Okay, so we're going to finish up on retinal vascular diseases, not including diabetes.  And this time, we have a lot of kind of smaller topics to cover and we'll try and get through them as much as we can. We'll start with ocular schema syndrome, hi good morning. So severe carotid occlusions can lead to reduction in the blood flow, and this reduction in the blood flow from the carotid system leads to both anterior and posterior segment ischemia. Most common complaint is vision loss, this is gradually progressive over weeks to even months. A fair number of patients will come in complaining of pain. And this is typically an ischemic type pain, so the pain gets better when they lay down just because they're lowering their perfusion pressure and they're able to perfuse the eye when they're laying down. The pain can also be inflammatory for anterior segment inflammation, or the pain can be from elevated intracular pressure because they can come in with neobascular glaucoma as well. We often see this in older men and it can be bilateral. It's pretty rare, but it is thought that this could be underestimated because it can also mimic mild to moderate NPDR or a mild non ischemic CRVO, so perhaps we're not calling it as often as it really is. So just to refresh the anatomy, so the up-down the garbaderie gives rise to the central retinal artery, and then the posterior ciliary arteries, and those both arise from the internal carotid. If you have an occlusion at the internal carotid, you're going to get a reduction of the blood flow that provides blood to both the anterior and the posterior segments, as well as the retinal and caroidal circulation. So that's how we end up with more widespread ischemia, and they're perfusing from usually collateral circulation that's arising from the circle of willis. So the findings on clinical exam, they often come in with unexplained neobascular glaucoma or rubiosis. They can have spontaneous hyphemos, enter chamber inflammation. They can have more of a cataract on this side of the eye with the occlusion, and they can also have synechia, iris atrophy. On retinal exam, you can find vitreous hemorrhages, peripheral neobascularization. The most common thing we see clinically would be midperforal blot hemorrhages, but they can also have optic nerve changes with pallor and edema or even macular edema. They often will have pretty severe stenosis of that carotid artery on that same side, and this can be the presenting findings for carotid occlusive disease in a pretty high number of patients. I think this is important to keep in mind over at the VA where we have our vascular-pathic population because they often are associated with ischemic heart disease, prior TIAs, peripheral vascular disease, diabetes, hypertension, and they do have a higher stroke rate, 4% stroke rate per year compared to just half a percent in controlled population, which is age-matched. This is the retinal findings that you'll see, which is these midperforal blot hemorrhages. These are deeper blot hemorrhages as opposed to the more flame hemorrhages that you would see in a vein occlusion. In clinic, when you're looking at these patients and you're not sure, is this diabetic, is it a vein occlusion, is it ocular schemic syndrome, one thing you can do pretty easily is ophthalmodinomimometry, and so what you're doing is basically just putting gentle pressure on the globe, so while I'm looking with the indirect, I could just put pressure on the globe and you're looking for cessation of the, well, you'll start causing arterial pulsations, and you shouldn't be able to do that in a normal eye, but with these eyes with poor perfusion, you can overcome that ophthalmic artery perfusion pressure just with gentle, globe digital pressure, does that make sense, how I would do that, so you would just kind of have your indirect, kind of gently pressure on your finger, tell the patient you're going to press, and then you can overcome the central retinal artery and start to see pulsations, then that could be an indication of reduced blood flow and reduced perfusion pressure to the central retinal artery. The other clinical finding is to do a fluorescein angiogram. The most common thing you'll see would be prolongation of the AV transit, that's the most sensitive, but the most specific sign would be delay in the choroidal filling, so normal choroidal filling should happen within five seconds of the dye being pushed, but in ocular schemic syndrome, it can take quite a bit longer, even up to a minute. You can also see retinal vascular staining, and this is typically staining of the arteries, and then you can also have angiographic leakage into the macula as well. So this just shows the delay in the choroidal filling. You can see even at 24 seconds that the choroid isn't completely filled, and then there's pretty significant delay in the AV transit time, up to 49 seconds. We still don't have these veins filled out here. The other thing you can see is staining of the arterial walls. Oh yeah, you can get capillary dropout, you can also see microannurisms as well. I think this is a really good chart, this came from a review article of ocular schemic syndrome, and this just contrasts the different clinical findings between ocular schemic syndrome, vein occlusion, and diabetic retinopathy, and you're really severe a schemic CRVO, you're not going to mix that up with ocular schemic syndrome, but it's more of those kind of mild non-eschemic ones where you'll be like, I don't know, which could it be. One thing to look at would be the retinal veins, so in an ocular schemic syndrome they're dilated but they're not going to be tortuous, whereas in a vein occlusion they should be tortuous. Diabetic retinopathy you'll see more beading rather than tortuosity. And then yeah, this, Lee just answers your question, capillary dropout in the ocular schemic syndrome, which you can also see in vein occlusion and diabetic retinopathy. But you really won't see exudates, hard exudates in an ocular schemic syndrome like you would see in diabetes, and then central retinal perfusion pressure, that would be normal in vein occlusion and diabetic retinopathy. And then this, the angiographic finding of that delayed, caroidal filling. In CRBO you'd see vessels vein staining as opposed to arterial staining that you would see in ocular schemic syndrome, so I think those are the biggest things that can help you kind of figure out the difference. Obviously if you're not sure, you know, doing the test to rule out ocular schemic syndrome is a pretty non-invasive safe test and pretty low risk, so if you're really not sure, I think getting a carotid Doppler and just ruling it out is not going to, no one's going to fault you for that, if you're worried. So the, today I know getting the carotid Doppler, if that's questionable, then go into a CT angiogram. A carotid angiogram is always considered the gold standard, but it's not really done because of the high morbidity associated with it, they have a pretty high risk of strokes and TIAs associated with that carotid angiogram, so it's not really the standard first line test. The prognosis really isn't that great, if they have rubiosis, 90% will be legally blind within one year, so it's pretty high rate of visual loss, you can get rid of the neobascularization about 35% of the time with PRP, you can also use anti-vegeth agents for these patients to help control the pressure, and they do have a pretty high five-year mortality rate due to a cardiovascular disease, it's the most common problem. So as far as the treatments for the eye, controlling inflammation and with steroids and cycloplegics that can help with the pain and the inflammation and managing the intracular pressure, a lot of these patients end up with either shunting procedures from the glaucoma service or even diode, cyclophenyl coagulation, from the retina standpoint we can control the neobascularization with anti-vegeths and PRP, but the main thing is also getting them to the vascular surgeon for a carotid endoterectomy. Any questions about ocular schema syndrome? No, okay, so we'll move on to hypertensive retinopathy. So really most patients with hypertensive retinopathy when they're coming in with kind of mild to moderate hypertension, they might not have any visual complaints at all and the most common thing you'll see would be AV-nicking. There's really not any association between what the blood pressure is and the retinal findings. Patients that come in with vision loss, those are patients that come in with malignant hypertension, really severe accelerated hypertension that you see with like eclampsic, or eclampsic patients, or renal hypertension. So the modified shape classification, grade zero really have no changes. Grade one arterial narrowing, grade two narrowing with irregularities in the arteries, and then in grade three is when you'll see hemorrhages and exudates, and grade four you'll see optic nerve edema. So this is a grade three, you can see that the disc has a nice sharp clear margins, but you do have exudates, cotton wool spots, arterial irregularities, blade hemorrhages, and then this is a grade four with a severe optic nerve edema. Obviously this can be a lot of different things, so you want to keep hypertension on your differential, checking blood pressure in someone that comes in like this, but there's other things you want to