 It's my great pleasure to go ahead and introduce our next speaker our chairman dr. Randy Olson and we'll go ahead and and maybe dr. Olson can do some of his introductory comments that he didn't have a chance to give while we're working on getting his lecture up so I apologize I had an interview I had to do it was one of those things that they said you got a you got to take care of at least one part in here so I missed my good friend Steve fell in opining on than what he does so well on Steve it's a pleasure to have you here and I've Steve and I have worked together and a upo for many many years and he continues in that role in fact we traded each other when we were presidents and a person who's an amazing administrator and an inventor and a great neuropomologist it's just an honor to have him here so yeah we get it on the screen or all right well I'll just do some twisting and turning them and let's see that's my advancement right there all right good good all right so what I like first of all let me just talk a little bit about why we have this today and what's ongoing here as you know this was a meeting that essentially we call it clinical faculty day and we certainly have good people we have some people that are here today they're going to do that but my thought is is that we have so many great researchers here we've got so many people on the clinical side are doing great clinical research and what we often have lacking is communication between both sides all here people say that so-and-so got an award and they'll say I never had heard anything that they've done before I don't know what's ongoing what's happening and that's a mistake and there is a general thought that oftentimes that things have become so specialized in area that there is no ability to communicate and I think often what's really happening is there's a dearth of interest or desire to communicate and that therefore becomes a de facto truism that we lose the ability to understand each other and so we want to have this a fairly even mix we want people to sit down and talk and I do know in some cases in some of these areas it may be a little difficult to understand the core concept but I think that if we all try to make sure we're speaking in the lingo that is more every day and we work hard at this I think this can become a very important event so that we can understand a bit of the breadth of what's happening here because I have that opportunity where I am to see and understand that and feel it and I'm so proud of all that's going on here but you know we miss opportunities because oftentimes I'll hear about something and I'll say well well you know I see Alan Cranwell Alan Cranwell is working in that area or so and so on glaucoma well I didn't know that well we're not going to get the collaborations that are necessary until people do and understand so this is our first and I like to see this expand and move forward and hopefully everybody will have a great time so I'm going to talk about really a fairly simple easy way moving forward and something that's actually been incredibly productive I want to start out first of all as we talk about this that I've got a lot of colleagues here that are extremely important I got Jeff Petty sitting up here he's been very involved in this moving forward frankly Jeff Petty and Bill Barlow I'm assuming and the plan is they're going to be taken over the leadership and all of this as we move forward Brian Zog's been very involved Brian Stagg had a lot of other residents Ashley is now kind of taking over the leadership as we move this on the resident side but but it's it's an example of how it can be a lot of fun and it can be very straightforward and frankly I think it's been the most important body of knowledge that's occurred in this area certainly that I'm aware of during my career so cataract surgery what's the past been of cataract surgery it's been a bunch of talking heads talking at each other each of them saying that this is better than that with no scientific basis whatsoever for what they're saying and if you're in the know like Nick is and Alan is and I am we know who's being paid by a or B or C or D and we can all essentially guess what their opinion is going to be before they even say it and that's been the state of the art of this field here for a very long period of time so what happened is Griffin here Griffin Jardine did he make he's one of our newer faculty members Griffin I'm giving you a shout out and he's not here he's at seeing kids he's a pediatric office he was a medical student and I told him how frustrated I was we've been working on a project and I said we need something that will sit down and tell us what works and what doesn't work in regards to cataract surgery and we talked about it a lot and I've got to give him a hundred percent credit because I'm a pretty good idea guy but those of you know me I don't have a lot of time and so he just wouldn't give up and I'd say well let's try this or let's try that and he came up with what is affectionately known as the Cubanator and it's really really high tech so I'm this pointing this doesn't have to be something you don't need to get a million dollar piece of equipment so what exactly is the Cubanator let's make sure good yeah there's a pointer so the idea is is that we need to determine relatively equal size chunks of cataract material relatively equal size density of cataract material and then by having that and looking at it we can determine two very important facts for fragment removal so this is the fragment removal part of it and that is how long does it take to remove a certain size piece of material and how often does it bounce off the tip what we called chatter two very important clinical questions does that answer the whole issue of and I get that in reviews all the time no no but the perfects the enemy to the good right you start out with something and we'll talk about where we're moving now in regards to this but at least for the first time we can start debunking and objectively looking and seeing what makes sense in this field and what does not so again you take a nucleus and we'll start out with the human cataracts with Jeff