 Basically, when it was laid out, it was so clear that it's a better way to move forward that actually now, just four years later, in an environment that moves at a snail's pace when we want change, it's now going to be mandated across the country that integrated internships are now going to be mandated with very few exceptions. Starting one? That's the question. That's sort of the question. So after that symposium, a number of the real prominent programs, if you can't read these texts, my wife texts me this morning, you didn't kiss me goodbye, which wasn't true, first of all. Again, she was just asleep, and that didn't work out so well. And then I also didn't make it this morning. I almost didn't make it because I was looking for my keys. And last night when I got home, I went out and pulled some weeds, and my keys were down in the weeds somewhere. But I do have tiles, so I was out in my yard listening for my keys in a moment. So at any rate, so yeah, so integrated internships that's going to happen, which actually will really take away that, I think, a lot of that benefit of an early match. The idea of an early match came about because there were really competitive specialties, plastic storm ophthalmology, a few others, ENT. So there were a lot of early matchers back in the day. Because if you didn't match, you wouldn't have time to match into something else. We kind of are the last man standing as far as residencies doing SF match. Anyone want to venture a guess why? So Rob, do you know why? Yeah, basically they live in the same building as the American Academy of Ophthalmology. So one thing it will do if we decide to stick with SF matches, we can do whatever we want and actually be nimble and say, yeah, the way we're doing our applications isn't effective. Having the only number all the applicants have associated with them since their USMLE score that every applicant across the board has. Again, it creates a situation where we're over weighing and overvaluing the USMLE score. Maybe there are situational interview assessments that actually will give you a score. There are other assessments now that can be used for emotional intelligence. Do I think that we're going to be really innovative and move forward in a super innovative way? No. But we have that opportunity. So at any rate, this next year in January, we're going to be talking about these things. And while it's too late for you all applying, it's just an interesting discussion. Anyway, just something I think that's interesting involving you all. And then the other thing that I did want to touch on specifically, two concepts in education, both of which are valid and they, I'm on call, both of which are valid, but they in some ways are competing a little bit. So what's the concept of just-in-time learning? What does that mean? Rather than teaching a whole bunch of skills when someone first starts, like at the beginning of the year, you don't give them all that information early as those skills have become important to them. Give them a lesson and teach them how to do it. Right. Yes, well, just in time. So you're going to go on a cornea rotation, do a lot of corneal suturing. We're not going to teach you in your first day of orientation. Spend like two full days of corneal suturing, and then that's the last time you do it until 18 months later when you're in the rotation. It's really powerful. It works if you don't believe me. I can give you some evidence-based reference, but it just makes sense. So that's actually one thing that I just want to briefly just touch on for the residents. So there is momentum and there's motivation from the faculty right now to do wet labs to help you all be prepared as you go on a rotation. One of my goals this year is to develop a just-in-time wet lab curriculum for every rotation you go on, which would also include your consults rotation, because there actually are some specific things, such as laser agent suturing, that could be really useful. Frankly, you all know the things that would be really useful for you to learn. The faculty think they know, but generally believe and have found that you all know best. So that's something that will come through our education committee down to you all, but something that we'll all be working on together. So then the other sort of competing concept, which is also equally valid, is perhaps rather than a just-in-time learning wet lab curriculum. We did a something very consistent. So every other Friday afternoon you would spend time in the wet lab. That amount of dedication and consistency would also be a way that you could meet that end to the point that when you're actually operating on a patient, you've had some experience. Logistically, it's a little more challenging, but again, just an interesting concept. I'll ask questions before we dive in. Anything at all general or otherwise? Okay, cool. So what I want to do is it's really interesting. So I give the suturalist extra-cap talk at the Academy meeting at ASCRS, and there's actually a lot of different venues, but I realize that the residents haven't ever seen it or heard it, and I think it's actually really useful and helpful. So we'll start with this. So smallish is the cataract surgery. This was the most recent iteration. I like the story of this, so there's completely manual-based techniques. Couching, traditional extra-cap. Couching, explain