consider, Bartonella, mass lesions, anything like that, but if you see someone like this, you want to check the blood pressure in the clinic, and if it's high, obviously send them to the ear. So hypertension can also affect the coroid and the optic nerve. You can see these elishnic spots, these are these little kind of tan, lobular lesions at the level of the coroid, where there's non-perfusion. Initially they're kind of tan, and then later they'll become hyperpigmented. And then the other thing that's kind of classically seen with hypertensive coroid changes are these segrous streaks, and this is just a pigmentation that can follow the coroidal arteries, and this is associated more with acute malignant hypertension in young patients. You can also get serous RDE's and vocal or PE detachments. So check the blood pressure. If it's severely high, I'll send them to the ER. If it's more, if I'm not as worried, I'll send them to their primary care doctor pretty quickly within a week or so. But if it's 1.9,200, they're going to the ER from my clinic. You don't want to send somebody home, and they have a stroke. It's not good. So moving on, sickle cell retinopathy. This is kind of the classic test question. Not that we see it a lot here, but you will be tested on sickle cell retinopathy. The sickle cell hemoglobin S is the valine substitution, and then hemoglobin C is a lysine substitution. You get deformation of these red blood cells that then sickle, and then they thrombose and lead to vascular occlusions. The most common abnormality would be hemoglobin SS disease. That has more systemic complications and not as high a rate of ocular complications. The rate of proliferative retinopathy is highest in hemoglobin SC disease, and that I've seen tested for sure. So in the Iowa sickle cell disease, you get sickling of these abnormal red blood cells, and that leads to thrombosis, and then you get peripheral occlusion and non-perfusion that then leads to retinal neovascularization at the border of the perfused and non-perfused retina. In non-proliferative sickle cell disease, the classic kind of findings would be the salmon patch hemorrhage, and this is an arterial occlusion with downstream intra-retinal hemorrhage, and then that salmon patch hemorrhage can kind of de-hemoglobinize and then lead to these refractile deposits that you can see in the retina. And then the sunburst lesion, this is from sub-retinal hemorrhage, and then you get RPE migration into that. Sorry, I don't have many pictures of sickle cell retinopathy, so I had to take it from books, and they're not the best pictures, but you can kind of get the idea of it. The other thing that you can see in sickle cell patients is angioid streaks, and this is from occlusions at the coriocapolaris that can then lead to breaks in Brooks membranes, and this occurs in about 6% of hemoglobin SS and AS patients. Any other, what do we normally see angioid streaks in here in Utah? Yeah, pseudosanthemalastica. Yeah, that's where I've seen it mostly here. Dr. Kierke, why is it that there's more retinal management stations with the SC and the SS? You know, I was looking into that the other day, and I don't think that anybody really knows the answer to that. At least that I've found, I don't know, I can look into it more, but I didn't see a reason for that, but that's a good question. So the staging, stage one, you get peripheral occlusions and non-perfusion. Stage two, you get these anastomoses peripherally, and then stage three is when you start to see the C-fan, and then stage four is Victorious hemorrhage, and stage five is Attractional Detachment. So this is kind of that classic C-fan appearance, and these are in the peripheral retina, different than diabetic retinopathy, where you see it more in the posterior pole, but they get their proliferation peripherally, and this is kind of a white C-fan, and what's happened here is a C-fan is basically auto-infected, and then it's left this kind of white C-fan. On angiogram, you can see these C-fans just out in the periphery, just at the border of the non-perfused and the perfused retina, and this patient's had some laser treatment. It looks like they need more. And this is just contrasting sickle cell from diabetic retinopathy. In diabetic retinopathy, we see the neovascular membranes along the arcades, along the optic nerve, but in sickle cell, the neovascularizations occurring in the periphery. Another thing you can see are these coma-shaped blood vessels on the conjunctiva. So African-American patients that come in with a hythema, you want to screen for sickle cell disease. It can be much more difficult to control the pressure, and you want to consider an earlier anti-chamber washout. You don't really want to do carbonic and hydrogen inhibitors because that can dehydrate and worsen sickling. I would do a baseline fluorescing angiogram in a patient with sickle cell disease to look for non-perfusion and proliferative disease, and you want to follow them pretty closely. The thing you want to be careful of is that laser treatment in these patients can often precipitate tears and detachments more so than you would see in diabetic retinopathy. So often you start lasering, and then they can end up detaching, so you want to be pretty careful. People often will just do peripheral scatter laser to the non-perfused retina. Some authors advocate for actually lasering the feeder vessel of C-fans, but that's a little controversial because that does lead to tears just right at the base of that C-fans. So most people do laser to the peripheral non-perfused retina. So when considering retina surgery for these patients, you want to be careful with your surgical planning. You would not do an encircling buckle because that buckle can lead to anterior segment ischemia and problems with rubiosis and neovascular glaucoma. You want to be pretty careful with your cryopexy because of the risk of anterior segment ischemia from too much cryopexy. And you want to be really careful with your use of gases and epinephrine because you don't want to make anything worse by causing more sickling. And you have to monitor their pressure really closely in the post-operative period as well. Don't remove extracular bushings. Like you wouldn't detach any muscles when you're in the surgery because of the risk of ischemia from that. Not that we're commonly doing that, but sometimes you end up having to manipulate muscles, but you would not do that in a sickle cell patient. So like I said, the detachment usually starts in that area of the ischemic retina that can be precipitated by laser. And the surgery can be really complicated. They have a high rate of complications. These are tough patients to take care of. This is from your book, just to keep in mind your kind of differential diagnosis of peripheral neovascularization. I will not read that to you, but you can look at it. Yeah, Ali? So for your sickle cell patient, can you do them? So you could either use oil would be a really good option in these patients. I think most people would do oil instead of the expansile gas formation. I mean, to be honest, I don't have any sickle cell patients here in Utah. I think I had a few in Madison that required surgery. I saw more there than here. But here, it's just not a really common thing that we see. So it's not as common to operate on. But I would probably use oil for a lot of these patients. So arterial macroaneurysms. The thing that's always tested on macroaneurysms is you just want to keep this in mind in your differential for something that can cause blood throughout all layers of the retina. It can cause sub-retinal, inter-retinal, pre-retinal, blood, victories, hemorrhage. So that's always kind of like the main OCAPs question on macroaneurysms. Typically, you see it in the second order arterials and it can traverse the entire retinal thickness. These patients can get macular edema, macular fibrosis from the macroaneurysm. They can have vision loss from large pre-retinal, sub-retinal, and vitreous hemorrhages. They typically kind of spontaneously sclerose and thrombose on their own. So often, they don't need treatment once they kind of bleed, they fry bros, and then that's kind of it. But sometimes they can continue to leak and then you might need to consider doing laser treatment. Sometimes with a really large hemorrhage, you would need to do surgery to go in and clear out the blood. We typically see this in kind of older women, hypertension is a really high comorbidity with these patients. And just this is kind of the typical fluorescent angiogram finding where you can see this dense blood. It's kind of hard to tell in the color picture. Maybe there's something right there, but you're not sure. And you do the fluorescent angiogram and you can see that dilation really light up. And then there's another macronurism here that's not quite as big. There are people that advocate using anti-veg F agents for this patient. That's not quite as common. More commonly, you would see photo-quagulation either around the macronurism or even directly to the macronurism to help fibrose it and involute it if it's quite leaky. The risk of kind of treating the macronurism directly is it can lead to downstream vascular occlusion. And then radiation retinopathy. Radiation retinopathy really looks a lot like diabetic retinopathy and it's really managed a lot like diabetic