All right. Well, it's eight o'clock. Time to get started with grand rounds. So I've got refractive grand rounds this morning. Thank you for joining us. So we've got three talks. First, one of our fellows, Cole Millican, is going to give a talk on updating on ICL's, indications in sizing, and then Brian Zog and I have some basic related talks. All right. Cole Millican, one of the cornea refractive surgery fellows for the people I haven't met in the audience. So the talk itself is not meant to be a comprehensive review of all data pertaining to ICL, but maybe to give those that aren't familiar with the technology kind of an overview of how to approach it in the clinic and maybe some of the senior residents that are going into end-tier segment surgery, how to approach it in their own office-based surgery. So quick history of the ICL. The ICL is a posterior chamber-facic IOL, which essentially means that it sits anterior to the lens capsule and posterior to the iris right in the ciliary sulcus. And the idea of a posterior chamber IOL is actually not new, maybe out of the scope of this discussion, but there are a couple prior iterations to posterior chamber IOLs and maybe some of the more senior surgeons. Remember these IOLs, one of them was the Chiron posterior chamber IOL, and then the PRL-facic refractive lens. And both of those have been since discontinued, one caused quite a bit of AC inflammation, and the other I think had a kind of a predisposition to slip into the vitreous cavity. So both of those are discontinued, and being as such, ICL right now is currently the only FDA approved posterior chamber-facic IOL on the market. And a lot of us think of this as a new technology, but it's really not. So it was actually released by STAR in 1993, and it gained its FDA approval in 2006. So it's got a couple newer iterations of it, the EVO and the EVO plus ICL. And as you see here pictured on the slide, this is the EVO ICL, and these little ports in the center and on the side facilitate the flow of aqueous. So it decreases the incidence of anterior subcapsular cataracts, and then with the allowing of aqueous through the port, it'll decrease the incidence of pupillary block, and surgeons no longer need to make a peripheral iridotomy with these type of lenses. In addition to spherical correction, there's a toric version available, and that can correct up to four diopters of sill in the spectacle plane. So classically, I think when we think of ICL, we think about using it for patients that may not be candidates for laser refractive surgery. And this is all patient dependent, could include patients within pochimetry, history of inflammatory disease or corneal ectasia that exclude them from having LASIK or PRK. So it's different for every patient and surgeon, but typically speaking to our cornea team, a lot of times we'll introduce the idea of an ICL around a minus six. That being said, the indications for treating myopia are a little bit broader than that. So the FDA approved indications treat a range of myopia from a minus three all the way to a minus 15. And then in addition to that, the goal of your treatment, if you have a minus 20 patient walk into your office and they're looking for a refractive option, could be to reduce the level of myopia in those patients. So if you have a minus 20 patient and you implant an ICL that corrects them up to a minus 15, then they may be a candidate for an additional laser refractive surgery on top of that. The age and the anterior chamber depth are interesting in the FDA indications. Currently it's FDA approved for patients that are 21 to 45 years old. Overseas, that's expanded a little bit. So it's approved for patients that are 21 to 60 years old. So if you were to put this type of lens in a 50 year old patient, you wouldn't necessarily be wrong to do so, just knowing that it would be an off label FDA indication. Additionally, anterior chamber depth, there is some flexibility in terms of how you approach this, but that should be a little bit of a harder deadline for you. So the FDA indications approve it to a three millimeter anterior chamber depth. Some surgeons that use this more frequently will treat patients up to a 2.7 or 2.8 millimeter anterior chamber depth, and those are indications that are being used in Europe. That being said, going anything below a 2.7 or 2.8 millimeter anterior chamber depth can introduce problems in terms of sizing, having a little bit higher than expected vault of the lens may cause iris chafing and endothelial cell loss. So that should be a little bit strict or cut off for you in approaching patients in a preoperative exam. And then additionally, you want to see a stable refractive history. Contraindications I'll review here include pregnancy, anybody that's got a closed anterior chamber angle, low endothelial cell count, and they kind of guide that by age requirements, but typically anything over about 2000 cells will keep you out of trouble. And then additionally in the United States, it's currently only being approved for myopic patients, but overseas they're using it to correct hyperopia as well. So your preoperative evaluation should include a manifest refraction, a cycloplegic refraction, a measurement of white to white, which sounds simple, but it actually isn't. There's kind of some discussion on how to approach the measurement of white to white in order to size your lens. Agonioscopy exam, so you can look at their angle endothelial cell count in a dial aged exam. Now, the sizing of the ICL is probably one of the most crucial components to making it a successful procedure. And when we talk about the vault, the ICL is vaulted over the natural fakic lens, but it's