couching, Brad. No couching. Oh, anyone else? Louder, I need to hear that. Take a long needle on someone's advanced cataract and you poke it through the cornea, and it pushes their dense lens back into the vitreous. So that was the earliest form of cataract surgery. It is still being done in parts of the world, thankfully less and less, but kind of by traditional healers. All right, what is an intra-cap? So that's taking the whole capsule and the lens out. Yeah, so you've seen a capsule of rexis. So instead of doing a capsule of rexis or opening the capsule and removing the lens, you actually fillet the cornea, you open it up, you fold the cornea over, you take your cryoprobe, you freeze it to the anterior capsule, and then you use that to pull the entire thing out. So there are still cases where we'll do an intra-cap here, maybe once or twice a year, when essentially you might have a case where the lens is literally free-floating. Zero zonules, whether it's trauma or something else. So then extra-cap. Extra-cap is a form of cataract surgery, which includes FACO, but an extra-cap is anything where you open the capsule and then remove the lens out. Now, I put FACO in a little different category here because FACO is reliant on technology. Femto, I can probably take out entirely, oh, sorry. And so for extra-cap, this is manual extra-cap. You're not using a machine. That's where you actually deliver the lens whole. There's the traditional where, again, you make a large incision. You kind of fillet the cornea. You bring the whole lens out like you're delivering a baby, and then you have to suture that wound up. And it really was a suturing that was the challenging rate limiting step. And then there's this idea of a small incision extra-cap and what that looks like. So just a few sort of milestones in cataract surgery, but the one that I really want you to pay attention to is this, these last two. So with this extra-cap surgery, manual extra-cap dominating in the 70s. By the way, if you do hear of patients talk about their parents having surgery where they had to have a sandbag on their face and be an inpatient for a week, those were intra-caps, those were large incision intra-caps. So we had this transition to FACO. And I find these transitions new technology to be really interesting. So what happened with this in particular? So in wealthy countries, wealthy countries where patients had resources and there were healthcare systems, there was a transition to FACO and took time. There are still in the late 1990s, early 2000s residency programs where there were faculty that were still just doing extra-cap that never made that transition. But in resource poor countries where you can't have a FACO machine and afford a pack, they continued to do extra-cap, this big sutured cap, extra-cap. Bonnie Henderson is one of the thought leaders in ophthalmology. She asked this question in early 2010s, do we still actually need an extra-cap cataract surgery at all? Should anyone be doing this sutured extra-cap? Essentially the answer is no. There are two better techniques for surgery, but that's really the answer. So who's being taught this still? This was 2010, it has evolved. 80% were learning this large sutured extra-cap in 2010. It's down now to below 50%. And then what's really happened is we actually have sutureless extra-cap being taught. These vary simply and rapidly by doubling their contents and splitting in two. Just one bacteria, dividing every 20 minutes, could produce nearly 5,000 billion, billion bacteria in one day. Extra-cap, these were sutured extra-cap. But what they found is if they could develop a technique that didn't rely on sutures, they could finish the surgery much more efficiently. So eventually they developed a suture-less form of extra-cap. And it really has revolutionized cataract surgery and not just in terms of its efficiency, but also its effectiveness. So Gettai Hospital is an example of why this evolved. So at the Gettai Hospital, this is where my mentor was every day in the busy season, between 300 to 400 patients will arrive with cataracts ready for surgery. That's every day. So it is a lot like maybe like wood stock. People literally like they just sleep out on the ground because there's not enough beds for everyone. After surgery, there are beds for patients. They do have at least 400 beds now in these buildings. So they stay as an inpatient overnight. But all the family, they're just out here camping, cooking their rice over wood fires. So the issue is if you don't do all 375 surgeries that are in the queue that day, let's say you only do 300 because it was a hard day. 350 arrive the next day, now you have 425 in the queue for that day. And it just keeps building. And so they really had to develop systems, not just a surgery that was going to be efficient. So they call it small incision cataract surgery. It's not a great name. It's a massive incision compared to what all of you were saying. Size is relative. A much better name is sutralis extra cat. That's much more descriptive. It's a better acronym of sex. So I do, I don't know if this is appropriate anymore. I don't, was it ever appropriate? Yeah. Sorry, that's so horrible to look at. I apologize. I have to cover my own eyes. So let's look at one. So this is Dr. Vidyapant. This is essentially an unedited real time. And if you wanted to start yourself, watch fine. But