retinopathy and really keeping in mind patients that have had treatments for ocular melanomas. But then there's also patients who've had a fair amount of radiation for other tumors to the head that can have radiation retinopathy. So if you can't quite explain why they look like a diabetic and they're not diabetic, you wanna ask about radiation to the head. It typically comes on a year and a half or so after external beam but with plaque treatment it can come on quite a bit earlier. Their treatments, a lot of anti-ved Jeff agents are used nowadays. Tramsidolone, focal laser for macular demon and PRP. They can require vitrectomy for neobascular complications and vitreous hemorrhages. And then moving on to valsalva retinopathy. Valsalva retinopathy can happen with any kind of strain. You can see it after food poisoning, you can see it after patients have had pneumonia and they've been coughing a lot and they just get these ruptures of these blood vessels. They can be really mild or more severe and they're kind of ruptures of these small capillaries in the macula. Often the blood is under the ILM. Usually it just resolves on its own but sometimes it does require surgery. This is kind of a more mild valsalva retinopathy and this would be one that you would really just watch and that would get better. They would get quite a bit of visual return. This more severe hemorrhage, that would be one that if it's not clear and you'd want to consider surgery for something like that. And then moving on to perchers retinopathy. So perchers retinopathy is due to, usually it's an acute compression injury to the thorax of the chest. It was initially described in someone who fell out of a tree. It's thought that it's kind of activating the complement cascade system and then we get leukocyte aggregation and then occlusion of arterioles that lead to this ischemia. They can also have optic nerve edema that leads to optic nerve atrophy. They can have irreversible vision loss. Sometimes it will get better but they can't have significant visual loss related to this. This arrow is just pointing out perchor fleckin and so this is this polyethanol shape and it's hard to tell here but the whitening doesn't actually reach the vessels. There's a clear area from the whitening to the vessel and it's the occlusion of the precapillary arterioles there from leukocyte. Yeah. The last one is history. Yeah, so with perchers they haven't had a direct blow to the eye, right? That's the main thing. Like perchers retinopathy, you have to have like that compression injury. Perchers-like retinopathy which I'm just gonna cover. That's other causes that can look like this.  You can also see it with autoimmune disease but comatio, that's that direct trauma to the eye and if patients have severe trauma, they might not know, right? But perchers, it can have some hemorrhages. Usually comatio, you would really severe comatio or dysphilitaria, you're gonna see more hemorrhages associated with it too. And perhaps with comatio you might see like a caroidal rupture that could clue you in that there was a strong blow to the eye as well. You wouldn't see anything like that in perchers obviously because it's all happening at the level of the vessels with that, with the complement activation is the most, the biggest theory on what's happening with perchers. And then Tersan syndrome. This is intracranial hemorrhage or even severe elevation in the intracranial pressure that can lead to these rupture of the retinal vessels. It can happen really quickly after a intracranial hemorrhage, almost within an hour of a large subdural hemorrhage. Can you see intraocular hemorrhages? Often these patients are gonna get better on their own and they have a pretty good prognosis for visual recovery. If they're not clearing, then you wanna do surgery. This is kind of the classic double ring sign that you would see in Tersan. So this inner ring, the darker ring is sub-ILM blood and then this outer ring is sub-hyloid blood. And then Coates disease, kind of moving on to other retinal vascular diseases. I just feel like there's so much to cover in this lecture that you don't get to talk about each as much as you might want. But Coates disease typically presents in young men, young boys actually and infants. This is in your differential of leukocoria. They can have that white, red reflex. You wanna differentiate this from retinoblastoma. Ultrason characteristics to differentiate from retinoblastoma would be calcium. Yeah, calcium, if they have calcium, it's not Coates disease. You wanna be thinking about retinoblastoma. So this is retinal telangiectasia with these ectatic arterioles, microannurisms and exudative RDs. There's a broad differential obviously for leukocoria that you guys should know backwards and forward. And then there's two different staging systems for Coates disease. They're pretty similar in terms of the different stages. I don't actually know why we need two different staging systems for Coates disease, but we have them. Stage four is total RD and then stage five is when you get complications. Usually that's when they have glaucoma issues and they get an enucleation from a blind painful eye. The treatment, kind of the standard treatment is laser photocoagulation to the ectatic arterioles. They can often do cryotherapy as well. These patients, if they get a total RD or even a pretty large RD, you might end up needing a buccal drainage and then enucleation for those blind painful kind of glaucoma to size, which are the really advanced stages that we try to avoid. There is some role for anti-vigil agents in these patients as well. If they present at a younger age, they usually have a worse prognosis than those present later on. So macular, telangiectasia, three types of macular telangiectasia. Type one is unilateral in males and it's really thought to be a variant of Coat's disease. So it's also called Lieber's milliary aneurysms. You might have heard that as well. So some people actually just group Coat's into type one macular telangiectasia, but the BCS separates the two. The real differentiating factor is Coat's disease is gonna be in the young kids, the young boys, and then type one macular telangiectasia. You'll often see that in older patients. Type two is the most common. I feel like type two we talk about all the time. I think you guys probably know type two mac tel pretty well from fluorescence or being in Bernstein's clinic with the studies that he's in. And then type three mac tel is really rare, and I actually don't even know if I've ever seen type three, but they have bilateral disease with retinal capillary obliteration. I can't even think, last night I was trying to think of a case off the top of my head and I don't think I've ever seen it. So I don't know if you guys ever will. So type one, so you can see the similarity with Coat's disease. There's a lot of exudation. And this exudation though is not quite as severe as we were seeing in the pictures of Coat's disease, but it's in the temporal macula and they can have macular edema. Another picture of type one Coat's. Type one B, so one A is the congenital type. Type one B, you often see this in kind of middle-aged males and they'll just kind of have a couple little microangerisms. They have excellent vision, really good visual prognosis. They're usually 20, 25. Often this is something that's not treated at all. And then type two, mactail. This is the one that we talk about a lot. This is often bilateral. There's a genetic component to it. You see RPE hyperplasia with these right-angled venules. They can get crystalline deposits in the macula. Singerman spots are these glistening white dots you can see in the retina and then advanced stages can get caroidal neobascular membranes. So the staging of mactail type two. Stage one, normal exam, but you'll see fluorescein changes with temporal staining. And then stage two, you start to see grain of the phobia and then telangiectetic vessels on the fluorescein. Stage three, you get the dilated blunted venule that's kind of diving at a right angle into the retina. And then stage four is when you start to get pigmentary plaques around those venules. And stage five is when you get neobascular disease. You can see OCT changes on all stages. Here's some autoflorescent changes with mactail that you guys should be pretty familiar with. This is the crystalline-like deposits that you can see with mactail. Gloresins. That's pretty classic. It'll be bilateral temporal leakage late. And then the OCT changes are pretty specific for mactail. And you can see cavitations in the inner and outer retina. And then type three, this is the really rare bilateral capillary occlusions. They can have abrupt loss of vision. And then later, the telangiectetic vessels develop. And like I said, this is just really uncommon. So, type one, the Coates type, often that's just treated with laser. You can also use anti-veg gas. And then type two, there's really no known treatment. Dr. Bernstein's getting involved actually in a study for different treatment options. They don't respond well to laser. People have tried a lot of different things for those retinal cavitations, but there's nothing that really treats those very well. The only treatment really is if they start to develop a caritone vascular membrane, then you would want to start anti-veg treatments for that. All right.


