 Alright, so hi everyone, Austin Akatsuka, outgoing cornea fellow, and I just have a presentation to share before we move on to Dr. Crandall's presentation. So I'm going to share my screen right here. So this presentation is called an update in the acute management of Stephen Johnson syndrome, and I'm going to talk about a modified surgical technique. So I realized that this is a topic that has been talked about before in the past. However, there are a few things that I kind of learned about based on some papers and then trying them out myself in terms of the surgical management of acute Stephen Johnson syndrome. So I'm going to show some pictures of that and some cases that I at least attempted to do. I got a lot of my input from Dr. Lin, who's kind of our go-to for Stephen's Johnson's here. I have no conflicts of interest or disclosures. So very briefly, Stephen's Johnson syndrome, a very severe dermatologic emergency characterized by bull's lesions of the mucosal tissues and skin tissues. T-cell mediated, causing apoptosis of skin keratinocytes. Usually drug incited, often sulfa-based drugs, although mycobacterium pneumonia has also been implicated and other infectious causes. It's a very severe disease, mortality rate of up to 40%, no matter what we do. In terms of the treatment goals, it's really just removing the offending agent if it's identified, life support as well. Using high-dose steroids is controversial in terms of whether or not it actually affects mortality, but it's very commonly done. There's also some studies that have shown that IVIG and systemic cyclosporine have had some benefits as well. And then in terms of the ophthalmic sequela of SGS, these can be very, very severe as many of us know and have dealt with. In terms of the acute findings, pretty severe conjunctivitis, patients can present with pretty severe period of conjunctivitis, even congenitival pseudomembranes, which we'll see an example of shortly. And then persistent corneal defects or epithelial defects as well. Very rarely, they can also present with uveitis, at least it's been described. In terms of the chronic downstream effects, this is where patients can really be severely affected. So patients can have severe symblephron, which can be irreversible. Forensal destruction requiring forensil reconstructions, limbostem cell failure, which can basically cause irreversible scarring of the cornea and need for corneal transplants and severe corneal ulcerations, eyelid keratinization, recurrent trichiasis and permanent dry eye can also occur basically due to destruction of the mybomian gland orifices, goblet cells and lacrimal ducts. So very, very severe disease, similar to severe burn patients and OCP patients as well. It's interesting because a lot of these patients, they may have some severe dermatologic findings, but often they will complain about their eye symptoms the most if they're able to, if they're not intubated, that is. This is just an example of some of the scarring that can occur. So here you can see a near total pacification and neobascularization of the cornea. And this happens to be caused by a patient who had SJS. And this required either a type I capril in the top right, or this is something called a type II capril which involves the eyelids as well for more severe cases of scarring. And so the medical management of Ocular Stevens-Johnson syndrome basically involves topical steroids, cyclosporine and or antibiotics for prophylaxis and basically very, very aggressive lubrication around the clock. We typically recommend preservative free forms of drops in all cases just to help preserve the ocular surface as much as possible. And then daily foreign steel sweeps to remove pseudomembranes, this is something that was classically taught in the past. It is relatively controversial about whether or not this can actually help prevent severe scarring, but frequently residents will find themselves doing that as well. And so this is a table that was published in 2016 in ophthalmology, and basically what it kind of shows is a grading criteria that was sort of made basically separating mild-moderate severe and very severe disease. And the main thing that's important here is it sort of helps to tell us when surgical intervention with amniotic membrane transplantation is indicated. That's in the severe and very severe forms. The other thing to note is that the severe and very severe forms in this table are separated by basically any sort of corneal staining or defect and or more severe eyelid margin staining or involvement. And this is another grading table that was made as well, but the difference with this table is this table basically separates severe and very severe categories based on whether or not their pseudomembranes present, which was notably absent in the previous table. But I found this to be quite helpful because truthfully when you're examining these patients, it can be very difficult because they're very sensitive, they're often in a lot of pain, and you're usually examining them at the bedside in the hospital. And so, you know, you have limited exam instruments as well. And so one of the things that's kind of easiest to identify, which basically will tell you, hey, this is a severe disease, we need to do amniotic membrane transplantation is whether or not there's pseudomembranes. And again, we'll show some examples of that. So this is a