 As you can tell by the slide here with the wave, I'm a bit medical student from a coastal medical school. I'm from the University of California, San Diego. My name's Spencer Fuller. And yeah, a lot of my lectures and professors at UCSD use ocean or beach-themed presentations, so as I made this, I thought that would be fitting. And some of my professors actually have really cool pictures of them surfing and doing awesome things in the water, but those definitely don't exist for me. You just get a really cool wave. I am going to be presenting this morning on a project that I did with Dr. Natalie Afshari. She's the chief of cornea and refractive surgery down at UCSD. And it actually relates similarly to what Brian just presented on, which is trying to help understand better what patients go through during cataract surgery. Yesterday, in Dr. Manlis' clinic, we had a patient who just talked for several minutes about the light show that she got to experience during surgery, and this really cool experience that she had. And so Dr. Afshari, when we talked about this project, she said, let's try to video record that. Let's, you know, from the patient's perspective, at least make an attempt to try to record some of those phenomena. So that's kind of the general summary of my project, and you'll see that it's actually very difficult and basically impossible, but this was a really great learning experience for me and a really fun project that I got to work on. In addition to Dr. Afshari, I'd like to thank her international research fellow, Dr. Fukuoka. He was visiting from Japan. He's since gone back. He did all of the cataract surgeries. And then Spencer Yamada helped with the film editing. I presented this research at Arvo this past May, did a poster, and the film that we made was presented at the ASCRS Scientific Film Festival this past May as well. That was in Los Angeles. And the project was funded by the Research Supervent Planus. All right, so, similar to what Brian said, lots of patients have anxiety about their cataract surgery. Doing a let review, I found that up to 50% of patients report visualization of colors during surgery. These are based on post-surgical questionnaires. Up to 50% of patients report light intensity changes during surgery. Makes sense. Up to 30% of patients report being aware of surgical instruments, whether shadows or, you know, yeah, it was mostly visual experiences. So actually seeing shadows of the instruments. And then up to 16% report being fearful of their actually, their intraoperative experience. This isn't asking about preoperative or postoperative. This is actually what they're seeing during surgery. About 15% experience some sort of fear. Is this normal? Am I okay? Is everything going all right? There have been several techniques to try to record cataract surgery, or at least into your segment surgery from the posterior segment. And these include the Miyake technique, the apple technique, and the home-grown approach which is the revised Miyake apple technique by Dr. Manlis and Dr. Werner. Yeah. And they basically involve cutting the eyeball in half roughly and fixing it to some sort of transparent slide or some structure then you can look through. And this is just an image right here. This is just a picture of that. However, because we were trying to record what patients are experiencing, we wanted to try to develop something from the macula, which proved tricky to say the least. And I kind of described a little bit about the purpose of our project. So the goals were to come up with some sort of video footage to quantify the light intensity changes during surgery and also to eventually come up with something that might be patient facing to educate them or help them understand. This is what it might look like for you during surgery. So what we did is we obtained some post-mortem pig eyes and we dissected the tissue and prepared them. We created what we call the maculostomy, which was a roughly 5-millimeter hole over the side of the macula, 4-millimeters, temporarily from the optic nerve. We put these eyes on kind of a modified styrofoam, creepy-looking surgical face that are in the wet lab. And we cut a hole in the bottom of it. We modified it so that way the camera could look up through the maculostomy up to the surgical field. We recorded the video footage on a front-facing iPad camera. There were several reasons for that. One was that the camera was really small, so it could actually look up through the maculostomy. Another is because the IOP would drop when we performed the maculostomy. I would move a lot as Dr. Guglug was doing the surgery. And so we were, you know, readjusting things, re-aligning things, and having the front-facing iPad camera gave us that immediate feedback so where we could know, hey, is the maculostomy situated properly over the camera? And initially, we were trying to induce cataracts in these pig eyes. However, we tried the microwaving technique as described by the paper referenced here. The paper actually says, to induce a cataract, you have to microwave a pig eye for about 8 to 9 seconds. However, that's really close to the amount of time it takes for the eyeball to explode. So we were kind of like, all right, let's give this a shot. And it turns out that actually when we made a good cataract, the zonules just broke really easily. So we tried coming back, and we just really weren't able to create a meaningful cataract visually and still keep the integrity of the surgery. So we ended up just abandoning the idea to make a cataract with microwaving. Later, I'll talk about other techniques we could try in the future to induce a cataract that might not compromise the zonules, but for our methods initially, we weren't able to do that. All right, here's some images, us dissecting some of the tissue. There's the maculostomy. And here's Dr. Fuboka in action doing surgery. You can see the setup here with the mouse. Yeah, you've got the front-facing iPad camera here. You've got the surgical setup, and the eyeball is right here. You can't really see it. So this is basically how we did things. After we got the video footage, we extracted images from them to add predetermined steps of surgery to then use for the data analysis. And we ran them through an imaging processing package that's free. It's developed by the NIH. It's