 Good morning! So I want you guys to sweat up into two groups because this has to be interactive otherwise everyone can fall asleep. Okay, so I need at least those of you that have done feckles before, you've got to be on one team and then whoever has the most experience after that has to be on the other team. Split up. So this is about machine settings. It is part of your BCSC book and I think how many guys got some questions on feckles machine settings last year? Not a lot of questions, alright? Maybe two or three at the most? Alright, so I want you guys, let's see, this side of the room Tina's team, I want you guys to look through those those terms because we're gonna discuss all those terms and I want you guys to come up with definitions for that list and then this side's Robbie, your side will come up with definitions for the right column. I'm sorry, let's do this way. Tina, you guys take tuning down to venting and it's offside you take down cavitation to stroke. Okay, so go ahead and discuss it for about 10 minutes, okay? I want to make some copies, I'll be back in just a moment. So look through that list. Yeah, shoot, so we got all the tough ones. So here are the ones that we can talk about first that are energy around the two terms. Yeah, we can talk about the ones that I know. There are some basic terms on that right side. So first thing would be aspiration, which is essentially just your vacuum pad. It's bouncing off, the particle is bouncing off like this, because it's just like you don't have enough. Start with Faco, or start with Karex Rotary, first position on your foot pedal is, you know, you're at least down to position two. So how often is it on, like 1% is really not enough? This is actually Faco power, but aspiration is super important because a lot of what you're doing, Faco is not actually using Faco power. You're using aspiration to bring pieces to you, and then you brought the piece to, and you are using occlusion to move the pieces around. So that's one of the next ones. The process is not the follow-ability. Yeah, yeah, exactly. And so that movement of your piece, so I think that you need to sort of just make a little bit of that. What you're actually doing is you're going in, you're using your vacuum on a piece until that piece either comes towards the tip, or you bury into. If you can see where the tip is going, like how fast it's going. If you're burying your tip in that way, you can actually move that piece where you want it. So out of the bag, safe to actually Faco them at that point. So occlusion then is really important because if you don't fully occlude your tip, you're just going to kind of nip away a little pieces of nucleus and other things. And you're never going to really be able to get into the piece where you can safely Faco it. So the follow-ability is a specific thing after it's occluded? It's sort of the movement while it's being occluded, while it's in that process. And then... That's crazy. Because they did during the... I'm not sure. It's more of on the tip of the Faco pieces. And that's like before you, but that's what the text usually do for you. Well, so it's like the machine basically does it for you, but it essentially makes sure that everything's working properly. Make sure that there's no air in the lines and all of that. So once you've occluded your... The rise time is how fast that sort of occludes our surges when you... They're all in this chapter. And then surge occurs when you lose that occlusion. Or they go up the piece, you sort of lose that tension. All of a sudden you get a surge, which is sort of a lower back that causes your cheek to produce it. Surges are very dangerous. What they're really trying to do with fluidics is trying to prevent surge. So you can imagine if you're like pulling, pulling, pulling on this piece. You're like building up vacuum, building up vacuum, building up vacuum. And then for some reason it breaks. All of a sudden you have a split second between where you can stop that vacuum and where that break occurs. And all of a sudden things are going to surge and your chamber is going to shallow. And so rise time is how fast once you've had that occlusion, that's what power surges after. It's like the time of the surge. Yeah. Well, so not the surge but the occlusion. The surge is when that occlusion is broken. Your back sort of all of a sudden, because you still... There's a lag between where the pieces let go and you can stop your vacuum. It breaks and all of a sudden... The rise time is between... So... Yeah, I'm also confusing. About rise time. Yeah, which like section of it. Okay. Yeah. So... Your describing makes sense but it's the period of time. That's where I find that's not clear. Okay. The rate at which vacuum builds once the aspiration port has been included. Okay, so is that... After... Yeah, that makes sense. So is that probably controlled by your foot? Like how strong is the pressure on the vacuum? And how... Yeah. And your settings. So your machine setting is going to be more aggressive into where... So once you include all of these quickly want to build... Hold that piece to your tip. It's just helpful to know how to set up the vacuum machine. It's already attached. Uh-huh. Preach. Automatically build the vacuum. That's why it feels so... It's achieving an appropriate amount of stuff. You necessarily need a quick rise time but... But yeah. The next thing is... Okay, how far does that make sense? Yep, yep. Yes. Exactly, nothing's coming through. It's done? Pretty much? Okay, close enough. All right, so let's go through the ones that are... I think the ones that are more intuitive are easier to get. Strong on your guys' list. Which one do you want to do first? Well, no, let's do the ones that are more esoteric a little bit. Just pick any one from the list. So, cavitation is one that we're talking about that they could be a little bit more esoteric because it's like you have a distance between your tip and the piece that you're trying to fake go and there's like these bubbles or micro bubbles that form. They're not allowing you to directly touch the piece and just like these high energy bubbles that are in the way for you to have good maybe follow-ability. Does