What's up everyone it's your girl Kenzie here from Layton Sports Cards and I'm ripping a personal for Thomas W. We've got a 2022 Panini Daunris Optic Baseball Hobby Box. All right good luck Yogi. Here we go looking for two autos. Let's see a hot box and get five. That would be something huh. Or we could pull the parallel hot box. Yeah get a parallel on everything. Yeah a number to Here we go. Josh Lowe Rated Rookie. We've got Jose Abreu on the red, white, and blue that is 156 of 199. It's a good look for the start. Tuve, Jari Peña. We've got Reese Hoskins on the hollow and Pomara is on the rated prospect. Claibor Torres, Julio Rodriguez Rated Rookie. We have to 49 Alejo Lopez on the light blue Velocity Rated Rookie Auto. Very nice. Nice looking hit there. Matt Manning the rookies. Walker Bueller, Mike Trout, Splash Hollow, Vladigrower Jr. and Mythical Trey Turner. We've got Blue Bob. We've got Jackson Coar. I thought that was backwards. Lights out. Yeah I like optics. Every sport of optic. Eli Morgan what do we have here? We have Giants Hollow, Camilo Duvall on the rated rookie auto. Giants Hollow Auto, Camilo Duvall. Lights out, Garakul. And last now we've got Hollow Mythical of Trey Turner and Tatis. Court Seeger. We've got Black Stars Rated Rookie Jackson Coar that is 147 of 149. Gwander Franco on the rookies. Hendricks, Hollow, Bracen, Stott Rated Rookie, Phillies, M.J. Melinda's Rated Prospect. Ah here what is this? Kristen Yellich. That's gotta be some type of parallel. What is that? I've not seen that one. Oh that's yeah that's the um dang it. It's the short break. Yeah it might be. Ultra Rare Neon. Is that what that is? I have not seen one of these yet. Here you go Yogi. I'm gonna pull up the checklist here. Xander Bogart. I pulled it with Forrest one time. Did you? I have not seen that yet. Yeah it's a short break. Not seen that. Turner Hollow Lights Out, Robbie Ray. That's called Jonathan India. Oh no Neon is this one. It's gotta be a short break. What are you just gonna look into? Because I'll remember when Forrest said it. Arias, Yifas, Ryan Reynolds, Detmerce, Lay It's Out, Groom, Hollow, Diamond Kings, Wilson, Contreras. I think this one's just called Blind Green. That's it but it's not numbered. Schwerber, L. Wade, Bobby Whitton Jr. Rated Rookie. That's Bomb Squad, Salvador Perez, Hollow, Rated Prospect, Michael Harris, Brace, Louise Frias on the Hollow Rated Rookie. Harris, Rated Prospect. Wow, Marsh, Vladdy. See a Photon. See a Photon for Yogi. Ryan Hayes, Hollow Mythical Max Muncie, Bieber, Jake Berger. Got Light Blue Rated Rookie of Kevin Smith, 34 out of 50. Kevin Smith is everywhere. Last pack here. Good luck Yogi. Thanks again for hopping in. Hollow Max Scherzer and Rated Prospect, Louise on Hell, Acunia. Nice. All right Yogi, that'll do it for your box. Congrats on those hits. Thanks again for hopping in and for hanging out with us. We'll get these right out to you.


Welcome to my presentation on from remote first to what they think first. Happy to be here at Open Source Summit. My name is Isabelle Trestfromm. I'm open source strategist at Europizagé. I'm also a member of the Apache Software Foundation and the co-founding member of the InnoSource Commons. I also created Berlin Buzzwords, which is a conference on all things search scalable and data analysis. Now, for decades this conference ran as an on-site conference, like many other events this year. It moved to an all remote format, organized by a little agency in Berlin called Plainschwards, who did an awesome job moving a conference that lived from a lot of hallway conversations and socializing into a digital format. I also created FOSPEC Stage, which is a conference on all things open source. But behind the scenes, think of licensing, think of governance, think of community management. Also, this conference is going to be remote first in 2021. Call for presentations is still open. So if you have ideas, if you want to share what you're doing in your communities, looking forward to your submission. Now, a lot of the ideas in this presentation are based on what I learned at the Apache Software Foundation, in particular at a presentation at ApacheCon in 2008 back in Amsterdam, which happened to be my very first ApacheCon ever. It was a talk by Bertrand de la Cretace on asynchronous decision making. So if you're interested in diving deeper into this topic, I would like to invite you to head over to YouTube after my presentation and watch Bertrand's video on asynchronous decision making, why and how. Now, throughout my presentation, there will be different interactive parts. We will use an other pad where you as the audience can collaborate on answering some of the questions around moving towards asynchronous communication and decision making. You don't need to write down this URL right now. You can head over to it and have a peek into what the questions will be like. But I will show the URL again on all of the slides which have questions on them. Let's get started right away. When thinking about remote working, what is the first sentence that you think of when hearing remote first? I will give you a couple of minutes to think about that. Head over to the other pad and together with all of the other people in the audience, try to brainstorm on what the first sentence looks like when you hear remote first. I thought during the pandemic or during your open source development or even in a corporate setting. Ready, steady, go! One more minute to go. Okay. Now, before going through this talk, I also talked to some of my friends and colleagues what their remote working experience looked like. So here's the answers that I got. There was one human telling me, I lost all flexibility. We moved all pairing to video conference sessions and we pair all the time. It's exhausting. I'm on back to back conference calls all the time. It's worse than on-site meetings. What could have been in email still is a video conference. It's chaotic. I'm making time for the conference call but it doesn't have an agenda or even moderation. But there's also different feedbacks that I got. I managed to get more done. There are less distractions. Colleagues moved to another country. Remote works. So what is the difference between these teams? In order to figure out what happened, we will first have a look at which types of communication you have in your typical office. There's a coffee machine check, which happens to be incidental, unplanned, which also is very informal and which still helps in formation to flow from team member to team member but also across team boundaries. Plus it helps with bonding team members together because they don't necessarily only talk work topics. There is pairing where a lot of mentoring happens but also knowledge sharing on how a certain piece of code works. There's team communication happening at the desk, which is mostly informal but very fast and very speedy in order to get feedback. If you have a question, ask your team members and you will very quickly be able to move on. But there's also formal team communication. Think about scrum stand-ups, think about planning sessions, review sessions, etc. There's also cross-team meetings. Think about architectural synchronization sessions, thinking time deadlines between dependent teams, etc.  Everyone else mostly listening, like in a presentation setting. But there's also lunch breaks, very informal. Sometimes people talk about the work, sometimes they don't. Much like the coffee machine lunch breaks mean that information can flow across team boundaries but also team members are being bonded together. And that adds much longer sessions than what happens next to the coffee machine. So with that in mind, with all of those different types of office communication in mind, think about which purposes for communication you can think of. Could be mentoring, could be teaching, what else is there. And after that, think about which properties of communication can you think of. Think about confidential versus transparent, which other properties are there. And we'll give you again three minutes to think about that. The S&P URL still is in the lower right corner. And people go through that and think about how to move that to an online first or remote first setting. Some of the purposes of communication that you could have thought of are, for instance, giving feedback to someone. That's something that within an open source project we are fairly used to. Think of pull requests coming in where you give feedback on how to improve the pull request. There's also a purpose of socializing. Think about the coffee machine chat. But there's also things like resolve and conflict, which is harder to do in a written-only context. There's also things like making decisions. Think about moving towards one architectural path. But there's also things like teaching, motivating people, or simply sharing information. Now, if you think about different communication channels that we are used to in open source projects, it could be something that is either archived or it's something that could be deniable. For project decisions, architectural decisions, all of these should be archived. But some of the conversations likely should be deniable. Think about someone sharing with you where that project is being used, where the users themselves don't want to disclose to the wider public that they are using that project, but they still want to be involved, they still want to contribute to it. Think about communication being transparent versus private. Technological decisions, process decisions, all of those likely should be transparent. Once it goes to people decisions, personal feedbacks, that's something that should be private. Communication channels also can be either higher bandwidth or low bandwidth. Think about meeting face-to-face over lunch that's very high bandwidth.  