 I just wanted to say that I take this opportunity to tell you a little bit about how awesome she is. She has completely cleaned up our resident room, which probably has 15 to 20 years of past resident things. She does a lot of things for us that make, I think, residents' lives easier. She'd be an epic, she'd bep the epic people to make a list of inpatient consults for us so that we can ease on transition care. She actually rusted that. Oh, rusted that. She bugged them to get a fix then. But she does a lot of things like that, helps with different epic bugs. And she also, there's a time where we had our morning lectures where she was frantically sewing on pockets to our call bag to help things get organized. That call bag eventually stopped rolling. But anyway, she's going to be a great retina specialist, a great researcher, and I'm excited to hear about our carriage noise. Carot noise. Sorry. All right, so I'm going to talk about a clinical research project that I've been working on with Dr. Bernstein. And some of the preliminary data that we have, we're still continuing the study and hope to recruit more patients. But I'm going to talk about the role of carotenoids in patterned dystrophy. First, I'm going to give you some background on patterned dystrophy. As one of the other residents pointed out, you may have the impression that it's just a grab bag of things that are characterized by spots in the retina. But there are actually very few specific diseases that are part of this category that are shown to be linked by their clinical features and also genetics as well. So the one that's the most common is adult onset foveo-immacular viteliform dystrophy, which I'll call adult viteliform or AFVD for short, as well as butterfly-shaped pigment dystrophy, as we can see over here. And chogren reticular dystrophy of the RPE. There's a couple other rare entities that also fall in this category of patterned dystrophies. So a bit more about the genetics of patterned dystrophies. I'm going to talk mostly about the tel-o-form, because since it's the most common patterned dystrophy, we know the most about its genetics. Unfortunately, we actually don't know that much. It's still not clear whether it's sporadic or autosomal dominant with incomplete penetrance. But it is clear that for a certain subset of patients, it's definitely autosomal dominant. And the gene that's linked to it is a PRPH2, which has some other former names, but PRPH2 is the most common name used now. And this protein is a membrane protein that localizes to the photoreceptor outer segments and is important for the structure of the discs. So when this protein is mutated, the RPE cells are not able to take up the shed material from the photoreceptors. And this material accumulates between the retina and the RPE, which causes those yellow deposits that characterize these diseases. Mutations in PRPH2 have also been associated with butterfly dystrophies, as well as some other diseases, central areolar coroial dystrophy, autosomal dominant, RPE, and then patients who clinically have stargarts, actually some of them have mutations in this gene as well. This just kind of illustrates the, I guess, transition that we're making in ophthalmology between making diagnosis solely based on clinical features to incorporating genetic testing. And fortunately, there's not like a one-to-one correlation in a lot of diseases, and pattern dystrophies are some of those. There are also mutations in some proteoglycans that are in the extracellular matrix between the photoreceptors that also have been associated with pattern dystrophy. However, most of the patients that have adult veteleform don't have mutations in any of these known genes. They estimate that maybe around 10 to 20% of patients with adult veteleform have mutations in known genes. So that leads to the question of what do these patients have that don't have known mutations? Is it that we haven't found the mutations yet or do these patients actually possibly have another disease like macular degeneration where there's not a clear monogenic inheritance? There is some overlap between AMD and adult veteleform, and some people have suggested that adult veteleform is actually a subset of AMD. So both of these diseases are characterized by yellow deposits, but in adult veteleform, the deposits are underneath the retina and above the RPE. This has been demonstrated on pathology, whereas in AMD, the deposits are below the RPE. You can see it pushing it up here, whereas here you can still see the RPE going across here underneath the lesion. So one might think that you could use pathology to distinguish AMD and adult veteleform, but there is some overlap there as well where there are patients that have adult veteleform where on pathology, they have basal linear deposits which are characteristic of AMD. And also clinically, we know that Druzen are characteristic of AMD, whereas veteleform lesions are characteristic of adult veteleform, but there are patients who have both and it's really unclear how we should categorize these patients. Do they have adult veteleform or do they have AMD? Or do some of these patients that just have these central yellow spots actually have AMD as