 We're putting the final presentation up and everything's getting ready. I'll introduce Dr. Olson. Of course, before I introduce Dr. Olson, just to remind the residents and the fellows that there's a billing meeting right after this, so stay. And we're going to talk a little bit about documentation. And of course, Dr. Olson doesn't really need any kind of introduction. You all probably know him better than I do. But I will share one personal story. The first time I met Dr. Olson, I think it was on the day that I came for residency interviews. And I walk in and he's just totally sick, like just has this cold. And he's, you know, sneezing and just tear, you know, everything. And, but yet he's still cheerful and happy and excited to see us, or at least he seemed that way. And I remember thinking to myself, it would have been so easy for the chair to kind of blow off the resident interview at that time. But yet he still, you know, took the time to talk with us and made us feel welcome. And I remember thinking to myself, you know, this seems to be someone that is putting, you know, others' interests above his own. And you always, everyone talks about how the chair sets the tone for the entire department. And with all my attendings, I've seen that same, you know, kind of benevolent attitude towards others. And it's something I've really appreciated while here, you know, as a resident. And it's something I hope to carry on, you know, as I leave. So I think Dr. Olson for setting that tone here in our department. And as a topic today, if you put a little accent mark above the O on function, it's actually in your handout, understanding fake O function. It's a little bit of Spanish there for you. So let's turn the time over to Dr. Olson. So thanks for those kind comments. And it's interesting actually that it's also French. It's also Portuguese. And it's also Swedish, Norwegian, all of it coming from Latin originally. So we have many words on that. It's a pleasure. These are a series of vignettes. These are a lot of different projects that have been ongoing. And we've got people here in the room that have involved in some of these projects. But I thought it would be nice to just go through some of these over the last several years, many of which are now either in publication or accepted. And I do point out that I have no conflict of interest in regards to any of these talks that we're giving. So what works and why? You know, that's a big question. And I've got Nick Mamelis back here and others who've been around for a long time. And typically what happens when you're talking about cataract surgery is you get a bunch of talking heads. And a lot of them are allied with this company or the other. And I say, well, in my experience, this is better. In my experience, that is better. And one of the comments I used to love is that there is no post-occlusion surge whatsoever. The chamber is absolutely stable. And, you know, these things are just not possible physically. I mean, of course, there's some. The question is how much? What's the difference? So really, this is about eight years ago. And there's Dick McCool. We made a statement at a Hawaii meeting about heating and comparison with two machines. And I'm a physics major. And I said, that's physically impossible unless we've somehow obviated the laws of thermodynamics. That can't happen. And so it's just how can we understand this? And it's been trying to objectify all of these different things and see if we can come to some better conclusions about these different modalities and what they do. So this was the first one. Really set up by that meeting at Hawaii. I just said, you know, we got to figure out what's going on here. And I figured the culprit likely was 100% power, couldn't be consistent among the different machines. And so this is a great Britain son, Jason, who was involved. And some people remember Rajiv Kumar, who was here. And what we did to make a long story short, I think you dropped right down here, is we found out exactly what I expected was the case that percent power had no correlation between the machines. So if you set legacy, this would be in a balanced salt solution at 100%, it had the same overall power and heat output as sovereign at 43% as a millennium at 36% and infinity at 71%. So people comparing 50% percent power back and forth were comparing apples to oranges because they weren't the same. We've been among the same companies, they weren't the same. And then we were interested in what happened when you have a load because unless your resonance is getting started, it doesn't do much good to feco the aqueous. Usually you want to feco nuclear fragments, right? They're a little harder and that's what you're trying to get out. So we put a load. In this case, we went ahead and put away. And it turns out just the friction of being in a tight wound is the equivalent of about 175 gram weight hanging off the tip. So this is very real. And you can see that indeed they respond differently. Now, it turns out millennium and sovereign were about the same and on signature and Stellaris are still the same in regards to that. But you can see legacy is the outlier. And it turns out that they had different modalities of responding in regards to load. I don't think we understood that very well. It turns out that what happened in the legacy is it was called a stroke length protected power module. What does that mean? It's like a cruise control in your car. So if you have your foot pedaled a certain amount, it wants to control the actual excursion of the tip. So what happens with the cruise control? Well, if