sitting below the iris. So the ideal size of this vault is somewhere between 250 and 750 microns. If you leave them with too little vault, it's going to hug the anterior capsule of the lens, and it's going to give you an anterior subcapsular cataract. If you create too much vault over that 750, you can imagine that it's going to be bowing into the iris, can cause iris chafing. And prior to the new iteration of the EVO ICL, you may have had some pupillary block glaucoma. So there's a sweet spot in between the two. And the way that we control the amount of vaults is by changing the size of the lens. So you can imagine it's kind of like contact lens problem on your OCAPs or boards. The larger the lens, the more that's going to bow anteriorly. The more vault that you're going to have, which may lead to trouble in terms of iris chafing or pupillary block. And then the opposite is true, too small of a lens, and it's going to hug that anterior capsule. So here's a good picture of a UBM, and you can see that lens vaulting over the anterior chamber, but just below the iris surface. So really important component of using the ICL is to accurately size it. And in order to accurately size the vault, it's very important to get an accurate white to white or sulcus to sulcus measurement for the patient, because the sizing of the lens depends on that measurement. Now the ICL doesn't necessarily come in custom sizes. So there's four preset sizes that include a 12.1, 12.6, 13.2, and 13.7 size lens. And there was a really nice study that was performed by Dr. Wong and his group, and he compared the different tools that we use to measure white to white, because, believe it or not, with all our biometers, there's lots of different ways to obtain this measurement. So he included in his study a measurement with the PenaCam, a measurement with the OrbScan IOL Master, and then he used these Castro Viejo forceps here. The study included 107 eyes, and it compared the white to white measurements using each of these different technologies. And what he found is that when you're using the IOL Master and the PenaCam, it predictably overestimated the size of the white to white and oversized the lens, and he found that OrbScan and the calipers were actually the most likely thing to accurately size a lens with the desired vault of 250 to 750 microns. So very similar to IOL selection, people have kind of taken this information and run with it, so you can get into the weeds as much as you want in terms of sizing and refractive outcomes of the lenses. There was a really nice study done by Dr. Moshefar, and he tried to summit the different nomograms that are being used to size the ICLs. So in that paper they reviewed over 18 different nomograms, and here's some of those listed to the left. And the difficult part about it was there wasn't necessarily a consensus as to this formula is better than this formula all of the time, but it's patient-dependent. So some of the formulas worked better for patients with certain size, white to white measurements, others worked better in other scenarios. I found a simple approach to looking at these is the one that is produced by the manufacturer, so the star nomogram, which is I know what we use here at the Moran. There are nomograms that require topography or biometry, so using your PenaCam or your IOL master, and then there are nomograms that require UBM, so you need an ultrasound in order to do it. Now the UBM is kind of an interesting component of it because you really have to trust the person that's taking your ultrasound. I know Dr. Zogg and I were looking at one yesterday, and there's kind of blurred lines in where you're going to measure that sulcus to sulcus measurement, so you have to get really, really accurate pictures of the sulcus, and you have to have somebody that you really trust taking those measurements. And then one of the newer developments are these nomograms that utilize machine learning, which is kind of a cool application at AI. I think that the majority of surgeons are using the star nomogram at this time, so I'll review that one. As I mentioned, it's created by the manufacturer, and its requirements are a white-to-white measurement, the ICL power, keratometry measurements, corneal thickness, and an ACD measurement. So there were a couple studies kind of in my literature review that showed when you're using the star nomogram, you need to be a little bit careful, especially for the larger size lenses. So if you're implanting one of the 13.7 size lenses, it was shown that the star nomogram can sometimes underestimate, and you'll get an oversized ICL, and you'll have more vault than you originally anticipated with that. So be really careful if you're borderline in between one of the larger size lenses, maybe the 13.2 or the 13.7 size lens, and one of the alternatives that they suggested was using this optimized white-to-white formula. So it uses all the same variables, but it's better for the patients that are at risk for a high postoperative vault. So if you're putting in a larger lens, you may benefit from having a patient run through this optimized white-to-white formula instead of using the star nomogram, and it's just an extra kind of word of caution on that. In general, when reviewing all the different nomograms, the formulas that were able to successfully use UBM and have somebody that was accurately taking those photos were more accurate in predicting postoperative vault than the ones that use biometry and topography. Overall, the two had very similar refractive results. And then one word that's worth mentioning, there was a study done in military patients where they actually showed that over time, the