 So, yes, I will be presenting on visualizing comfort, palliative care and ophthalmology. Thank you for the introduction. So, I hope this presentation can help us better understand the options or resources we have available here to help provide patients with more individualized care. The share, yeah, let's forget. Oh, no, you're good. Awesome. Thank you. So, we all likely strive to develop, or we all strive to deliver optimal eye care with a particular emphasis on restoring or preserving vision as a fundamental aspect of this mission. However, engaging in various conversations with patients has helped me to reassess the true essence of what best care means. These interactions have presented a challenge in recognizing the significance in preserving grace and dignity in medicine. An aspect that may not always be readily apparent but holds up most importance. And if you haven't watched how I'm gonna highlight a little bit. That conversation starts with how we define the blind and the paid-by. Out of every 10 individuals affected by blindness, one person experiences a condition known as a painful blind eye. This is described by many as vision that is unsalageable and poorly responsive to popular, or poorly untalented. A clinical examples of this include what's listed here. There's a lot more examples of what can prompt us to kind of conserve eye care efforts. In these cases, traditional efforts have been made to help provide comfort but has been poorly infected. So, how do we define pain? I think we ought to challenge a conventional understanding of pain to encompass not only physical aspects but also emotional and financial factors that patients may encounter. These interconnected elements oftentimes magnify one another and then disturb patients' overall experience. Of course, there's the obvious and sometimes not so obvious physical pain that a patient is in. And as evidenced by the cluster of this slide, there's a plethora of studies that show that there's a connection between the emotional and physical burdens that patients might experience. In 1969, Elizabeth Kugler-Ross defined five stages of grief. We've probably all been kind of pushed to memorize these stages. And I think it's actually really important to consider this in our conversations of palliative care discussions. And our role as providers is often crucial to assist patients in making well-formed decisions. And to achieve this, we may need to understand or better understand the time frame for attaining acceptance in these five stages of grief. During my literature review, I saw that it took about on average four weeks for people to define a painful, blind eye, i.e. the pain persists for at least four weeks. Is this duration sufficient for patients to make perhaps critical decisions that might include an evisceration or a nucleation? Grief, of course, is complex and deeply personal. There's no predetermined timeline for how long each stage should last. So it's of utmost importance for us to deeply connect ourselves with our patients and help make them make the best and most rational decisions. This is another cluster slide, but I'm not going to delve into all the possibilities listed here, but it's showing us the various modalities that we can use to help address patients who are in need or in discomfort. It's important to note that these interventions can often lead to significant financial burdens, exacerbating the emotional and physical distresses patients' minority experience. Fortunately for us, many insurance providers recognize the necessity of covering these interventions when a patient receives such a diagnosis. However, we also need to acknowledge the challenges faced by being insured. To support them, we do have charitable institutions here that have been established, examples of which include like the Callister Fund for prosthetics or billing offices offer charitable care after charges have incurred for our patients. These are just a few of very many resources we have available. So what is palliative care? It's a specialized approach to medical care that focuses on improving the quality of life and providing relief from physical and emotional burdens of individuals facing serious illnesses. The primary goal of palliative care is to enhance comfort and support both patients and their families throughout the course of illnesses, regardless of their primes or disease. Who is palliative care? I think healthcare professionals come together in a collaborative effort here to address all aspects of patients' wellbeing. I really also want to emphasize the importance of loved ones in this process as well. They play a huge or critical role in providing holistic care. And in the realm of ophthalmology, there are various tools that we can use to provide palliative care. Here are a list of some of the many. Of course, there's pain management, symptoms of patrol, which I'll talk a little bit about later, low-division devices, psychological support, which can come in the form of counseling or spiritual support. There are also various support groups for specific eye conditions of visual impairments, allowing them to share their experiences with one another, obtain emotional support and access valuable information. An example