it help you? I mean, what's that? It doesn't help you. If you're just... If you're not actually occluding properly, it's probably not helping you, but I don't understand the completely. Okay, so actually cavitation is helpful. You do need some cavitation for fake emulsification to occur. So there's a pressure change that occurs on the tip. And when that pressure change occurs, you get these gas bubbles that expand and contract. But it's that collapse of the gas bubbles that releases energy, that releases heat pressure that allows you to emulsify the piece. So it's actually a good thing. That's what's happening at the fake go tip, is some cavitation. So this is my cheap version of the animation. Fake a tip vibrating, bubbles expanding, bubbles collapsed, pieces break up. Heat and pieces break apart. That's cavitation. So it's actually a good thing for you to have cavitation. Okay, let's go back to the list again. Tina, your side. They did cavitation first. What do you guys want to do? It's actually to start at the top. Okay, tuning, pretty basic. Your technician's doing this. Yeah. You guys never have to worry about this. This is the reason that we have software in there. And what you want to make sure is that what you tune in the machine is actually occurring at the tip, right? So you're going to get an error. If you don't plug in things correctly, you'll get a tuning error, okay? But your technicians are usually taking care of this. You guys rarely ever have to worry about this unless you've been on outreach with us and you're having to set up your machines yourself. Then I'm going to need to know that, hey, this is not tuned properly. What are some things that can go wrong, though, with tuning? So let's say you plugged in everything correctly. What's left in the whole system that could go wrong? With your seals and your fluidics. Oh, sorry. Yeah, the tip is not attached as well. The tip is not attached as well. So those of you that have done Faco, your ear will become a tune to that buzz and what the buzz sounds like. And if you don't have the tip on properly, it'll chatter funny inside your hand. You'll feel it. It just doesn't vibrate properly. And it might vibrate at a different frequency. Worst case scenario, your machine will give you an error, that there's a tuning problem. So what do you do? You come out of the eye, you type in the tip again, and you go through the whole tuning process again on the machine, okay? All right. Your side. Let's take it from your list. So we can do, yeah, aspiration. So the next part of aspiration is just the actual vacuum power that's like withdrawing fluid contents from your Faco tip. So it's that sort of pull out of the eye. So you aggressive fluid. So be careful about using the word vacuum, okay? Sorry. So it is an aspirating force, okay? That's an actual attracting force that brings stuff to your tip. The way I remember is that A for aspiration is attraction. That's how you attract pieces to your tip, okay? So those of you that are on that last chip in Faco, we say don't go into the bag, okay? You don't need to go into the bag and actually go and touch the piece. Why? I want you to use aspiration flow rate, okay? And the way aspiration flow rate is, as soon as you press in position two, currents are now flowing into the eye because you already passed position one. Position one is irrigation. Position two is now actually sucking things into the tip, right? And that's what you're using as you're using the attraction force of the machine to bring pieces to your tip, okay? So that's why you can be just above the capsule, position two, and get that last chip out of the bag, okay? Assuming that it's free and it's not stuck in physical elastic or it's not stuck in the sulcus where you actually have to go and actually touch it to create some vacuum, okay? So we're going to talk about a couple different types of pumps but for your board's purposes, almost exclusively, except for a few machines on the market, our facial machines are peristaltic pumps, okay? So if you ever look when they set up the machine, you'll hear rollers moving, okay? You guys should look inside the machine. Just before they punch the cassette in, you'll see a round mechanism that has maybe six or different seven rollers there. And that's basically that peristaltic pump that you see in your book. They'll give you a diagram. Do you guys remember that from your book? There's a diagram of that peristaltic pump. Now, if you're going to go into retina, retina guys don't like peristaltic pumps, right? They want to have exclusive control of the vacuum, right? And the unique thing about a Venturi pump is that the vacuum rises independently of occlusion, okay? And that's why retina guys like it. They want to bring vitrious immediately and chump it up, chump it up, and let it go, okay? They don't want to actually wait for things to come to the tip and wait for vacuum to build up. And that's why Venturi is for retracting me. So V for retracting me, Venturi, that's what they may test you out on your boards, okay? All right. Next. Throw off-side. Got the list. What do you want to do something for you? You do power. We've got something we're already having discussing. Okay, power. Okay, so go ahead. What do you guys think about power? Without looking. Sorry. I'm talking about like work over distance. So it has to do with you have the distance that your tip is traveling and how much energy it's creating at the side of the tip. Okay. So the total amount you could calculate maybe at the end of the case is how much power was used but it's not something we, or is being used in a certain period of time. Right, right. So you would define a couple of things that we'll define. You said stroke. I heard stroke. And then I heard you say power and energy. And that's exactly what we're doing on the machine. So when you guys program the power, remember our Faco needles move in two different ways. There's longitudinal, which moves in a coaxial fashion with the handpiece. And then there's non-longitudinal. On the Alcon machine, they call it torsional. And that's because the tip moves, instead of moving this way, it can also move this way. Okay. So that's a non-longitudinal stroke