you sit at 50 miles an hour and you're going uphill, you hear the gas surge, right? You're maintaining that power. But when you go downhill, the gas comes off completely. It wants to keep you at 50 miles an hour. Whereas in this particular case, most of the other machines are like a gas pedal. If you hold your power, your gas at a certain level, you're going to go real slow uphill and fast downhill, but you control it with your foot pedal. So again, that was a big difference. Does that make a difference in regards to how you use it? Potentially efficiency, potentially wound burn. Those are all questions. And so each of these different projects resulted in a new desire to try to understand what this meant and what was ongoing. So we're going to move from there. That's going to jump forward here about four plus years. And we're going to talk about some of the facial power modalities and capsular breakage properties. These are two papers, the beginning and later on that came out in the American Journal of Ophthalmology. Joe Schmootz was the one. He presented a little of this a long time ago, but that was earlier in the project. And then Jay Meyer was the other one. And we were interested with these different modalities. If you contact the capsule, how likely are to rupture it? And is there a difference between different modalities if you touch the capsule? Obviously it's touching the capsule, most likely when you're going to break it. And does it make a difference? What kind of modality was there? So this is the power run. And the reason why I thought this was important to understand is that a lot of the talking heads at meetings were literally saying in regards to some of the newer horizontal things like Ozil, they were saying pedal to the metal, don't take it off because you can't get a wound burn. Absolutely protective. There's very little friction inside the wound because it's not a normal longitudinal. It's a wagging from side to side. And therefore you don't need to worry about wound burn. Well, was that the case or not? And you could easily show there's a lot less friction in the wound because you didn't have nearly the same amount of motion. But is that the only thing that was happening? And so what we discovered in regards to this is indeed the one thing that happens if you wag a tip, should be no surprise here, that's sitting stiffly inside of a needle, is you're going to get metal stress heating. This is the same thing you do when you take a paperclip and open it and close it real fast. If you feel on the bend after a while, it'll burn your fingers. It gets very hot. So here's our heat generation. Turns out that it's in the direction of the bend. And then you can see that it was actually hottest at the hub and coolest at the tip. Ellipse had more consistent heating all the way around. And so this tells us that the needle tip itself is not subtending an arc, but is actually subtending ellipsoid. It actually has some longitudinal movement as well. What does that mean in regards to efficiency and how it functions? We didn't know that. I can tell you that ellipse FX produces a lot more heat and is not going to be different from Ozil, so it makes sense. If you're going to add a lot more oomph to that needle, then you're more likely to get some additional heat generation. But now we showed there was a new heat source. It isn't just the friction now. We actually have a metal stress heat source. And when you're talking titanium, it's not going to take long for that to propagate on down the needle. So we raise the issue. Maybe this isn't completely safe. Maybe wound burns are a possibility here. And maybe you better rethink that concept that you can use all this ultrasound energy essentially freely without worrying about any possibility of burning the wound. So this kind of summarizes all of that different thing. Our suggestion is that at 100% power for extended runs with minimal chatter, which is a huge advantage of things like Ozil and ellipse, chatter goes way down. You can get these long runs because it's not bouncing off the tip that there'd be a possibility for wound burn. More about that later. So then we went on and did this study in regards to our likelihood of breaking the capsule. We started out with some lenses. And these were fresh human lenses. Sadly, once you tapped it and broke it, then you couldn't use it again. So we ran out of lenses relatively rapidly in this particular project. But we could show that there indeed were differences. So this would be 6-12. So 6 milliseconds on, 12 seconds off, milliseconds off. That would be something like hyperpulse or white star or ultra-pulse. All variations the same thing. We looked at Ozil, which you can see sitting here. Here's ellipse. And then ellipse sharp. One of the big things that we noticed with this is the Dewey radius tip was very protective. Indeed, not having a sharp edge rounding it, that indeed you could tap many more times it was much harder to break that capsule. Now the interesting sidebar of this is that without ultrasound, just with aspiration, we did not break the capsule. And this is just touching it now. I'm sure if you pushed on it, but if you just touch it and come up with ultrasound is where you could get that capsule to break. So we went to, with this human, so 100% power Ozil may be more likely to break the capsule Ultra-pulse more likely to be at low power and transfer ultrasound at high power because that's how they're going to be used. A radius tip is protective. And so we just said there's some things we're seeing here. And so they went, I thought it was very innovative