of which would be in our neurologic clinics, we have migraine support groups, which are listed in a lot of our handouts. The talk of the patients seems to be very, very beneficial for them. There's advanced care planning, education, specifically for patients and their families, could be super important to help them understand a little bit more about their condition, treatment options and available support resources as well. And as previously mentioned, care coordination and it being a collaborative effort is super important. And back to that involved slide, I won't touch in detail on all of this, but essentially there's so many different ways in which we can target the pain and symptomatic management. There's no established guideline that offers clear directives on how to approach patients in these various circumstances. A group in Columbia offered an algorithm which I think serves as a nice starting point. A lot of these symptomatic treatments were already aware of. And I would like to dive a little bit further into the kind of community resources we have here at the Marin Eye Center. And actually in the state of Utah as well. So patients with severe vision loss may benefit from using low vision aids and devices to enhance the remaining vision and improve daily function. Several programs exist to help facilitate that. This includes the Division of Services for the Blind and Visually Appared or DSBDI. Veterans Affairs has a low vision group as well. The Utah Council of the Blind, of course we're blessed to have both outreach and our low vision group here as well. Many of these services can also connect you with other services and such as a library for the blind, senior services, Medicaid if there's financial assistance in need or meals on wheels. For the DSBDI, it provides a wide range of complementary services to individuals in need. These services can include cane training, home management guidance, assistance with technology, computer usage without screens. Additionally, they provide support in patients pursuing their hobbies. And that includes activities like quilting, crocheting, crafting pens or cookies, and even woodworking, which I thought was really, really fascinating. They can learn to operate saws. And I believe the only specialized tool that they have in these groups are a ruler. Interestingly, in the conversation with Dr. Ord, a lot of these patients, they learn blindfolded even if they have some remaining vision. And she shared that some of them would actually do better with the blindfold on than with it off. For the sake of time, I actually won't click on this link. There is a really fascinating link on the DSBDI. It's about two and a half minutes set. Really dives into the patient experience and the options available from there. The Utah Council of the Blind, like the SBDI is another free service, offers valuable, invaluable visitation services and information on skilled assistance and essential aspects of living that includes cane traveling, braille learning, kitchen safety, organization, mobility and so much more. These dedicated teams are equipped with individuals that help these individuals discover adaptive technologies that can enhance their independence at home. The VA, of course, also has free services for their patients as well. The slow care on the fourth floor, they have various support crews and skills in addition to many more resources. At the Moran, we're blessed to have fantastic low vision department. Dr. Bob Hutchinson is dedicated to enhancing day to day functioning for individuals with vision loss. Among his many roles, he evaluates light and contrast sensitivity, assisting patients in identifying and utilizing tools that cater to their specific needs. Dr. Lisa Ward has our patient support program and offers invaluable services such as orientation to vision loss, private counseling and support groups. Amanda as our social worker, she takes charge of facilitating our free support groups. They hold hybrid sessions both on Zoom and in person. These groups operate on a eight week basis with a two week race in between allowing new members to join. This ensures a maximum accessibility and also kind of ensures that they're not introducing, you know, each other every single visit and kind of really focus on what they need to focus on. Upon receiving our referral Guillermo, loyal is not pictured here, but also works in a low vision group, personally contacts the patients to inquire about their specific challenges, ensuring that we provide the best most individualized assistance. Janice, our occupational therapist, conducts in-home assessments to help patients navigate their daily routines safely and independently. Though not pictured here, Dr. Karina Taylor also plays a crucial role in organizing our monthly orientation to vision loss. She was diagnosed with Stargardt's disease and currently teaches at UIU while holding PhD at their symbol. Serving as an inspiration for so many in these situations. While most of our services are offered free of charge, our counseling service notes his fee base and there are limited by the insurance to be accepted. And this is actually fewer than what we use in our typical offalming appointments upstairs, which is interesting