Tabin also shout out to Jeff was able to get us a bunch of you know hard fresh human nuclei you cut them into slices then you cut them again and then you cut them again and you throw out the smaller ones and you essentially get a two millimeter on a side cube now are those exactly two mothers they're not exactly are they exactly the same hardness no but by mixing them up together and randomly selecting them we can do 20 controlled experiments have enough power to be able to analyze and compare we're going to talk about some of this work that's happened testing is simple you just bring them up in your regular little testing chamber we all have bring it to the tip how long is it there before it's assumed time it if it bounces off you stop the timer and then put it on again and every time it bounces off it's a chatter about this is not again this is I mean it's amazing that no that none of this had ever been done before but this is the overall scenario moving forward so the power of this as you can see on these this work that was done with human nuclei is that we can sit down now and we could do the equivalent of thousands of surgeries in a controlled fashion something you cannot do clinically too many variables there's no there's no really we've eliminated everything other than the variable that we're looking at and we're doing it and this first big study that we had that came out by de mel I think the most powerful thing that we found out that we didn't realize is how important parameters were a lot of people always wanted to talk about what was the mode of fecal or ultrasound they were using and if you look at the efficiency in regards to time here is an example we could go from 31 seconds to 5 seconds just based on the parameters so if you don't know what your parameters are I can show you anything is better than anything else and you have to know what are optimal parameters before you compare it so this was our first landmark study and I think very powerful and open for us opened our eyes as well how critical parameters we spent a lot of time trying to optimize those and understand it the next step was in as much surgery as Jeff does he's so busy these days he probably almost could have supplied it for us but it's not that easy getting human nuclei and from the third world and so we needed to get a another model and so this particular group that we put together as we we were working on a pig model pig lenses we get plenty of that were equivalent to these human lenses so what do we do here same thing here's your Cubanator putting it in place we sucked them in balance all solution for 24 hours this is the end result of lots of different experiments to find what would work and then after formal and soak different times will talk about that then you cut it and you mix it and then you compare it what do we find out well the density test it was really how much enter how much did it take to crush it to half of its overall size and you can see well two hours looks like it's pretty close to these human nuclei that Jeff Tabin was bringing over from Africa so that's a pretty encouraging right so what happens when we do some clinical comparisons between those well here's looking at left the ellipse FX and we use the best parameters from the original study and here's looking at Ozil IP and you can see two hours and I don't know why we didn't have it we had a we actually have a three hour in both of these and they were quite a bit higher and here's the human wow those are really comparable right so looking pretty promising at this particular point and now we now have that and it's essentially a two hour soak if you want to get harder you can do a three hour soak if you want to do software you can do a one hour soak it is enough variability and a lot of it depends upon the age of the pig nuclei that whatever we run now we have to run with the same batch and that's the only difficult part about this because when we're ready to have a big run I know the team puts it together sometimes we're talking 15 16 hours but and and you want to try to get it short a period of time we've actually put a lot of data and information about this so one of the questions that's been out there for a long period of time is with ultra pulse is what's the best on time and off time I've heard people argue about this and also argue about out as a matter long pulses is good now continuous is better etc we can answer those questions right now so we're gonna go fairly rapidly through some of this so here's a paper by Kirk came in 2014 and it's rare that it gets this clean and it turns out that there's a very clean improvement going down to six millisecond that makes sense the more energy you have the more overall effect you're gonna have but look at this once you get to six it flattens out completely you're putting more energy and you're getting any more efficiency whatsoever I'd love to have time to discuss why the physics of this is because I think we understand this fairly well but look that tells you that you're when you sit this you want six milliseconds is the time that should be on what about the off time a lot of people have said 12 10 you know you know everybody has their own opinion about this and moving forward surprisingly clean again I don't know what it was but six milliseconds and then after this rather than be flat it actually got worse statistically worse so that six milliseconds on six milliseconds off that's your sweet spot in that as you continue off you could as much as a double your inefficiency or your overall time it takes net to remove material for the same time that you have it sitting up on your tip clinically important information available for the first time what about Kalman tip here's one that just shows me I actually some of the some of the people here were back when I gave my the worst lecture I love that the worst lecture when I first told Susan that I was asked to give the worst lecture she said well you can do better than that you know Jan Verst is the triple I see has one of their big lectures and I talked about this we have been taught by Charlie Kelman from time immemorial that the most way to do efficient way to