about using saran wrap around a coffee can tightly put as a capsular substitute to see what's the likelihood you'd make a hole in the saran wrap as time went on. And so this would be percent breaks for 200 taps in under scope. You just touch it and come back and come back. And this was at, we don't have it here, but it was at high vacuum. Now these are peristaltic systems. So the question is how much vacuum you have if you're just touching it and whether you left it longer. But this is the information. So you could see if it's a 19-gauge sharp that it was more likely to break than a 20-gauge. Well, that makes sense from the laws of physics. The overall area of aspiration or power is going to be a square of the function of the size of the port. And 19 is bigger. So you're going to have more hold on that overall tip. And it turns out that, indeed, again, we found it was a dull radius tip that it really did cut down the likelihood of breaking. The other thing to find out, which is a study coming up soon, is does that also decrease your efficiency, though? Physics rarely gives something without taking away. It's always a double-edged sword. And that's something that we often forget about. You've got to think about what is that negative that potentially you're going to get in association with a positive. You can see if you drop the power, though, it's really fairly forgiving. Here's the lips at 100% power. And you can see that, again, we found the radius tip was very safe. Something interesting happens here, though. In both these situations, when you go from a 19 to 20, every time it is statistically significantly less likely to break with a 20, but it's significantly more likely to break with the OZL going from 19 to 20 with the intrepid cartridge. What's up about that? And that doesn't fit with our laws of thermodynamics. So gave us some time to think about that, about exactly what's going on. I hope I included that particular information here. Yeah, so there is another thing going on, and that is in trying to control post-occlusion surge. There are lots of different ways, and if we had a long lecture, I could go into the different ways we have of trying to control the fluid flow to minimize that occlusion break surge or collapse of the capsule. And one of them is to make very, very long, thin channels that the fluid has to go through, and that will dramatically cut down the velocity of that flow, which will cut down the surge. The problem in association with that, again, laws of physics is, is that your actual vacuum at the tip, even un-occluded, is much higher than I think people realize. And that's what this particular thing is here, un-occluded flow vacuum. So this is the amount of vacuum needed at the tip with these new cartridges in order to allow the fluid to flow. And you can see the intrepid, which does a very good job in controlling post-occlusion surge, with a 20-gauge tip of having extremely high vacuum. So the difference in vacuum here was enough to overcome the decreased size of the radius. And the vacuum itself, because the vacuum was much higher, even though the overall area size was smaller, was enough that it was more likely to break the overall tip, the overall capsule, or in this case, our substitute. So another thing that we know we have to look at. So I'm bouncing through these fairly rapidly, and we'll have time for questions later on. So we felt that it's clinically used, occluded with long, high-power ultrasound runs, that it's going to be highest wound burn for Ozil and I think likely ellipse FX. We haven't studied that in this detail, because it does produce similar amounts of heat. Transverse in general is clinically used, which means very high power. If you touch the capsule with a sharp tip, you're more likely to break it, because you don't use longitudinal ultrasound at those high levels. And the key thing here is that it does take ultrasound to touch the capsule to break it. If you're just aspirating and you touch it, as long as you don't put any pressure, they will not break. I think that's a critical lesson we learned from this. And in trying to control post-eclusion surge, what we're ending up with vacuum levels is high as venturi just to get the fluid to flow, even without occlusion. So in trying to answer more about wound burn, this particular thing that happens and briefly in regards to wound burn, it's actually a thermal contracture of collagen around the wound, and it's been shown to occur at 60 degrees centigrade, and it typically at that temperature takes about a second. Now the problem is, is that you don't have any way of knowing what the temperature is, and so you may feel you're perfectly safe and you're sitting at 58, 57, but you get over that little point and then obviously the burn occurs and it occurs very, very rapidly. So we didn't have much of any information other than a series, so the first paper we did was a relatively small survey here through Northwestern United States, and this paper in AGAO, we showed that it was, and we defined it as contracture or fold. So this would be significant wound burn, about 1 in 1,075 wound burns, and we were able to look at it in a little detail to find out what it meant in association with the burn, and it gave us a handle on more that we wanted to look at. But again, I just mentioned the 60 degree rule, it's a result of friction and metal stress, and obviously the other risky thing we do in regards to a very bad wound burn is that if we occlude the tip so we don't have the cooling of the fluid going through, then the rate, I didn't put that particular part of