to know. In terms of access, so I won't delve into the specifics of how to get access to these various groups within the Moran. I just wanna assure you that, you know, if you have a question or have a need, there's probably an answer out there. I'm happy to share this PowerPoint with anyone who might need a contact or resources to help reach out. But there's so many invaluable resources just right downstairs for us. And so in conclusion, there exists a critical responsibility in improving the quality of life for patients confronting advanced or terminal eye conditions. Considering the burdens they often face with their numerous medical decisions in line. Our primary objective is to center on ensuring that these patients receive holistic support and compassionate care at every step of their medical journey. To achieve optimal care, physicians must excel at attentive listening, valuing and responding to the unique needs and concerns of each individual. I'll leave you on this quote from a German American theologist, Paul Tillich. The first duty of love is to listen. The sentiment holds true in numerous aspects of our lives, including our roles as physicians. When we made the commitment to serve as healthcare providers, we inherently pledged to demonstrate love and compassion towards our patients. So a few acknowledgments. I want to personally thank Dr. Elisa Ward for sitting down and talking to me and sharing these resources, as well as the rest of the little vision team. Dr. Bob Kirsten who engaged in conversations about various treatment modalities for these patients. Dr. Schachall, who actually first initially described or got me thinking about this, it's something I wasn't fully aware of as a PGI one. So we were just driving down and on and he was driving on and he was kind of mentioning these things to me just put it in my mind to begin with. And also to all the faculty, fellows and co-residents I've had the pleasure of working with who have constantly stressed the importance of listening in both their words and actions. I thank you. And so with that, I'm done. I'll leave you with this out of the blue winter. Many of my co-residents, thank you. Take any comments or questions? I can't see. Oh, Brandon, sorry. Great job. I think about late. So it's an interesting talk. I just wrote a book about an author. I do like to do R&D and he talks about he's served a lot of people in the end of life and the last vision and talk a lot about screening their dignity in contact with their habits. That's something I feel like if I don't ask if I'm not purified, sadistic situations, sadistic character, sadistic situations, the process of getting in contact with the board, what is it an email or a view? I'm not sure you said that. Yeah, no, that's a great question. Number one, she is right here. And so I do want to acknowledge your presence. Number two, let me see if I can flip back to that. Sorry. Council, program anytime. Okay, that's just important. Council, it's an ophthalmology vision rehab patient support program. And one of the choices will be somebody just needs resources, somebody needs emotional support, or somebody needs AAR, which is basically a shared response thing that's going on in their lives that keeps them from maybe applying to the treatment program or something like that. So, and then we can follow the patient and assess what they need. And we also have referrals to DSBDI, the state service, if they need training, that is the best place that they can get the blind skills training. Second best is the Utah Council with a blind it's just a smaller program. And they will go out to that. But the DSBDI has a wonderful center. And hopefully maybe in this year we can also do a tour for residents and fellows. And so just to reiterate the question, it was, how do we get access to low vision resources specifically that we saw? So I just flip back to this slide here. That award, essentially, I mentioned ordering consult. So vision rehab and patient support consult. When we order that consult, several different options will pop up that can lead us to whatever direction we choose to go in. Thank you. Yeah. Any other questions or comments? Yeah, actually. So I mean, I feel like I see this a lot that Oklahoma, the hospice with the eye, I think that probably also shares that presentation. But what was interesting to me is actually the place where Lisa was invaluable to me was the patient who had had a stroke and had a home on a second of day. From that, and he was in clinic, actively suicidal from his vision loss. And you guys were just Antarctic and reaching out to him and supporting him through really the first three months of vision loss. So I guess my comment is one, oftentimes for me is, I think of you and I think that the patients who are like in 2,400 count figures, he actually had like the essential vision that he had as an individual, both of you guys. And so I was initially really surprised to encounter how much stress he was. And so it can happen in any vision loss situation, it doesn't have to be what we totally consider to be. And also these are emergent issues to come up and probably sources are incredibly helpful in those situations. So thank you. Oh, sure. And if Amanda and I are