length. But this is the traditional way that we've talked about stroke length, this moving back and forth, back and forth. Now the AMO machine moves in an ellipse fashion. So instead of moving just this way, it actually goes like this and more of an ellipse. Okay. But the infinity that you're using at the VA, you can program each of those independently. Longitudinal as well as non-longitudinal or torsional. Okay. Now, if you had a straight tip on the Alcon machine, what do you think would there be any advantage of doing a non-longitudinal stroke? So straight tip on the needle. So you can move longitudinally this way. But would it make any sense to go this way? It's a straight tip, right? So that's why if you guys look at the tips, we traditionally use some kind of bent tip when we're using the Alcon machine. Why? With that tip bent like this, now you get more motion for that non-longitudinal action. Okay? Instead of a straight tip, which would just do this and just kind of bury a hole. Right? It's not going to be as helpful. Okay. So when we're actually programming the power, we're actually programming how much of the stroke length we want to use. Okay. Okay, Tina, your side. I should just keep going on the most guys. What do you think? Followability. Okay. So before I put up the definition stuff, what do you guys tell me? What do you think about followability? So... Why is it important? How would you define it? So I was less sure about this one and we were less sure a little bit about followability. But thinking that it was most likely like the draw of your piece to the tip and sort of that movement and how important that was. So the draw, we just talked about the draw, the attraction to the tip. What's that? What actually controls that feature? Aspiration. Aspiration flow rate. So the slower your aspiration flow rate, it's kind of what we call slow motion FACO, kind of beginner FACO. We don't want you guys to use a lot of aspiration flow rate. We want things to move slowly to the tip so you don't... So you have time to react. So in case the iris or the capsule or some other structure comes to your tip, you have time to come off the pedal. So how would we get pieces to our tip fast, really fast? What would we do to the aspiration flow rate? Increase it. So if you look, when you go to these FACO courses at Oscars and you go to these breakfast meetings, and you watch people showing their settings, they'll show off and say, oh, I use an aspiration flow rate of 60. That's impressive because it happens very fast, right? If you're an experienced surgeon and you know what to expect, yeah, you can probably get away with operating an aspiration flow rate of 40, 50, 60. Okay? And you guys will get there. You guys will at least get to 40. Most of us have a 40 on our settings, but it's fast and that's what attracts pieces to the tip. So now that we've discussed that, what is actual followability, though? So you've already talked about attracted pieces to the tip. That's good. So then keeping them there? Keeping them there. Right. So would it make sense if I'm FACO-ing a piece and all of a sudden it just goes bing, bing, bing? Would that be helpful? No. It would be so inefficient and you guys would drive us and that's because you'd be going towards the bag, you'd be going towards the cornea, towards the angle, trying to get those pieces out, right? So chatter is a problem. We don't want chatter, so we talk about trying to optimize our settings so we don't get a lot of chatter during surgery or follow-up. We want to have good followability and the opposite of followability, which I already defined was kind of chatter, pieces kind of pinging off and going away from your tip. So it's ability of the FACO tip to attract and hold the piece at its tip. Okay? Now it's also impacted by something that we talked about, aspiration flow rate, right? So you have to have enough aspiration flow rate to keep pieces at the tip or to continue to bring pieces to your tip, okay? And the FACO stroke pattern is important. So this is why, part of the reason why non-longitude will cave into fashion, right? Because with this, can you imagine you're pushing those pieces away every time you're kind of pushing them away, right? So if you did this motion, you'd probably have a better chance of keeping pieces having better followability by not constantly pinging those pieces away from your tip. Okay? All right. So Rob, your side. Talk about chatter. Talk about chatter, okay? Okay, what would you guys, what's duty cycle? Oh yeah, we talked about duty cycle. Talk about duty cycle. So duty cycle is the amount of time that the FACO is on when you're doing a certain setting. Yup. So those of you that have done micro pulse with me, that's the same concept. We're basically cutting the FACO power into packets so it's not constantly on. Now what would be the advantage of lowering your duty cycle? We talked about this in M&M this year, this past year. Those of you that were at the M&M, M&M that I presented, I think it was maybe two M&M's ago. Talked about a womb burn. Less FACO energy. Less FACO energy, right? So that would be important. So let's go duty cycle, pretty much everything we talked about. Duty cycle is on or off. You can control how often you want it on or off. Now on the machine, how do we do that? We do that through a couple of different settings, that you guys are going to hear about, right? Continuous. That means what? FACO is on all the time. As soon as you're in position three, it stays on all the time. How about pulse? What would pulse be? Off. Now how about those packets of energy when they're on, off, on, off? In pulse, is that equal or not? They're equal. So the time on and the time off is going to be consistent no matter how deep you are in position three, okay? Now how about the opposite of pulse? Not really the opposite of pulse. What's the other last setting that you can use to change your duty cycle? Burst. So what happens in burst? That's right, that's right. So did you hear that? So the deeper you are in position three, which is your FACO setting, that duty cycle becomes closer and closer together, right? Energy packets are going to come closer and closer together, okay? All