nice little paper that was done at Loyola by Dr. Lin and authors. But essentially, just really quickly, I just want to point out that they looked at quite a number of eyes that had SJS and were treated. And basically they found that early intervention with amniotic membrane resulted in a better outcome compared to those that were only medically managed. And so this talk is mainly going to focus on the surgical management of SJS. And so just quickly, I'm going to talk about the traditional technique that I was kind of first introduced to when I got here and that we've been doing for the better part of the year and has been done previously as well and is described in a couple of papers. But this is basically how we have been doing it. So basically, we take a sheet of amniotic membrane here and typically we take a five by five centimeter sheet. And what we do is we cut that in half and we use each half for each eyelid. So basically you have a five by two and a half centimeter sheet of amniotic membrane that you're using for each eyelid. Here you can kind of see us dealing with the amniotic membrane and as many of you know who have dealt with this before, it's very sticky material and can be sort of difficult to work with. And so marking it with a marker is a very important step to kind of know where your boundaries are. But essentially what we're doing is first we overlay this anterior to the lash line. We do remove the lashes beforehand. And then we typically secure it to the skin with running sutures, usually nylon. And after that, we are basically, after that has been secured, we basically secure the other end deep into the fornix with a proline suture, which you can kind of see here and here as well. And so it can be a little bit difficult in terms of the view. We use a muscle hook to try to give us the best view possible. And we try to go as deep into the fornix as we can and pass that proline suture and it's then secured with bolsters to the eyelid skin. And basically that will effectively cover up the eyelid margin and mybalmine glands with the amniotic membrane and then as much of the tarsal congenitiva as possible as well. And so this is sort of what it looks like when we're finished with it. We place a prokera at the very end, which is a amniotic membrane fused to a symblepharone ring. And so the limitations of this procedure, so this typically requires the OR. The reason being is because often, again, these patients are very sensitive. So they often need to be sedated. We do need a controlled setting because we work with very small sutures that can be very difficult to work with at the bedside, especially if these patients are in an ICU setting. So they have a lot of lines and vents and things like that around the head of the bed so it can be very, very difficult at bedside. It can be fairly time consuming when you're doing each of the lids individually and relatively costly, especially if you're using the operating room. One thing I also want to note is that, excuse me, sometimes we have to use general anesthesia for these patients because of their sensitivity. And the problem is that these patients, when it comes to intubation, they have SJS. So their mucosal tissues are typically emaciated. And so often dermatology will ask us, hey, please try to do anything possible not to intubate these patients, which unfortunately, sometimes we can, sometimes we can't. So I wanted to talk about a modified technique that I became aware of after reading some papers and that I became particularly interested in that may kind of help us a little bit in terms of making this procedure a little bit more efficient in some ways. So basically this was a paper out of Mass Eye and Ear in 2016, I believe. And basically it describes a suture-less way to place these amniotic membranes with cyanolacrylate glue for acute Stevens-Johnson syndrome. And so essentially what is done and described here is taking a larger piece of amniotic membrane and it's basically a five by 10 piece. And this is overlaid, over-antired to the eyelids, just like we did previously, but it's glued with cyanolacrylate glue, typically the same ones that we use for corneal gluing, actually. And basically it is glued first to the upper and then to the lower. And then essentially that amniotic membrane, because it's so large, it's just able to be overlaid over all the fournesses and the cornea and the entire eye itself. And then after that a symlephron ring, which is made, is then placed over the amniotic membrane to hold it there. So first off, this is a picture just describing, pictures describing how to make that symlephron ring. This is just made with IV tubing, that butterfly tubing and cyanolacrylate glue. And then the, and this is just showing how it's placed. And so this was just a case series of four patients that they described this technique in, but they had pretty good follow-up over a year. But it's just interesting, they all had actually relatively good visual acuity outcomes, but it's interesting to note that they all had irregular eyelid margins, eyelid margin characterization and congenital stagarring, regardless of whether the procedure was done. And this is common and true to in other studies as well. And this was another paper in 2015, another case series in 2015, describing a similar technique where basically they made their own symlephron ring. They used sutures, but