do fake emulsification is a bent tip called the kelman tip nobody has questioned that wisdom nobody's question that wisdom so we said okay we've got the technology now is that the best way as certainly at least for fragment removal to have that angle tip and the answer in regards to that for efficiency is no what actually doubles the time it takes to remove a tip and it doubles the chatter I submit that's four times worse we've taken that on somebody's word with no one challenging it for 35 years so if if those of us involved in clinical care aren't willing to try to look at and see and question what's happening all kinds of errors crop up and nobody knows about it and another one I'll just talk about from the worst lecture I love that anyway was a condition known as athletes heart those of you are there can't answer so I Lilliana's Liliana here she can't Nick you can't who here has heard of athletes heart so Bob Sinski was diagnosed with athletes heart in 1940 athletes heart was a standing pulse less than 50 only happened to athletes and the treatment was that you have no exercise no climb any stairs no activity whatsoever and if you do that your pulse will come back up towards supposed to be and that's what Bob Sinski was told he had to do Teddy Roosevelt was diagnosed with athletes heart when he was Harvard I love this his doctor this is back in the 1880s said sir if you quit don't quit all you're running around and you're climbing up trees it was weird for his day he used to go out and run for an hour and a half or two hours just for the fun nobody did that back then nobody did that and he had a standing pulse rate parent like 42 he says you'll be dead before you turn 30 and Teddy Roosevelt famously said sir I'd rather die and quit all my running around well he was doing the right thing what's an athlete's heart stop super healthy person so what finally changed that diagnosis went forever it was World War two we had all these elite troops paratroopers etc they were diagnosing them one after another with athletes heart when some somebody finally said we can't do this we're eliminating our entire cadre of people and elite troops maybe it's okay and it was really not World War two until finally this diagnosis died like we may have more athlete hearts out there than we realize tip diameter again big discussion and going on real short 0.9 seems to be the sweet spot we've run into some smaller size tips that do quite well with interesting design and that's that's then then you're looking at other features but as far as just a core regular round trip going on that the combination of wanting to make sure that you totally seal to get vacuum but you you're losing efficiency by the size of the tube you're trying to ram it down 20 gauge seems to be the magic place micro poles what are the best fluidic parameters associated with a lot of interesting work if you look at low flow that it turns out it doesn't make any sense to go higher than 300 millimeters of mercury because you don't get anything look at that why is it because it turns out that if your flow is only 20 milliliters a minute you can't generate more than 300 millimeters of mercury you can't pull enough to generate additional vacuum above that well a lot of people didn't know that you can see that it does make a difference when you start getting up at higher flow because you can't get that full vacuum realize you put in place again new information nice paper venturi we know a lot about venturi a lot of people say it's better is it really what is it what happens with it indeed as you can see that 20 milliliters per minute it consistently is two to three times better than peristaltic as far as its overall efficiency same time though is that if you look at 20 at this is looking at transverse as far as chatter venturi dramatically better you start getting up at 50 milliliters per minute it makes a difference at lower vacuums but time you get the high vacuum they were statistically the same but here's the big one how much flow are you getting with venture remember venturi is vacuum based you don't control how much flow it's inherent inside the system well turns out your flow rate when your vacuum base is sitting up here at 70 to 100 milliliters per minute that's a lot that's why a lot of people have been leery about how fast things want so there's a price you pay turns out from a physical standpoint that if you were to take peristaltic flow to the same level you should have the same overall effect between the two so you can gauge and judge but no question that for most of what we do venturi is more efficient but there's always a price here's one I love Steve Dewey made a proposition that if you round the edge of the tip and you touch the capsule are you more likely to break it and so this is the do this is the regular tip the idea is if you touch the capsule with ultrasound you're gonna break and tear it if you round the tip and you touch it you will not now that's something that he talked about for a long period of time wasn't good facts and association with it so we started with some fresh human lenses we took a look at it and wow looks like maybe there is something to this turns out that you've got one shot of a fresh human lens once you break the capsule you can't do it anymore but at least for the number we had this is number of taps to break it took four versus 47 that was statistically significant it's about a tenfold difference so again we said we need to come up with some way that we can duplicate these results without having to go through a human lens every time that's not that easy to do solution Saran wrap over a coffee can high tech and it works we've got several good papers in association with that we'll go on this is a very busy slide and I don't get all the details but the key thing I want to do show you here is you look at it from sharp and dull it was significantly better every step of the way these comparisons were highly significant Steve Dewey was right that it indeed is very protective of the capsule often five to tenfold less likely to break it but is there a price to pay as a person is an old physics major I'm telling you that physics is a