 All right, I think we'll get started for today's grand rounds. We have two presenters. The first one is Lydia Sauer. She's a PGY3, and the title of her presentation is the role of gender in ophthalmic surgery training. Something interesting about Lydia, she has a beautiful dog named Milo, and she loves to do photography. Thank you so much, Tyler. I'm excited to talk about a topic today that is something different than what I usually present on. And it's very dear to me because doing ophthalmic surgery is something that, especially coming from Germany, is not as easy to do as a resident, and especially as a woman. And I'm just very grateful to be able to train in such a fantastic place as the Moran Eye Center. But I do want to look at the role of gender in ophthalmic surgery training. So I'm going to start with a little riddle. And maybe some of you have heard of this before. A father and a son are in a car crash, and they are rushed to the hospital. The father dies. The boy is taking to the operating room, and the surgeon says, I can't operate on this boy because he is my son. What's happening? How is this possible? And unfortunately, a lot of times when this riddle is asked to people, they think of all kinds of scenarios of, like, did the father really die? Is the father doing the surgery? Is it a gay couple? Is the child adopted? But the simple answer to this is, the surgeon is the mother. And this is just a good example to talk about unconscious bias. Unconscious bias is also known as implicit bias, and it is a learned assumption of belief or an attitude that exists in the subconscious. So we're not really aware of it. Implicit biases are developed over time and through life experiences and by being exposed to different stereotypes. They are composed both favorable as well as unfavorable assets, and they are activated involuntarily and without the individual's awareness or intentional control. And being aware of or becoming aware of this unconscious bias that exists is an important step to overcome it. And gender bias is a type of unconscious bias. And unconscious bias is learned since childhood. There are many examples, but I thought that this was very fitting for this topic of unconscious bias or gender bias that is taught to us from childhood on. This is a children's book from the 1970s, Boys Are Doctors, Girls Are Nurses. And that's just how we grow up. But does this still exist nowadays or is it only something that happened in the 1970s? When we Google of Tomology and look at Wikipedia, the picture that shows up on the Wikipedia page is a group of male surgeons doing eye surgery on a patient. Or if we Google eye surgeon, typically the patients are female and the surgeons that are depicted in the pictures are of male gender. And then just kind of going through this, clicking on the ophthalmologist part, suddenly some females show up, but they are all in clinic. Like there's a female physician looking at a patient or here as well, but all the surgeons that are depicted are of male gender. So the question that I'm posing is, is this just the internet or do we have unconscious gender bias in of time surgery training as well? And that's what I want to talk about a little bit more. So there's quite a little bit of research on gender differences in of time surgery training. This is one study that is published that I found as the biggest study where a large number of residents were looked at, a total of 1,271 of time ology residents from 24 US residencies were investigated. And it was found that female residents performed fewer surgeries than male residents did. And to the point it was 7.8 to 22.2 fewer cataract operations and 36 to 80.2 fewer total procedures when comparing female residents to their male counterparts. And this was in a time period from 2005 to 2017. And so the current state of surgical training in of time ology residency deserves to be further studied to ensure that male and female residents have equivalent training experiences. This is another study that was done in Australia and New Zealand where the difference was even greater, whereas female trainees completed 41.7% fewer cataract operations compared to their male counterparts. And this is something looking at different countries, especially in Europe as well, female residents definitely get fewer surgeries compared to their male counterparts. An interesting discussion that I found online is this article, it's called the gender gap. And if you wanna look up anything, I thought this was very interesting because I talked about how the gender gap is actually decreasing in of time ology, how there are more female of time ologists, more female surgeons, but looking at the actual numbers, especially attention drawn to the surgery, the percentage of full professors in surgery who are women is 8%. The percentage of associate professors of surgery who are women in of time ology is 13%. And the percentage of assistant professors of surgery who are women is 26%. And those numbers are still very low. And this is just one part amongst many others where the numbers of women are fairly small compared to those of men. And this is a very interesting review article that kind of stated all of the previously mentioned biases. So surgical experience for women differ considerably for those of men. They have fewer surgical opportunities and disparities in surgical numbers. And this lower surgical exposure may contribute to the fact that fewer women trainees select surgical subspecialization because women tend to subspecialize in medical retina, ubiitis, and pediatrics, whereas men are more likely to subspecialize in surgical retina, oculoplastics, and cornea. Another interesting aspect is that the operative autonomy during residency, so the opportunity to complete a procedure without the help of a supervising faculty was 19.3% in women and 33.3% in men. So I posed the question, have you noticed any gender bias in atomic surgery to a couple of colleagues and friends? And I just want to read out a few of these comments. During surgery, men often talk about baseball or other sports and I feel completely left out of the conversation. My attending said that every resident is allowed to do one case by themselves on their last day. My male colleagues, however, were allowed to operate