 All right, so our next speaker is Chris Smith, one of our cornea fellows. He's gonna be talking about pre-loaded DMEC tissue, which you take it away. I didn't let her announce, but I guess the buck's out now. I took a job in Billings, Montana, so you guys can spread the news. So I'll be up there next year, working with the eye clinic, Dr. LaGreka. So, this is kind of, not a big issue to most of those that aren't performing corneal surgery, but I think it will be a little bit more beneficial, especially as corneal surgeons. I know one of my past attendings that worked at the Moran Eye Center, John Holds, always used to joke while we're in the OR. It's $200 a minute, so if you add up the different time for preparing these tissues, that can get quite expensive, especially with long procedures like DMEC that can be lengthy. So this is a new technique that I first wanted to thank the Utah Lions Eye Bank, especially Wade McIntyre, that's helped me out with this. And this is something that they will be introducing to be available to corneal surgeons, hopefully very soon. I have no financial disclosures in this talk. So, I love the Eye Bank data. I know we all like to kind of go through it. It's one of my favorite yearly things that come out to see kind of the trends of going out. And this makes me really excited about how far we're pushing DMEC and DSEC. The endothelial transplants over the last five years have gone up a thousand each year. And DSEC is actually decreasing, and that's mostly because DMEC is kind of taking the load on that. And we can only imagine that that's just gonna go higher and higher and higher. Especially here, there's kind of this exponential increase here. And if you were to compare this to your, and this just kind of shows the year to year as it kind of goes up. And if you were to compare these trends to your coin-based data, it's actually very similar to the Bitcoin. Whether that's a coincidence, I don't know, someone's gonna have to do a little correlation here. Unless you were one of the suckers that bought in November of 2017. So I'm just gonna kind of explain, this is more of a visual, audio visual, because the video is kind of the most important thing of this, how this gets loaded and gets into the eye. So this was done at the EyeBank. This is them preparing the tissue. So I'll kind of talk us through each step here. And I'll stop exactly kind of where, half of this is the EyeBank's already been doing kind of pre-stripping and getting the tissue ready for us. And then the other half, we have to do in the operating room. And I'll point out to that point in the middle here. So first they're going, this is Optosol. They're gonna kind of just place on the corner. They kind of score decimates. And this is similar to what we would do to the host tissue when we were stripping decimates. You just kind of score into there and make a separation plane that you can kind of flat back. This is them scoring it. And then we want to stain. It really highlights decimates and gives us kind of idea, clue what we're peeling back and they'll rinse it out. This is just kind of opening, stripping the outer skirt so that they can get a plane to peel that decimates back. And then they'll flap the tissue. So if we can, we start to see decimates with that staining. This, they're gonna pull the entire, very gently. And this is very important not to turn the tissue, manipulate as little as possible here because we're stripping it back. And the main purpose of this is to get the S-stamp. And without a good S-stamp, this surgery's impossible. So here's a Derm Punch. They're actually gonna be punching the stroma anterior parts of the cornea. They're gonna, then they'll lay that decimates that they stripped back flat. And this, I didn't go into detail, but it's very important to get all the fluid out of there and get this really flat because we need to trefine. Then they peel that punch hole back so that the anterior decimates is actually exposed. This is the cornea flipped around so that they can use this S and make a nice S-stamp for the surgeons to orient themselves. And you'll see it kind of pop on there. So that's upright. That's what you wanna see when the case is over. It's upright. You don't wanna see a two, you wanna see an S. And they'll put that little cap back on and flip it over. So I should pause it here. So this is at the point, normally, when we get the tissue, it just comes in the optosol in a container. It comes about this prepared so far. And so all of this will be new that they will do an eye-bink to kind of save some time. So they will, this is a, they'll start off with trefinating tissue. And this is usually what we have to do in the operating room. So this is a trefine that they use to punch a nice graft. And then they'll stain it again and the outer skirt that you punched doesn't, in my experience, it doesn't come off this easily, but they did a really good job. It just kind of fell off there for them. And then you wanna make sure all that tissue is removed. You don't want any tags or anything like that. So I could disrupt things. Then they gently peel back the use of forceps. And this is just like a one-touch technique. Probably the only time you really touch the tissue. And you kind of pull back and straight up and it kind of flops in its own itself. And then you lay it back in the fluid there and it'll start to roll up. And this part will actually save a lot of time because we have to stain the tissue. And that, I mean, you put the, you want a really good stain or