A lot of that is missing in typical open source communication which tends to be written first. So the goals of remote first should be to gain flexibility both in terms of location and in terms of time. So we shouldn't simply take office communication and move it as is to remote communication, simply replacing face-to-face communication with video calls. This won't give us the full potential. Still we want to transform office communication to digital alternatives, but likely we will have to take different paths. What we also want to achieve as a by-product is to increase innovation speeds through transparency. Think about how communication changed in science during the pandemic. Instead of going through a lengthy publication cycle, scientists shared research results as quickly as they could on pre-print servers. That meant that a lot more conversations were made public, it also meant that a lot more mistakes were made public. But it also meant that innovation could move way faster than any time before. For the general public it also meant getting used to scientists making mistakes. It also meant that publications that before had the reputation of being correct and well-checked suddenly meant that there could be errors in there and the entire quality process was transparent and visible as well. So we have to learn that making mistakes is okay for as long as we work to correct these mistakes as we move along. So step one, we want to convert in-project communication. This is what I observe in a lot of typical software engineering projects. If you have a question around architecture of component X, typically the answer is go to Bob, he has the answer. Or it's about go to Alice, she knows why this was implemented. Essentially this boils down to mass media where everyone has to talk with everyone. This scales very well up to a team which is roughly two pizzas sized. But it doesn't scale much larger than that because connections grow exponentially and we've learned during the pandemic what exponential growth looks like. Open source does that slightly differently. Especially in Apache ProTechs what you have is a central hub of communication where everyone goes to in order to ask questions, in order to coordinate and in order to make decisions. At Apache those typically are mailing lists. Some of the properties that this communication hub has to have is that it's public and transparent for everyone. That it's archived and archived is searchable. Plus that every message sent to that communication hub can be referenced with a unique URL that is stable over time. So we want to replicate this. We want one hub that everyone communicates in. Of course in a typical setting you do not have just one project. You have multiple projects, a project unicorn and project kitten. Both of these projects have their own hubs with team members communicating through that hub. Now what happens if project kitten depends on project unicorn and has a question? They no longer go to a certain team member, instead they go to the central hub just like everyone else and ask a question there. What is the benefit of this way of working? It means that everyone standing around is seeing the question. Including people who have the same question but didn't dare to ask. And including people who didn't even know that they have that question but are still interested in the answer. On the other hand, it also means that everyone who could potentially contribute an answer has a chance to do so. So you will automatically tap into the knowledge of more than one human being answering that question. Just recently at my workplace we had a question concerning string comparisons. It went to a dev list and the person asking the question in the first place was very surprised by the extensive answers that he received. Not only on the specification but also on the specific implementations within the JD case themselves. So asking a group of people in that way means that everyone can contribute their perspective. And you do not receive repeatedly the same answer because people know which knowledge already was shared. Of course the same can happen the other way around where project unicorn watches project kitten, watches their releases and gets involved. That's a very nice way of communicating for sharing information. You don't need synchronous meetings in order to share information. You can do this very easily in an asynchronous way. We've seen in open source projects that this also works well for motivating people. Where by constantly sending and reinforcing positively good behavior. People can be mentored towards working in a way that matches well with the project goals. It can also work very well for giving feedback. Also doing so asynchronously means you need higher communication skills than when doing so in a face-to-face manner. Because you cannot see a reaction of the other participants directly. You see it if at all was a certain lack of time in between. It can work well for teaching. It can work well for making decisions. But it's harder to resolve conflicts that way and socializing is even harder. It's archived. It's transparent. But if it's written only it also means it's low bandwidth. But there's a nice side effect to this way of communicating. It means that passive communication is created as a side effect of your day-to-day communication. You don't have to sit down and write everything down. But you can rely on having a baseline of documentation already there. Think about those questions that you receive over and over. Those are already answered in the archive. Will everyone search the archive for the answer? Clearly not. But still you can link to previous good answers and provide them again without having to retell them or retype them. Now is that enough in terms of communication channels? We're here at Open Source Summit. That's not asynchronous and it's not written only. So even in Open Source projects we do have additional communication channels. Which I'll say. The one with the highest bandwidth is meeting in person. It's great because humans are great at reading faces. However it's expensive to set up. Not only during the time of the pandemic. But also because they are synchronized in both time and space. Everyone has to have time at the same day during the same time. Think back towards the brainstorming exercise that I built in into this slide deck. In order for it to be kind of inspiring. It helps to have people fill in the survey at the same time watching each other. And influencing what everyone else is writing. It does work asynchronously. But it's faster and it's more inspiring and more creative if you do it together at the same time. Which can mean thinking back towards the purchase of the foundation where you have people in Asia, in Australia, in Africa, in Europe and in America. Someone always has to wake up in the middle of the night in order to participate. Meetings in person are also of course expensive to set up. Because you have to have everyone at the same physical location. So you have to ship people around the globe. Plus it's not particularly durable. It has to be repeated for every human new to the project. Now you can tell me that you record everything that you talk about. But still if someone's joining your community as a new member after 10 years, having to rewatch everything that was set within those 10 years, that's not feasible. It's very good for motivating people. It's very good for socializing. And because you see people face to face, that's also great for solving conflict. You have immediate feedback. You have an immediate back and forth. There's various stories about contributors to open source projects that had a conflict with each other. So it was then resolved either over beverages or over shared meal. It's fairly informal and it's high bandwidth. We can add video chat to that. It's pretty high bandwidth. You still see faces. Also a likely less body language. But it's still pretty expensive to set up because it needs to be synchronous in time. Plus it needs good technology in order to really work. Plus it's fairly durable. So even if you record all those video chats, having to rewatch them is fairly expensive. If you lower the bandwidth a little more, you can include more people. You can have online group chat. It's also cheap to set up. It's still kind of synchronous in time because what you send are tiny sentences, tiny bits of information. It needs a decent client in order to work well. It's pretty durable. You can search and skim locks. But have you ever tried to deduce architectural decisions from IRC locks or even Slack locks? It's still very hard because it's fairly unstructured. You can add a bit of structure to that, create a web forum or mailing lists. Slow bandwidth because it's usually text only, maybe with graphical emojis. It's also cheap to set up. It's asynchronous. It doesn't need any special technology. Plus it's pretty durable. You can search. You can follow archive discussions. And typically texts are longer, providing more context. Same with mailing lists and a decent client plus an archive. You can add more structure to that by using an issue tracker. It's asynchronous. It's well-structured. But still it's fairly fine-grained because it moves in very small increments. So it can be very hard to piece together the entire picture of an architectural decision. For that, you can use wiki pages in order to give higher level views. Or you can move to something that is very durable but also takes time to set up, which is to provide a web page which gives higher level overviews, not only for first-time users, but also on how to get involved with your project and also on what the architecture of your project looks like, what changes look like. So to summarize, what you want to create is one canonical place in order to keep current status, which should be provided as self-service. If someone is working on an issue, it should be made transparent in your issue tracker. You want one canonical place in order to keep documentation and the goal here is to avoid repeating yourself. Plus you want one place where you track previous decisions. What you achieve by that is that you provide your project with a long-term memory. So what about the coffee machine chat? What we've replaced so far are all of the formal conversations. What about the deniable, informal, incidental communications? Head over to the other pad and think about which types of ways you found in order to replace coffee machine communications, lunch communications in a remote first setting. Ready, steady, go. Giving you two minutes, half a minute to go. Okay, now let's head over to step three, scaling decision-making through transparency. So far we've looked at teaching and resolving conflicts and socializing setting goals, sharing information, motivating feedback. We haven't looked at making decisions so far in detail. I will pick one example which is how to make a meeting with dozens of agenda items take an hour or less. A lot of this is based on experience I've made at the Apache Software Foundation on how they run their board meetings. Okay, what's the secret? The secret is to make agenda items available for reading well ahead of time and the agenda items there doesn't mean only bullet points of what we want to talk about. It's really the bullet point plus all of the content below so that all of that can be read ahead of time. So you don't have to use precious meeting time just for sharing the information on the content that you want to discuss. This is shared ahead of time. Plus you enable pre-approvals.  