on their own for half of the rotation. I am curious if there's any difference in surgery numbers between male and female residents. I don't think there are any significant differences. I really want to support women, but if I'm honest about it, I take over during surgery more frequently when a woman is operating and I don't even know why, it's awful. I felt like one of my attending in particular was slower to let me do anything in the oar compared to my male co-residents for no good reason. Why would you want to go to medical school to be an eye surgeon? Wouldn't nursing be so much better for you? A little girl like you does not belong in a time of surgery. And as shocking as these sound, these are actual comments that were made at some point of time. So what I want to look at with this study is to look if there's any gender bias in our training here at Moran. So I've done a retrospective analysis of the ACGME locked surgery cases for the Moran residents in the past five years. What was analyzed is male versus female residents, primary versus attending cases, and I focused particularly on subspecialty cases. My study population entails nine male and nine female residents that graduated in the past five years, which is a 50% male and female ratio. The graduating years are 2018 to 2022. And I have here the total cases that were locked amongst all of these residents where the numbers don't differ as much. It is important to know that these are not in any particular order and that they also include procedures like interval injections, which are locked very differently by residents. Some lock more procedures and some just lock the 10 that are required to graduate. And I want to highlight the limitations because this is a retrospective study and it has a lot of limitations. I think the most important limitation is the small number of individuals that were included, which is a number of nine female and nine male residents. And then there are also classes of three and four residents that graduated, which may pose a bias. We had the COVID pandemic that may influence the data as well as the possibility of a fluctuation of total surgery numbers that may change with time. And the individual case law may be different. Some residents may stop reporting cases when the minimum required number is reached. Some residents may under over-report surgical involvement. Some residents may forgot to lock surgeries during busy rotations. And others may have inaccurate locks. And looking at this, I just kind of locked a few cases of injections yesterday that I've done. You kind of have a template. And if you lock multiple cases, the template stays the same, but you can only go back and edit the past five cases that you've locked. So this is another reason why if you realize you've locked a couple of cases as an assistant, whereas you were the surgeon, you can only go back and change five of those. And the investigated surgeries that I focused on are glaucoma, cornea, oculoplastics, retina, globes, strobismus, and cataract surgery. And first I want to take out cataract surgery just because the numbers are so different and it wouldn't really work well on the charts, but I'll get to cataract surgery later. And here is just a graph of the cases that were locked between male and female residents in the past five years. And what I think is striking is that in nearly all of the categories, male residents had more cases compared to females. And this is especially noticeable in surgeries where more procedures were performed. And the two subspecialties that look fairly good on here are cornea and globes, but I think it's important to point out that for globes, these are done in a random fashion, just on call. Whoever is on call when a globe comes in will do the procedure. And for cornea, the minimum number of required cases to graduate are 14 and these bars are somewhat at that number. And the more additional procedures we do, for example, as in plastics, we see that the gap increases. Looking at the actual numbers, as well there is all the, as I said, all the male residents had higher numbers than female ones, but the P values were not significant for this. The highest P other lowest P value was for ocular plastics at 0.162, whereas for globes it was 0.377. So none of these were significant, which is kind of nice, but it may also just reflect that our number of investigated residents is too small to really make a good case on this. Looking at kind of all of the surgeries in total, I took out globes and I took out cataract as before, we'll get to that, but since globes are kind of a randomized fashion, I just looked at all of the surgeries that are dependent on attending sending over cases and the P value is 0.113, so not significant, but it's becoming smaller. And I think that if we look at just more people, there's a good chance that this P value may become significant at some point. On the flip side, looking at cataract surgery, this is actually nice to see. There is no significant difference between male and female surgeons. Male residents still have a higher number, but the numbers are fairly close overall with a P value of 0.365. So in conclusion, I want to say that gender does play a role in of atomic surgery and in of atomic surgery training, but gender bias is often unconscious bias, so we're not aware of it. At Moran, we see a non-significant trend of higher surgical numbers for men compared to women in training, especially in the non-cataract cases, but larger studies are needed to truly understand the gender bias in of atomic surgery and of atomic surgery training, particularly. Moving forward, I thought that this is a very nice common to kind of put at the end. To overcome unconscious bias, we must become aware of its presence, reflect on the nature of prejudice, determine how it affects our ideas, and then commit ourselves to implementing practical strategies to counteract bias through behavioral change. And with that, I would like to thank my mentors, Dr. Simpson and Dr. Lauchel, as well as Elaine, who really helped me get these cases together and all of you for your attention. And yeah, this is open for discussion. So, Lydia, I mean, what you're talking about is very real, and it's a major problem. I think it's transitioning, and I look at my 