essentially, this is going to be about 3 and 1 1⁄4 minutes. Start to finish. So we've done a conjunctival peritomy. Pulled the conjunctiva back to the scleral groove of 50%. And now, just advancing, this is a partial thickness flat. So we're not entering the anterior chamber right now. We're still in the cornea. We're tunneling. So we've created a pocket. This is actually a pocket which will have ends to both sides. It's a really beautiful, elegant pocket. Now, with the keratum, we're actually going to enter the anterior chamber at this point. We open this out to the side. Now, we don't want the anterior chamber to collapse. That's actually a pretty big incision already. We have a probably 4 millimeter incision. So we put the viscoelastic in to maintain the chamber. And now, open that up to the left. So now you have a funnel incision, funnel shape. 6 millimeters on the outside, 10 perhaps millimeters on the inside. Now, don't freak out, but he's making his capsulotomy here. He just went and entered the anterior capsule. So let's pause here because I know it's a mild-like moment of fascination. So I'm not using the term capsular rexis. Capsular rexis implies tearing circle. It's a capsulotomy, which is opening a capsule. Before capsular rexis was developed, what was the primary form of capsulotomy? Can opener. Someone explained he can opener for me, even if you haven't. Anyone seen one? Either on a video or Chris, go ahead. Basically, just going, you're just making these little radial tears kind of zigzag fashion around. So you're not getting this opening cap for a knife rather than an actual can opener. Yeah, I mean, basically, it's puncturing here, here, here, here, here, here, here, all the way around. So you create this opening like that. And that was the initial way that people were doing this for a long time. A can opener capsulotomy really doesn't have a role anymore. There are much better ways of doing this. But it still is taught at certain times. So he came in and he made a capsule out of me. Entered the anterior capsule right here. So residents, why does that make you nervous? It's easy to do that. Not controlled, okay, I'm going to tear it further. Yeah, yeah. So one of the things we talk about in cataracts that we worry about is when the anterior capsules we're trying to do our capsule rexis, it tears out. Why is that a worry? Yeah, it keeps tearing all the way around on zips. It just opens a nice little envelope and there goes your lens at the end. So there is a reason why this doesn't tear around. This is called an envelope capsulotomy. I have seen what I think I've seen essentially every potential complication of doing the surgery. I have never seen one of these capsulotomies tear around the back ever. And we'll get to why. Start there. Again, so our capsule otomy, making the capsule otomy. So we've made an opening now. An opening that the lens can be delivered from. So this is your hydration step. Coming in, we're actually hydrating the lens up. So you now you see the lens, it's actually tipping up. And so putting a little viscoelastic gel behind the lens. It's called a fish hook. It's a bent 25 gauge needle. You put it in, slide it under, tip it up to tip up slightly where you can impale the cataract. And we are at two minutes. I just want to be clear. Lenses out, two minutes. So the cortical removal takes essentially as much time as your wound creation, your capsule otomy and removing the lens. Why spend so much time on cortical removal? It reduces complications. So what happens if we leave cortex behind? PCO. So PCO, you can do a beautiful surgery and leave a piece of cortex behind. And you guaranteed that person to have returned to 20, 80 vision in probably 12, 12 months if you leave a big piece behind. So all of the effort you've gone to curing them, he's still polishing. It looks clear, right? Does it look like there's any cortex there anymore? No, and yet so meticulous. Three minutes. So he spent a full minute on just cortical removal. You can see the anterior capsule really well here. So this is an oval, this is a pocket. The posterior capsule's intact. This is the anterior capsule that you can. That you'll be putting a lens in. Just go elastic into the pocket. We've just opened that up really wide. This is going to be a single piece PMMA lens. PMMA is a plexiglass material. It was the first intraocular lens. Now what happens if we leave the anterior capsule in place? Phymosis, you guarantee if you leave the anterior capsule in place you'll have an opacification over the frontal lens every time. So he's doing a capsule of ruxus of sorts right there. Now I'll just rewind it just so you can see. So what he did is he's making a cut in the anterior capsule on the right and a cut in the anterior capsule on the left. So now that envelope has two cuts. And rather than going with the utrata forcep to pull it around or assist the tone he aspirates it through this port and he essentially like sucks it and then pulls it all the way in. So then the anterior capsule is entirely removed. I paused it a lot and rewound. Yeah, this is five minutes, this whole thing. Start to finish. Clearing up viscoelastic. Why does this wound seal? And the answer is partially it's long. You're talking about out here? Kind of making that a frown incision. That is actually a really intuitive guess. The frown incision helps with the stigmatism