right, good. You got your side? Okay, take a stab. That's just when the piece of lens comes and includes or covers the FACO. Okay, so yes, 50% correct. It's not just lens material. It's anything. Iris, capsule, vitreous, discolastic, anything that occludes the tip will cause occlusion. Make sense? Now you guys always think about it as lens material because that's what we're trying to do, but it happens all the time. We talked about wound burn, okay? One of the issues that we had with wound burn, on my case that we presented M&M, was that there was already occlusion before I had any lens material at the tip, right? How do you know that the machine is occluded? Those of you guys who have done FACO, what's your cue that you're occluded? If you have it programmed, you'll hear a bell, ding, ding, ding. That means your tip is occluded. What's the other way? Nothing's coming to the tip. Nothing's coming to the tip, right? So it's basically just almost like stagnant water. There's no currents moving. Nothing's coming to the tip, okay? What's another one? A little bit more easy that your technician's going to notice. You're not necessarily going to turn over and look. It's on the screen. It's on the screen. It says occlusion. Ding, ding, ding. You'll see a red thing. I'm looking at it. You guys aren't, hopefully, okay? But occlusion, those are the three ways you can tell. Intuitively, inside the eye, it's stagnant. Number two, the bell goes off. Number three, there's a red blinking light that shows occlusion during the FACO, okay? Yeah, created by obstruction. We already talked about that. And then let's go back. Okay, so Rob, on your side. I wasn't so sure about was load. Load. But load is maybe like the actual material you're working with the whole time? Yeah, sure. That's correct. Pretty basic. So that's why we want to chop pieces, right? Chopping gives you smaller fragments to work with, smaller loads to work with. It's easier for the machine to actually emulsify a smaller load than a big load. Now, what are options when we would want to actually impale into a big load? Yeah, or when would we want to actually? We want to pull a piece out out of the bag and be able to work within a safe space in the AC rather than in the bag. Okay, and then, or if we want to chop it, right? So we want to go and actually grab a decent size load, right? Because it wouldn't make sense for you to grab a small load and pull it out of the bag and then chop it again? Not really, because it's already a small load. You just want to get that piece out of the bag and then safely emulsify it. So the time is when we want a large load. We're typically doing a chopping maneuver. We're trying to hold a piece. We're trying to bring a piece out of the bag. Okay? But eventually you're wanting to work with smaller loads. You don't want to work with a large load because that's going to require more energy. Okay? All right, Tina, your side. Nice time. This being the time from occlusion or aspiration, I wish when power is increasing until suddenly you'll lose that occlusion and reach search, but I think my time is before that search. So you mentioned a couple of things. You mentioned aspiration flow rate. So rise time is very dependent on aspiration flow rate. Okay? So this is straight out of your book. Okay? I think you guys might have gotten this question. Do you guys recognize that diagram? Did that ever show up on your test at all? And the last, those of you that have taken it a couple of times? Last year? No. So if you look at the graph, okay? Rise, you got time on the x-axis and then you've got vacuum on the y-axis. That's the critical piece. And now if you look at each of those lines, they're all different colors to represent different aspiration flow rates that you have programmed. So look at what happens with the blue line. This is what we would consider kind of a more advanced aspiration flow rate. It's fast, 40 cc's per minute. Look at what happens to your vacuum. What happens? It's very rapid. Like, less than one second, you're already maxed out at 400. Okay? Now, what's something a little bit more? Let's go to the far right. A very slow aspiration flow rate. Okay? 10, that's very slow. I don't even think you guys want to operate that slow. It is slow, like butter slow. Like watching paint dry kind of slow. Okay? This is not a good setting, but it's to illustrate to you look how long it would take for you to actually develop enough vacuum to hold on to a piece and chop it. Four seconds. It doesn't seem like a long time, but that's a long time in FACO standards, okay? So this would not be an appropriate setting for you to use to do a chopping maneuver, because you'd have to wait forever for the vacuum to rise. Now, is there a moment when you would want to use maybe 10, 15 where you wouldn't want the vacuum too high? Last piece. Last piece, maybe, yes. Or the, what, cortex, maybe? You wouldn't want it to go that fast, or epinucleus is what I meant, not cortex, sorry. This is something that I want you guys to kind of vary in your mind about why this is so important rise time. So on the machine, we can actually program the rise time to go up exponentially. So we don't do it a lot, but if you look at the infinity machine, there's something that's called dynamic rise time. It's a little tiny box that you can touch and you can go into minus steps or you can go into plus steps, okay? And all it really is, is it's basically either speeding up the aspiration flow rate, okay? The acceleration time, or decreasing it, okay? Depending on what step you're in. But most of the time I would say at most of our settings it's programmed at zero. We don't really want to manipulate that. We actually want to manipulate the aspiration flow rate itself rather than trying to, you know, look at the machine and it says aspiration flow rate 40, but we reduce the dynamic rise time by minus four. It just doesn't make sense. It's just better for you to intuitively look at the machine, decrease your aspiration flow rate if you don't want the vacuum to rise. 2,000. Is the aspiration flow rate not, does that control all the panel? Is it just not enough? Like it doesn't... We'll go over that. It is. You can control it. You