here on the screen, we are happy to come up to clinic to talk to those patients who are not dealing with news that's not going to get better. And I'll just briefly summarize that for those online. That just sits in front of a patient who was significantly emotionally disturbed and suicidal as a result of their vision loss. And our resources here at the Moran were able to be contacted. Dr. Orton and Amanda helped, hopefully, save or alleviate some of the concerns this patient had. So I just wanted to restress that they're both non-emergence and emergent ways to contact these resources. And once again, I'm always happy to share this information if you can't find it. One easy phone call away or perhaps email although I don't necessarily respond to those quickly. No. Any other questions or comments? I'm also going to give Gino a quick happy birthday shout out to this birthday today before I introduce Ashlee. Ashlee, I'll be right in, you know. Alrighty. Next up, we have Ashley Polsky. She is another third year ophthalmology resident and she'll be presenting, oh, actually fun fact. She just completed a half marathon, something I can never accomplish. Congrats to you. And she'll be presenting presentation titled, Ugg Syndrome After Hydrous Microstem Placement. Thanks, Nana. All right, I'll go ahead and get started. I have no conflicts of interest to disclose. And this case involves a 72-year-old man who initially presented to the VA walk-in clinic in March 2022 with a chief complaint of headaches, nausea, and blurry vision in his right eye. He reported that when he awoke that morning, the vision in his right eye was very cloudy and he was seeing halos around lights. He also noted a two-day history of headaches localized to his right brow that were associated with nausea and he had no recent injuries or illnesses and he was not on anticoagulants. His ocular history included bilateral, mild, primary, open-angle glaucoma, and non-excited macular degeneration. And a few months prior to this visit, he had undergone cabaret surgery with placement of a hydrous microstem in the right eye. His post-op course was complicated by an immediate post-op hyphaema as well as CME, both of which had resolved about a month after surgery. His ocular medications included latinopross and bermanidine in his left eye and he was finishing a prolonged ketore lactaper in his right eye for his recent history of post-op CME. His chronic health problems included hypertension, hyperlipidemia, and he has synophilic esophagitis. He also mentioned a history of cold sore since childhood and he had no medication allergies, no relevant family history, and a non-contributory social history. On exam, his visual acuity was 20, 30 minus two in the right eye, which was decreased from 2020 at his prior visit. His left eye, which had not yet undergone cataract surgery was stable at 20, 50 minus one. His pupillary exam was normal and he had full extracurricular motility, full visual fields to confrontation in both eyes. His intraocular pressure was elevated to 28 in his right eye, which was increased from about 12, 13 at his prior visit and was actually the highest IOP ever recorded for this eye. Slate lamp exam of the right eye was notable for traceable heart congenital injection and four plus pigmented and non-pigmented cell within the anterior chamber. There was also a very small layering hyphaema inferiorly in the right eye. And on careful examination, there were no iris trans elimination defects and the posterior chamber IOL appeared to be well positioned without obvious fecodynesis or tilt. And I know sometimes photos show up a little strangely on the screen, but this is the split photo of the patient's right eye on presentation. And hopefully you can see there are numerous pigmented and non-pigmented cells being eliminated by the light beam within the AC. With Gonioscopy, we were again able to visualize a small hyphaema layered along the inferior angle. The inlet or proximal end of the hydrous was visible in the nasal angle as shown in the photo here. And this inlet appeared to be just slightly extruded and in contact with the anterior surface of the iris. And if you look at the diagram of the hydrous microstem that I included at the bottom of this slide, you can see that beyond the inlet, there are these three open windows that run along the length of the hydrous. And these windows should typically all be visible through the trabecular mesh work when looking with Gonioscopy. However, in this particular patient, we were only able to see the very first most proximal window, but not the other two windows which made us wonder if perhaps the stent was positioned too deeply or too posteriorly within the angle. We also performed a dilated fundus exam on this patient which was stable with no signs of macular edema and no new revelations. So given this patient's new findings of anterior chamber inflammation, hyphaema, and elevated IOP, we were most suspicious at the time for UGG syndrome or UVINUS glaucoma hyphaema syndrome. And based on the appearance of his hydrous micrason, we wondered if subtle malposition of the stent could be causing UGG syndrome versus something like chafing of his posterior IOL along the backside of the