they tacked it down instead of glue to enter to the lash line and then stuck in the symlephron ring. Notably though, they did state that temporal symlephron did occur. So they did five patients with the traditional technique and then four patients with this technique. And they noted that symlephron occurred in more patients that they did the traditional technique in than with this technique. And it's, and they speculate that it's possible because the amniotic membrane covers up more of the congenital tissues, which makes sense. So basically that series, although it's just a couple of patients seem to kind of favor the large amniotic membrane technique, at least in terms of outcomes. So these are my attempts at a, at some form of a modified technique. And this one, so I had a 14 month old patient with SGS caused by back term use for a leg abscess. And, and this was definitely the youngest patient that I've ever seen with SGS and or done amniotic transplant membrane transplant for I did look in the literature and SGS has been reported in cases as young as three months old. And there's in case as case series describing ophthalmic or ocular involvement in cases as young as six months old, but none that really described amniotic membrane transplant for a child this young for sure. So, I knew that I had to kind of modify it anyway because I wasn't sure that a regular pro caro would fit in the patient's eye. So, so this is what she looked like beforehand and so this, this staining here. So you can see the entire, what looks like the entire Tarsacon's entire was staining but then when it's rubbed off with a cotton tip applicator. We see that it easily is removed without any bleeding and so these are pseudo membranes. And so I quickly identified that this is some pretty severe disease and you can see the island margin staining as well. And this. So, basically, I had to make a modified some left run ring for her because the pro caro would not fit. And so what I did is I just took Ivy tubing and I didn't really think to use glue and basically I just use some of the proline extra proline suture and I just tied it together. And as you can see it kind of makes a teardrop shape here which you think oh you know wouldn't be wouldn't fit as well in the patient's eye. However, because of the dimensions of the can't die and the eye, which are basically, you know wider horizontally than vertically, it actually fit really well, just behind both of her can't die and so here you can kind of see that teardrop shape here. And this is the section where kind of the knot was actually rotated through the Ivy tubing. And she was actually very comfortable with it and she ended up leaving it in for about two and a half weeks before I removed it. Well, so this is what it looked like just after the procedure I did do the traditional technique with the running suture. And, and so this patient. This is after we removed this and left run ring and the amniotic membrane, and she did have some Tarsal congenitival staining. I'm sorry scarring, which it was pretty much inevitable that she was going to have some but she did not have any some front formation. And here you can see that this is staining but it's it's really kind of just pulling the areas of scarring but the island margin. It's kind of hard to see her was actually okay and been following her and she's actually been doing seems to be doing okay so she might actually do fine. So this is a nine year old with SGS caused by some sort of antibiotic and so I don't have any pictures for this but that's probably best because this didn't really work out so well, but basically I use the glue technique, but I don't have the five by 10. I did not have the five by 10 amniotic membrane so we just use the five by five cut in half and I did up the bedside and I glued it to his eyelids but I didn't have anything to tack down the other end with so it's kind of loose and hanging there and he basically pulled it off within two nights or something like that so that didn't work out so well but that patient actually did okay because he was actually very borderline moderate to your disease. This was a 70 year old with SGS caused by Bactrim and I did the glue technique with her but we did it in the OR and let's see is this going to play oh so this just kind of depict some of the pseudo membranes that were that I found and essentially what I did was I glued it to the skin and then I placed a few interrupted sutures just to kind of hold it down because I wasn't sure the glue was going to hold and I'm sorry this has some appointment on it so it looks sort of more greasy looking than it really did right after the OR but it actually held very well and this is post-op I think this is post-op week one or two and it's still holding and so essentially she actually did fine with it and it held for at least a week and a half to maybe even two weeks before I eventually took it all down and she's been doing okay follow-up has not been great because of COVID lately so haven't seen her more recently. She did have some some left rub but that was already there even prior to the procedure and then lastly case for this is a 32 year old with SJS and she was on multiple medications so we're not sure which one caused it but anyway I also did the glue technique with interrupted sutures on her I also did her case in the OR and she had to be under general anesthesia