can either, we're going to talk about something called fixed panel, okay? Or surge and control. Fixed panel means that on the machine you type in 40, as soon as you go into position two you get 40 right away, okay? If you do surge and control that means as soon as you get into position two you start at zero or some other predetermined setting and then it will go up to your maximum the deeper you go into position two. So it is customizable for certain steps, okay? But you don't always want to have control or don't always need control of your aspiration flow rate, okay? Maybe you just want it to be 20 right from the get-go and keep it there and maintain it. Okay, do you know your side? Almost done. Surge. Oh. It was nicely in the surge. What's that? It's a little surge. Of surge, yeah. It's one of my research. So surge is, once you have this great big vacuum build as you're holding a piece, what... So you're occluded? Let's say you're occluded. And your vacuum's going up and you've got this sort of great build and then for whatever reason it's the worst that will break. So either you're loose like me and somehow you kind of let go or you break through a piece and all of the sudden you get this sort of rapid change in pressure because you've been building, building, building and then that breaks and there's some lag time between the kind of reaction of you to get off that vacuum and that piece breaking and that can cause your chamber to really dynamically change in size so rapidly shallowing which can bring a lot of problems. And so what we're doing with all these fancy fluidics and the new machines is essentially trying to account for that rapid change and prevent the chamber from shallowing or a big kind of rapid pressure change. And the new, the new machines actually are like the century and it's really, really nice. There are fluidic sensors in the handpiece and in the machine to try and anticipate that sort of break in pressure vacuum change and keep your, keep your chamber stable. There's also separate chamber stabilization software that's also trying to do the same but the biggest problem that that gives us in surgery is that that bag or other things can kind of immediately come right up into your FACO tip and you can get into big trouble with surge. Yes, so older surgeons who trained prior to FACO understood surge more intuitively because we had to do manual aspiration. Okay, so we used a syringe. Some of you have seen this device on outreach or once in a while we use it here. Simco, have you guys seen the Simco in action yet? No? Okay, the Simco is basically a cannula. It has irrigation, gravity-fed irrigation and it has vacuum or aspiration created by a syringe that's attached to your tubing. And all I'm doing is I'm pulling with my thumb and I'm pulling to create that that aspiration flow rate, occluding and then the vacuum will start to rise. But if you're too aggressive with moving that plunger, like really hard to pulling on it, all of a sudden you slurp up that piece and you're still pulling back on the syringe, on the plunger, what happens is the chamber will just completely shallow up. Okay, it's because you're pulling so hard creating that vacuum that suddenly as soon as you break through and you're no longer occluded, it just dumps the entire into your chamber into your tip because you're pulling so hard on the syringe. This is what we're trying to avoid in surgery. Now, what are some clues to surge in surgery? Those of you guys have done FACO. Maybe you can give everyone a little bit of flavor about what you're looking for when you're in surgery that may suggest that there's more surge. Showering on the chamber. Showering on the chamber. Instability, right? The bag is coming up and maybe flopping a little bit. The red reflex can change. Pupil winking, have you guys seen that? Pupil will just wink like this. If there's a lot of surge propensity, not necessarily bad surge. But you'll see the pupil wink. You'll see the chamber become unstable. The bag kind of just pulsates back and forth. Every time you clear your vacuum, every time you break your occlusion, everything's just starting to come shallower. Now, a little bit of surge is okay as long as it's manageable. But if you've got a significant amount of surge, that's where it gets dangerous and that's where we're going to have issues with popping the capsule. So, let's see. Peace came off. I was under occlusion and then I'm still aspirating, right? I'm still in position two and three and boom, chamber dumps. And that's what happens during surge and that's what you're trying to avoid. So on the new machine, there's actually a pressurized infusion. The centurion doesn't have a hanging bag anymore. You guys may notice that if we still have the infinity by the time you do Faco, you'll notice it's different. In the bag, again, we rise the pole up, but when you're here at the Moran where we only have centurions, it actually goes into a container with two walls and the walls actually come together and squeeze the bag and that's why we use soft bags. When we're using the infinity, we're using glass bottles still, right? But here, we're using that soft plastic bag to kind of squeeze together to actually pressurize infusion inside the eye. Okay, Siroff. This is part of the Faco tip that is moving in the ultrasonic motion, too. That's great. I doubt you'll get a question on this, but it's just more about how Faco is working. There's an actual crystal there that converts electrical energy into mechanical energy. So electricity comes in, causes the crystal to vibrate, your tip will vibrate then. All right, Tina. A little more. A vacuum. So vacuum is important and the reason it's important is because we want to actually hold on to pieces during surgery and it's important because we also want to have good fallibility. If our vacuum is too low, pieces will tend to go away and we won't have good fallibility. Now, this is an important principle because we're going to talk about this a lot when you're in surgery but the vacuum... Now, this is in contrast to retina surgery, but the vacuum doesn't rise in Faco until you're occluded. Okay? So one of the classic things that we'll talk about is cortex