well? I definitely think it's clear from the genetics that some of these patients that have veteleform lesions definitely do not have AMD. They have only adult veteleform. They have looked at whether adult veteleform is associated with complement factor H, which it's not, and HDRA1, which it is, but it's questionable whether they had enough patients to pick up the association. So a little bit more about the clinical course of adult veteleform and the other patterned dystrophies. They usually have a fairly good visual prognosis. Visual acuity can be somewhat decreased in the stage where they have this hyperreflective subretinal lesion on OCT. However, this lesion often resorbs over time and can leave the patient with atrophy, which can actually result in very poor visual acuity, such as count fingers. It's also possible for these patients to develop a choroidal neovascularization. There have been some studies on anti-vegeth. They tried to use anti-vegeth for this, but that didn't help visual acuity at all, but they did also use anti-vegeth for choroidal neovascularization secondary to adult veteleform, and that did work. PDT or photodynamic therapy did not work. They did a small study where they caused many patients, a few patients to lose vision and didn't improve anybody's vision with that. And so since adult veteleform progresses, oftentimes, to atrophy with poor vision, it's really unfortunate that we don't have any current strategies to try to prevent this from occurring. So one thing that could potentially show promise, since it does work for AMD, are arids to vitamins, so lutein and zeaxanthin. However, this has been totally not studied in the case of adult veteleform. There's no evidence for its use or against its use, and that was one of the main things driving our study. A little bit of background on macular pigments. So lutein and zeaxanthin, not sure what's happening here, okay. They are localized to the Henleys layer, and they are what give the fovia lutea that yellow color and they absorb blue light and they are antioxidants, so they're thought to protect the retina against blue light and oxidative damage. So we are able to measure macular pigment in patients' eyes by several different methods. By one older method, Raman spectroscopy, Dr. Bernstein demonstrated that patients with macular degeneration have low macular pigment levels and that when they take the arids two supplements that does increase their macular pigment levels. So this kind of demonstrates that low macular pigment is involved in the pathogenesis of AMD and that demonstrates how taking those supplements could possibly help. And we'd like to see if this could be also demonstrated in adult veteleform. The current instrument that we're using to measure macular pigment is actually the Heidelberg Spectralis, which can use auto fluorescence to measure the macular pigment. So it's done on the same machine that can do an auto fluorescence and OCT. The way it works is by, on a normal auto fluorescence, you're measuring lipofusion mostly in the RPE and those of us that are familiar with the normal auto fluorescence, there's that dark spot in the middle in the foveal center, which is from the macular pigments absorbing that fluorescence from the lipofusion before it gets the camera. So by using that strategy, we can measure macular pigments. So this is a typical printout from the macular pigment software. And basically, this is the foveal center here and it totals up the measured macular pigment within this red circle and then within the blue circle and then within the green circle. And you can see that in the foveal center, that's where macular pigment's the highest. This is kind of like a line scan averaging from the center to the periphery. And you can see that in the center, the macular pigment's the highest and then it drops off very rapidly as you exit the fovea. So in this study, the measure that we used was the sum of all the pigments within two degrees, which is this number right here. It does give you a lot of numbers. Most of them correlate really pretty well with each other. So I'm gonna give you a little break before I go into our study design. This is just some photos from my family reunion in Olympic National Park. It was taken by my one cousin who is a big fan of the iPhone panorama group selfie. This is us in the whole rainforest and then at Rialto Beach in the Olympic Peninsula in Washington. So a bit more about the rationale for our study. The main driving factor is to figure out whether these arids two vitamins are useful in adult vitrella form. However, unfortunately we don't have the resources or I guess even the rationale right now to do a huge study like arids two to see whether we compare patients that are taking them versus not taking them to see if they can reduce progression to atrophy and CNV. But we can measure macular pigment in our patients that we have here in clinic just as a one-time thing to see if their macular pigment is low. If it is low, that does give us some rationale for using arids two in these patients. Other reasons why it's useful to measure macular pigment in patients with patterned dystrophy is to better understand the relationship between