44 years when almost all the surgery, including ophthalmology was partially male, lily white male, and so there has been change, and it has been positive change through that period of time. So, I do think that it's become less what was really conscious bias. Remember, we had a brilliant resident female in the early days, and the chief of surgery kept calling her just, you're a little girl. Can you believe it? And he was a very accomplished person and delivered in the little right in front of her. It was just, I was so furious. I just couldn't stand it. So, but now it's probably more moving to unconscious bias. And I see specialties where there are essentially no women like neurosurgery or orthopedic surgery, or certainly that's transitioning and changing even a lot of areas. There are some that lag more behind others. Now, the next big barrier that's occurring is obviously in that leadership area and moving forward. But even that's starting to change and that's starting to move forward. So, I think it's important to realize that this is a vector that I think is moving in a positive direction, but clearly it needs active work to see that we do better. I'm glad to see the numbers you had in regards to what surgery here. And I do think there's a real attempt here to try to do that. And if we don't recognize our unconscious bias, then we run into a situation where we, we're responsible moving forward. We'll let these things continue without actively trying to counteract. It should be, the system needs to be fair and transparent for everybody to feel good about it. And that's all the way through. That's from leadership, that's for faculty, all of the rest and how we can do it and how to handle it. Now there's one other issue that I'm a little trickier, but I think it's worth exploring and I think that's cultural. Now, and this, what I mean is, is that a lot of this, I think simply has to do that with, boys are encouraged to be kind of rougher and tougher and what a boy would get away with is considered being correctly forceful and moving forward whereas a woman, it's not. And so I think women often are more reluctant to push, more reluctant to move forward. And I think that's something that also needs to change. So it needs to be a fairness on that. But there's a lot of studies that I've read in regards to this that do suggest that I went to an owl meeting, for instance. And this is, you know, leaders in ophthalmology in which there was, they had a dean, I can't remember, it was like Michigan, there was one of the major schools where women talk about how in her own career that she had difficulties with both imposter syndrome and not doing something that she could see her male colleagues got away with for that reason. So I think, you know, women also do look at the fact and recognize that they need to be prepared, they often not as good as negotiating for salary. That's why we're trying to make things transparent so that everybody knows exactly what it is, you know, no special deals, but we still have work to do and need to move forward. But all of those things are part of what we're talking about. But there's no excuse for it, and we can do better, but I want people to know that in my career, I've seen dramatic change that is in a positive direction. Thank you for the comment. I definitely believe that it's going in the right direction. But I think it's, as you mentioned, important to really focus on this unconscious bias that all of us have, that it's hard for us, our children with sports, and just by how we go out or how we search on Google, and I think it's important to recognize that these bias still exists, so we can fight them for them. And it's not to be great male presidents, I think it's just to equalize, and that's also- Fair, fair, transparent. Everybody recognize they're getting equal opportunities. Yeah, did you, I may have missed this because I'm way in the back and I can't really read the slides, but did you do a subsection of, or were these all cases where the resident list solves primary surgeon? These were primary surgeon cases, except for Bretona, and there are a few subsets of surgeries where both primary as well as the sustained columns as electrolysis, ACD, and milk. So those are all together where it's the ones where all the primaries count on the penis. But if they're all subsets, it wouldn't seem to much of that to present at all. But it was very similar, but of course all of the different subsets that I looked at. That's really interesting because you would think that if there were a lot of unconscious bias that that would really show up and there should be a difference then between the cases where you're just doing the case versus a case where you're being turned over as the primary surgeon, and it doesn't look like you're seeing actually a great deal of difference there. I think that is due to a small case numbers. And then we also that maybe different in what people were caught. So there were certainly, for example, my husband that didn't know about any existing cases. That's really valid. You'll be interested to see if that's different between men, women, and people. If you have the data set, you might be able to look at that. But the numbers are all very small. And spilling it up in these couple of subsets has very small surgery numbers. We may have to go back beyond the five years to just see and get more better, not a subset of data. And with more classes graduating, we'll have more. Can you compare the total cases in a certain field compared to the number of primary surgery cases? I can certainly do that. I mean, that would be within a surgeon, right? That would tell you more about the reporting level or the turning over level. Very, very interesting. And we're encouraging than I expected based on the introduction. I think we're doing a really good job in one. Helping to my colleagues over in Europe. I think that I feel very fortunate. Thanks to everyone who's part of that. Right. Thank you, Lydia, for the wonderful presentation. Our next presenter is Tony Mai. And he's presenting on mind and matter, the intersection between glaucoma and meditation. Tony is a PGY3 ophthalmology resident here. He enjoys meditating in his past time, as well as exploring the wonderful food scene here in Salt Lake