Fine, fine by me. Go ahead. You can mark this as pre-approved and if enough people do that it won't appear in the meeting because enough people pre-approved it except when someone says I want to discuss this. So a lot of the items are moved out already by this process. Now you ask yourself certainly there are some items where you have tiny questions where you need a little bit of clarification. In order to enable that, you enable asynchronous communication in order to clear questions. If there's a tiny glitch, if there's a misunderstanding that can be cleared asynchronously before the meeting next agenda item that moves out of the agenda. Now this looks like rocket science, doesn't it? Actually it's not. It's a text file put into version control. This text file essentially is the meeting notes. So you can read through everything that would have happened in that meeting that you know before the meeting happens. Participants can go through and mark writing into this text file which items they pre-with, which items they pre-approved. Now because of course the text file for meeting minutes at the Patria Software Foundation is a bit longer than the average letter page there is a web app on top which reads the text file and which generates comments but at the end of the day it's just a text file. So for communication what they use simply is a teleconference. You can dial into it, there's a video conference part in it where you communicate about that plus they go through that text file piece by piece. Of course again because it's rather lengthy so the web application that helps the secretary goes through the meeting where every participant can follow the course of the meeting in the agenda and where additional comments are being made just in time. Now in order to keep conversation on the verbal channel on topic and in focus what they also added is a back channel, written back channel essentially IOC is like whatever, just a chat where back chatter can happen. All of the socializing, all of the little jokes but also all of the little additions all of the tiny corrections can go to chat where they are being picked up. Now take that to the next level, how to make transparent and open decisions that's mostly based on things I learned at Apache but also from the book The Open Organization. In Open Organization there is a sentence that was really interesting to me in order to drive engagement and collaboration to the roots of an organization you need to get people involved in the decision making process. Okay, makes sense except that at Apache we have more than just three people. Let's read on. While making an executive decision by Fiat is fast but that's when the real hard work starts. This is a funny thing, you make a decision and then the lengthy change process starts at the end of which you have finally reached a state where everyone is working according to your decision. If you manage to engage people in the decision making process this change management becomes unimportant so you start your decision making process and then you hit the road running. So the funny thing is that the leader's role then becomes making sisters and parents decisions integrating everyone but making change management itself superfluous. How does that work? Well in open source we do not only open the software a lot of people would agree with me that simply taking a piece of software that is ready flapping an open source license to it and publishing it doesn't help very much maybe to some extent because it adds to transparency but where you reap the real benefit is by also opening up the creation process opening up architectural decisions as they are being made and opening up towards influence from other players including your competitors. Now you do the same in your organization when you make decisions. You engage with people even though it takes a ton of time you do not only explain what you are doing but you also explain why you are doing stuff. Now if it feels overwhelming at some point in time likely someone is moving too fast making these kinds of transparent decisions and engaging people in this decision making process takes time however those slower decisions typically lead to better results because as soon as a decision is made likely a lot of these stakeholders already have been engaged. In order to do that you enable asynchronous communication in order to prepare consensus. You communicate about an outstanding decision ahead of time and you prepare consensus asynchronously. That means that only those pieces of that decision that are really controversial have to be discussed face to face. So you save precious meeting time for the pieces in the decision where you actually need this precious meeting time and you can focus on stuff that is controversial. You leverage your soapbox in order to poke and prod on issues that you believe are important but you also share plans early and now comes the hard part you share them even if they are half-baked because only that way and that release early release often manner it's possible to receive feedback to refine your plan and to make small and reversible steps.  It also means that you have to create an organization and making mistakes is okay. That way you inspire other volunteers to become active, to help you out and to provide their vision and their knowledge and their expertise in your organization. Now how to do a lot of that is being explained in INOSOS. There is an organization called the INOSOS Commons which is collecting patterns for collaboration and for transparent communication in organizations. It tries to move patterns how we communicate in open source projects into organizations themselves. Essentially what I've once heard people say it's where you go for the patterns but you stay for the community. Careful it's just one step on a journey. The goal is to train more humans in open source practices but not only to make those organizations internally more efficient and more innovative it also means lowering the barrier to get involved upstream. One of the feedbacks that I heard from many people that is most challenging and frightening is the way we communicate in open source. Very transparent. Transparent to the point where our communication is public. Now all our mistakes are public. We have our way of thinking our way of decision making is public. It takes a certain level of training a certain level of getting used to in order to become comfortable in this way of communicating and in order to understand all of the benefits that this communication brings with it including early feedback including learning including getting better including collaborating and communicating across boundaries building bridges between organizations that otherwise would not collaborate. So essentially using those practices means teaching people all of the advantages that come with them in order to lower the barrier for them to get involved upstream. And here's the funny piece it actually works. I do know people who started out working in an InnoSource project and his end became much more comfortable communicating and helping projects in the open source world that they rely on on a day to day basis in order to get their work done. And with that I would like to thank you for your time today and I'm happy to take any questions either synchronously in chat or asynchronously afterwards through whatever channel you would like. Thank you and bye bye.


Nice, there's like no traffic. Welcome back to another vlog. It's currently Saturday morning. It's a chilly gloomy day and I am headed to the salon. I was supposed to have a color client this morning but she canceled earlier this week and at the time I was like a little bit bummed out about it but honestly today I'm so grateful because I'm just really not in the mood but I am doing two of my co-workers hair.  I don't need to impress them. But the one co-worker whose hair I'm doing is our massage therapist so we are doing a trade. She's gonna give me a massage later. I think I might just be giving her a blowout and then my second co-worker is just getting a trim but I'm really looking forward to this massage. I've just been having one of those weeks where I've just felt very blot and gross. I feel like this always happens when I get my period because like I just physically feel disgusting. You know, like I just feel all bloated and my skin is like not its best. Like I got a pimple and you know, just feel meh. And like my lashes really need to be filled. So just in general, I like haven't been feeling the best. I've been having like really bad body image because I'm like so bloated and I just physically feel so like uncomfortable and heavy. So I'm trying to just do some self-care things to pull me out of that funk and get back to feeling like myself. Now I look even crazier than I did. I don't know what's going on with this hair. See, this is why I don't wear my hair natural that often because it just gets wild. If I had just blown it out, it would look totally fine right now. That was a good day. It was nice and easy and the massage was amazing. That woman is a miracle worker. I've been having a lot of muscle pain around my knee, my right knee. Ever since I started lifting again, the first few weeks I was doing it, I was not good about warming up and stretching and yeah, my knee has just been pretty swollen and really tight and it would hurt to bend it past a certain point. I've been sleeping with it elevated, drinking a ton of water, stretching it, using resistance bands, all that kind of good stuff for it and then her just getting really into the muscle and giving everything a deep massage. I feel it's also going to help a lot. It already feels so much better. So I'm gonna be better about stretching and warming up and taking my time because obviously I don't want to cause any injuries. So yeah, lesson learned. I feel so relaxed and zen now. So I am just going to head home. Okay, this vlog took a little bit of a turn. I was planning on coming home and like doing some self-care things but I got home and I was so exhausted. I don't know if it was the after effects of the massage or what, but I ended up taking a nap and then I just put a little clay mask on that pimple that I had because it was starting to hurt and just look disgusting.  Oh, and after I woke up from my nap, I was starting to feel a little bit weird. Like my throat was kind of feeling a little sore.  I'm feeling okay now.  And I'm just gonna watch movies and relax the rest of the night. It's 7.30 on a Saturday. Love that for me, but I'll see you in the morning and we'll do some more mood boosting stuff then. Hello, it's the next morning. My hair is still looking crazy. The saga continues. We're gonna get it together today. My whole process is feel better physically because like I said, I was feeling so bloated and swollen from it being that time of the month.  