iris, although we didn't see any evidence for the latter on exam. Other considerations included a traumatic hyphaema which seemed less likely given this patient had no known recent history of trauma. Herpetic anterior UVitis was also a consideration, especially given his history of recurrent cold source since childhood. And although our suspicion for this was low, post-op endothelitis was also considered given his history of intraocular surgery a few months prior. For treatment, we continued his daily catorilac in the right eye, and we also added topical prenus alone and cyclopenelate. We started two glaucoma drops, Timolol and Bermanidine to manage his elevated IOP. And just to cover for any potential herpetic infections, we started him on a seven day course of oral valtrex. So this was the starting point, representing my initial exam of the patient in March, 2022. And about four days later, after being started on the medications I just mentioned, he returned for repeat exam and reported complete resolution of his headaches and blurry vision. His visual acuity measured 2020 at this point in the right eye and his IOP had improved to 12. He still did have some residual anterior chamber cells. So we kept him on cyclopenelate drops and began to taper his topical prenus alone. About one month after initial presentation, his anterior chamber inflammation and high fema had completely cleared and his IOP remained stable on Timolol drops. We had the patient return in early May, 2022 to see Dr. Harry in order to attain some additional imaging. In particular, we wanted to evaluate the positioning of the posterior chamber IOL just to see if there was any potential contact between the IOL and the iris that could explain his episode of inflammation. So Dr. Harry performed ultrasound biomicroscopy at the VA which demonstrated appropriate IOL optic and haptics positioning with no evidence of posterior iris touch. And here's another UBM view again with good positioning of the posterior chamber IOL. And in this view, we could actually see the hydras within the nasal angle which the arrow is pointing to in the photo here. We also obtained anterior segment OCT to get a little higher resolution of the hydras and anterior chamber structures. And in both of these images, you can see a cross section of the iris and then just above the iris within the nasal angle, there's that linear kind of thin hyperreflective structure and that's the hydras microstem. And I wanna emphasize that at the time these particular photos were taken, the patient was still using topical cyclopenolate which is known to posteriorly rotate the iris ciliary body complex. And so at this time, we really didn't see clear evidence that the hydras was pushing or rubbing against the surface of the iris even though that was something that we were expecting with his previous episode. The patient's anterior chamber remained quiet and so about a week after those photos were taken, I called up the patient and had him stop the topical cyclopenolate. And I had plans to follow up with him about one week after stopping the cyclo. Unfortunately, within just three days of stopping the cyclopenolate, he returned to our walk-in clinic complaining of recurrent headaches and blurry vision in the right eye. His IOP was still well-controlled on topical Timmelal. However, sure enough, he had a recurrence of four plus mixed AC cell and a new layering hyphaema within the anterior chamber. So we repeated his anterior segment OCT at this visit now that he was off of cyclopenolate. And this time we were a little more convinced that the hydras seemed to be in close contact with the anterior surface of the iris. In these photos, the arrows point to the tip of the hydras inlet. And as we kind of follow that tip with progressive OCT cross sections, the inlet of the hydras seemed to dive further and further posteriorly towards the iris. And of course posterior shadowing behind the device really limits our ability to fully visualize the posterior aspect of the hydras. But based on this downward trajectory that we were seeing of the hydras inlet, we inferred that there likely was contact between the hydras inlet and the iris. So the patient was restarted on topical cyclopenolate and again demonstrated excellent response a few weeks later with resolution of his symptoms and near complete resolution of his anterior chamber cell. So by this point, we were fairly confident that it was indeed the hydras that was causing his UG syndrome flares. And so after discussing options with the patient, we moved ahead with removal of the hydras and goniotomy in July, 2022. Interoperatively the hydras was confirmed to be positioned just slightly too posteriorly which had caused angling of the hydras inlet in the anterior chamber and contact between the inlet and the iris. And thankfully this patient has done very well post-operatively. His vision and IOP have remained stable on topical latanoprost and bermanidine and he has had no further recurrence of anterior chamber inflammation, high FEMA or IOP spikes as of just a couple months ago. So at this time I'd like to transition and just talk a little bit more in depth about UG syndrome and how it relates to the hydras micro-sten. UG syndrome