one of these papers, and the rate of increase of your temperature goes up anywhere from 3 to 10 fold. That makes sense, doesn't it? If you've got fluid flowing on something, it will take the heat off very, very rapidly, that's what you do when something is hot. You put it under water and let it run, it cools it off very fast, but if you've occluded the tip, you don't have that cooling influence, so the heat temperature is going to go to the OVD, we're going to talk about that, viscoelastic may be related, practice patterns, these are all issues that we thought needed some additional work and we need to understand it. Here's an example of a very bad wound burn, and Jorge Alio showed this to me and was interested in how this was possible. You can see it's so bad that actually the iris was burned and had to be removed, they had to do a corneal transplant. This is a year out and the patient was still only 20, 60. Here's the hooker on this. This wound burn happened from the time, because they had it on the video, from the time ultrasound was hit until the wound burn occurred was three seconds. That's not much margin for error, three seconds in a very bad wound burn, as you can see. So how is that possible? How can we explain that? So this is some of the in vitro work that we talked about and so we know it's aspiration block, time ultrasound is on, total energy use, so that's time per power level, and ultrasound in OVD. I thought I had that work concluded here. Here it is. So this is Jeremy Valentine, Michael Floyd, two medical students doing some work and we went ahead and had a nice project. I was suspicious that something funny has happened in OVD. We used to think it's just that you block flow. I said, this doesn't make sense. I said, I think viscoelastic may be exothermic. And so we measured the actual heat production. So this is occluded. So we knew that it's the same, and so we used one would be balanced salt solution occluded. And then how much heat was produced when you had viscoelastic occluded? And you can see it is exothermic and variably exothermic and quite exothermic across the spectrum. And it turns out that I've now figured out what this is and I'm talking to some engineers and association who know OVDs well. It's a resonance of disulfide bonds that exist. And this correlates exactly with the number of disulfide bonds that exist in the different viscoelastics. But who would know that if you did ultrasound inside of viscoe, for instance, that it's seven times more rapid heat buildup occluded than it is in balanced salt solution. So we thought that this also was something of potential importance in regards to that wound burn occurring. And another feeling about this is that if you're going to be using something like CHOP and you're not going to use as much ultrasound it would seem that your approach was probably protective. If you're going to be more parsimonious in ultrasound use, I mean it made sense that and there was a suggestion of that in that survey in the 2006 AJO. So this is the latest. This will be coming out in JCRS and we happen to have the editor, Nick Mamelis in here. So Nick, I'm not going to give all the facts here. I want you to know we're not going to give all of the good information coming out in that paper. Yeah, yeah I know. So what I do want to tell you in regards to this and we had some people who've been here scattered around the country that were involved in putting this together Sorensen and one of our medical students but we found that and we ended up with about a million surgeries and over 400 burns so nothing like this had ever occurred before and we found that the greatest correlate was with the surgical volume it was the inverse, the busier the surgeon the less likely the burn to be. So what does that mean exactly? What that means is I don't think you have to be a busy surgeon to avoid it, that if you're busy you tend to be parsimonious you've got to be relatively fast you're being careful how you use your energy and if you're going to do that then you're less likely to have a burn that was highly statistically significant the second was with surgical approach and these are all independent and these are modified with a Bonferrani correction so these p-values had to be very high in order for them to be statistically significant so we did have multiple comparisons and you can see that that was also very very significant and correlated with how you approached it which we kind of thought would be the case it's nice to have that but the third was with OVD so which OVD used had an important role in stating whether or not you were going to get a burn now no other was statistically significantly correlated however there was an independent variable that was more important than any of these that showed a marked randomness through this overall sample size in regards to Wumber and we call that high-risk behavior and I'd like to explain high-risk behavior just by talking about my five children and we've got incredible kids but we knew we were in trouble when this event happened for our number two child when he was two years of age I was at UCLA and we could on weekends go and use the pool that they had for the swimming team and the high dive group and I thought it would be kind of cool to jump off the platform I wasn't going to try to dive off there so I go off the high dive platform and the water there is about 15 to 18 feet deep because they're doing these high dives and I jump into the water and as I'm coming out everybody's screaming about this little kid and say what are you doing and I look over in horror to see our two