called Fiji. And from each image, we extracted what's called the mean gray value for each image. And that's basically a unit-less summary of the image's light intensity. And for the statistical analysis, we did crude and paralyzed comparisons of the mean gray value. It's kind of an annoying thing to say, the difference between those values for successive steps of cataract surgery. We also did a paralyzed comparison of the mean mean gray value for after-Iowa placement compared to the start-up surgery, because we wanted to see, well, since we didn't have cataract in the lens, was the light intensity similar to that initial image? And we did the analysis on STATA with a significance level of 0.05. All right, so here's some qualitative images. Here is an image from the beginning of surgery. Here's an image after we empty the anterior chamber. This is after we filled the anterior chamber with OVD. This is what it looked like from the camera. You can't really tell, but it's kind of bluish, but it's very dark after a tri-pan blue injection. This is after the washout. This is after FACO. And this is after the Iowa placement. In the end, we had 24 images available for analysis. We had to do a lot of trial and error experimenting with maculostomy size and balancing IOP requirements to do the surgery. The microwaving obviously destroyed a few eyes. So we had 24 images. And the mean gray value range was 5.5 to 133. Just to give you an idea what that looks like, the lowest light intensity images were after tri-pan blue injection. And those with the most light intensity were after the AC was full, so you can compare these two. Excuse me. This is a table that basically just shows the crew differences in the mean gray value for successive steps of cataract surgery. So basically subtracting the light intensity for the AC images to starting image and going all through surgery. The greatest decrease in light intensity was going from a full AC to after tri-pan blue injection, like I showed you before. And the greatest increase was after the tri-pan blue injection to washing it out. And as you can see, there was dramatic variation in light intensity throughout the cataract surgery. And our sample size was small, so any of these differences statistically significant. And yes, going from an empty anterior chamber to a full anterior chamber significantly increased the light intensity by about 60%. Going from a full anterior chamber to after-faco, we only had one image for each of the tri-pan blue steps because tri-pan blue is expensive I learned. And so we couldn't do statistical testing on one image. So comparing after-faco to a full anterior chamber, there is a very significant decrease in light intensity. And even though it's not statistically significant, it approaches significance going from after-faco to after implanting the IOL. And then the last table shows you the result of that pairwise comparison of light intensity after the IOL was placed compared to the starting image. And as you can see, there was virtually no change in light intensity compared to what's after surgery, after the IOL was placed before. And you would hope that, but we actually were able to quantify that. All right, let's go back to this. I love that song, too, the music. Anyways, so that was not patient viewing just as a disclaimer. I should have said that before. Some more results. Unfortunately, as you saw in the video, we were not able to record any colors or visual phenomena like patients often describe. So moving to discussion, as a result, Dr. Afshari and I and Dr. Vokog were thinking that, well, like a lot of other people think, the color phenomena are probably more likely related to effects of the cataract surgery on the retina, changes in that intracular pressure, photoreceptor stimulation, or saturation, because we had a complete optical system looking up at the surgery, and we weren't able to see any refraction of light or rainbows. We were hypothesizing that we might have seen something around the hydro dissection or fake emulsification steps, but we weren't able to see anything. So there are a lot of limitations of our study in terms of trying to actually record the patient's experience. So the first was that we weren't actually able to make a cataract. It's kind of a big one. Second was that the iPad has a complete optical system. So the video was much more in high def and focused than a patient would actually be able to experience. Additionally, the light intensity data has some limitations. So the iPad has an exposure auto adjust setting that we could not turn off. So even though the images weren't really changing that much throughout every surgery as we did the video, we still can be 100% sure that there weren't some subtle changes that might affect the results. Although over the course of the six video recordings we did, we were hoping that that would kind of all wash out. And also the pig eyes would move, as I explained before, due to decreased intracular pressure, and the tray kind of moving. So we had to reposition it a lot. So it wasn't 100% that we were getting the exact same image at every single step of surgery. But again, we hope that that kind of random error would also be washed out in the analysis. And we also had a small number of images due to the reasons I explained before. So just some ideas for future improvements on this project. We thought about getting a camera and removing the sensor and placing that sensor at the maculostomy in order to try to see maybe more what the redness is without the optical components and the focusing components. We also thought that we could revise the setup and figure out some way to fix the sensor at the maculostomy. We could maybe try something like the revised myocardial technique where we actually glue the maculostomy to a slide that might actually help with the intracular pressure issues. So that's another thing we could try. And there's a paper that described different formalin to alcohol ratio injections you can do through the limbis to create a cataract in the lens without compromising the zonules. So if we wanted to try actually inducing a cataract and then I'm doing the surgeries again, that's another thing that we could try. All right, well, I hope you found this interesting. And I thank you for your time. And I wonder if there are any questions.