removal. You guys tend to grab the cortex pieces and then push on the pedal, right? Hoping that it's going to be more efficient. But what you should think about first before you step deeper on the pedal is occluding the tip. Okay? You want to grab the cortex, almost stuff your mouth full, like just completely stuff your mouth full and occlude the tip then depress the pedal to build the vacuum up, okay? But you guys tend to do this and basically ramp up the vacuum before the tip is occluded and that should cause you alarm signs. That should make you shudder, okay? You don't want a lot of vacuum. That's not necessary. Those of you guys that have operated with me, you guys will complete all the cortex removal if you do it properly at about max 250 vacuum, right? The machine is set to 450 under my settings, but I'm trying to teach you guys a principle during surgery. If you hear... it gets really, really high and nothing's happening, right? That's a setup for surge, okay? Because suddenly if your occlusion is broken, you're going to grab the bag, those are the reasons why we don't try to ramp up the vacuum by stepping deeper in the pedal until we're occluded. So you actually want to grab the cortex. We'll teach you this kind of tornado technique, right? And the purpose of the tornado is that you can get more cortex inside the aspiration tip. If you just grab one clock hour, you can do that, but as Alan will show you in his videos, every time you grab one clock hour cortex and strip to the middle, you're creating a lot of stress and you grab two or three clock hours and you distribute that force over a larger area so it's a little bit gentler on the zonules, okay? But remember, vacuum doesn't change until you're occluded. I talk about this every year when I do this lecture in two years, big glass of water and I've got a marble down at the bottom and I'm going to ask you to take it out with a straw. How are you going to get that marble out of the bottom of the glass of water? Just using... Fill all the water out first and then you're down to the bottom and have the marble. No, that would be totally inefficient. You would take the straw, you'd go down and actually create a collusion first and then create a negative suction in your mouth and then take the marble out, right? That's why this is so important. We want you guys to occlude first then the vacuum, you have control over the vacuum and then we can get it to rise, okay? How does the machine control the same process of... No, so vacuum, as we showed you on that diagram with the three, vacuum rise time increases faster if we have a faster aspiration flow rate, right? You do control the vacuum setting in terms of your max parameter, right? But the vacuum doesn't actually go up until you get occlusion. So the vacuum is like only the negative pressure part of it? Yeah, it's that holding power, right? That's what we want. Remember, aspiration is just things coming to your tip, right? Water, it could be lens material, iris, capsule, it's just things coming to your tip. It's making that full circle, right? You've got irrigation coming in, now you've got to bring it to the tip, okay? And it's just that full cycle of irrigation, aspiration. But the actual holding power, like your regular vacuum, or anything else, okay, or that suction cup when you put it on to a solid surface, that holding power, that's the vacuum. Now, this is totally different in retina surgery. If you've ever watched the machine, those of you guys are on the retina service, I want you guys to look over at the machine when they're doing the retrectomy. Look what's happening to the vacuum number. It's actually increasing, and it's not necessarily occluded. And that's the beauty of a venturi system, okay? Is that you can control vacuum in the system independent of occlusion, okay? And that's why retina guys like it, okay? They don't want to have to go and chase vitreous at the retina level. Otherwise it might suck retina with you, right? They want to be able to just remove all the vitreous and do what they need to do and stay away from the retina, okay? So they want to have exquisite control of vacuum, and that's why the venturi pump does that. There's a few fake-home machines on the market that actually have peristaltic and venturi settings. And it's pretty amazing, I must tell you, because you can be... During cortex removal, you can be almost in the center of the eye and press on the pedal, and the cortex just comes right to your tip. It's a little freaky, okay? And you could be hovering up high in the AC, and you could have a piece way down the bag, and you could press on the pedal and that piece just goes right up to your tip, and it happens very quick, okay? And why? Because surgeons want to be quick. They want to get down with the case quick, and they may like to go in and out of peristaltic and venturi vacuum. But most of our machines are just peristaltic for fake-home, okay? Who goes next? Solve your side. A couple more. We could do stroke. Okay, so we talked about it a little bit when we talked about power, but it's just that distance that we're traveling, right? So the stroke is the entire distance, or whatever you set on your machine. This is something that we don't change, okay? You guys don't change the power stroke. I'm sorry, you don't change the stroke length at all. But what you do change is duty cycle, the time on, okay, and you change the power, okay? So when we have that hard, dense piece, it makes sense to use a longer stroke length to break up the pieces. You're creating more heat, more energy to break up those pieces, okay? All right, team out your side. Last one. So we didn't get to talking to venting, and I think you used some information about venting. I know it has to do with like the equalization. That's it, yep. Exactly. So errors introduced into the tubing, which equalizes pressure with the atmosphere to minimize surge, okay? The machine's taking care of this. You guys never have to worry about this. Just understand this with engineers or programming to machine, okay? In order to try, it's one more thing to prevent surge, okay? Surge is probably by far the way that we think we talk about the most, because that's where we