year old he was two in diapers, never been in water before he's climbing up the high dive platform and so you know you see the life grid hey little kid get off of there, what are you doing and I'm like Patrick what are you doing get off of there and he's laughing he thinks this is pretty funny so he climbs up on the high dive platform and jumps off the high dive platform he's two so I'm closest I'm sitting on the side so I push off the side I go down and I pick him up deep enough in the water that I can push off the bottom and I'm convinced that he's going to aspirate water he's traumatized, who knows what happened he hit pretty cleanly which was amazing in and of itself I push off the bottom, hold him up in horror he cracks a big smile and says do it again now which of our five children do you think has been in an avalanche broken five bones fallen off a cliff you know everything you can imagine in associative so that's high risk behavior and all the things we talked about what you do obviously you can get yourself in trouble in regards to womb burn so let's look at this in more detail so surgical approach we already said that surgical approach was very highly associated in regards to whether or not you get in a womb burn what I like about this this is fully adjusted and that's the problem when you have variables where there are multiple different ones in place and we looked at a whole host of variables so all of those have been adjusted trying to look cleanly at juice womb burn it kind of splits fairly nicely you've got dividing conquer and carousel are sitting up here stop and chop somewhere sitting in the middle and all the chops are sitting right here and they're statistically not different this actually is different from these two except with the bond for any correction it isn't but it kind of fits in this category but this group is highly different from that and it all has to do with if you're going to use more mechanical approach if you're not using much ultrasound and obviously you're much less likely to develop the heat that you need to produce a womb burn clearly this is more likely to happen with a real hard nucleus but I do think the chopping approaches and we did see this not on a multivariate analysis but independently in the first survey and so I do think your mechanical approaches are more likely to prevent the events of womb burn we're going to save questions until later because I know you're thinking I can see it on your face you're looking that one over now in each category it's quite variable there are people who I know who chop who use a lot of ultrasound and then I'm very parsimonious I only use little burst as little as possible so obviously the less ultrasound you're going to use the less like you can generate heat and that's just pure physics you can't get around that look at this in regards to OVD fully adjusted again and you can see Helon 5 is the big outlier Helon 5Y we showed very exothermic and it does an incredible job of blocking any flow so that was the highest overall group we had it was highly statistically significant we never studied acucote my guess is because it's about it's not particularly viscous that it was that high I have a feeling it's also highly exothermic but other than that it pretty well correlated with the exothermicity ratio but you can see there is a difference here these kind of split into this one and then you've got this group sitting right here that held together and then you've got these down here that were lower so they were three different groups that were significantly different between them but something to remember here's the takeaway though oh I didn't show you the takeaway is you can avoid OVD wound burn every time you just have to allow about 10 seconds of irrigation and aspiration to produce an OVD free zone over the nucleus and you're not going to get this problem it's Jorge Alio's case I asked what did you use when I had these results and it went back and it was Helan 5 and it was pedal to the metal using OZL right off the beginning and you're not going to get any fluid flow you're putting ultrasound immediately into a very exothermic substance and that's how you get a burn in three seconds that's the record I know but you can do it in three seconds out of those circumstances just doesn't take long just a few seconds to produce that OVD free zone over the nucleus you can avoid that this has to do with power burn rates adjusted for surgical volume and you can see here's a continuous now this one is clearly an outlier sitting here on the high side with a bond for any correction it didn't quite make it but otherwise that's sitting up here significantly worse look at OZL plus longitudinal it came in number two so the issue here is OZL is not protective if you're going to go 100% power with long runs even OZL alone sat right about in the middle of the pack we had too few cases to analyze this so we can't make much of that particular one but you can see how the overall correlation with what your particular approaches are and hyperpulse in this case did not turn out to be protective either but there is no power modality that you can just use it and not get to 60 degrees that's the key thing here and the idea that somehow that this is free and you can proceed forward it's just not possible so you got to be careful how you use all of these you can exceed that temperature so light on the pedal never ultrasound anti-air chamber full of viscual acid just give it a little time to aspirate I think if you enhance mechanical approaches you can consider more forgiving ultrasound modalities where