's the model is very reliable we know what it was really we know how the cell dye is how far the dye is and we have a very good app now for ganglion cells, so that's why we now and then we start looking at another model is looking at amyloid cells so one of the amyloid cells is the interneural and I should say now for ganglion cells 5% of the ganglion is very important for the ganglion cells to have a normal function so the amyloid cell we are looking here is a transient amyloid cell it expresses the green fluorescent protein in those pancreas cell dye and then you will use antibody and label that cell if that cell releases a silicon so we call it conical energy dye if we use an antibody labeled that way we can this is easier those green cells are all red and the red label is an antibody and the green is the JV fluorescent dye what that means is we put starburst amyloid cells we give the YFP but all the YFP hospitals are the starburst amyloid cells so we now look at then we look at the pancreas structure after the eye injury after the ganglion cell injury what we found here is we get a much lighter crash so 10 days later we lose about 28 to 30% of the ganglion cells so in that in this sense we don't lose a lot of ganglion cells we try to solve it with only 30% of the ganglion cell death while the amyloid cell is infected what we found here is actually just like seven days after the crash if there is no direction to amyloid cell the amyloid cell dye of the ganglion cell the amyloid cell didn't die but amyloid cells start to lose their redness property so amyloid cells die by 30% in seven days after the ganglion cell dies so even the cell don't die the amyloid cell don't die but they lose their structure so this structure is very good in that way so that's the conclusion about that then we start to look at what we had of ganglion cell death by a wound in the cactus can we protect it from so what we tried is a growth factor so we injected those drugs chemical into the eye and then either crushed off the nerve or co-injected the wound into the eye to cause the toxicity and then count the cell numbers what we found here is the drug with BB cannot completely protect itself on the body but those drugs can't protect it by reducing it by 24% so we go from here and leave it with that but we looked at optional nerve crushed and that same drug has no impact at all which means even if those cells die it looks like we need to die but when you put it on your protective drug the drug can protect itself from some causes so this is the same slide that I pointed at here before so we're trying to look at if there's any genetic way we can actually find out that the molecules expressed by cell can control the cell death if we manipulate the activity of the gene it can protect itself so the first thing to do is to find if any gene actually can control the cell death maybe we found one gene for that particular cell so this is before the lack of and the cell is very adjacent to the gene but when you look at the lockout which is the triangle that is here so when we lock out the gene in that particular cell and then we put the gene on the retina we see that cell is no longer adjacent to the gene so we're working on the process so this is actually when we lock out the gene in the cell the next step will be if we activate the gene in the cell, can we protect the cell we're working on that so this is the conclusion so Ganges are a little dangerous before cell death with all kinds of various pathological enzymes so far we've tested and the cell type specifically from genetic models is provided very powerful for us to actually look at a new wave of time for cell death and some of most neuro-protective agents which become protective of cell cell from death for some causes so there's a response to the same agent for cell death since very well it depends on what's the cost of that and then since then we find a gene which could potentially help us protect the cell so we can activate the gene before we do so this work most of the work is by an individual student and then there are visitors who are hungry and there are two other people who are not what kind of advice do you say that are supported by multiple agents? Questions? Are other cell types affected when the family cells die besides the animals themselves? So it's a very good question people now that if the folder serves that I guess you've heard of Ron Johnson earlier this day if you take the freeze not the folder but die completely besides the whole retina circuit they wait non-enough but very few people who look at that post-certified thank you for that how much impact is on the retina circuit that's the study of it so it's a way you guys probably have to stop for a bit you need to figure out how is it going to impact so our final talk Jun Yang is a research associate professor he's going to talk about understanding the mechanism underlying cone-brot distribution you get extra credit points for being the last person to see if I need to take spheroes trail and mid-mountain so first I would like to spend a bit of feedback and for any needy opportunity to put that on this stage here so the topic of the treatment for these diseases so during the past eight years we have been focusing on type 2 we use a model of the study disease and artisanal is a syndromic disease so it's an artisanal type of artisanal type of artisanal together we use a helios and we use a fist function so we found that the gene that we're coding that we're coding the cost of doing it is more or less so we decided to use contact in both social sectors and we will not talk about our research on artisanal and we already published a few days ago so if you're interested you can read our figures so now we're just about to talk about our research on cone-brot distribution so about four years ago we were focusing on cone-brot distribution and the study and new research project and compared to this is a rare disease so it's a factor why is it 30 to 45 in the world however, compared to RT CRT is more severe problems so what's the RT so unlike RT, RT affects a lot 40 seconds first and then cone 40 seconds and CRT affects the cone and then cone and sometimes CRT applies cone, rod and cone 40 seconds at the same time and also CRT can be inherited with all three environmental patterns of inheritance so although right now after 30 costs the gene has been identified for CRT and the genetic process is that half of CRT cases are unknown and for the identified genes quite a few don't really know their biological functions or very limited information about their biological functions unknown so in my life I've been interested in C8 of system genes which was identified by Astrolabe and since then more than eight more papers have