it makes it more difficult. So you put the stain in and that takes, you know, you gotta wait about four to, you know, we usually do about four minutes here. And then we dilute it out. You wanna make sure that thing doesn't flip around because it can actually get washed out of that chamber there. And this part is also new that we don't do in the operating room. They're filling it up with Optosol because as they load these things, they want the tissue in Optosol. And then they'll take this Jones tube and suck it up with the Optosol and you'll see it in there. And obviously you wanna try and get it that no air bubbles is ideal. And just plug it up and plug kinda both ends up there and then that'll just kinda soak up as you see it there in the tissue. It's kinda hanging out in the Jones tube. And then now that, so this is all new done in the iBank and when they bring us tissue, it will look like as they prepared it. First, your computer will spasm and then it will look like, now hold on, it'll look like that. It just comes in the Optosol, it kinda soaks in there and they transport this. And ideally, you know, it would be stripped the day before so that this all would be less than 24 hours. Although Mark Terry, who's up in Oregon has kinda been one of the big pioneers on this, has shown up to three days. It's been, you know, good and viable tissue of transporting. And they fly it around and bump it around on the road and stuff so it's good to transport. And then this is actually from a paper by Mark Terry and his group. This just shows the tissue being loaded because we haven't done any of these at the Moran Ice Center. I just kinda wanted to show that the tissue, you know, you pull it out of that tube and it's ready to go and all you have to do is just kinda pop it on the syringe. Most people will dilute that Optosol out and you have to gently do that with BSS here. You'll see them kinda replace, not to, you don't wanna push your tissue out but you gently replace the Optosol and then just inject it into the eye. I wanted to show this because I mean that's pretty incredible staining still for, you know, considering that's really good and enough for the surgeon to see and be able to get things upright and do a good job to, you got a good S-tamp there, so. Anyway, that's the goal of kinda things how they should. So the next question is how is, how is this fair as far as endothelial cell loss? Is it going to make our tissue less successful during the transplant? And this is a paper published this past year with by the Terry Group. They report, you know, with the losses like 15 to 18 or 13 to 18% in these. And they're all similar, you know, compared to after the processing shipping graph to start. It is significant compared to pre-stripped only but there's not, I mean that doesn't really help us because, you know, you are manipulating the tissue after you pre-strip it anyway so there isn't good data there. And no one's really published yet these graphs after they've been injected into the eye and, you know, months later and stuff like that. So the buck's still on that but there's good anecdotal evidence that these are doing very well. And then this is some, another way, this is kinda shows how they evaluate the tissues with, without injecting them and doing a, you know, confocal microscopy to measure endothelial cell density. This is a certain stain that they put on that after that they can just inject the tissue not into the eye but on a plate and a microscope and evaluate them. And the more folds, the more staining they have the more endothelial cell loss they can predict. And so these are all the different ways. This is unstained pre-loaded at the top. Still pretty good tissue, not a lot of staining. Also pre-stained, which most people do. And then at the bottom is kind of pre-loaded stain as a little higher, kind of an uglier, ratty looking tissue. And I'll show a picture of what they did with this of pre-loaded stain. It's just a, or a, just in case you don't get a good stain or something it just goes to show that, see is this tissue really isn't stained at all. It is a, there is a possibility you can still stain it inside the tube, which is good just in case, you know the stains runs out because without that you're pretty toast, you can't do the surgery without a good, well, it'd be very difficult. So they're rinsing out the optosol and then you can kind of see that tissue in there kind of floating up. The stain will come in in just a second. There it is. They just inject it straight into the tube and let it stain in there. And then as they dilute out the stain and replace with BSS, the tissue is pretty well stained. But that was a little more damaging on their results compared to the other two. So I don't know if this step is necessary because, you know, we can stain it in the, at the iBank and stain it really well and should be good to go. And this was a paper done actually before. I just kind of wanted to, it was really interesting too that they were, they put the tissue not in a Jones tube but an IOL injector that they just loaded in and pulled through and they got decent results with this as well. And this was a 2.2 millimeter. Normally those Jones tubes are about three millimeters. So smaller wounds obviously just like small incision cataract surgery, better for the patient outcome. So, but once again, there were a lot of problems with this including tears, loss of endothelial cells and all that stuff. So, do you guys have any questions about preloaded DMACC? All right, thank you.