management. It has less to do with why it seals. And we're done. Why does a corneal wound, any corneal wound seal? It's an internal valve. So inside the cornea as we enter you're going to have that inferior flap of your wound. That is the piece that will seal it. So if you have a premature entry and you don't, you're going in and you, instead of going into the cornea and making a nice pocket you accidentally enter at the level of the iris and you don't have that flap. You'll have to suture that. So for your corneal wounds as you're doing cataract surgery of any sort it's really that internal flap that's going to help you. Questions on that? What are you just on? So when you made the cuts on the capsule how did you keep it, they start to suck and how do you keep it from just going back? How did you get it to turn? So. Basically the same idea as a rexus where you're just kind of the. It is the same idea. If he was using utrata it would be a little more clear. You can't draw this unfortunately on the board. So. Anytime you're doing a capsule rexus and you grab a flap you can turn it and lay it over and start directing where it goes. As soon as you reach a certain point you have to actually rather than lay it over and keep pulling you have to start pulling kind of towards the middle. You start shearing it a little bit. Be a decent example. So if this is my capsule you're initially going to fold the piece over and then you start tearing like this. And that's how I'm going to start getting it to turn. Now at some point it gets long enough that rather than I either have to come and re-grab here to direct it or I can start using what's called a shearing. Where I'm actually rather than pulling the direction I want it to go I have to pull a little different direction. So if I want it to start turning back I actually have to start pulling like this. I'm pulling in a totally different direction. And so I finally can start to get that curve even though I'm not folding and leading it each time. So what he did is he pulled and just pulled towards the middle in it. Something like that. Other questions? All right, which is harder to learn? Any guesses? What do you guys, what would you think? Small incision. Small incision? Faco. Faco. Faco, small incision. So it depends on who you ask and you're all right. If you ask these Nepali residents which is more difficult to learn they will tell you Faco a million times out of a million. So they do in their residency, you know, four to 500 small incision extra caps. They don't actually ever get to learn Faco. They have to learn Faco after their training. So when they go to learn Faco it's like a whole new world. It's like a paradigm shift for their brains. What about these yahoos? If you ask you all after you've done 300 Facos and then you go and you go to an Apollo and try to learn, it's small incision. Pretty universally you'll say it's a much more difficult surgery to learn. So it just depends on what you know. I'm just gonna pause and give you a little global ophthalmology perspective for a moment on residency training. Anyone wanna take a guess how many cataracts are mandated to do if you're in an EU residency program? How many do you have to complete? So what's the number in the United States? 86. That's what we're going for for you, Chris. Get you to 86. We're pulling the flag at that point. Take a guess. Let's look at five guesses. Whoever's closest? Oh. 242. 242, I like that. 50? 500. 500. I think it's a low one. 200? 243? 242. What game show is that? Price is Right. Price is Right. $1, Bob. Did you guys hear about the guy that mathematically played the Price is Right and got up there and actually won? And Drew Carey was like pissed because he actually ended up winning everything like both of the showcase showdowns at the end. It's actually really interesting. Okay, so the answer is zero. So for the entire EU, there's no standard. Now that may not come as a surprise. But let's take Greece or Italy, right? How many cataracts do you have to finish in those two countries? Three guesses. Three guesses, anything. Is that right? Four. Someone said zero. Someone said four. 40. 40. 100. 100. Zero. You finish residency having in, this is Greece and Italy. I was in the Republican Georgia and their residents don't do any fake go. Well, they don't do any surgery, essentially. And that kind of bothered me. I thought maybe it was a weird Eastern European like holdover from Soviet Union or something. It's actually pretty rampant. So the EU right now is trying to figure out. One of the things about the EU is you theoretically could finish your law training in Prague and then go practice in Belgium. But for medicine, that's actually incredibly problematic. All right, what about the UK? How many do you have to complete in the UK? What's the average number they finish with? 180, 200. They finish usually on average with about 6 to 700. How long is the training in the UK? Longer. How many years? Six, seven, eight years. Remember they say you're done, right? That's actually true in part of the system. There's no guarantee you actually become a consultant in the system. I only mentioned that because I think that type of concept is really interesting for you all, the level you're at. Medical training is unbelievably variable throughout the world. So, what I wanna do is, from the perspective of someone who's going to be