AMD and patterned dystrophy since this could be a common risk factor if AMD patients have low macular pigment as well as the patterned dystrophy patients. And maybe it could help to clarify which of those vitrella form patients really have something that's more similar to AMD versus which ones maybe just are more likely to have PRPH2 or other autosomal dominant mutations. And this also could tell us more about the pathogenesis of adult vitrella form. If it's autosomal dominant with incomplete penetrance this could help us to understand what are those factors that cause one person with a mutation to develop it and others to not develop it. So in this study we looked at patients with either adult vitrella form dystrophy or a butterfly shaped pigment dystrophy. I excluded all patients that had drusen just because I didn't want to capture any of those patients that could just have like a central drusenoid PED type of thing in macular degeneration. And I also excluded patients that had macular atrophy in both eyes. So you can see from this picture on the right that this patient has some mild macular atrophy in the center after resorption of that hyperreflective lesion as I showed earlier and that the macular pigment is very low right in the center just because that outer retina is gone or not healthy. And I figured that's not useful information if there's no macular pigment just because there's no outer retina. So I excluded patients that had atrophy in both eyes. And then I chose age match controls that did not have macular degeneration, cataracts or other macular pathology. And I looked at that number that I showed you which is the macular pigment volume under the curve within the central at two degrees. We also measured in some of these patients serum and skin carotenoids. So I was able to find 11 patients and get them to get their macular pigment photos done. Some of them had adult vateliform, some had butterfly and one patient had adult vateliform in one eye and butterfly in the other eye which has been published in the literature before. Surprisingly, the vast majority of these patients were on A-red's two supplements despite the total lack of evidence for this and this disease. But they're Dr. Bernstein's patients. Most of them were Dr. Bernstein's patients but I would say that 100% of Dr. Vitalli's patients also are on A-red's two. So I don't think- They're not going to come in. Right. I think part of it may be that a lot of them- The macular issue is a problem that people could put on A-red's two. The macular is fine. Yeah. I think a lot of times they come in with a diagnosis of macular generation initially when they're referred, so maybe that's why. There were average older age and here's the female to male distribution. I'm going to show you before I show you my data some of the pictures from my family reunion. This was to celebrate my grandma's birthday. It's very hard to get 40 Huangs to all do the same thing at once because this can be illustrated by myself here. So it was quite an exciting time. So we compared the macular pigment in that central two degrees between the control patients and the patterned dystrophy patients. Unfortunately, we didn't demonstrate statistically significant difference between the controls and the patterned dystrophy patients. However, I think a major limitation of this was that most of our patients were already on supplementation. So I tried to look at just our three patients that were not on supplements that have patterned dystrophy and there wasn't a difference there either, but it could really be a limitation of the small numbers in this study. I think what kind of numbers would you respect in patients with clinical macular degeneration of different what they do for these patients? So they were about 33% when they weren't on supplementation. So this is a different measure. But this is 148 in AMD patients without supplements and then 219 in patients that are normal. So yeah, about a 33% difference. And I did a power calculation to try to figure out what kind of numbers I would need to pick that up and it's 26, which is not astronomical, but is still kind of a reach for a somewhat rare disease, but we're working on getting more. Your controls are not on supplements. Correct, the controls are not on supplements. We excluded any normal people taking ARIDS too. They were age matched, yeah. Because it has been demonstrated that macular pigment decreases with age. So I also looked at skin and serum carotenoids. And in this, I used a database of normals because I didn't have enough age matched controls since all the older patients in our study have AMD. But so I didn't demonstrate any differences here, but the numbers were pretty small. Dr. Bernstein has a study ongoing where he's measuring skin and serum carotenoids in many different patients. So I also looked at those patients that I excluded because they had both drusen and the teleform. And there were some really interesting findings here. So this one patient just had macular pigment measured and that was in the normal range. However, two of these patients that had drusen and the teleform lesions had kind of shockingly low macular pigment, skin and serum carotenoids. So