because she was very very very sensitive and she was as you can see she's pretty severe case and again I'm sorry I put the ointment on before but you can see here that the glue actually dries down pretty well I did have the interrupt that's there but essentially she had some scar and escher so I really wanted to make sure that that was holding on but there's one area here where it was a little more normal on its skin and even after we put it on I was thinking we really don't need the sutures because it actually held really well we could tell on the OR and she's been doing okay with it I think recently it just started coming off so I just removed it actually yesterday she may need an additional grafting as well because of her disease so essentially the only thing that's been holding me back from doing the full 5x10 technique is truly the cost the after looking into it the 5x10 pieces of amniotic membrane costs twice over twice as much as the 5x5s do it does save you the use of a prokera so basically if you look at all four eyelids doing the calculations the cost of the traditional technique is a little more than $5,000 and then the modified technique would be about $10,000 for two 5x10 pieces because those sheets are so expensive it doesn't include the cost of the glue sutures IV tubing but I'm kind of looked into some of that and that's negligible but by doing the modified technique you maybe can avoid going to the OR and of course we know the OR costs a lot more so that was initially why I was actually interested in the technique was I was hoping it would save a lot of money but I didn't realize the amniotic membrane was going to be so expensive so anyway in terms of the main points we all know SGS is a devastating disease that affects ocular tissues and can be devastating despite any sort of intervention but early intervention with amniotic membrane should be considered with any SGS patient with moderate severe ocular involvement because it improves outcomes and the advantages of modified glue technique could include perhaps time and efficiency if it's truly that quick to be doing at the bedside a customizable procedure because you can create that blepharone ring as big or small as you want it to be avoidance of the OR as we know is very important possible improved outcomes although this hasn't been completely proven and then possible costs depending on what the OR costs are and these are my references and that's it so thank you for your attention any questions Austin thank you so much this Jeff Petty I just wanted to say thank you for the presentation one of the questions that that I had is how would you design a study if you were going to kind of take this and try and you know try and really assess whether this this would be something that would work long term and then the second question is how frequently could could you anticipate avoiding the operating room during the financial costs there are a lot of benefits for keeping these patients out of the OR not you know not not even just the intubation but other potential benefits. Yeah sure so that's a great question and it's funny because there's something Dr Lynn and I were just talking about last night. First off I think in terms of designing a study you need volume of patients right and initially the number of SGS cases that we were having was not quite that high, but this past year between Maddie and I we've had almost 10 cases that we've done amniotic membrane floor. So if I can combine that with happen to be staying next year then I think we'll have enough patients for more than just a series. But the other thing is so so I would probably look at it like visual acuity. And then most of it would probably be descriptive in terms of eyelid margin how the eyelid margin looks. It's hard. The other thing in terms of follow up at least for patients here is it's been difficult because a lot of these patients are from out of town or out of state so it's a little bit hard for me to kind of track these patients. So it would be difficult in this setting to do anything more than a case series but if I was say able and had the time to you know write up a protocol or anything like that then I just I probably compare retrospectively to the cases that we've done before and then going forward prospectively try to do this technique on a number of patients. The other thing and then your other question. Oh, in terms of saving our time things like that. I think first I would have to see how successful this would I haven't had a successful case at the bedside yet. But just by kind of trying out this technique even in the or with the glue. I kind of know and I'm pretty confident that hey this holds pretty well for the most part most normal skin. So, I'm a little bit more confident about trying it out at the bedside. So once I can kind of try one case out at the bedside and see, you know, how that goes most of it is just whether it holds there. It's going to kind of stick there, then I would be confident with trying more additional cases. I think one thing that we could try is, you know, if you're still taking patients to the or you could try doing the glue technique in the or without without any of the interrupted sutures because I know you put some interrupted sutures and last couple cases. So maybe trying it without see if it holds and if those hold maybe we could, you know, go to the bedside