 Okay, thank you Chris, nice job. Now we're gonna have Isha Gupta present. So Isha is from Salt Lake, did medical school here, and I've known Isha for a while. She's been working with Dr. Unbody for the past year and doing some research, and today she's gonna be talking about some research that she's done with Dr. Olson as well, so thanks Isha. All right, hi everybody, it's nice to be here and to start off this year of ground around the presentations. I'm a fourth year medical student here and I'm applying into ophthalmology. So like Brian said, I wanted to talk a little bit about my research with Dr. Olson and all the different studies we've done and how we've tried to optimize Faco emulsification. Today in specific, I'm gonna be talking about the radius Faco emulsification tip. My outline today is I'll give a little bit of background on Faco emulsification. The problem and the complications that are seen in this, some questions we came up with and then the study design we also designed and results and conclusions. A little bit of background, cataracts affect nearly 22 million Americans age 40 and older and by age 80, more than half of all Americans will have cataracts. They say that if you live forever, you will have a cataract. More than three million cataract surgeries are performed per year in the US and that almost ends up costing us about $7 billion annually. As you can see, cataracts really are the bread and butter of ophthalmology and so they're a very important thing to look at. Faco emulsification is the main method of cataract removal. This is for a variety of reasons. It's safe, it's controlled, and it's fast. So therefore, research in this field is actually focused mostly on improving efficiency and patient outcomes. While the complications are relatively rare with this surgery since it is so safe, some of the more common complications include inadvertent capsular breakage, infection of the eye, swelling of the back of the eye, corneal edema, blood in the eye, and retinal detachment. Today I wanted to focus a little bit more on capsular breakage. It's feared among many residents and incoming new surgeons, what do you do? So capsular breakage is pretty common. I mean it occurs in about two to five percent of surgeries and it becomes more important when you start looking at posterior polar cataracts and it can occur almost 25 percent of the time. There's a couple of qualities of capsular breakage that make it more or less prevalent in surgery. The amount of pressure tip against the capsule, the amount of active vacuum at the tip, the aspiration flow rate, the gauge of the needle, the needle sharpness and degree of angulation and the energy modulation. And in this study we wanted to specifically address needle sharpness and degree of angulation. So what we looked at was a radius fake-o tip and what that means is this tip is actually has the inner and the outer edge are rounded and this is thought to protect against capsular breakage. This tip is available in any gauge, bend, bevels, similar to most fake-o tips. And in a study of Myron's colleagues, he showed that there was substantial and significant decrease of capsular breakage when using this tip. The study does point out that perhaps in exchange for the safety profile you are risking a decrease in efficiency and an increase in chatter. This is really important as surgeons because we all know that over time is very valuable and as well as expensive. So our study was actually looking at the efficiency and chatter of the fake-o emulsification when using this radius tip. So as you can see here, there's a couple of pictures. On the right is the traditional fake-o tip. It's got a sharp inner and outer rim. And on the left, there's the smoother edge. You can see the inner and the outer edge are rounded and this bottom is a schematic of what the tip would look like when engaging nuclear material. You can see that it's probably less likely to break through that material. So our study is a design. This has been used in a bunch of our studies looking at optimizing fake-o emulsification. We use three different ultrasound modalities. The Alcon, which is a torsional ultrasound. The Amel Whitesur, which is a micropulse. And the Amel Ellipse, which is a transversal modality. We use the same powder, bottle height, vacuum, and aspiration to keep all parameters kind of even between them. Our lenses are a porcine lens nuclei that we order and then we soak them in a 10% formalin solution in order to mimic human cataracts. I actually looked at two different types of lenses that would be comparable to both a 3 plus and a 4 plus human lens, cataract lens. The tips, they're all from MST. We use a 0.9 millimeter diameter, which we have found to be the most efficient. In previous studies, 30 degree angle bent tip except for micropulse, which we use a straight tip just because that's what you tend to use with that ultrasound. And then we use them with their direct counterpart with a radius cutting edge. Our study design, it's a basic design. We take the lens cube and fill it in a BSS chamber. We engage the petal just enough to get the tip to be occluded with the nuclear fragment. And then after occlusion, we fully depress the tip in order to activate the vacuum. A stopwatch is recorded for the time of removal and we also counted the amount of chatter events, which is when the lens material actually removes off the end of the tip and we have to re-engage it. Chatter was delay in time distinct from the total particle removal efficiency was measured in the amount of time required to remove the lens particle. So we have some really exciting results. These are our overall results. I'm actually gonna break each one down. So in our torsional ultrasound, as you can see, we found some significant results. They actually showed that with the radius tip in both the two and three hour, in both the three plus and four plus lenses, there was a decrease in efficiency, which was kind of interesting. So that being said, the radius tip didn't perform as well. In our transversal ultrasound model, we found no significant difference between either the two plus or three plus lenses. And in our micro pulse model, we also did not find any differences in time. So in words, the torsional efficiency was significantly worse with the radius tip for both the two hour soak lenses and the three hour soak lens cubelets. We found no significant differences in the other ultrasound models studied, including transversal and micro pulse, and just some kind of interesting facts overall. In the two hour lenses, the transversal non-radius tip performed significantly better than the micro pulse non-radius tip. And when we came into radius tips, the transversal tip performed significantly better than the torsional tip. When we looked at chatter, we weren't able to find any differences among any of the time, hardness of the lenses or the ultrasound model. So some conclusions that we kind of came from with this study, that fecotip motion must have an impact with radius tips. The reason being is micro pulse is a longitudinal motion. It's kind of a jackhammering. You can picture a jackhammering in your mind. It's straightforward motion. Transversal is an ellipsoidal motion where you have both horizontal and longitudinal motion. And then a torsional is a sub-ten arc and it's kind of a shaving motion or you can liken it to a chisel motion. And since we saw that the radius time removal almost doubled in the transversal model, we're thinking that the amount of sharpness on the tip must have some sort of effect on a chisel and if you think about it, if you have a sharper chisel, it's probably gonna be more efficient whereas the jackhammer effect can just be just that pure power going right at that and you don't really need the edge sharpness. Finally, in conclusion, radius fecotips are reliable and a safe option for feco. A previous study had shown that capsule breakers is dramatically reduced with this radius tip. And then in this study, we were able to show that in certain ultrasound models that being longitudinal and transversal, you do not lose any efficiency or have an increase in chatter. This is very important in the field for many surgeons this could be a practical thing that they could employ right away and you could increase safety and maintain efficiency. So that's here are my references and are there any questions? Here I am. I think studies like this are important because we always want to look at the trade off between safety and efficacy. We want to make sure we don't lose efficacy when we are looking for increased safety. And I think this radius tip that Steve Huey designed is a good way to try to increase safety, especially when we're working with residents in that. Previous studies have shown that there's less risk of breaking a capsule with this tip and he thinks we're all increasing the safety. It's interesting to see the differences in that. Of course, you did a very good talk that you didn't mention company names, but it's very interesting that this tip was designed for AMO and works better on the AMO machine. AMO will be very happy out front, we'll not be happy. But it's interesting to see if this will play out practically to see, I think we need to start looking at these tips with both types of machines in a real world setting and see if there really is a difference. Studies like this are important because they're controlled and that you've got cubes that are the same and the problem with the VA is... Dr. Petty. You should actually have one important comment and I guess full disclosure, I'm going to go after some of these papers. So, Paula has a real profound saying as basically the more time you take. Thank you.