two-edged sword you rarely get something for nothing there's almost always a price you're going to pay and so again very protective as mentioned we published that American Journal of Ophthalmology we've now recently done a similar one came out in a Joe in 2015 and we showed that in comparison to a linear approach same energy that transfers and torsional increase the caps that are breakage rate I think if you touch the caps you move them from side to side that's easier to shear something than going straight in and out and it was not a huge difference but it was statistically significant so what's the price well we can decide and look at that and you can see that if you're looking overall say at an Ozil type approach a torsional that that we about doubled the time so when you're talking about pure torsional yes the Dewey tip is going to cut your efficiency roughly in half and that was statistically significant but if you're looking at a transversal it wasn't those numbers are not only not statistically different P a point nine I mean those are the same what about micro pulse ultrasound those are the same now when we first submitted this particular article in regards to this using a radius tip versus non-radius tip the questions that came back to us on this is well you're just looking at a really really soft nuclei here is this really going to hold on something it's harder these things probably don't work on harder and so what we said fine you know we can make harder we can make them as hard as you want how long they're going to soak in formalin so we repeated it there you are a double the time again significant significant in regards torsional transversal the same so for those you don't know torsional is the motion that's used most in the country and the tip wagged side-to-side and subtends an arc so it's a shaving motion essentially transversal the tip subsumes an oblipsoid so there's some back and forth a lot of it is motion but if you look at where the tip is over a period of sale probably you know hundred hundred milliseconds your net of that whole thing is there's there's an ellipsoid think of a football shape overall whereas linear it's very simple it's just going straightforward and back in each of this case and so you can see that those are exactly the same and then and so we repeated it completely with the hard nucleus even when we had and again I just want to give some general concepts that we're not going to go a lot of detail I don't have enough time because the physics of this is a little complicated but it's important clinically to have this information so where are we going now in regards to this we've got new lines of inquiry that we know are important to do we need to look at sculpting and we've got an overall concept and ideas we don't have it yet fully on the drawing board the idea is a very controlled fashion where you could stick a treated nucleus and you have a fixed pressure and how far does it move based upon the exact parameters and the exact amount of time so that we can see what's more efficient than the other we're very interested in seeing how femtosecond laser and what it does and compare the modalities to see which is the better pattern and which is not and then we're also very interested in now looking at something which is what does ultrasound due to the Cornel endothelium can we measure that accurately can we find out what works and what does not work so there's a lot of things that we have to take for granted because we can't know everything about everything but if we take everything for granted we're never going to advance we have to be prepared to question we often assume that these are very complicated difficult concepts try to get your hands around nothing that I talked about here is nearly as high tech as a lot of our research people are going to talk about and yet clinically it's been extremely important so just remember that opinions are often just that their opinions and that the best thing to do is to try to figure out what the facts are and the more fact based we are the more we're talking in regards to what's going to work whether what we think might work and I'll also point out that clinical research like this is frankly a lot of fun I'm like a little kid when we get a new project what did we find out we've had some results where I just I don't have a clue what that is and it's been fun trying to figure it out thank you very much there's some time I think for a few questions questions for dr. Olson well just a comment I think this is an area that's just screaming for for research because there are so many opinions that are put out as dogma and we really need to step back and look at it and my old professor Daniel Patrick Moynihan had a saying in terms of politics and he said you're entitled to your own opinions but you're not entitled to your own facts and I think this this really fits into this setting because there's a lot of people giving their opinions but they're really not based on sound scientific method and they're not based on a way where you're comparing apples to apples instead of apples to oranges and so this research is so important because we really do need to look at the dogma that's out there and see if some of the claims that are made are truly legitimate or not and I'm happy to see that that some of the younger faculty and some of the residents are continuing to do this important research because as a journal editor I'm having a heck of a time when I get papers that state something from one group because you can't even get unbiased reviewers so it's either they're in company a or other company a and so you have difficulty trying to get unbiased opinions but unbiased reviews but just unbiased literature in general and that's why I think these studies are so important thank you I've got a question griffin did walk in so I just want to make griffin where are you griffin griffin Jardine let's all give him a hand I gave you credit for starting this whole line as a medical student he persevered to figure out and bring the Cubanator to life and that's been a host of different paper ever since then griffin great to see and have you here well thank you dr Olson