So we got that sorted out yesterday. I'm feeling so much better. My period is now done and I'm feeling just less bloated all around. Next thing I wanna do is go to the gym. I'm gonna make sure I do a nice long warmup and stretch and everything before I actually start. I do my lifting first and then I usually will do like 20 to 30 minutes of incline walking on the treadmill afterwards just to get like a little bit of cardio in. And then I can come back here, shower, and finally do something about this hair and further pull myself out of the funk. It's finally time to take a shower and wash this hair. A shower always makes me instantly feel 10 times better. And it was one of those nice long showers where I shaved, exfoliated, about to get some good sense going in here. There's nothing better than having a clean apartment and then lighting some candles, cracking the window, getting some fresh air. This one I've been obsessed with lately and I've already burned it. I wanna say this is like probably at least the fourth or fifth time and like look how much is still left. It's really powerful, but it doesn't burn super fast. This candle is from dossier. They are sponsoring this portion of the vlog. If you guys have been watching me for a while, you know I'm always raving about dossier and using their perfumes literally on a daily basis. They make dupes for designer fragrances and they also now make candles in some of those same fragrances. This one smells amazing. It just smells like a sexy man, but I will show you my dossier collection. I have a lot of fragrances from them now and some of my favorites are the Ambry Saffron, Powdery Hawthorne and Floral Berries. This one I actually used as a white elephant gift for my salon's Christmas party and people were literally fighting over this because it smells so good. Dossier's fragrances start at $29 and they're just as high quality and smell exactly the same as the designer fragrances that they're inspired by, but for a fraction of the price. And yeah, I'm super excited that they have candles now because I am also a really big candle person. If you wanna try out dossier for yourself, I do have a discount code. I will have the link and that code, everything you need to know in the description. So go ahead and check that out. Thank you so much dossier for continuing to work with me. They have been a very loyal sponsor to this channel and I really appreciate it because nowadays sponsorships are just necessary. Sorry, my dishwasher is running. Anyway, I am going to lotion up now because that's another thing that will make me feel so blah and like gross is ashy skin. So I always use the Palmer's Cocoa Butter. I get the big value size bottle at Target or Walmart and I just put this all over my body. I'm gonna be honest, when I was getting my massage yesterday I was like, ooh, my toes are looking rough. Feet are rough. Legs are hairy and dry and I just was not, you know, feeling my best. Another thing that's part of my regular everyday routine after I get out of the shower is this PFB. It's a post waxing and shaving serum. You just roll it on and it's just basically like a light chemical exfoliator and it helps to prevent ingrown hairs, which I tend to get. So I put this on my bikini area. I use this a few times a week and then I will like manually exfoliate and it's amazing and so satisfying if there are any ingrown hairs that are starting to form they just like pop right out. Like why is that stuff so satisfying? Picking out ingrown hairs, like popping pimples and stuff. It's so gross but it's so satisfying. Next, I want to do a face mask because I showed you guys this breakout that I got. It did pop this morning. Like after I rubbed off that clay mask it really sucked everything out, which is nice. So it's pretty flat now at this point but it's still like really red and inflamed. So I'm gonna put on the Origins Original Skin Retecturizing Mask with Rose Clay.  It feels kind of cold when you first put it on which feels nice.  Doing a face mask always makes me feel better. Like literally take a shower, light a candle, put on a face mask or light a candle, put on a face mask and take a bath. I like to bring it down like under my jaw too because sometimes I get a little like congestion under there. So that's gonna sit on for a few minutes. Next, I'm gonna give myself a little pedicure. Well sort of, not like an actual pedicure I guess. I just need to cut and repaint my toenails. It's bad. So we're not gonna do anything fancy. I'm just gonna use some acetone to take off the remainder of the little bit of polish I have left and some nail clippers. I think that's a nail file. Make sure they're nice and smooth and I don't have too many nail polishes left these days because I normally go and get my nails done. I think that'll be good. This is a nice nude. My vampire is buff.  These are all the nail polishes that I have. These ones are all gel and I don't have my gel machine here. I left it at my parents' house and I don't feel like bothering doing gel right now anyway. But so these are like all the regular colors. So I just have a lot of like bright neons or like darker colors. So yeah, I'm feeling a lighter color and I have this Essie top coat. I'm really bad at doing my own nails but I just don't really feel like spending the money to go get a pedicure right now. And I feel like it will be kind of therapeutic and relaxing to just do it myself. And I'm gonna watch a video while I do that. I've been watching the show The Last of Us on HBO. Amazing, fantastic, love it. And it's based on a video game and years ago when the game first came out, I remember watching PewDiePie do like a play through of it but I had never finished watching the full game play like all the way through. So now that I'm watching the show, I'm like, okay, well, I wanna see what happens in the game so that I can compare it to the show, like what things are similar, what things are they changing? And also I just kind of wanna know like what's coming next. So I started watching PewDiePie playing the game again from the beginning. This game, it is kind of like a movie at the same time because there's a lot of these like cut scenes and it's just an interesting story. Comment down below, let me know if you're also watching The Last of Us. I am going to continue watching this while I do my toenails. Also, I'm gonna put on some clothes so that I don't flash you. I am so lost. Let's go away. Not good, but certainly a lot better than they were. So now I'm gonna dye my eyebrows. I do this like once a month or so. I feel like right now, I just kind of need a little bit of a touch up because they are still kind of dark towards the inner part but the tails, especially on this side is looking pretty light. And I always know that it's time to touch them up when I am spending more time filling them in when I do my makeup. So I just eyeball it and I try to get equal parts hair color with equal parts, 10 volume developer.  This is four stroke, seven one from Wella. It's just like a dark chocolate brown. She was like, so she said that her son, I don't know what he's going to school to be, but I think by the doctor, they will study and should be done. Okay, sorry, I took a little break, but here's how the brows came out. See how they're just darker and like more filled in in the tail? This eyebrow is naturally fuller than this one, which is kind of annoying, but whatever it is what it is. But I got sushi delivered. It was so good.  And I actually had a free trial of Uber one. So you get like free delivery and like reduced service fees and all that kind of stuff. And the trial is going to be up in like two weeks. So I was like, you know what? Let me take advantage of it and get some delivery while I still have that free trial. And now I'm about to blow dry my hair, but of course I'm like, I feel like my hair air dried so cute. Like these curls look cute and a little more tame, but I want to blow it out. It's just easier to deal with when it's smooth because it just doesn't get as tangled and as frizzy and crazy. Yes, I have to put some heat on it to blow it out, but then it's good for like the whole rest of the week. This is my Dyson supersonic professional blow dryer. I can love this thing. And by the way, I did get that Amazon dupe and I'm in the process of doing an in-depth review on it. I've used it twice so far. That video will be coming next. It's either going to be the one right after this vlog or like in two videos from now. So stay tuned for that. I don't want to give anything away because I want you to just like be able to see that video and see it for yourself. But all I'm going to say is if you were thinking about getting that one, wait till you see my video first. I'm putting this Lanza Healing Oil Bounce Up Spray in my hair. This is just like a blow dry spray. Gives heat protection. And then I'm going to put some of this Lanza Root Effects Moose. You spray this at your root. I just put a little bit. I really like this stuff, but I find that if you go a little too crazy with it, it just feels like too much. It almost makes your hair feel kind of dirty. Let's blow dry this real quick. So much better. Now I'm just going to put some dry shampoo in it. I always do that. That's my little secret to making my style last longer and not letting my hair get greasy as quickly as I put dry shampoo in my hair when it's clean, freshly washed. I just lift my hair up and I spray it like just below the root. Like I'm not aiming for my scalp and I don't spray it like directly on my part. That way if I accidentally apply a little bit too much, I don't have to worry about a white cast. But I like this one. This is the Not Your Mother's Beach Babe texturizing dry shampoo. I'll even spray this like throughout the ends of my hair sometimes, especially if I'm like adding waves to it or something to give it a little bit of texture and grit. And whether you prefer the look of my curly hair or not, it just, it feels nicer on my head to just have it blown out straight.  Like no, leave the curls. Good morning. Oh, I'm so excited to go get my lashes filled today. My appointment's in like an hour. This eye is like really, really bad. This one's not so terrible. So that's my first appointment of the day. And then I am going for a laser treatment, which I'm excited about like starting this process. But I'm also nervous, not really nervous. Like I can handle pain pretty well, but like I know this is gonna be uncomfortable physically. So not really looking forward to that. But I've mentioned before that I got a boob job two and a half years ago. I got a breast lift on one side and then I got an augmentation, but I got keloid scars. And I did everything. Like I used all the scar cream. I followed all the aftercare instructions. I've been using like the silicone sticky things that they say to put on your scars. Like cocoa butter every single day and nothing is helping. There's a client at the salon where I work that is a PA and she owns her own practice and she does like Botox and injections and stuff like that. And she also has this laser. If everyone it's called, I'll give you more information later when we get there. But I was talking to her about, you know, my concerns, I showed her my scars and she said that this laser treatment that she does would be perfect for it. It's not gonna be like an instant overnight thing. It's gonna take, you know, over this man of a few months. I'm just excited to like start this process finally.  