 Thank you. My name is Kamalani Hanamaika or Kamalani Keoko Hanamaika. However, you'd like to say it. So I'm from AT. And I'm going to present some of the scientific data of corneal crosslinking, what we have up to date, and then also present some additional information from ICENTER that I worked at down in Provo XL, ICENTER, with some corneal crosslinking data over the last three years. Very quickly, I'd like to say thank you to my attendings, as well as Alicia Dox and Dr. Chaya, as well as Dr. Ambadi. And also Dr. Parsons, who was one of my mentors in ophthalmology as I was growing up through undergraduate. As well as Dr. Ronald Gaster and Roger Steinert from the University of California in Irvine. I've gleaned a lot of their information over the last few years about this specific topic, and I wanted to recognize them. So a little bit about the history of corneal crosslinking. It was developed in the early 90s, I believe 93, as well as when Dr. Steyler as well as Eberhardt at the University of Dresden began to investigate the technique of corneal crosslinking. This is a picture of Dr. Steyler, I don't know how I'm saying that correctly. Patient treatment began in 1998, and in the United States currently we are, that I could find were in stage three clinical trials currently with this technique. So indications for corneal crosslinking. First and foremost, keratoconus, I mean that, but in addition to keratoconus, other ectatic disorders of the cornea, including pollusive marginal degeneration and other entities like post-lasic ectasia. As well as corneal melting, post-HSV infections, other infectious keratoconus. There's actually a paper that's very interesting about the treatment of pseudomonas keratitis. That's refractory to medical intervention with amniotic tissue grafting in addition to corneal crosslinking and then corneal edema as well. So the procedure itself, it was started as what they call an epi-off technique where the epithelium is taken off and then after which riboflavin drops are administered to the cornea until it's penetrated the cornea and you can see with slump examination that the riboflavin or the yellow of the riboflavin has penetrated the cornea into the anterior chamber. When that's been achieved after 30 minutes, then administration of UV light is applied to the eye for a period of 30 minutes. This specific dosage of UV irradiation has been calculated and I'll show you some of those calculations. But the standard of care is 3 milliwatts per centimeter squared for a period of 30 minutes with continued preparation as well as riboflavin administration. Post-operatively it's managed with topical and oral analgesics as well as antibiotics and steroids. So riboflavin, a very important concept in the development of corneal crosslinking, acts as a photosensitizer and works synergistically with UV irradiation. This effect produces oxygen free radicals in the corneal stroma and leads to an increase in corneal crosslinking thereby. All of the calculation I'm speaking about as far as dosage with the UV irradiation is based off the Lambert beer law which relates light absorption based upon the media through which it travels. So in this case with the riboflavin, it was very technical. That took me probably a very long time to understand or even glean and understanding thereof. But the long and short of it is that Dr. Steyler worked through this equation and decided on that specific treatment regimen as far as strength and duration. In dealing with the treatment of the cornea, this is data from a book published in 09. It's called Care to Cone of Surgery and Corneal Crosslinking. You can see here that with time and in an anterior to posterior fashion you can see an increased deposition of riboflavin into the cornea and that is rather satisfactory results are achieved within 30 minutes of treatment. This is another important point that was developed with the advent of corneal crosslinking. You can see here, it's a very easy picture to understand. Were we to treat the cornea for 30 minutes with 3 mW per centimeter squared of UV light, then you would have actually significant endothelial damage and subsequent corneal prognosis thereof. So with the use of riboflavin it acts not only as a photosynthesizer but if you will it focuses your UV radiation into the stroma in an anterior to posterior fashion just like we see here on this previous slide. Also, at the University of Dresden they had isolated a toxic threshold of 0.35 mW per centimeter squared on the endothelium which would lead to the endothelialization of the cornea given that threshold. This is a, I apologize it's a little bit blurry, but this is a information that was presented at the Orch County Vision Symposium in 2010 by Dr. Gaster. And it just kind of, it explains rather in a visual fashion, explains the theory of where the effect, if you will, of corneal crosslinking which he says has both intra-helical crosslinking and inter-helical crosslinking effects post-treatment. So there's a lot of evidence that is in favor of the positive effects of corneal crosslinking. Some of the first papers that I could find in dealing with this subject were one from Dr. Wolensack who used albino rabbits and treated them pre and post and measured the lamellar thickness and had a significant, 12% significant increase in the lamellar thickness anteriorly and 4.5% posteriorly. In addition, there's a lot of data that supports this treatment but patients with keratoconus obviously, they, this is kind of conservative data. Dr. Gaster has presented data that keratoconic patients post-treatment have up to a three-fold