both of these patients have macular and skin levels that are less than the 10th percentile for normals. And then this one patient actually had undetectable serum carotenoids just totally below the detection limit of the HPLC. And they're the only patient we've had so far that has had that. And then the other patient had somewhat low serum carotenoids. Surprisingly, one of these two patients was taking A-Reds two supplements and I verified their refill history. So they're at least refilling them every month. So it's just surprising. So I'm not sure what to make of this. This is just a few patients, but it kind of does, it is interesting to think about its implications. So I talked about how we're trying to increase our sample size. So I will be sometimes contacting you to let you know that your adult the telephone patient is coming in for follow-up and that I've already called them on the phone to ask them if they'd be willing to get an additional picture when they get the rest of their pictures done, which is the macular pigment photo and then meet with Kellyanne, our study coordinator to get the serum and skin measurements if they're willing to do that. So I have IRB approval and I've been calling some of them so you may see that happening. The Retina Clinic can help you if you have any questions and if you have any patients that are interested in participating and getting these measurements done, it's just a one-time thing. You can just let me or the Retina Techs or Kellyanne know. I'll also be trying to recruit more older normals for our database. So you may see me around your clinic then as well. Dr. Mamelis was very helpful the other day with that. And another study that we're interested in doing in the future is to clarify all those other patients that don't have PRPH2 mutations. Do they have autosomal dominant mutations in other genes? So we're planning to use the Utah Population Database to try to link up these patients that we have with adult the telephone to see if they're related and then if they are, maybe that's, we can work on trying to find more genes for that. But that's a big project for the future. I'd like to thank Dr. Bernstein for his guidance and for initiating all this project. I'd like to thank Jim Bell, who actually came up with the idea for this project. Chris Conraddy, who's also working on macular pigments in normal patients and AMD patients. Kellyanne, thanks to the Photography Department for taking all these macular pigment photos. And Aruna in Dr. Bernstein's lab for running the HPLC. And definitely thanks to the ARCS Foundation for supporting me so that I can pursue these projects. And that's it. Yes. Dr. Bernstein can probably talk a little bit more about that. So if it's using resonance problems spectroscopically, I haven't happened on that method of basically trying to be light on the skin and measuring the amount of light to the back of the skin. It's very validated and very, and very, and not, in basic way, to do it. It has been commercially marketed as the bio-permanent scanner that you may have seen around here, that used in farmland use and stuff like that. It's a great way to correlate very well with conventional consumption of the skin when it's bi-biopsized in the skin. Well, I also have core, I'll just want to say it. I think it would be the telephone reasons. I think the thing that we're kind of seeing in these patterns is that even the ones around supplements are not all that high. Right. So I think that my limitations in my product are that any hand-made patients who come in, have just, if they're all on supplements, they have huge macrophages, but not four of them people are not on supplements. I think that even the ones that aren't just I make those from low-light skin products are not all that high, so there may be something that they're not responding well to at supplements. You know, the pathology is not, it's not like they have geographic apathy or no other supplements. Right, right. Well, the question for you, you're using auto-corrosions in these measurements, and you also use the resonance from mom in the mac, which do you feel is more accurate, how they correlate with each other? So resonance problem like you do with the eye is a difficult thing to do. It's all homemade systems that we make, and at the light levels are very high. The software, remember we have a specialist who is very well known, and you have to have, at least to do it right, you have to have the newest generation specialist, which is a two-dip by green and blue agent. But the software right now is not FDA-released, they're not gonna be approved, so only you have to have it under an IRB, and I need like 10 sites in the U.S. and half of us. But as Jim can say, it's very easy to measure things, and literally 30 seconds. We think it's accurate, it's pretty accurate. I would love to do, if I have the funding, and be equipped to do it, the spectrals could, in theory, be modified to do the resonance problem. I mean, they need to have everything together. That's a several hundred thousand dollar project and we need more cooperation from the Eiffel Tower. So that would be the most specific way to do it, but the Eiffel Tower process is not the