City. All right, good morning everyone. Like Tyler was saying, my name is Tony. I'm a third year here. And today's title is not mind over matter, but it's actually mind and matter because we're going to be looking at the intersection between glaucoma and meditation. Great. So we're first going to start out with a picture of my lovely grandparents here. And this was taken just this past winter in California. And I know this is what winter looks like in California for any of those who don't know. This is my grand, I know it's pretty beautiful actually. So this is my grandpa here. And he has been living with glaucoma for many, many years. And we as a family have really seen what it's done to him. It's really taken away his independence. He can't really do things like drive, read, and even just walk around the neighborhood anymore. And so it's just hard to see how much this has taken a toll on his mental health. As we can tell, he's just not confident enough anymore doing these daily life activities. He's depending on his family more often now. And for him, it's just this looming sense of vision loss of doing all of these surgeries. And it's just really not helping very much. So him being in that state has really affected the whole family. And this has made me think of how do patients really relate to vision loss? Is this something that we honestly think about? Do we ask patients about this? And so I ask myself, what are questions that I engage with patients like right when they walk in the room and the first ones that come to mind are, how's your vision? Have you been taking your drops? And clinic is going fast. It's hard to really dive in. And sometimes if I'm being a really good resident and I'm proud of myself for maybe even asking, how does this affect your daily life function? But rarely I think do we ever ask like, how does this vision loss, this disease, make you feel? And I think it's because we're all hesitant to open this Pandora's box of them now sharing their feelings because what do we do with feelings? We're not trained to do that. We don't really know how to handle that. We're there just to see what's going on, if they're progressing, move them along, see the next patient. And I think this is a great place to step back and say, this is a full patient here with an emotional response to what's going on. And many times we're not really considering any of that. And so this is a interesting comic that I found in one of the papers I was reading where as clinicians, we're really focused on a lot of the treatment management. But again, we're not really considering what the mental burden is on patients for these diseases, especially something as chronic as glaucoma and retinal diseases. So I want to present to you a model of how vision loss, say like glaucoma, relates to mental stress and how that also relates to the physiological responses that that stress brings up and how that also predisposes the person to more vision loss in the future. And so we're going to start here with vision loss and that's real like a visual deficit or even just the thought of vision loss being told that you have this chronic disease that's going to keep getting worse, but we're just going to do what we can to slow it down. And this over time can make a lot of stress for the patient, them just thinking about impending vision loss of what this might mean for them in the future in terms of disability. Am I going to be able to do my work? Is there anyone that's going to help me do my daily activities? Do I need to find a caretaker? And then not just that, but the stress of going to the clinic of doing those dreaded visual field tests. We all know everyone hates those and the patients always come back to a room saying, I think I failed it. I think I'm doing worse. And a lot of times they're not, but this is how they're just feeling and perceiving it. And also the stress of taking eye drops every single day, some of them having trouble tolerating it, something barely even push or like, squeeze the bottle. This is all very difficult for them. And through the research over the decades, we have seen that stress causes a true physiological response in the body. It's not just mental. There's a mind body connection. And this stress brings up responses like stress hormones, namely cortisol. There's systemic inflammation that happens in the body. And there's autonomic dysregulation, with high pressure, with stress. And all of these can actually damage aqueous outflow pathways like the trabecular meshwork. It can also damage the optic nerve head. And these collectively can lead to increased pressure and more vulnerability to glaucomatous damage. And that feeds back into predisposing the patient for vision loss. And so you can see this is a big negative feedback loop. We have patients who are worried about the vision loss to get stressed about it. And then that makes them more likely to even lose vision in the future. So the current medical and surgical therapies that we have right now all focus on lowering intraocular pressure. And so this steps in right at the physiological response section that green, more forest green, part of the circle there. But unfortunately it's only at the very end of this cycle where the pressure is already raised where a lot of the cellular responses have already taken place and the stress is already there. And so what I am wondering is, is there any way to target other upstream factors before we get to the raised intraocular pressure? Are there any therapies that might be able to address these more adequately? And here I want to share with you a quote that I found from one of the papers I was reading. It was funny, but it was also very true. I'm gonna read out loud here. It says, despite a compelling body of rationale, stress is of little concern to clinical ophthalmology because we, as ophthalmologists, are neither trained nor paid for helping with psychological problems. And I find that to be pretty accurate as we're in clinic. This is not something we really think about. And a lot of times we think it's not our problem. But I think this data that I'm gonna be presenting is encouraging us to think about the whole patient because in the end, this really might help with their vision and prevent loss in the future. So bringing up