a FACO surgeon, there's really just a few what I would call unique things that you're really gonna have to learn. So these are the steps. You could read this in a book. By the time you're done in residency training, you're going to have a level of competency. You're probably, when you're finished with residency, most programs you'll be what I would call an advanced beginner surgeon. You've reached a level of competency, but you're still very inexperienced. Depending on the program, you may be a little further along. But you'll know how to basically do all of these things. I mean, you'll have an idea at least. You'll have some experience. But this tunnel, the wound entry, the capsuleotomy, and mobilizing, and getting a nucleus delivered, those are all like kind of foreign, unique things that you wouldn't necessarily learn. So your self-sealing wound, just kind of breeze through a few of these. Again, in terms of just in time learning, this isn't just in time learning, but for perspective, you do want the self-sealing wound. If you do want to read more about this, there's a great focal point. So I have the PDF. I'm happy to send any or all of you. If you have an interest, just email me and I'll send it to you. It's seven pages of essentially how to do the surgery. It's really practical. Should have a few different ways of doing this. So scleral groove looks quite simple and elegant. It's a little difficult to kind of figure out what 50% depth is. That's experience. You'll find times when you're too deep or when you're too shallow and the resulting problems from that. It's another way of doing it. This is what your wound will look like early on when you're training. This was one of my early cases after I'd come back from Nepal. You can see this is mind numbingly slower. I paused there and probably looked at it again. I don't know what I did. What I'm really trying to do here is I'm trying to get that right depth. If you're doing a hundred of these a day, which there are surgeons that will do that, it's going to become pretty automatic. If you're doing this, maybe a hundred of these on a camp and then you're here and you don't do it for six months as you start to do this, you can actually see this is a pretty thin flap. You can still see the crescent through the sclera. You want to be able to see the crescent, although over here that might be, that's probably a little too thin. That makes me a little bit anxious. You can practice this on a pig eye. Pig eyes really have excellent fidelity in terms of their sclera if you want to practice how to do the sclera tunnel. When we do the small scissor white labs, either here or at Academy or ASCRS, it's really all pig eyes doing sclera tunnels over and over and over. Questions about this? It's a read of corneal complications on these. It seems very traumatic. Yeah, that's a good question. As you watch, what's giving you anxiety about it? I think it just seems so much more traumatic than bacon type surgeries. I'm wondering if there's high incidences of Brown-McLean syndrome or any other endothelial type. Great question. So we're in the stroma. We're in the layers. We end up entering into, we make incisions into the epithelial. Decimates. This is dramatically more friendly to endothelium than FACO, because FACO is giving you that mechanical energy, that kind of constant trauma to the endothelium. You can have complications. The complications is primarily when you, what's called premature entry, where you might make a really nice tunnel out to here and you can see the blood that sort of outlines that tunnel. But if you go into your keratome and you don't cut at the distal end of your tunnel, let's say you come in, you prematurely enter here, your iris will flow. If you get flow over the top of the iris, it's going to flow out. And if you don't have that space between the iris and where you enter, you can deliver the entire iris out of the eye when you deliver the lens. There really less corneal complication with this. But iris, all right, capsillotomies. Little paradigm shift. You need to be large enough to accommodate the lens. You'd love it to be small enough to have some overlap on top of the lens. It doesn't always happen. And then you want it to be stable. These are your different options. V capsillotomy. So, the question was earlier, or Saravan made the comment answer the question. Why wouldn't this tear out? Because it looks like it should. So I'm going to pretend that these are zonules. This is not the iris, okay, these are zonules. Zonules are radial. They attach onto the edge of the lens, like springs of a trampoline. But it's not just in a single plane. It is in multiple planes. They attach from anteriorly, posteriorly as well, all the way around. And then again, they will attach radially. If I have a, if I have the top of my lens and I have a tear that's going straight out, it's really easy for it to bisect the zonules and go around back. If however, probably the easiest way to show it, if however my tear as it comes out, it intersects these tangentially rather than radially, it's really difficult for it to tear all the way through. It actually requires some energy to do that. So as we make this V capsillotomy. At this point, before the anterior chamber entered, a capsillotomy is performed. Actually, now inserting it into the anterior chamber. Each bevel of a 27 gauge needle, attached