you potentially can use the less energy I think all that together may be important I think it's a largely avoidable complication so the final thing we're going to talk about here has to do with the kind of the holy grail of a lot of this I was going to throw in our post occlusion surge information but I think we've talked enough about that before and I know that you've got to get on to another section here soon let's finish with this fecal efficiency and chatter so what we want to know about these different modalities do they make a difference in regards to how rapidly they're going to remove a similarly sized nuclear fragment that's very hard to do in cataracts because every cataract's different and how do you randomize that between different groups it's extremely difficult to do so we wanted to come up with some type of in vitro way and chatter of course efficiency and association with bouncing a particle off the tip and if it bounces off the tip you've got to go seek it and get it back again and obviously you're not doing ultrasound during that period of time so we want to remove something but we don't want to have chatter of that piece bouncing around and in actual fact it says submitted but this is being redone and reworked and we've got a much better paper and Jeff Petty has been involved and we've got some very interesting thing I think we've got a way better paper that's about ready to be submitted but we've looked at different ways of microwave and formalin and Dr. Wong who's a former resident worked a long time on this we wanted to try to create a consistent hardness and a consistent size particle this is a lens treatment regimen that we came up with and a Griffin Jardine which is finally perfecting a pretty innovative way of sitting here and slicing these hardened lenses and you can see a slice them one way turn them slice them another way and then finally you end up with cubes that are two millimeters squared so they're consistent in regards to their size and we started out in our way of trying to show that this was an effective and a good way approach with Ozil, Ozil IP ellipse, ellipse FX about those modalities and how they work and what they do so it's pretty simple you put it inside of this usually a little chamber that you use and then you just aspirate it and then you have your parameter set and then you hit the pedal down all the way and then you look at the number of times it bounces off try to time it only when it's sitting at the tip and the chatter is the number of times you can clearly see it bounce off the efficiency is time to removal and do 21 for modality and so you have statistical power you make comparisons so the original thing that we had we looked at these are the numbers that we had but these are very very long and the criticism made is that's innovative and interesting but those are way longer than anything close to the clinical situation and so you've got to show us something that's clinically more relevant you can show that indeed that if you increase the power that you would often increase the chatter and of course chatter would result inefficient I think it also results in complications it's looking after that piece that's bounced off you're more likely to get to the caps you're more likely to break it all of those different things and so we went back to the drawing board and David DeMille, Brian Zog, Jeff Petty and Jeff you've want to present this so I'm just going to give a little tidbit here I'm not going to steal the thunder so you've still got this that you or anybody that wants to present but thanks to Jeff Taban, thank you sir he brought us a bunch of fresh human nuclei these were all inked out of Africa so we've got good hard human particles and we cubed them cut them down where we could look at and this work I think is extremely solid lots of lots of different runs and a more comprehensive look at exactly what's going on and I'm just going to summarize a few things when we looked at that that OZL-IP was better than OZL that's what they say and we certainly showed that in general ellipse FX, then ellipse in general it was way more complex there's a lot of this is going to be a really nice pair there's a lot of nice complexities what's going on optimal OZL-IP and ellipse FX were statistically similar and you optimize their parameters and it wasn't what you think a lot of times it isn't more power because then you get the chatter and once you've got a lot of chatter then the efficiency drop like a rock so too much power, less vacuum and increased chatter which hammers efficiency and that's all I'm going to say so Jeff you know you're ready you've got all kinds of tidbits there but we're rushing to get this together and get this submitted because I don't think anybody's ever done this before how many runs total did we do with this human lens particles aren't we sitting up like about four or five hundred runs three hundred so this is beautiful work and with some very nice statistics and really very impressive so conclusions and this was just Vignette associated with a few of the articles that started when actually it would be 2005 in January I said you know we've got to get a better handle of this there's probably about 25 or 30 papers all told looking at different aspects of this newer ultrasound modalities increase efficiency lower vacuum too much power results in both excessive chatter and decreased efficiency so understanding those and it's now a lot of people are saying is this really better than ultra-pulse well we're going to be able to look at that and we're going to validate an animal lens model that