this model, again, I found stress invokes this physiological response. There are many methods over time, over the decades that have been brought up to help mitigate this stress. And they include things like yoga, meditation, psychotherapy, biofeedback, even just normal exercise. Some of them having more data than others for working. But the one I'm going to really focus on today is meditation. And this is one as an aside first is because I myself am very passionate about meditation like Tyler was saying, I do this a lot. And I have been doing this for many, many years, having seen the benefits for myself and other people, but I'm not gonna get into that today on the benefits for just the person. What I really want to be focusing on is could this truly be a therapeutic avenue for patients? So my first question is, can meditation be a glaucoma therapy? And we're going to look at a series of meditation, randomized control trials for primary open angle glaucoma. The first one being done in 2018, the next one in 2020, and then the next one, 2021. So just as a quick overview, the first one was looking at patients with pressures between 12 and 21. Overall, these patients had preserved vision, they were already on a couple of drops and they were just more about moderate glaucoma, they weren't too severe. And then the next study looked at a different subset of patients where they were on max therapy, we couldn't get their pressures down, they were all above 21, and they needed some kind of impending surgery soon. This last study, instead of looking at a type of patient population, they looked at blood flow to the optic nerve using OCTA, trying to see if there were differences between patients who got meditation, those who didn't. So we're going to go first into the study in 2018, this was a single-blinded randomized control trial and single-blinded because clearly we couldn't do a placebo of meditation for patients, but at least for the researcher side, they could at least be blinded to who was getting which treatment. So they included patients with moderate sphere poag with pressures below 21 and pretty good vision of at least better than 2040. They excluded anyone who had any other reason for vision loss, any other disease affecting quality of life, any prior meditation or yoga experience, any recent eye surgery or a new diagnosis of a glaucoma. And so there were 90 patients split up randomized into an arm with just continuing their normal medical management versus doing so, but with an addition of meditation and this was one hour daily at 8 a.m. in the morning with a verified instructor. And after three weeks of daily meditation, they looked at intraocular pressure. They did a WHO verified quality of life survey. They looked at stress hormones, namely cortisol in the blood. They looked at inflammatory markers and they also did whole genome expression too to see which genes were being expressed if there was a difference between the two groups. And what they found was for the first item for quality of life, we can hypothesize that it's going to be better with the meditation. And that was verified to be true here. I wanna bring your attention to that red box. That is compared to the counterpart, the more black one that's just on this survey, patients do have a better quality of life after having received the meditation. That's not something new that we really expected. Now they looked at the blood and so compared with the control group, the people in the meditation group had significant decreases in these serum markers. First was cortisol responsible for remodeling the trabecular mesh work increasing pressures. And we also have found that high endogenous cortisol can be linked to ocular hypertension too. Interleukin-6, which is an inflammatory cytokine, TNF-alpha, which is an activator of matrix metalloprotonases which remodels the optic nerve and then also a decrease in reactive oxygen species which can damage endothelial cells in the trabecular mesh work. Conversely, there were increases in beta endorphins which decreased cortisol. There was increase in BDNF which has been shown in some basic science studies to reduce the retinal ganglion cell vulnerability. So this could also be a protective factor for glaucoma and also increase the antioxidant capacity which decreases the stress from those reactive oxygen species. And lastly, in terms of genome expression, these patients who got meditation were shown to be expressing more anti-inflammatory cytokines and they had decreased expressions of proteins that were involved with apoptosis, inflammation and remodeling of the trabecular mesh work. And so here I'm thinking to myself, this is all great. This is reducing inflammation. This is reducing stress hormones and making the patients feel better. But at the end, is this actually affecting intraocular pressure? That's really the endpoint that we're carrying about. And so they looked at the patient's baseline pressures. They were all about 18, 19, and there weren't a significant difference between the two groups. The two groups were also the same in terms of their demographics, number of drops they were taking and the types of drops too. Now, after the intervention, there was a significant decrease in intraocular pressure for those who were doing meditation. And this is six milligrams, millimeters of mercury, a 32% drop after just three weeks of one hour meditation. And I thought to myself, this is a massive drop as much as an additional drop of glaucoma medication. And I didn't know if this was the true or not, like this is real data. So luckily we have another follow-up study in 2020. Again, another randomized control trial. And the inclusion exclusion criteria were very similar, but I just want to point out in that red box that they looked at patients who had worse pressures, max therapy drops already and who had a large cup to disc ratio, something above 0.7. So these patients already have sicker eyes at baseline. And for this, they had a very similar model. The phase one, they split up two groups, after three weeks, they looked at intraocular pressure. But the new thing here is they looked at diurnal intraocular variation over the day. Because we know that this itself is an independent risk factor for glaucoma just progression. So sure, we