to a syringe containing ringer's lactate, is used like a knife to make the two incisions with fine chopping motion in the anterior capsule. Thus, a triangular flap of anterior capsule still attached at its base is created. The apex of the capsillotomy is stripped in. Same thing with this linear capsillotomy. This linear capsillotomy, if we have made this cut right in the middle, it would come around and it would tear around in the back. But because we're doing it here, by the time this starts to intersect the zonules, it's intersecting them not radially, but actually still tangentially. That's the reason it doesn't tear around. Questions on that? All right, how do you deliver it? Few variables. Simco Canyon, I want to give you the anatomy of the Simco Canyon. What's an IA Pro? Give me the basic anatomy of the IA Pro. What's on it? Aspiration port and a box port. Yep, that's it. Infusion and aspiration. How is the infusion and aspiration controlled in FACO? Yeah, foot pedal. Position one does what? Irrigation, position two does what? Irrigation and aspiration. Yeah, it's exactly right. So irrigation is always on. So Simco Canyon. Have you ever heard the name David Chang? Okay, David Chang, Alan Crandall. Alan Crandall, David Chang, they're in the top 10 like most well-known cataract surgeons in the world. They are truly like the best of the best. So I had a trip to Guatemala, it was early on when I was kind of junior faculty. Rand Paul, anyone know what Rand Paul does? Ophthalmologist. Yeah, he's an ophthalmologist and part-time senator. When you become a senator, you actually can no longer practice medicine. The rules for the house and the senator are the same. Because of conflict of interest because you're setting Medicare payments, you can't then go work and make money through medicine. So the way that the house has interpreted that is you can do work as long as you're not taking Medicare or Medicaid money. The way the Senate interpreted that if you're a physician, you can work only if it's pro bono. So once you become a senator. So anyway, Rand Paul had worked in Guatemala. Rather, some Guatemalan patients had come, they'd returned to Guatemala. He wanted to go back. Yeah, yeah, there were several news outlets. It was a giant bluster, as I'm sure you guys used. We had been in Micronesia three weeks prior, done similar amount of surgeries. We had a team of 18 people for the Rand Paul trip. The team that was down there were 46 people. Same size medical team, but then it was media and security and media and media and media. Anyway, long story short. After Rand Paul leaves and everything calms down, we finally have an affirm to set up another table. So David Chang is doing FACO. Alan Crandall is doing FACO. And there is a little hall. And at the end of the hall, we clean it down, we sterilize it and we get a table and the table kind of goes against the wall. We bring patients in like this and I can sit at the head. All I needed was to hang an IV pole for an IV for your infusion. If you want more infusion, let's say you're operating in the eye and you're not getting enough infusion, how would I get more infusion? With raise? Yeah, you just raise it up, right? So that's it. Anyway, so I'm operating there. And all of a sudden I realized what's happening is they're selecting all the easy cases for David Chang and Alan Crandall and they're selecting all the really difficult cases for me, which has nothing to do with my surgical skill. It's more the fact that this is so well suited to really advance pathology, sexually in many cases, and put our surgery. So, but it still felt cool that they were getting the easy cases and I was getting the hard one. So a Simco Canyon is an irrigation aspiration instrument. Irrigation is controlled by bottle height as you have an IV pole. And then there's a small aspiration port. Anyone, has anyone seen one of these in real life? Okay, so how do you control aspiration with this? With one hand that's in with like a, what are 10cc syringe, whatever it is, and you're slowly kind of pushing fluid through, and then, I can't remember exactly how that is. No, you got it all right. It's just the infusion's happening through one port and you're actually aspirating with, so infusion's on, they just, you unclamp it and then you actually manually control your aspiration. So as you go across, you wanna pull out some cortex. That's what you're doing. So, I've got irrigation. This is Simco Canyon. This is actually here. This was a primary small incision case. Oh, I'm sorry, this was Micronesia. So, tell me what's happening here. Little tight, big enough to get out. That's about right, but you can see my wound relative to the ones that you had seen before is probably a little bit small. In irrigating Simco cannula, deliver the nucleus into the anterior chamber by nudging one edge of the nucleus into the anterior chamber and then delineating the cleavage between the iris and the ledge until the lens is entirely delivered into the anterior chamber. A corrugated irrigating nuclear extractor is passed posterior to the nucleus and placing the tip beyond the distal pole. Gentle lifting and retraction with the cannula, plus opening of the external foremen with gentle downward pressure from the heel of... Good questions on lens delivery. This is your fish hook. Does this give anyone anxiety seeing that on the eye? You find that