was originally described by someone named FT Ellingson in the 1970s which is why you may sometimes hear this condition referred to as Ellingson syndrome. And UG syndrome is comprised of a triad of uveitis, elevated intraocular pressure and high FEMA. And additional features may be seen in patients with UG syndrome including iris translumination defects, iris neovascularization and CME. And the photo on the right here is an excellent example of iris TIDs in the setting of UG syndrome. And the TIDs in this particular photo correspond to the temporal haptic of a sulcus IOL. Classically UG syndrome is caused by mechanical rubbing or chafing between an intraocular lens implant and the iris. And this often actually necessitates surgical intervention to definitively treat. But in addition to IOLs, there have been multiple recent reports of other types of intraocular implants causing UG syndrome such as capsular tension rings, expressed shunts, eye stents and as in our case, hydrous micro-stents. And I'm sure many of you are familiar with the hydras and have hands-on surgical experience with it but for those who are maybe less familiar, the hydrous micro-stent is a type of micro-invasive glaucoma surgical device that was designed to essentially bypass the trabecular meshwork and stent-open-schlems canal in order to provide a more efficient aglius outflow pathway and thereby reduce intraocular pressure. The hydras received European CE approval in 2011 and subsequently received FDA approval in 2018 specifically for use in combination with cataract surgery for adult patients with mild to moderate po-wag. The hydras is inserted by placing a pre-loaded injector through a clear corneal incision and advancing the cannula tip through the trabecular meshwork until it enters schlem's canal. And then a tracking wheel on the injector is used to advance the micro-stent until only the small in-lamp portion remains within the anterior chamber. And after insertion, as you can see, the hydras spans approximately 90 degrees of schlem's canal. And here you can see the three windows that we were discussing earlier through the trabecular meshwork. And just for review, the hydras has three main components. The first being a rounded distal tip that allows it to pass smoothly into schlem's canal. The second component are those three open windows that I keep mentioning. And these windows are spaced evenly along the body of the hydras. And the goal of this open scaffold design is to dilate schlem's canal without physically obstructing outflow access to egg-based collector channels. And then the final portion is the proximal inlet, which is the portion of the hydras that was contacting the iris in our case. Multiple studies have now compared the efficacy of hydras to other forms of Guacoma treatment. For example, hydras was non-inferior to canaloplasty and achieving a significant reduction in IOP at two years. Hydras was also shown to be quite effective when compared to selective laser trabecuoplasty, with 47% of hydras patients achieving a drop-re-status at one year compared to only 4% of SLT patients. When compared to the ISTN, the hydras achieved a greater reduction in mean intracular pressure at one year and also achieved a significantly greater decrease in number of medications compared to the ISTN group. And when combined, hydras and cataract surgery was compared to cataract surgery alone in a two-year prospective multi-center randomized controlled trial, the hydras cataract surgery group demonstrated more effective IOP reduction and decreased drop burden compared to the cataract surgery only group. And this particular study is known as the horizon study, which was an extremely important trial in demonstrating the efficacy and safety of hydras over two years. About 80% of the original 556 horizon study patients were followed for a full five years. And based on this extended follow-up, Horizon investigators recently published long-term hydras outcomes in 2022. And at five years, the hydras cataract surgery group still showed significantly greater IOP reduction and significantly reduced drop burden compared to the cataract surgery only group. The horizon study did highlight some complications of hydras implantation, including transient post-op hyphema, uveitis or iridus requiring slightly prolonged steroid treatment, micro-STEN obstruction and malposition of the STEN. The only long-term finding that was noted at five years was development of tissue adhesions or peripheral anterior sneakier at the trapecular entry point. And interestingly, about 1.4% of the hydras devices were found to be malpositioned post-operatively. However, none required device removal in this particular study. And although a syndrome wasn't specifically recognized as a significant complication in the horizon trial, a couple of recent cases have been published that highlight a syndrome as a possible, the rare outcome of hydras implantation. And the first case I wanted to highlight is a case from the University of Colorado Department of Ophthalmology. And this patient presented very similarly to our case with persistent pain, mixed anterior chamber cell and elevated IOP about one month following otherwise uncomplicated cataract surgery with