I just put on a little sunscreen.  So no sense in putting anything on my face because it's just gonna get messed up. I'm just gonna get dressed, take Benny out for a walk real quick and then head to my lash appointment. Oh, and then I'm gonna have like a gap of time between appointments. So I'm gonna pop into Sephora because I want some more rare beauty liquid blush. And I just wanna like take a look around also and just, I don't know. I haven't like gone makeup shopping in a while. Okay, here is the outfit for today. This crop top is from H&M. These pants I got from Aerie. I don't think they're still available. I tried finding them on the website. I had got them in store in the clearance section and I think they were like one of the last pairs left. They're just kind of like a wide leg sweatpants. They have some distressing on them, but I just, they're so flattering. I love them. And then I'm wearing my new balance sneakers. This bag is from H&M men's section. And then these sunglasses, I got these on Amazon. I do really like them though because they're comfortable and they're polarized. So they really do a good job. Like I have some sunglasses that they're just for looks really, but they don't do much for blocking out the sun. But these actually really do something for me. So yeah, I like them.  Here's the lashes after. So much better. And now we are at Coles right across the street. We don't have a standalone Sephora here unfortunately, but we have a Sephora in JCPenney and then Sephora in Coles, which this one's actually pretty decent. So let's go in and see what we can find. I'm home. I stopped at Trader Joe's on my way home. So let me just show you, well, I put the stuff away. Just show you everything I got. I got this mushroom and black truffle flatbread with mozzarella cheese. It sounded intriguing. Although now watching the last of us mushrooms freak me out. Then I got some salmon, chicken sausage and ground turkey. I got some Brussels sprouts, which I am obsessed with. I just, I love Brussels sprouts so much. I could literally eat them every single day. And then I got green beans. I also got, this was kind of an impulse thing. I just thought some roasted potatoes sounded really good. Like even for breakfast, like, you know, on the side with some eggs or something. And then I got some more protein powder. I got this other one recently and I hate it. It's just way too sweet. And there's zero grams of sugar. It's just like, there's an artificial sweetener, I guess, in it. And it's just way too much. Like I do not like it at all whatsoever. But this one, I love, it's really good. But it's not super sweet. If there's a protein powder that you take, that you like, comment down below, let me know what it is. As long as it's not something that's like super sweet or has like a really strong artificial taste because I hate that. And I am not really a chocolate person. So I prefer vanilla flavor. So let me know. And then I got these cookies. I've had these before, I'm pretty sure. The dark chocolate chunk and almond cookies. I always have to have something sweet around just in case I get that craving. So Sephora, I mainly was just interested in getting another Rare Beauty liquid blush. They were completely sold out of everything. They didn't even have like testers left. But everyone has been raving about this Illia Super Serum Skin Tint. My one co-worker uses this and loves it. Her skin always looks amazing. And they barely had any of these left. What's nice is like this is kind of more sheer since it's skin tint. So you don't have to be like too, too precise with the color match. It has broad spectrum SPF 40 sunscreen, niacinamide, squalene and hyaluronic acid. So it's hydrating with natural protection. I always put skincare on my face no matter what. I always put on SPF. So if I can have something that has a little bit of a tint that will kind of even out my skin tone on like a light makeup or no makeup kind of day, why not, right? Although everybody keeps saying that the smell is really weird and gross, which I agree it does have a very gross smell at first.  I think I'm just going to apply it with my hands. Let me give it a good shake first. And I got the shade 11.5. So it has like a squeezer, dropper, kind of applicator. Oh, this is thicker. Oh God, yeah, that smells really bad. Ew. Ooh. Okay, this is, I was expecting it to be like way more sheer and like liquidy. And I do feel like that's a really good shade match. They were completely out. This was literally the only one left in this shade and the only one left in like the medium range. All that they had otherwise were really dark shades or really, really light. So this was my only option anyway, but I do feel like it's a good match. I really like that a lot. Okay. And I like that I can just rub it in with my hands because I feel like I'm wasting less product that way. Let me show you a natural light. I would say it's like a natural like set in the kind of finish. Like you obviously can see my skin through it but you see how like I have these little red, like old breakouts and obviously you can still see them but it definitely blurred them and you can't see as much of the redness compared to before. I probably could add a second layer if I wanted to like build it up just a tiny bit more and it would be really pretty for just like a light natural makeup or I could just do the one layer like this and literally just leave the house like this and it wouldn't look weird without putting on like bronzer and blush and like other stuff, you know? I could wear it just by itself just to like even out my skin tone a little bit and then obviously get like the SPF benefits and whatnot. Ooh, and it like, what a good match, right? You can't even tell. Honestly, I was not expecting to like this much. Wow. I thought it was gonna feel kind of greasy on my face and I was gonna be like eh, not worth it, gonna return it. I'm gonna just leave it on the rest of the day and then I'll show you tonight before I wash my face how it's looking and I'll let you know how it feels and stuff but that's really, really pretty. Anyway, I want to tell you how the laser treatment went. It was really quick. I was in and out of there in like maybe 30 minutes. Honestly, the longest part of it was sitting with the numbing cream on. So she just applied like a topical numbing cream to the areas and I had to just sit there with that on for like 10 minutes or so and then the actual laser treatment itself, I didn't get any clips of it because obviously I can't show her doing it because of the area it's getting done on.  It's not, it's different from like a traditional old school laser or like an IPL laser or like a laser hair removal type of laser. It's not like snapping and zapping at the skin. It's like done with a frequency. It's not hot or anything. It's literally just feels like a little shock. Obviously I did feel it.  It was like uncomfortable but we were talking through it the whole time and honestly it was so quick. I don't think she was doing it from honestly more than like maybe five to 10 minutes tops. It was so quick. It was more of just like an annoying, uncomfortable feeling. Like I just kind of wanted to like swat her off like, ugh, stop. But I have no hesitation going and doing it again and she said that there's no downtime. She said it's just gonna feel kind of hot and like a sunburn for a few hours. And I mean, at this point, it's been an hour since I left there and I feel fine. I don't feel uncomfortable at all. Like I feel no irritation. She said that I have to wait at least four weeks before my next treatment. So we scheduled that for five weeks from today and she said it could take three to four sessions to like fully get the results that I'm looking for. Pricing wise, obviously it's gonna depend on the size of the area you're getting done and who you're going to, where you live, all of that. But she charged me a hundred bucks. I have to get a little bit of work done. I'll check back in with you later and I'll give you an update on how I'm liking this Ilya stuff. It's a few hours later. I just made dinner. Oh my God, I'm so excited. It smells so good. I made that chicken sausage that I got earlier. I just cut it up into some chunks and just sauteed it in a pan. Made some jasmine rice and then roasted Brussels sprouts. I've been putting this sweet chili sauce also from Trader Joe's on top. Just drizzle some olive oil, salt, pepper, the chili sauce, put it in the air fryer for like 10 to 15 minutes, bomb. My friend is trying to FaceTime me. So I'm gonna go chat while I eat. Also I put on my robe because I was getting kind of chilly. Are we all here? Yeah. Okay, it is now, this lighting, not good. There we go. It's now seven o'clock. The sun has officially gone down. I made myself some chamomile tea. I wanted to show you how the skin tint looks. Obviously I didn't have it on for a full day but it's been like at least five hours and it still feels really good. Like I don't feel like I have anything on my skin.  I am definitely going to wear it again tomorrow and I'm gonna spot conceal with concealer, like the little areas where I have like extra redness and dark spots. And then I'm gonna put it on top of that and see if I can get like an even smoother base and I'm gonna wear it all day and I will report back to you guys. So stay tuned for my next vlog. I'm gonna end this one here so that I can edit it and get it up in the morning. Oh, and also update on the laser areas I got lasered. I still have not felt like any kind of hotness or burning or irritation or anything. Like she said that it might feel like I got a sunburn and I don't feel that. Like I honestly keep forgetting that I even got the treatment done at all. So that's good because I was a little bit nervous about that, that it was gonna be uncomfortable for the rest of the day. That's another thing that I'll continue to update you guys on in future vlogs. So make sure that you're subscribed and have the notifications turned on so you don't miss my future uploads and I will see you guys really soon in my next video. Bye.