can have just one pressure after the meditation that might be better, but how does the pressure vary throughout the day? And they also looked at quality of life. So just the brief results here in that red box, we see a 23% decrease again in drop. So not as good as those patients below intraocular pressure 21, but still a large amount. And then for the diurnal IOP range, this was surprising to me, almost 60% decrease in how much the IOP fluctuated throughout the day. And so this potentially could be helping those patients who have night spikes, something that we're always really worried about, especially for normal tension glaucoma. And then quality of life, 40% increase, and that's not too unexpected. So at this next arm, this phase two, they decided to split these patients up in those two groups. Anyone who had pressures below 15 were told to go home, do meditation at home, and we're not gonna have class anymore. We're gonna see what your pressure is like after six weeks. And I just wanna point out that based on the parameters of this study, 15 of those 30, so 50%, actually met the criteria of being below 15, and they avoided the trabeculectomy that all the patients above IOP of 16 received. And so now we have three groups in the phase two, and those patients who got that trabeculectomy actually had the trabecular mesh work sampled during the surgery, and those were run under gene sequencing to see which genes were expressed. And they showed that those patients who were in the meditation group actually had changes of gene expression even in the trabecular mesh work in the ocular tissues themselves. And they showed that there was increased nitric oxide synthetase, which we know increases trabecular mesh work flow. You can think of a latino-prosting view nod that having nitric oxide in there, and there's decreased inflammation, fibrosis, and thickening of the trabecular mesh work, all these genes involved in remodeling. And so back to this flow chart here, after they were split into these groups, after they received trabeculectomy, at the very final nine-week follow-up, they looked at the mean IOP again. Those patients who were just told to go home, they didn't have any trap, they maintained their low intraoperative pressure at 12.8. Those patients who got both trabeculectomy and meditation had the lowest actually of 11.8. And those who just got a trabeculectomy and did their medical management, they had 13.3. So I want to highlight that the only ones that were significant was the drop in pressure between the meditation plus trabe with the home meditation. But regarding these three, correct, not significant. Yeah, they're very close actually. But the one I do want to highlight is just the one who was home meditation and did not have any trap. It was very interesting that they were able to maintain this even without coming to regular class, even just being told to do this at home, because who knows what patients actually do at home. But regardless it showed that their mean IOP still stayed below 15. So just in summary, 86% of that meditation group, the original one had at least 15% drop. And this drop was sustained even when they were told to just do it at home. It showed that this can be combined pretty well with surgery, even though not statistically significant, those patients who had trap and meditation at the same time seemed to have the lowest mean intraocular pressure. It was able to decrease the diurnal fluctuations. So hopefully also decreasing the independent risk factor. And there were direct changes to the gene expression of the trabecular meshwork. So the first study showed that the whole body genome was a little different in the blood, but in the trabecular meshwork, the ocular tissues themselves actually responded to this therapy. And this last study here, this is a more quick study, just looking at OCTA vessel imaging around the optic nerve head of these two different arms of intervention. One being meditation, the other one just medical management. And so this first OCTA picture is for patients who did not get the meditation. And this second picture is the meditation group. And I'm not really good at reading OCTA. So to me, I couldn't really tell the difference here, but this next picture was able to show it a little bit better. Here on the left is the control group. Here on the right is the meditation group. And looking at the boxes, those numbers are small, but the ones who had meditation, they had a perfusion of 46% around the optic nerve compared to a perfusion of 43% in those who did not. And this was statistically significant. There was also, you can look at those heat map boxes at the bottom right, there are also more red areas too in those patients who had meditation. And so in summary, the study showed that the intervention group had more vascular density that was not shown in the picture, but through the readings, there was more vasculature around the nerves. There was also more perfusion around the nerves too. All of it statistically significant. And so this suggests that meditation might offset glaucomatis nerve damage by increasing blood flow. So overall, these three randomized control trials, they suggest that meditation targets these upstream factors like mental stress, the physiological response, hopefully before it gets to increasing pressure. But this as an effect, as we can see through these studies, also has the effect of decreasing pressure and hopefully stopping the cycle before it leads to more vision loss. So we're gonna pivot and look at just overall complementary and alternative medicine for ophthalmology, especially for glaucoma. There was a study done at Will's Eye Hospital and this was about 20 years ago. They looked at what are people using for glaucoma? What are they doing if there were traditional therapy versus this more complementary and alternative medicine method? So about 95% of patients actually were just subscribing to traditional therapy prescribed by their doctors. A 5% of them were using complementary and alternative medicine. And most of them actually being just herbal medicines and other substances, but only one person out of the 1,000 survey was using meditation glaucoma. And I know this was 20 years ago. There might have been a change since then but this really