your wound's too small. You can't, can you go in and enlarge it or...? Yeah, you can enlarge it. So with that, remaining case score of point up, that's a post-op day one for a dense white hard cataract. I wish Tara were here to talk about her post-op day So do they not get much corneal edema even though you're going through this trauma? Yeah, I mean, intuitively you'd think you're killing the cornea, you're dragging that lens across it. This is what you see post-op day one unless the case is just long and complicated. The longer you're in the eye, the less clear your corneal edema is the next day. So what do you expect? As you guys try this, as you guys kind of go in, you think you've learned some surgery, you know what to do, you're pumping yourself up, you're gonna go to Nepal, you're gonna jump in and what happens often? Oh! Oh! Oh! You run into this. Oh! So I do just want to come in on a couple things, just a couple things with training. It's a little bit more acute and it feels more intense when you're doing surgery, but you're all experiencing this regardless of what level you are in. Tara Hahn right now, she's right at the beginning of the Ketterach surgery. Last week we did surgery and it was, every case was just hard. It was just a slog, you know? Like your level of like anxiety starts to raise a little bit, you raise your shoulders, you're not calm, so it's harder to get your hands to what you want. It was just case after case, right? She's like, you know, I just had a couple of good cases. And then yesterday, yesterday was the most beautiful like day. I mean, each case went exactly how you'd want. Rexess, everything just kind of built on you. At the end of the day, she's just feeling like, I got this. But what's coming? Yeah. Like, and there will be day, there are still days for me where I feel like I'm just not on my game. And I have enough experience and skills to be off my game and have things be okay. But as a resident, there will be days in the near future, probably next week, frankly, where she will feel like she has never done one of these before in her life and she's working on her first one. And the analogy really had applied to you all and what you're doing. So, medicine's a really interesting gauntlet, a very humbling gauntlet and you guys are experiencing this. You just began to be moderately useful on a rotation. And then you switch and go to something else. And you're right back to being as useless as you were. Now, you all, you start out being moderately useful on a rotation in residency. Give or take. And then you actually do develop some real competency. So, for perspective, when you finish your last day of neuro-ophthalmology, that is the day likely to last day in your life that you will know that much and be that competent neuro-ophthalmology, the rest of your career. Your trajectory in neuro-ophthalmology doesn't continue in an arc unless you become a neuro-ophthalmologist. And I want you to realize that. In fact, the other thing that where you are specialist and you actually will know more than you're attending is at the end of your PGY3 year, you will be the best subspecialist in acute urgent ophthalmology care that we have in the building. Because you guys are seeing it day after day after day. And even though you're calling us and talking to us about it, we're recalling back 10 years. So you do develop legitimate true expertise in residency even though you don't give yourself that credit. You don't feel like it because you're working with Judith Warner who not only is she one of the most brilliant people I've ever met, she just has this uncanny ability to give Chris Ricks like, well at least in the skit anyway. Not in real life. In real life. So we don't give ourselves enough credit for what we know in residency and what the levels that we get to because again, we're in the Scotland where the next week you're on a rotation and you feel like a complete fool and you're inept again. So I guess just as a philosophical finish to this, when you adopt a new technique in ophthalmology or whatever you end up in, if you don't get in ophthalmology, just kidding, I shouldn't say that. I think you've decided to bring it back. That's not funny, I can't help myself. It's like the weirdest thing. It's not even funny to say that. As you kind of take these steps, you endeavor on this path, it's an emotional, intense gauntlet. As you guys go through, please, please find the place you fit well. You'll be really attracted by sexy names, sexy surgical numbers and things. I have zero doubt that this is one of the best training programs, literally in the world, no doubt whatsoever. But if you figure out it's not the right program for you at the end of this, because any reason, not the right fit, whatever, that's powerful information, and that's important. And you should feel a little bit more confident in yourself than you probably do. It's very, very likely by virtue of you guys making it through our application process to just get a rotation here that you're gonna match. You guys all actually, I don't think any of you have been sociopath by this point. So you set yourself up pretty well to match. And then for residents, even though you're in this kind of humbling gauntlet where you're on your new road meeting or making mistakes as you should in this learning process, you have a lot to offer and are really valuable. And