been published to report more C8 of system 7 mutations and also patients in different groups so I just show you the mutations identified like now C8 of system 7 gene so we can see that the mutations are distributed throughout the gene and they include bicep mutations and n-z mutations n-z mutations and also gene change mutations and these mutations can cause CRT and also RG together with early laparoscopy and also we can see it can cause Babido syndrome so Babido syndrome is another syndromeic form of RG which is highly modified RG together with obesity renal problems polygactylic and cognitive deficiencies so at the protein level this protein is like 200 percent immunized in humans however the Chinese understand this protein is that there is no known functional domain and also there is no known similar proteins so right now this protein is just named by the producing of the gene in human kind of a so but finally the C8 oxyphenin protein sequence from mammals to lower eukaryotes we found that the C-terminal region of this protein is really conservative so it indicates that this protein probably very alone and in a very important process okay so what's the function of this protein and why mutations in this being can cause so first we just set out to set up an animal model to study this protein so we set out to generate the C8 oxyphenin out of our minds it was increased for acetylene technology so but you would be too small like the RNA having X1 and X5 of the gene regenerate the gene of life so the first one has a big distribution in X1-1 that also includes transducers like CODA-AC2 and the second has a very big distribution in X5 and third has a large distribution in X1-1 to X5 and now we see the animal model we found that all three using the mouse lines below the X5 C8 oxyphenin full length or transducers meaning that these three lines are complete KO lines okay so then we assess the retina function of this not out of our minds using electro-retinal at 5-6 of age so we can see that offering mind so the right color is the one line green color, different line third line blue color and also the dash line is mutant mind so we can see that all three mutants not out of mind have about 50% reduction for the topic baby and also 50% reduction of the topic baby and indicating that both large and calm these functions and then we just focus on one mouse line because they still have the same retina function so we focus on one mouse line we test the ERG at different age and we find that both large and calm these functions show a progressive trend and then we ask whether these mice have the retina determination because sometimes the retina function has a problem that the focus center the number is still alive so first of all we use this non-invasive approach the OCT approach to study the retina so compared to the control retina we found that in the now how retina at both two months and six months of age this of segment and in effect junction line is moving and also at the six months of age these focus center nuclear vigor is much clearer compared to the control in the given retina generation okay and then we did the standard histological analysis and the results just confirmed our findings so you can see that all the segments layer and all the nuclear layer gets thinner at the beginning they are fine compared to the control and eventually all the segments is disappeared okay we found that both female and male mice we don't just show retina after six months of age and also they don't show this polydactylic thing which are kind of like the labido syndrome treatment and symptoms so in some ways these palaeontology successfully generate the C8 of certain now how much models and this mice show both the organ of home dysfunction and progressive generation however they don't show other symptoms outside the retina so these models and the models that is retina generation and then we see of C7 division okay so this mice may ask the question so why is C8 of C7 mutations now how cause retina generation so well we first look at down the polydactylic morphology by scanning the electron so either both both male and female so compared to the control polydactylic we saw now how polydactylic show normal all the segments here so these off segments show are thicker and less uniform in diameter and also less densely packed and then we want to know what's happening inside these off segments so we see the transmission electron by property so this is just the control of the segments so as expected we see membrane is tightly stacked and then horizontally aligned and in the now count of segments we see some membrane this is probably not big but this is a membrane thing it is very long and it is vertically aligned and apparently we do see membrane wall in these off segments region there is molecular body back structure and however there are several structures and also the compartments are normal so it is connected with the body like the kanjiya and even ER biology arises so when we zoom up to look at moving membrane in the now count of segments we see that this is horizontal membrane it kind of blow overblown as a membrane region and then turn vertically and also we try to look at the horizontal horizontal piece and the vertical piece and we don't see horizontal membrane in between so this suggests that the vertical piece we are left by half a membrane inside the same off segment so this kind of plane I would explore scanning back on across the off segments deeper and less moving form I just want to clarify that the heterozygous knockdowns look like a wild type yes because this disease is for three-eighth off-center so for the heterozygous we see the structure is similar as the wild type so we consider this control so now we did a series of a lot of analysis and then we found that many of the membrane probes and associated probes have a special level decrease which I marked here in the graph and other proteins they are okay they have the same normal expression level in the knockout and also I marked these proteins but I suffered these proteins in green so these proteins are coded by non-CRD so this indicates that the migration of CRD type of genesis in patients with C8 off-center nutrition probably share among patients with nutrition in these genes okay so and also in the field is known that the RDIs GAP2 and G1 are involved in organizing all the sediments in the photoreceptors so the association between the RDIs and the RAMO1 with these BNTP1 can link the membrane pieces to the plasma membrane and also the cell interaction on GAP2 with this so we found that the reduction of GAP2 CNTP1 and RDI so that can explain why we see that the membrane is a misalignment in the knockout form of ligament so now we know why this C8 off-center