increase in corneal stiffness with bending, et cetera. But this is what came out of this book, Corneal Crosslink, or Corneal Surgery and Crosslinking. They stated that 8-point, excuse me, 1.8 times in comparison with normal corneal tissue. In addition, they've, other stories haven't done like shrinking of corneal material based on temperature and they found that there was an increase from 63 degrees centigrade to 70. Complications in dealing with corneal crosslinking include endothelial damage from UV exposure in addition to permanent keratinocyte death in the area of treatment over several years. In addition, post-op haze is very common which can affect the vision and then of course with the de-epithelialization you have an increased risk of infection. There's also ongoing research at various locations. Dr. Gaster is working on kind of playing with the dosage of strength in addition to time of exposure with UV irradiation. And Dr. Rabinowitz in addition is treating keratoconic patients and post-lasic atatic patients with intax and corneal crosslinking as well. And he's shown very promising data with roughly 2 to 3 diopters of flattening in the cornea post-therapy. There's a, like I said, this is a growing field. I'm sure everyone knows that and there's lots of data and lots of very interesting data. With my remaining time I'd like to go ahead and share some of the information from the physicians with whom I worked down at XLI Center. So they've been doing corneal crosslinking for the last three years. Kind of a serendipitous event on how they received a corneal crosslinking machine. There's a parent of a patient who really wanted their son to receive corneal crosslinking. So he literally flew to Australia, bought the machine and flew back here. So I guess if you have the money. So over the course of the last three years, 84 patients have been treated and 125 eyes. Traditionally, again, the modality of treatment is to de-epithelium as the tissue. However, there is, again, there's growing data that's showing favoring keeping the epithelium intact, which reduces corneal haze in addition to a post-operative discomfort and recovery, as well as a decreased incidence of infection. So these are the different treatments. I put it in kind of a graph form. I like visual examples better. So the majority of patients treated were caret iconic patients. And in addition, post-lasic being a large population, or rather the second largest population treated. The age range here, the thought of treating caret iconis is that Dr. Gaster states that younger caret iconic patients are the best candidates for corneal crosslinking because over time, he says if you can imagine this, over time in UV exposure, we receive kind of a incidental crosslinking, if you will, just by living your day-to-day life and being exposed to UV radiation. So the focus is primarily on a younger age group, and this specific group preferred patients for their younger. Okay, so as far as serious complications, there have been none reported in this group. Patients did have a corneal haze post-therapy, and in specific, and I just want to cut to this really quickly here, only one really felt that they had subjective visual impairment. The remaining of the patients, and I'll go back here, reported 91% no change, if not an increased change in vision. This is supported as well by Dr. Rabinowitz's study. This is best corrected. Dr. Rabinowitz's study as well, treated 58 eyes in addition, had a very wide breadth of visual acuity changes on the snelin chart, going from negative 2 to plus 8 improvement. So his study, I believe, was six months post-therapy, and this data is over the course of 22 months. Okay, so these are the physician's theories as to the reasons for which adverse post-operative complications occurred. Again, these are just theories, and there's a lot of data being researched into it presently. And just really quick, I want to go through this last piece of information. This is a specific case, is a 12-year-old girl, a Hispanic girl with a keratoconus, and this is her original manifest refraction with presentation on my mom's birthday in November 22. So over the treatment of this female, you can see a reduction in her manifest refraction, and there wasn't consistent topographies that were taking place with treatment, and that's something that is actually being improved there. But the most impressive to me is her manifest refraction in January of this year. She's seeing, I mean, going from 2400 to 2030 is quite amazing, and she's doing very well, very well, seen her a few times in clinic. So at any rate, yeah, I really appreciate this opportunity to present, and I would be happy to take any question. I don't believe that that is a... Yeah, so there's been a lot of growing debt. In fact, that's kind of one of the topics in dealing with corneal cross-linking. I just barely read a recently published article with 23 pediatric eyes in dealing with non... or rather the treatment of cross-linking without de-epithelializing the tissue. And there are promising results, but it's something, again, with the advent of this procedure, it was traditionally... removal of the epithelium was just the standard of care fuel. So there's growing data. I believe it was Dr. Ruben... Oh, excuse me, Dr. Rubenfeld that presented last year at Deer Valley. He was speaking about 15 different centers and how they were treating with the epithelium intact, and they were still showing significant corneal flattening as well as improvement in vision. All right, thanks, Cal. So our next presenter is James Tucker. He's a medical MD, PhD, right?