hydras placement. And in the corresponding slit limb photo here, they showed that not only was the hydras inlet extruded, but even the first window of the hydras was visible outside of Schlump's canal and was kind of just resting on the surface of the iris. And so in this case, the patient also opted to have the hydras removed after which he had almost immediate resolution and was pain and inflammation, just like we saw in our case. Another case that was published in Glaucoma today discuss a patient who presented with recurrent hyphemas in her right eye about two years after having combined cataract surgery in the hydras placement. And on exam, nothing really seemed to be remarkable about this stand. And in the photo on this slide, you can see that all three hydras windows were visible as would be expected. And the inlet doesn't really appear to be significantly extruded or angled. The ophthalmologist who was managing this patient's care, Dr. Jacob Brubaker theorized that perhaps a hidden vessel within the nasal angle was in contact with the stent and that when the patient was upright, the stent's downward trajectory would allow red blood cells to just escape into the anterior chamber. And he initially planned to also remove the hydras just like the previous cases we've discussed, but based on shared decision-making with the patient, the stent was ultimately repositioned to a new location in the inferior angle after which the patient's hyphemas completely resolved. So this is just another interesting example that demonstrates an alternative approach for managing hydras-related OGS syndrome. In summary, the hydras microsent is an overall safe and effective method of achieving IOP reduction and in many cases also reducing drop burden for patients with primary opening glaucoma. And although cases of OGS syndrome secondary to hydras are rare, it's important to consider this potential complication in patients with recurrent hyphaema and IOP spikes, particularly if there are signs that the hydras is mal-positioned. And as demonstrated in our case, imaging modalities like UBM and anterior segment OCT can be really useful in these OGS syndrome cases, especially for distinguishing between hydras versus IOL implants as the potential cause of inflammation. And finally, although few cases have been specifically published on this topic, hydras removal or repositioning seem to be reasonable options for definitively managing hydras-related OGS syndrome. And I just wanna thank the following people for their involvement in caring for this patient and for teaching me a lot about this case as a new intern at the VA at the time. And special shout out to Dr. Harry and also Dr. Wyatt, one of the VA opometrists who were instrumental in getting me all of these photographs. Here's a list of my references and happy to take any questions or comments. Yeah, Dr. Christensen. I just wanted to say we're actually just approved to do a study on the incidence of mal-positioned hydra-scanicent. So any of your clinics where you're seeing patients who have these will be your information on how we pick them involved with the study that is compensation on auto-managing. But I suspect it's probably higher than what we previously thought. For those online, Dr. Simpson was just saying that they're in the process of putting together a study looking at the rates of mal-position of things like hydra-scanicent. And so keep an eye out if you see any stent mal-position in your clinics. Yeah, how hard was it to get the stent out? I'm pretty sure Cole and Dr. Stag did the surgery, but yeah. Either sligh-headle or you give them a nice little Okay, there it is, okay, most of the time. And you just use the injector to like read? Yeah. Retract it? I think Craig had one where it did cause a clot which was unable to repair. But it's not like side-pass, right? That was very, very difficult for them. Which is important. I see, and in view of everything this patient went through, looking back at the decision to put the device in again, what was the need to put it in compelling enough for the patient to go through all of it? Dr. Simpson's shaking her head. Yeah, one of the questions I would ask, you know, is that not involved in doing a home cataract surgery in adults at the VA? Yeah, I mean this particular patient, I'm sure would say no, I saw him many times. And I think by the end of everything, he was very happy to just be on a couple of drops in that eye without dealing with issues of recurrent pain and blurry vision. But yeah, I know we see a lot of other patients that have gotten it in love, not having to take drops, but. Yeah. We're definitely like depending on everything, right? The device first came out and we were like, it's for everybody and now it's starting to swing a little bit more again the other way, which is if you're really, if you have a mild glaucoma and you're stable on your medications, nothing is going to do with the night. And so is it, in fact, I have a patient yesterday where we had a really long conversation about whether or not she wanted to send, she's like, I am 100% fine, just hang on a drop, like stable on a drop, and then follow the patient if that drop needs to be sent. Good presentation. Thank you. Thank you.