have complications. Okay, Srav, just a few things. We kind of... You have too much shadow in your frequency. You don't move back and forth through each stroke. Somewhere between 27,000 and 60,000 hertz, okay? Our hip hurts cycles per second. Okay. And then inflow. I'll just kind of go through these quickly. We already talked about this. Irrigation flow going into the eye. Nothing special, okay? And then load we talked about. And then I think there's chatter. We also talked about this is important, though. So lens fragments are repelled because we don't want chatter. It makes it less efficient. And then you've got pieces down in the angle and the sulcus and the bag, and they're not staying with good fall ability at your tip. Okay? So this is what happens during chatter. Needle moves, boom, pieces go away. Okay? We don't want that chatter during surgery. Okay, now look at your handout. Just the last 10 minutes here. And I gave you two sheets to look at. So go home and play with and write down what you would want for settings. You can go and study everybody else's settings. What I'm showing you on the first page is what my settings are, okay? And let's go through those because I want you guys to look at some themes, okay? Let's say you were given a faker machine on outreach and you had to program it and your handy trusty technician representative is no longer there with you. What are you going to do? You're going to have to figure this out. Everyone's going to look to you as a surgeon. If you're going to do this, you guys have to do this on your own. So let's look at the first one, sculpting. And sculpting what we're doing is we're just starting the case. We're just kind of gently removing that soft, fluffy stuff. Or maybe we're creating our trench, right? So when we're sculpting a piece, just like an ice sculptor would do, do we actually want to have a lot of vacuum? No. So look at the vacuum column and notice what you see there. 80. Now the diagram is lines that are there for a reason. When you see a straight line, that means you're getting 80 all the time once you're occluded, okay? So the straight line, that's also referred to as panel or fixed control, right? You're not changing the amount of vacuum that occurs. You just want it to be constant as soon as you occlude, right? So that's what the straight line means. That's surgeon control, okay? And that means the deeper you step into that position, the more of that setting you're going to get. So notice that the vacuum is 80 and then the aspiration flow rate is also, is it fixed or is it surgeon control? Fixed. It's fixed. Why? You know, you're not trying to attract pieces to your tip and sculpt. You're actually using the tip and actually moving it around and shaving, right? There's no reason to stay in the middle and get a piece to come to your tip, right? So if you wanted to think about this, you could have made this 20 and it wouldn't have changed anything, but the ratio is important and it's basically 1 to 4, right? So aspiration flow rate 20 and then times 4 you get 80 for your vacuum, okay? Now, the IVH that's infusion bottle height not as important now with the centurion but when you're at the VA we're going to say go up on the bottle height down, okay? So these are some general settings of the bottle height. Now, the bottle height is also very important because it's dependent on where the patient's eye level is, okay? If the patient, if you were operating on the floor sitting Indian style, okay, when your bottle height was at 90 on the machine, you'd have a massive amount of fluid coming into the eye versus if you had it in a normal position. Does that make sense? So the infusion pressure that system is dependent on the eye level, the patient relative to the bottle height on the machine, okay? So most of the time the bed height doesn't move a lot. I mean it does move a little bit depending on how tall you are and if you can get your legs underneath but for the most part it doesn't change a lot so that's why we're changing the gravity pole and moving it up and down if we want more infusion. If we're losing our chamber, if things are getting shallow that's one of the things we can do What's your favorite conversion between bottle height and IOP? You know, I haven't looked at it I don't know the conversion but typically I will tell you on the Centurion when they first set it up for me they were setting up an IOP infusion pressure of 70 which retina guys do a lot that's what they operate a lot. In my personal opinion it's too high, okay? And there's a phenomenon that's been described a lot and that's basically this intraoperative malignant glaucoma or BSS misdirection and what happens is when you're pressurizing all that fluid into the eye it's got to go somewhere, right? Either you're aspirating it out but if you're not aspirating that fluid's going trans-onular hydrating the vitreous causing a lot of posterior pressure so Borsmel, you can have I think he won the video last year at Asper's if you haven't seen it yet, it's great he'll show pieces, lens fragments sitting in the high-loid, anterior high-loid and why does that happen? Because of that pressurized infusion, right? It's too high and it's basically causing that fluid and little tiny lens fragments to go and sit behind and you may think, oh, I'm going to go and grab those pieces when I'm polishing and you think, oh no, maybe those are just floaters but in some cases it's actually lens material that's actually sitting in the anterior high-loid because it's gone trans-onular because of this problem with the new infusion pressure bottle heights or pressurized infusion systems personally, I operate at 40 I think that's plenty of pressure I have a lot of glaucoma patients I don't want them to live at 70 during the case even though we're coming in and out of the eye but I tend to operate at a 40 IOP on the centurion which is probably around 90 of infusion bottle heights there is a translation there when you see the centurion, you can either see IOP or you can see centimeters to kind of give you that QO I used to operate at 90 so this is the pressure I want to operate on but in general I think the infusion pressure is too much on the centurion