highlights how low of an amount this is actually being done, at least here in America. So I bring up the question of why is the prevalence so low? And these are things I've found is that there's just not a lot of strong evidence thus far at least showing that there's evidence that it works. Now these studies I've showed have been more recent. And so hopefully now that's changing the way that we see this therapy. There's just low awareness in scientific communities. And I think that also feeds into this sense of skepticism. Does this actually work? A lot of people I've heard feel like it's just bogus or it's just a waste of time. And even patients might have certain perceptions about meditation too. And so these are all just obstacles that I can see that can get in the way of this moving forward. Next is a time commitment for patients. It's about these studies at one hour every morning and back there's a lot to ask of a person to do every single day. And lastly, there's no formalized referral structure. So even if I wanted to have someone start this, who do I refer them to? Is there someone I can trust? Is there someone who's certified? Is there even a meditation certification that we know of? And so these are some things that are just all unexplored right now. And my personal perception when I think about this as someone who might be potentially interested in this in the future is, will patients even believe me when I bring this up? Is there, is it too much to ask of them? Are they gonna see me differently if they have certain perceptions of it? And lastly, how will my colleagues even see me? Because I know that this is something that might not be widely accepted. And so this, will I lose trust from other people? And so asking the question, how do patients feel about it? There was fortunately a study that was just done this past year. Namely, this was in Australia, so not here, but it showed that actually 63% of patients of all of those surveyed agree to doing a 45 to 60 minute meditation daily, if it was specifically prescribed by their ophthalmologist. And interestingly, the demographics of this showed that they were more likely if they were single, if they had prior meditation history and they had a new diagnosis of glaucoma. Single, I'm guessing because maybe they had more time and prior meditation history, they had a better perception of it already. I couldn't quite figure out why a new diagnosis of glaucoma would push them to do this, but I just found this to be pretty encouraging data where I didn't think that people would be very receptive to this, but it sounds like they would be willing to try it at least if we actually told them to. So just to summarize the key points in my presentation here, I really want to express this idea that meditation has the potential for breaking this negative feedback cycle of vision loss, stress, physiological response, predisposing to more vision loss. We know that improves quality of life, but we see through these studies that it can also lower pressure, decrease inflammation, decrease stress hormones, these all helping with progression of vision loss. It works well as a complementary treatment to what we're already doing. So I'm not saying to get rid of what we're doing, but this could be something that people can be doing on the side without side effects and with a lot of positive beneficial alternative effects like quality of life. The current usage is very low as we saw in the study, the survey, but it seems like patient perception might overall be positive. So this might be an opportunity for us to start exploring this a little bit more. So looking forward in the future, I really am curious about the knowledge, attitudes and practices of the meditation being done for ophthalmology in the US. All the studies I presented, except for the Wills I won, was all done elsewhere, like in Australia. All the randomized control trials were done in India. And so I'm curious what it's like here because I know that there's also a cultural perception and usage of meditation. And that's different in many different countries. I'm curious about how the meditation length can affect intraocular pressure too. They all did about 45 minutes to one hour, but we're busy here. This is a fast moving society. And I'm wondering what's the minimum amount that would still create a significant IOP drop? Lastly, we just need more trials. We just need more studies, more systemic reviews, meta-analyses to see is this truly a therapy that we can pursue in the future? And lastly, thinking about how we can actually integrate this into our healthcare system, if it truly is something that can be helpful. Think of PT or OT, these are referrals that are easily made by anyone. And we have a streamlined way of getting patients to see these like instructors or practitioners. But for meditation, it's not established yet. So it's not something that we're able to do very easily. But hopefully with more research, this might be a very promising avenue for patients in the future. So just giving acknowledgments to Dr. Chia, Dr. Chamberlain, Dr. Gulotti for taking a look at this and giving me some feedback and ready for any questions. Thank you. Many positive aspects, but some serious negative aspects. And one of the biggest is maybe an understanding of a very little time span or effort, three powerful things outside of the usual practice of medicine. And that's real more emphasis and understanding of the importance of exercise, diet. And together, they're very powerful. And there's larger studies that show that chronic diseases that are such a huge burden could be dramatically reduced if those things were really emphasized appropriately. The biggest problem that you're running into in this is something you didn't mention. And that's the problem of money. So the lobby groups of the rest are anxious. I mean, we have a national institutes of health, but we don't have an institute of healthiness. Isn't that interesting? Everyone is a disease related category. If you look at the money that's available, I mean, if you telling us you had a blockbuster drug that was gonna do one of these, where a drug company charged $300, $400 a month, there'd be billions of dollars available overnight to run those studies and put that together. Who is