fully. Anything else. Let's see. So, I have, let's see, I want to stop share here. So I have the pleasure of introducing Dr. Alan Crandall who needs no further introduction as we all know him. And I will get to know him I'm sure a lot more next year. I'm going to be presenting two video cases, or two videos, one of which is his presentation that recently won the award at Ascarus, which was sort of held online this year but it was an award for his video on the die matrix. And that, and the other is on some they go cataract efficiency type of settings. So, we're going to switch over to him. There you go. Okay. Right now. Yes. Okay. All right, good. So I got a pull up the video. Everyone can see your screen you just pick. Okay, perfect. So really, really to two quick presentations. This is a new. Essentially, it's a replacement in a pupil and larger, and it has some advantages to it. You'll recognize it isn't I did the surgeries obviously but Lily on it did all the work and Nick did all the beautiful talking so we'll just let that run. Not running. Okay. The expand manufactured by die matrix is a night and all people expand her with the 6.7 millimeter internal aperture created from a laser welded wire. It is a smooth and flexible ring with eight points of contact with the iris, which has recently been developed deal with small pupils intraoperatively. Dr. Charles Williamson from Baton Rouge, Louisiana has recently proposed the use of this device for technique called iridocapsular capture. This could be useful in many situations, such as in cases with missing or weak zonials intraoperative floppy iris syndrome, pseudo exfoliation, among others. This could be particularly useful in sewer exfoliation, as patients are at higher risk of interoperative issues related to zoning or weakness and poor pupillary dilation. Studies showed that the CCC can withstand loads of approximately 0.4 Newtons before Terry. As the expand is smooth, thin and flexible with low compression forces, it should not carry significant risk to the Rex's edge. The expand was initially evaluated with four cadaver eyes prepared as per the Miyake apple technique. It is easy to place the four feet of the expand that cradle and expand the iris from an anterior view with retro illumination. When the capsule Rex's was performed, two feet of the device were manipulated to capture the capsule Rex's edge in two opposite areas, which was enough to stabilize the bag and zonials during the subsequent procedures. Note how strong the capsule Rex's edge is, and no tears could be produced in the points of contact with the expand. The application of the entire surgery from the posterior view shows the stability of the capsular bag, zonium complex, during all of the steps of the fake-mossification procedure, and up to the IOL implantation. We also evaluated the applicability of this device during IOL exploitation by using a pseudo-fake cadaver eye implanted with a single-piece hydrophobic acrylic lens. We evaluated the anterior capsule of the eye shows signs of fibrosis, and there's a mild amount of summering's ring formation within the capsule or bag. The expand was placed in a way to fully expand the pupil and also to capture the capsule Rex's edge over two opposite areas. This stabilized the capsule or bags zonium complex during such steps as visco dissection of the capsule or Rex's edge, irrigation aspiration of summering's ring material, as well as mobilization of the haptics of the IOL out of the equatorial region. We have been using the pre-loaded expand in surgical cases at the Moran Eye Center. This is a case of an 80-year-old man with seurox filiation exhibiting weak zonials. The device was used for irrital capsular capture. Stability of the capsule or bag was obtained, allowing for pre-chopping, fake emulsification, and bimanual irrigation aspiration. The evacuation of the capsule or bag, the captured edges of the pupil and the capsule Rex's by the four feet and shoulders of the device can be well appreciated. The CTR was implanted, followed by in-the-bag IOL fixation. The expand was disengaged with a hook and placed in front of the iris, then engaged by the ejector for removal from the eye. This is a case of a 58-year-old man with a severe degree of zonular instability. Surgery in the contralateral eye of this patient had required use of multiple iris and capsular hooks. The expand was used in this case, especially for capsular capture. As some instability of the bag was still observed, iris hooks were used to secure the expand in place. Subsequent surgical steps could be performed without any issues. There was significantly more stability in this case and less faco time in comparison with the contralateral eye. After insertion of a CTR and in-the-bag IOL fixation, the device was manually removed with a forceps through the main incision. In summary, owing to its design and material characteristics, the use of this new pupil expander to perform iridocapsular capture is a promising technique in cases with zonular instability. Now, I know we've had this available at the Moran, of course, and at the Institute as well, but most of the use I get here, so any questions that anybody has, it's pretty easy to see. Trying to work with them to get a little bit better injector and removal because sometimes that's a bit of a drag, but it's actually been quite helpful in many cases. Just like