least good. Someday, Eiffel Tower could release it. I mean, you could mention that dietary nutritional factors, are you looking at those at all, do you have any history of that? We're not doing any surveys or anything like that, but it could be useful, since that was how, you know, initially the studies were picked up in AMD, in terms of poor nutrition being a risk factor. Well, zero skin and zero serum in one suggests that this is the person who only needs to be able to eat it. That's a clear sign of that, a lot of them. Yeah, the biomarkers work very well with the fact that it's important that you include too many nutritional certifications in that, it's the foundation that shows you're on them and what people think they're supposed to say rather than what they're really going on. Yeah, she did say she eats fruits and vegetables, but, you know. You may have something else going on. She may have an atherosclerosis or something, right? We find, we have occasional patients that we pick up in these real low levels, either have undiagnosed celiac disease or something else going on. She actually had celiac disease. That one with the zero had celiac disease. Dr. Roscoe. You use the term normal. I'm wondering if everybody's dying in a natural history study, constitutionally, so do we really have an idea of what a large normative database looks like? In pattern dystrophy? Or just in any human entity. Oh, well, I can. I think that is best we can. Yeah. That's what Chris, somebody talked about. Yeah, we're measuring as many as we can as we can in my point of view, not in the structure, but how in the structure. And then trying to correlate those notes. That would be really useful. Yeah, that would be really interesting. I guess it would be more of a Dr. Bernstein question because my residency won't be forever. I wish they were right. Dr. Owen. Thanks, I mean that was a great presentation. I just had a quick question. If you thought of maybe controlling for supplements in a day or two, I don't know if it's been demonstrated that normal in the case of a level of radenoids. But if your case population is on the supplement, you can't necessarily control for that. I think it might be a problem going forward. Right. People are being referred in for AMT. Right. Like you said, there's probably gonna be a high percentage coming in on the supplement, but you could potentially control for that by getting normal to take the supplement. It's a key if you might be able to find the difference. Yeah, that's a really good suggestion. I think a fair amount of Dr. Bernstein's normals could be potentially on supplements or other normals around the maran. Yeah, we have that. So I'd also want to add, you mentioned towards the end of that you could talk population database. And I just want to put in a little pitch about future projects that could be done. We have, so we talk population database is a huge database system, basically where you can find the relationships of patients coming in. And we're using it for the Mac Health Project recently, where I think the patients come in with accurate blanket of diagnosis and then asking, are these folks random patients? These are not related. Are they related going back into the population? Because the latest tip that we did, where I just put in 10 newly diagnosed patients and really identified them in the RAM, and asks, are they related to any of our other patients that we have or related to none of themselves? It turns out in that cohort of 10, three are probably the same man like us. They are four cousins, so they obviously, clearly probably don't know each other at all. But it shows that it's consistent with an autosomal dominant pattern. And right now I'm a group for doing it in Mac Health, but I'm trying to expand that to essentially any eye disease. So eye diseases like post-disease, like coliform, they clearly have a familial pattern, but we don't know what genes are and it's not clearly autosomal dominant. We can put in ICD-9 codes with just patient names and see if we should be pursuing a really cold genome sequencing to find common genes. So if you have ideas of, you know, a disease with cornea, and a proctoma, the accurate all sorts of things that you can start putting together. Just so everybody knows, it's been put together now for a long period of time. It's a combination of all the genealogies that the Mormon Church has put together along with all the birth and death records continue to expand. There's nothing like it in anyone in the world. So if we have a unique opportunity, we should be taking advantage of that. There's been a lot of major breakthroughs that have happened and that's when Barbara was running to raise her hand and she's got some fascinating stuff. But what have been possible about the Utah population, yeah, yeah. Yeah, just to kind of comment on that. So I think doing it, just through explanation, is really, you know, you cannot even, you cannot only look at the familial pattern to get the disease itself, because it's genetic. You can then also look at the associated comorbidities that may also be related to those illnesses. So I'm just, yeah, I think it could be really easy. Okay, thank you very much. Thank you.