so, as you go through this, the thing that I found the most helpful is to reach out towards juniors and reach out towards others that the more that you can kind of reach out and teach, the more competent you'll feel, the more comfortable you'll feel in what you know. And you'll recognize by that, yeah, you actually know a thing or two in this. So, with that, any questions at all? Are there any surgery, anything? I was curious what the cost difference is between small incision and FACO. That's a great question. Why don't you give me, no, I better not look for it. Okay. So there've been several head and head studies. There are now about 15 head and head studies between small incision, cataract surgery, and FACO. And the most well-known one was published in AJO. And so it was actually David Chang. So they took David Chang's FACO machine, they took his instruments, they took his microscope, and they transported all of it to a monastery in Nepal. They literally like set up his operating room with his own technicians, like trying to keep everything the same to the extent they could. And then they took Dr. Sandoq Rui, who's one of the small incision masters, and they set the two of them up in the room. I actually wanna show it to you. So let me just give me two seconds, see if I can find this really quick. All right, here we are. Yeah, this is awesome. Any of you guys ever watch Iron Chef? Yes, that's kind of what it was. So basically, I didn't make this slide, but I like it. So great. All right, so they randomized. So here's the results. That's pretty profound. That's significant. I don't have to give you the P value. Pretty similar, equivalent. You could have had a vitreous loss on either one in any given case. Corneal edema. Here's some actual numbers for you. 90% were 20, 60 or better. 50%, 20, 30 or better, 13% in your SICS. Actually, better numbers than the PENCO. So why is that on post-odd day one? It's edema. It's edema. It's really gonna be edema. Fast forward, one year later. Faco's got more 20, 20s. Best corrected. Why would that be? Because you look, it's equivalent, 20, 30s. Why 20, 20? What's? I think it's out, maybe. Good question. Could absolutely be cortex. I'm probably astigmatism. They didn't actually do topos on everyone, but you are going to get less predictable astigmatism correction, potentially some irregularity with a large incision like that. If you were to make that incision that same size right at the limbis, your astigmatism is so unpredictable and high magnitude. We pull the incision back, we tunnel into the cornea so that that, even though there is some relaxing in that meridium, because you have that opening, it's two to three millimeters behind the limbis. It's four millimeters behind where your anterior opening, so it gives you less, just overall, less astigmatism. So yeah, that's it. Awesome. I took that slide out of that one. So the cost per case, if you're trying to do it head to head, let's say you go to an araven where they're great at getting the cost down for either. You can dial down the cost with everything, the drape, the lens, the antibiotics, give during surgery, the post-op drops, the betadine, the drape for about $25 per case. And for FACO, once you start doing FACO, just for the disposables alone, you usually jump up to somewhere around $250 in those settings, even with reusable packs of things. So I went on a mission to Peru and was trying to pay attention before I really knew anything about anything, not that I know anything about anything now, but a little bit different, and trying to understand why they would decide FACO versus SICS for some cases. It ended up being a move point because the FACO machine broke on day one, and so they had to do all the SICS, but I was just curious kind of what leads you more in one direction or not. If you have the option to do both. Yeah, good question. So if you have clearly lack zonules or if you can tell ahead of time you have a brown or black cataract, that the amount of energy from FACO is going to be really traumatic for the Eidos you do with SICS, at some point. It is, for a developing world, you tell me like for your own eye, you'd probably rather have FACO given this 2020 thing. But an example, so Brad Jacobson is going to Mwanza to do a diabetic retinopathy screening and I think, I think Mwanza, when you take the whole catchment area, it's about four million, is that right? Is that, yeah, it's about four million people and how many ophthalmologists there? Two, two, two for four million. So if you really want to do surgery, go outside the United States, there's plenty. By the way, the surgeons have just finished their residency training, usually finishing with about 15 to 20 cataracts total when they're done. So in that setting where you have that ratio of patients, many of whom are going to have advanced blindness, FACO can't really be a solution, one financially and then two, just efficiency. If it's a 15 to five minute difference, that alone weights everything really towards small social cataract surgery just to get through the volumes of backlog. You can't do five, six cases and a half day there. You really have to get your numbers up to 30 to 40 cases and a half day. That's just something that can't be done in FACO. All right, it's time. So I'll stay and chat with anyone, students, if you guys have questions or whatever. Thank you, residents.