anything, though, there is technique and there's technique involved, so what I would recommend is using it on cases where you just want pupil dilation to start with and then try to figure out the size of rexus that you can do it in. In the Miyake views, we use very small rexus, that's why we only use two, used it in two spots, but because it gets the smaller the rexus, the harder it is to get the two side ones in. Any questions on that? Hey, Alan, two quick questions. So one of the challenges with the nightingale ring is in the removal, it tends to fold on itself. You could just comment on that for anyone using it. And then second, I like this technique, but one of the things I worry about is, as we know when you remove a Mal-Yugan ring, you displace the iris significantly. And as we've captured the capsule bag as well, as we're removing this ring, even though it is nightingale, it's flexible, it does iatrogenically potentially cause more damage to the zonules. So can you comment on how that might be removed without causing more damage to weak zonules? Well, in all these, in most of these cases, I'm not obviously not trying to get the below the iris into the capsule bag. So most of the time, it's really not much of an issue. It's so flexible. I mean, you can use a second instrument to hold the opposite sides and then bring them out and up. There are a couple of different ways to do that. And I'm working on a video so that we have different ways for different types of eyes. And also, sometimes you will get it, it doesn't work for everything. And we had one case where it didn't work and I had to take it out. And actually, this wasn't as loose as the guy that we got it in. And then we had to do an extra cap. So just like everything, there's always a learning phase, but this is actually one of the easier ones. The nice thing is, is that it's from a standpoint of a surgeon, it doesn't, you know, the thing with the malugan, which is, I love Boris's procedure, but it has more volume to it. And it sometimes, as you know, it's hard to get other devices in. You can do it. But this, this, even if you decided you didn't want to use it in the back, and you prefer to use other, you know, like MST hooks or whatever, cool hooks, you still could do that comfortably. So you can, you can make sure that it's above the Rex's easily. It's just visualization. And it kind of, you can counter traction, counter, put some counter forces on it. So when you, when you remove one of the sides, you don't just dislocate the lens itself. Like in that gentleman that I had, I kept those, those, those extra iris hooks to hold them so that there was no way it could be good drop. Once I pop the bag. Thank you, Alan. We don't see any other questions that have come up on the chat. If anyone would like to make additional questions, please post them there. We can unmute you and you can move on to your next video. Okay. This is an ongoing technique and I do want to, let me start with this one too. Okay, now I want to get rid of this. And everybody in this audience should know a little bit about that because I'm going to put up my references to start with. And because I'm not sure how many folks understand how much work is done in our laboratory here downstairs and this is almost always done with the residents Randy has spearheaded this for, I'd have to say 20 years. So these are the references that we that I think everybody in this center should have read prior to starting some faco, at least during this, the third and fourth year that they're working on. These things are they are it's a laboratory study, but it's very, they're very, very informative. And you're in this a lot. So I think you want to, you know, I just would recommend everybody take a look at all these references. They're easy to get to. We have them all over the place. So we'll start that way. Now let me open up my talk. Let's get up to where we started. And I'll cut out a quick a few things because I know we have everybody has to get to work. So, and for the last about two years, or yeah, about two years I've been doing was what I'm calling a fake or efficiency It's a combined study with myself in, in Utah, obviously, Takahoshi in Japan, and we have some, some of our international folks that have also been working a little bit on this. Unfortunately, for me, there are no conflicts during this talk so let's just play it up. Okay, so what is fake or efficiency, you can define it in any way you want, but basically what we're measuring is just looking at every maneuver during the entire procedure, try to analyze each step to look for ways to improve, use technique alterations, instruments, machine parameters, changes that we can improve our outcomes. You know, if you look at the United States, for example, the, I think last year the average visual acuity for most cases was 2050, you know, maybe black, you know, glaring down to 2200, but there are rocks, and they're all different and it's important to really understand that. So you really need to get to the point where you look at an eye, you realize that it's slightly different from the one you just did, and you need to look at your parameters, your instruments, and need to really understand what you're doing. Now, a good example of that is this, when we first started doing FACO 40 years ago for me, somewhere in that range, we were doing radial aspirations, and we taught radial