knockout can cause retinal degeneration or now why C8 off-center knockout can cause off-center membrane protein reduction so this is we're still in the process trying to understand that so that's why there's no clear answer to that but I just share with you our preliminary data so first we want to know where C8 off-center protein localized in photoreceptors so maybe the C8 off-center and we found that C8 off-center steaming so we found that this protein is a localized small photoreceptor it's not the outer segment however in knockout we also see this kind of signal happening so in that case this indicates that the signal we see in this control retina is probably a specific C8 off-center signal but also mixed with non-specific unknown non-specific signal so to verify the localization of C8 off-center photoreceptor we collaborated with the ashabic line so we did a tangential section of the retina and then we examined where the C8 off-center is localized and then we consecrated the retina section and here is the result so basically it's already labeled where the off-center is and then costusing and localizing where the photoreceptor is is that the outer segment so we see that the C8 off-center is in the inner segment not on-center so because like we know knockout of C8 off-center we can't pick what's going on so it's possible that we know that the outside of the membrane is in the inner segment and it's the transport to the outside of the membrane so that means sending right along in this process synthesize and then transport to the outside of the retina okay so we need an even screening of all knockout just like several of these off-center membrane the screening is going to be reduced between the three of mine however we found that most of the membrane localized normally in the off-center so this indicates that the C8 off-center from the off-center carpeted to the off-center and also we found that the off-center bumping through the retina occurs at the P5 to make a big fine during the family point photoreceptor still differentiate so the connection forming fact the off-center has not been formed so at least there's no off-center but the off-center membrane coating already refused to this also suggests the idea that C8 off-center is not involved in off-center membrane trafficking so now we think it's probably something wrong with the synthesis of all degradation so we still try to do the experiment to diagnose which part is a problem but in our life we also try to identify C8 off-center that will tell us what's the other process C8 off-center is alone so we did a series for the only analysis using mass spec mass spectrometry so we we did this mass spec study on coatings that even a precipitate find C8 off-center antibody from mouse retinas and also we did the program using GST-TAC C8 off-center coating from bone white retinas so we did this by time so each time we have we definitely have electric control so compared to the electric control we have these unique proteins identified by mass spec spectrometry so this does a lot of proteins so and then we just think if there is a real interaction it should be show up multiple times so in fact we don't see one coating that show up on five times so but we do see one coating there it show up on four times even across different approaches from mouse and bone white retinas so this coating is interesting so it's encoded by a known cone of people however this coating the function of this coating is not really well done because this interaction we still don't know what the function of this coating is but this way the coating is interesting so the KDM1 is ER so it's a mapping coating it can encurse the coating transmission factor when combined so now some of these coatings cause membrane coating synthesis to be and these two coatings are just they both have the opiculation activity so it suggests that this coating is involving the opiculation coating from degradation pathway so from this study it also kind of suggests two interactions so we need to feather to edit the conformity interaction and then kind of pull one three, one two okay so in summary model like that hopefully this is the last one like the two of them so first we successfully generating the state age of system knockout model this model is a good model for future and future study for the revenue generation and also the age of the system and second the age of system knockout can cause the outside of the mapping can cause outside of the membrane function to be released to offset the mapping needs alignment and eventually third, C8 of C7 A2 of C4 of C2 so it may be involving the outside of the membrane coating cogeal spaces but it's probably not involving the trafficking and finally the magnets of revenue generation C8 of C7 patients probably is shared among other CID patients in other genes such as C8 of C1 of C9 C8 of C4 so in summary finally I'd like to thank the people and mom in the family so the people in my life they really work hard and especially I believe he is a great student in my life I work at the genetic theorem also done by him and I'll call him to help with other people in the life especially when he also did a lot of work here and I'll remark that the great job life helped us to do the QM study as well for the department we've done here and we've been sharing the preliminary data on the last 28 studies and so this is our kind of multi-program so for the team they are just like a running call to see if they help us to generate the C8 of C7 of C9 and the crew and then they help us to study the biological properties of these two genes so I didn't present the data in the first place outside the university but in a test lab at Duke University helped us to localize the code for this study and a few hours at the University of Utah helped us generate any vector currently in this C8 of C9 so we're going to use this as a to some product direction ok so thank you so Duke a C8 mutation caused by the digital syndrome but it looks like in the mouse it just affects the eye it doesn't affect the kidney or the so it comes from a single paper there's one piece of that image in the picture called a single paper so he will look at that it's like the same exact mutation in another paper it says it's just the wrong CRD so here the exact mutation is too good but it says it's CRD the other is CRD and this group is a little difficult as I don't mean to be one the one thing to be done is that that mutation has so that's the problem with the digital it's kind of better also thank all the speakers that were involved and thank everybody who helped us to put this meeting together our photography department our administrator department I mean everybody who is involved with this thanks for a successful session and you