we think we can show is exactly the same as humans and with greater consistency and then we're off to the races 12 papers I've got outline ready to go Jeff's up to it and the rest of the team for the first time we can start to answer these questions which is way cool and I just want to point out that even though I always get ideas that bounce in I absolutely know none of this would be possible without a host of medical students residents and fellows and their hard work I got to thank them immensely for taking part and being involved and putting these things together and making them happen I'm not aware of a larger body of work that exists in regards to trying to look at a host of things but in this case looking at FACO and what works and what doesn't work and what's real and what's not real so it's been extremely I think important work in trying to make everybody honest about these overall debate and discussion and I can't thank everybody involved enough that have helped put these projects together thank you fire away Bala you had a question I thought you had one brewing and I thought you were about ready to go yes no but you're going to have to assume and there's always a problem when you do something like this but you're going to have to assume that by the time you've gotten up to a million surgeries that it's unlikely that there could be a gross randomized difference between groups and there's nothing you can do about that so you're just going to have to assume and that's what they do in these large surveys you've got to assume that once you get to a certain number of places that those kinds of variables would likely have randomized and I have no way of other than that is the usual theory but I have no way of knowing that for sure any other questions about this Nick so Nick's talking about something I've got plenty of bruises and scars from those battles over the years and but the word has to get out and makes absolutely correct and another thing that bugs me almost more is the science in which it's extremely rigorous but it's looking at things that are going to show a difference that don't represent the clinical situation and don't represent they represent an aspect of it so it looks like it's answering a question but we've already done enough work on it to know that they've it's an apologist way of trying to say this is it would be for instance like tobacco companies trying to point out there's no differences between smoking and they go to a population where nobody smokes hardly and things such as that but I'll just talk about one other and where's Jeff, are you still here so has this group already heard about, you presented the work that we did in regards to aberrometry I think already right so I mean that's a perfect example a good friend of mine I'm not going to mention his name was up there and oh yeah you can absolutely line up your intraocular lens you can do your limber relaxing incisions because you can measure right there in the case and change your intraocular lens because the power isn't right and I'm like give me a break it can't your overall cylinder and axis can't be the same you know with a speculum sitting there and let alone you've made an incision and how in the world can you know the anterior chamber depth I think that was a beautiful piece of work also coming out in JCRS which showed it's all over the place and frankly I'm kind of embarrassed for a couple of my colleagues who've been out there with who literally are telling people to change intraocular lenses on the table you don't know your anterior chamber depth at the end of the case what we found is no surprise it's usually deeper than it's going to be a week later on an average about a diopter difference but we hear that all the time I mean Nick shakes his head I mean he knows exactly what I'm talking about so the lesson for everybody is you need to try to have enough understanding to be look at this with some rigor be open minded but always a little bit suspicious about what's being fed to you and if you have questions and issues some of these things aren't that hard to do and it's kind of fun to sit there and figure out what's really going on and point out that may sound great in theory but in practice it's just not going to work so we didn't look at outcomes in this particular study because there's a certain limit to what you're likely to be able to get reliable information and we were right at that limit according to the biostatisticians working with us but we did define it as this was something in which you had folds in the cornea and that you actually had contracture of the wound so this wasn't, I think there's a lot of people are calling them wound burns and they're really localized edema, we didn't want to have that so you actually had to have folds and changes there's series that have looked at that and I mean you saw this one they actually had to do a patch graft and cover it with congenitiva to get this one filled and that happened in three seconds so the severity depends on how long the temperature continued to increase because the contracture will get larger and larger I've seen some, I was going to throw up this picture of one that has 11 sutures through a three millimeter wound and then glue over all the top to finally get that thing to seal and you can just see the cornea is just flattened down from that contracture in that area and there was 32 diapters of cylinder they can be very bad alright I think we're supposed to move forward to the phase two of this right so we'll go from the regal to the mundane and talk about billing is that what's going to happen