aspirations. And then when you look at what just happened to the zonules, when you're radially aspirating as opposed to when you do a tangential, so we're now teaching tangential. But how do we know, when did we find all this stuff out? Well, it was laboratory work done right here with Lilliana and Takashi and Brazil. I showed beautiful videos of showing that. So just a quick, let's go to the next. So, where is it? All right, it's not responding. Let's, okay, here we go. So, from a technique standpoint, what we want to do is not strip to the center. We strip radially as much as we can. And what I found is that it's significantly more, it's way more useful and quick. And they're also the, I used to teach grabbing to do your rexess. Now I do almost always and two or three maneuvers, and just pulling to the center, rather than that. And again, there you're looking at the vector forces, so you can analyze where your rexess, I have much more control doing that. And the risk of tearing out is much less because you have total control, and you're essentially doing 360 little maneuvers, so that you have absolutely good control. And then we'll just do one more, just to see the radial, I mean, the tangential aspiration, it's way more efficient. And we're working on some equipment that might make it even a lot simpler. So we'll just, we'll see, I know everybody's seen this, but it's always good to really look and realize what you're doing. Now the last piece, you could do that radially because there's no, there's nothing holding it on. So everything that we do, except for really impedes, and in super soft cataracts is a dividing conflict. The classic dividing conflict, which we start with is, of course, a sculpting procedure, and during the sculpting procedure, we want to use, as you know, we want to use lots of power and no occlusion, and we have different tips that we can use as well. I mean, you could actually have two handpieces, one with a sculpting tip, and one with a more effective vacuum tip, but we don't do that. There's vertical chopping and horizontal chopping, but all of these, again, are really dividing harker techniques. The issue is, how do you divide it into pieces? Classic way is the sculpt, vertical chopping, horizontal chopping are both important. Pre-chopping is what I use most of the time, but we're limited because the pre-choppers are instruments and they have different thicknesses. And so we've worked out with the companies, we now have very thin ones to help when you do a femtose laser and kind of break it up. And for this study, we have two new very sharp things. They look sort of dangerous when you look at them from the side, but if you realize where you're putting them, you can easily see right here. One crack through. This is a very sharp one. And of course, we have the my loop and there are some other variations on dividing harker techniques. So just for the first and second year residents, when you look at the variable parameters every single time, and this we go through every year, I asked their new fellows what their IOP aspiration flow side, flow aspiration flow and ultrasound are, and it's almost 100% say, well, it's just whatever is its first thing on the machine. And I think you really have to understand what you're, what you're telling the FACO tip, aspiration tip to do. And if you just look at these three things, there are 27 different combinations that you can do. If you want the IOP down low, you don't want the ultrasound, you may want the ultrasound power, you can leave that wherever you want, but you don't want high flow with a low IP. You have to look at the nucleus and figure out, okay, in this case, or if it's destable like in a PFC, you want the IOP at a certain range, but you need to then change your aspiration flow and probably change your ultrasound power. And the other thing that we have is we have different instruments. We can, we're looking at new instruments combos so that we can decrease the amount of handing back and forth. We have, I have a new piece that has a marker plus the rex, so you get, you just put a rex on, turn it around, you don't have to get a new instrument, and you can do your rexes. The new Aukahoshi hydrode sector is, I think, far superior to the common, the flow is really much easier to control, and we have some new Aukahoshis and Aukahoshi cranial pre-choppers. So the thing is to evaluate settings to improve the outcomes and different levels of hardness. And we also have to remember we have lots of tip designs. Here's some of the newer instruments. You can see down here in the corner how sharp the tip of this one looks. It's hard to see on this small ring, but if you look at it, it's about the size of a fecotip. So we scare ourselves a little bit when we use instruments we're not used to. They can look dangerous because we're going into the nucleus, and they can be dangerous if you don't know where you are, what you're doing, but they're very, very effective. These have different parts. This part up here is sharp. This, and this, of course, the flat part is not. We have one with a very sharp tip to go in easily, and then it's one with a slightly duller tip. And also the ball INA, excuse me, makes it easy to rotate, especially sub-incisional, but it's a different angle. So you have to get used to putting these in and bringing these out, but it's a very effective way of doing