there out there willing to put money into doing solid, strong, prospective randomized trials to perform these kinds of studies? There's no such thing as that. So unfortunate. And on diet, it's also the same thing. Now there is, it's improved and there actually is a little bit of time looking at alternative medicine. Sadly, I think because of the way that term is used, it sounds like it's pocus, pocus type stuff. I mean, there are solid physiological examples of what happened in association with these different conditions and a very large group that met together looking at all of the different approaches to dementia, which is a major problem. They said the single thing that has most reliably been shown to impact either progression or onset is diet and exercise. And I'm sure meditation would have fit in there, but it wasn't looked at. So that's where I think young people who are hopefully, and I'm surprised that another thing they didn't see as a positive correlation with who they was with age. I think it's more accepting, the younger people are others. And we have made a mistake, I think also in our life in allopathic medicine with the concept that there is a pill or surgery. And that whatever you have, it's all you need is the right pill. You just need to write vitamin, not getting enough fruits and vegetables. And I'll say, well, there's now a vitamin, no, it's just not true. I mean, there is so much else that could happen. I'm a, I've been a big believer in this for a long period of time and been frustrated and often frustrating my colleagues in internal medicine. I point out, why aren't we doing more to understand the impact on chronic disease of all of these issues? And because they are so important and the evidence says is they could be dramatically important. So I applaud what you say. And I think whatever you can do to help answer some of those questions, maybe foundations, and I think maybe we could help you find that, but the big money doesn't exist there. That's a problem. And it's a big problem for the health of this country. And it's a big problem for our ability to try to figure out ways that we can make some kind of changes in lives that don't have to cost a half a million dollars a year for a biological. Not that those are not important. I mean, they can make a huge difference, but these others are also in many ways looking at overall costs of our health burden of our general unhealthiness. I think they're the most important. I totally agree. Thank you very much. We lost questions. I think Dr. Warren met this. Not a question, but NIH does have a national center for complementary and integrative health. So it's not completely under the radar. I mean, that's NIH, they're pretty big. The funding for that is a fraction of the budget. It is something. I agree with something. But it's at least, you know, it's there. Thank you, yeah. And that's definitely worth taking to Ashley. You might have said that, but I was curious to the patients in these studies, were they given some kind of like guided meditation or format for like, were they all kind of doing the same method of meditation? Because I know from my own experience with meditation, there is kind of a method to it, especially if the opposite side needs to fit. Yeah, so when they were there, maybe they were there when the instructor who had a problem with the board started having one at the same time using the same method. And this was, I believe the same instructor all throughout the three studies because it was done by the same principal investigator. But the only difference is when the patients were told to go home or do the lab, suffered those six weeks. And even still, they still had to drop that. And maybe there were some hand readings over here. I think we said. Not sure. Yes, you know, one thing that you're forgetting is that you can always refer patients to the patient support program and Hocus Pocus. And, you know, if we have a big enough call, we can always start like a mindfulness based stress reduction, which is all about meditation. These are things that we talk to our patients about all the time. So it's nice to have the little bit of science that you've found to back that up. So we don't get so much eye rolling with the patients when we mention these things. But that is something that you can do. Refer them to us. Thank you. I didn't realize that you guys did that. For everyone else, all the other residents too, I think this could be something to consider. And then any patterns? Oh yeah, thanks. Can you hear me? Okay, I'm driving to mid-valley. Yep, we're gonna hear you. Yeah, okay, cool. So I took a GME wellness selective. It's a two week amazing elective, mostly targeted on physician burnout and wellness and kind of mindfulness and meditation tactics in terms of combating physician burnout. But a lot of the meditation groups and exercises or even writing exercises that we did were led by physicians or professors from the School of Medicine or even the undergraduate campus. So I think that's also a great place to start in terms of, you mentioned, meditation instructors or resources. So I think GME wellness can be really a great place to start because again, a lot of these workshops were led by an ICU physician, a pediatric physician. And I think if patients were able to attend workshops from a volunteer basis from these physicians that they already do, I think that could also make a big impact because they would see like, oh, these exercises are led by other physicians. That'd be really awesome. Thanks. And any other questions too, Brandon? Yeah, you might have mentioned, did they control brother vascular risk factors and systemic diseases, like hypertension, they've got all that amongst the two different arms in each study? There was controlling for just large chronic mental conditions. They actually didn't define what those were. So I'm not quite sure. I'm guessing conditions that were very significant or perhaps not, or something just kind of attention. And then just reading off to the comments here, Austin says that new diagnosed, or patients with new diagnosed glaucoma usually ask what more they can do, which might make sense why those are more receptive to trying to stand these out. And I think those are all the comments. Thank you everyone.