ok, let's go down, CHOP so what do you notice about CHOP now you've got infusion bottle height we've increased that the longitudinal FACO I'm only using longitudinal FACO and the reason I like to only use longitudinal FACO in the CHOP mode is that I want you guys to bury into the tip into the lens piece and occlude it so that the vacuum will rise so I don't necessarily want you guys to be super efficient and basically make a big cavity and then suddenly lose your occlusion I want you to jackhammer eeee vacuum goes up and just eeee you'll hear that high pitch noise meaning the occlusion is on so your vacuum will then rise proportionally and look what happens under vacuum or is it surgeon control under vacuum for CHOP fixed, because what I want you to do is as soon as you capitate into that piece and you get occlusion I don't want you to have to step deeper in the pedal and try to hold it I want you to basically for the machine to top out at 400 and then for you to relax bring the piece to the center and then do your chopping so that's why I personally like to have fixed vacuum for the CHOP mode that's the difference when you're with me if I have you operate in somebody's settings where it's not fixed what you have to do is then impale into the piece and then you actually have to step deep into position 3 just to hold the piece there and sometimes too much is going on you're thinking how am I going to CHOP this how am I going to bring it out of the bag it's one less thing for you guys to have to worry about once you're occluded so how have you felt it? have you noticed that? as soon as it's on fixed panel control the vacuum goes right up to 400 so you're not going to have to step deeper to hold it it's already going to occur as long as you're occluded now aspiration flow rate I have it on surgeon control it's a non-zero start it starts at 10 and then it goes up to 40 which means this is the attraction force again if that piece isn't coming quickly to your tip you can step deeper into position 2 control the speed of the aspiration flow rate and then bring those pieces quicker to your tip alright now let's go to quadrant mode and what do you notice about the vacuum in quadrant mode it's fixed or linear surgeon control and the reason for that is that once you've already chopped up the pieces you're just hanging out in the center of the eye I want you to be able to control how fast you emulsify the piece in that fall ability if you don't need a ton of vacuum then that allows you to just modulate okay, I'm going to go ahead and step deeper create more vacuum or let's say you want to chop a piece but you're in quadrant mode so you can step deeper into position 3 and then do another chop if you need to but I want you guys to be fully in control of how fast and how efficient the emulsification works and that's why you see vacuum and aspiration flow rate have that diagonal and it's under surgeon control okay now I have something under vacuum for everybody setting and that's the last chip vacuum SRAM is probably the only one that I've operated so far that's used it but what you're doing is you're trying to minimize the surge that happens on the last chip I wouldn't say all cases of bad breakage are due to the last chip but many are I pulled last year seniors and I would say 50% of the PCRs that we had last year were due to the last chip and everything else is just that one last chip right? this whole freak right there, bag hits your tip boom, bag breaks and it happens so quickly in my experience taking the vacuum threshold and putting it to 200 doesn't reduce the efficiency all it does is it helps to maintain that chamber because now you don't have that 400 of negative suction as soon as the occlusion breaks the maneuver of taking the vacuum down to 200 is now our last chip setting so when you guys are in that in that position if you feel like things are moving too fast and that bag is really dynamic the iris is winking you should go ahead and engage the last chip setting it's entitled flip at the VA okay? you'll go in the chop, quad and then we have one more setting called flip it's the same power it's using the same ultrasound energy but the vacuum has been toned down to 200 so you will not be even if you occlude the tip you will not be able to exceed 200 under the last chip setting and I think that helps to protect you guys and keep things a little bit slower compared to epinuclease it's also safer to use torsional power in that setting is it more efficient? this is my personal bias torsional is excellent it's really good it's so good that if you get close to the capsule and just graze it going like this you will cut the bag versus if you go in like this with longitudinal you can sometimes be lucky you'll grab the bag and you'll let go quickly and you will not have broken the capsule and that's because longitudinal fagal is not as efficient as cutting you may go and actually suck the capsule and then you let go no breakage it's very efficient with the torsional it's very good at cutting the bag so personally when I have you guys on epinuclease I don't have any torsional power it's all along with your tool of power but it's a lot lower we're only using 40% duty cycle only 10 pulses it's pretty slow in control but epinuclease is soft stuff you don't need the efficiency of torsional fagal to remove soft epinuclease stuff alright but in your mind you can basically remember 1 to 10 for your chop and your quadrant your vacuum and your aspiration flow rates are going to be roughly 1 to 10 in that ratio if you had to program the machine from scratch everything else just gets toned down epinuclease is less vacuum polish these are all very straight forward settings you don't control any power obviously all you're doing is controlling the aspiration flow rate the purpose is to have those on surgeon control so you can control how fast that vacuum is moving during the cortex removal okay second page is for you guys it's a blank sheet you guys can go and customize your own settings learn from other surgeons is what they're putting in but that's just for you for the future whenever you guys start to kind of customize your settings it's just a blank sheet for you alright question