this. The other thing we need is, if you look at power modulations, you have continuous, we have torsional, we have pulse, we have on and off with different powers. You know, if you hear the dinging and you're just using the standard stuff, what does that mean? I mean, you're kicking in a little longitudinal to free up the nucleus because you don't want it occluded. And that usually, we said it at 85%. So when it's 85% occluded, it'll start dinging. And that's telling you, okay, don't stop necessarily, but understand what's going on so you can change the power or reduce the amount of tissue that you're dealing with, or change your mode. You might want continuous, not torsional, because that way you can bury it. You might want pulse, which means you're telling the instrument, I don't want to be occluded at any point in time. So understanding all of those is really important. The next thing we have is, what tip design? You have straight, you have bent, you have burst helmets, and you have INA materials and tips all over the place. So there's a lot of things that go into understanding this thing. I'm just going to do a quick video. So run. And what I'm going to show is basically what we're doing in this procedure, measuring the pupae, the one make sure your wound is correct. So we're measuring, there's the Akahoshi pre-shopper, and it just really has a nice flow pattern to it. So it's really nice to use. And this is the really sharp one. You see how I'm just demonstrating that for the pre-shop. And it's just a slow motion. You get a very nice chop, you can rotate, and then get your second chop. I know we're running out of time, so I'm going to speed this up. And then we'll go to the FAKO, and you can start on any pattern you want. You want to off, you want to on, but you have to understand what each of these are. This is a reverse kelman. One of the studies from our laboratory said the .9 tip is the most efficient. And a .9 reverse kelman, in my hands, is the easiest to use for most of these cases. Now we've finished the case, we've finished that part. Now, the other thing about having the overlay, which is nice, is we can measure how much we use at each of these different steps. Let's see if I can find it. And there we go. So for the FAKO port, we used 27 CCs. Now, to power this efficiently, I need about 2,000 cases, probably to really tell, because there's so many different eyes, and we're a little more than one third to one half done. So then you proceed to the, you go to the INA. And this is the ball. It's a very nice, it's different, so every time you try something different, you have to play with it a little bit. This is the first time I used it. You can see a little bit of how it works. You can curb it, you can twist, move. But it is a slightly different maneuver, and you can polish with it. They're coming out with a silicone one pretty soon for people that don't like this capability. And then we'll just move to the end here and polish, et cetera, et cetera. So we, now at the end of the INA, at the end of this case, I think we would use 629 CC, or 31 CCs of fluid. Another one, we don't need to show that. So each time, then we took it to Tanzania where we were doing much harder cataracts and trying to see is it as FAKO usable in these hard cases. Now this is a 1.9 reverse Kalman Akohoshi tip, and it's pretty efficient. That was a cataract that might have before done with an SICS. So what we're looking at is the usability. Since one of the things we want to do is teach FAKO, but safely, having pre-choppers and things like that gets rid of the sculpting maneuver. And that's where most people get into trouble, and then we can reverse. In other words, once they get used to that, then we can teach them how to do that. So in the end of what happened, we increased the FAKO compared to SICS, the first two trips by 15%, but it facilitated skills transfers. So we could have them pre-chop, and then they were a little bit easier to understand the depth. And once they got used to the FAKO handpiece, it really facilitates that. In the West, what I've noticed is about reduced FAKO time by about 20% reduced INA by 25, and reduced the number of cases, residents from average of 120 to 80. We're still working on that. And of course, it depends on the time that they see it. August a little bit more versus the end of the year type of stuff. So we're trying to look at that as well. I know we don't have a lot of time to look at videos. I'm happy to do that at any time, but I do want to use my daily mantra of it's all about physics. Everything we do, you have to understand the physics of it. And I really suggest that everybody get those articles, understand what the different machines will do, so that you can really think about how hard is your cataract. What should the procedure should I do in this case? What's the safest way to get done, and the most efficient way. So with that, well, it's not bad. Probably no time for questions, but I'd be happy to talk to anybody on that. Jeff, I'll turn it back to you. Thank you, Alan, we are looks like there are no questions. And yeah, it's all about. None. I think everyone would love to give you crap Alan, they'll just have to do that after. Okay, with that thank you everyone for coming Alan sincere thank you for your time and Austin as well extraordinary presentations and videos. Have a wonderful day everyone. Thanks.