ICL, well, you'll have a decrease in vault. So over the course of a seven to eight-year postoperative period, those patients that had high initial vault generally flattened over time. So when discussing any refractive technology, I think it's important to go over outcomes. And the first off, we can review some of the FDA trial outcomes. And this was over a three-year follow-up period. And it separated them into different levels of myopia. So patients with a less than minus seven correction, 98% achieved greater than 20-20-year greater corrected vision. Patients with a minus seven to minus 10, 87% received 20-20-year greater vision. And then the people with the larger myopic corrections being the minus 10 plus, 84% of those had vision better than 20 over 40. So you can see that the more myopic you are, the higher risk that you come of not getting them to their desired refraction. Uncorrected vision, correct? Yeah. Thank you, Dr. Olson. And then there was an additional review that was performed. It was looking at active duty military members that received ICL technology. And this was reviewed over over 3,000 eyes and an 11-year retrospective review. And their measurement was rate of achieving desired refractive correction. So they found that 97% of those patients received their desired refractive correction at one year, 90% at eight years. And then they measured an adverse event rate at about 1.2, which is interesting because I think they ended up explaining about 4% of those IOLs, ICLs, I'm sorry. The adverse event rate, the most common thing that they noted was anterior subcapsular cataract or iris chafing. And in addition to that, the newer iteration of the ICL, the EVO has an even decreased incidence of the anterior subcapsular cataract with that central port that allows for aqueous flow. A question, Cole, about that military study. Did they include laser touch-ups in the achieving desired refractive correction by one or eight years, especially eight years? No. Just the ICL. Yeah, it was just the ICL. And then I think it's worth mentioning some of the upcoming technology in terms of the ICL. So this is a lens that's being implanted in Europe. It's called the EVO-VIVA. It's an aspheric EDOF-ICL. The indication ranges are 21 to 60-year-old. And it can be used for both fake and pseudo-fake patients. And the idea of it is to be a presbyopia correcting lens. I think their targeted demographic is early presbyopes that are 40 to 50 years old. So this is something that's coming down the line. Off the top of my head in the studies that are being published out of Europe, it seems that it gives you about 1.3 diopter range of vision, although the intention was to give you about two diopter range. But it's something that's interesting coming down the line. And here are my references. Questions? They're on Caranet, which is kind of a worldwide listserv of cornea specialists and anterior segment surgeons. There has been an uptick in discussion about using ICLs as a good piggyback lens. So it's designed for the sulcus. And so I've seen a lot of surgeons that have picked that up a little bit where they might need to do a refractive shift of some kind and don't want to do a corneal procedure. And so they'll throw in an ICL as a piggyback lens. I don't know that I've seen awesome stability studies as far as in pseudophagic patients, if it works well, but just something that I've seen kind of out there. Just kind of walked down memory lane. I actually put a patent in and tried to work with Star to put together a lens that would correct both for dysphotopsia as well as refractive precision and had a design and actually had a patent issued in Australia. And we're still fighting the U.S. patent. And I just had so much going on, let it drop, but that all was submitted and put in place in like 2007. So this is not a new idea. So I had to laugh when I saw that all of a sudden I would be curious to see and I wouldn't surprise me that this also would help with dysphotopsia. So this could be an easy fix for those with bad dysphotopsia with the ICL. One thing I'm surprised that the white to white still has existed because our own Liliana Werner did a study, a seminal study, you know, a long time ago. She's not, I don't think Liliana is here, right, or Nick. So this would be probably 15, 16 years ago in which looking at avarice, you know, in fresco d'avarice inflated normal pressure showing that there was not a really good correlation with white to white with the actual sulcus diameter side to side with, there was big variation. So it, UBM should be, but it is true. That's an art form as well. But I'm amazed that white to white has survived. Dr. Wong, I think in his group, their final recommendation on that paper was to take a caliper measurement. If you're only using white to white was to take a penicam and a caliper measurement and then kind of have the two or take an average of the two just to make sure you're not oversizing it. Kind of kind of kind of a bunch of fudge factors at this point. Hey, it's Nick Mamelos. Am I, am I on now? Am I allowed to speak? You're on. Yes. The study that Liliana did, it was very interesting because she was comparing the UBM measurements, looking at the actual ciliary sulcus as opposed to the white to white. And what we found in that study is, is that the white to white was really inaccurate. And I think the inaccuracies come first of all in defining where the white to white is. And if you look at that, there can be a fudge of, you know, millimeter on each side that can make that inaccurate. And the second thing is that it's not directly related to the measurement that you see in the ciliary sulcus.  It's really better. And you have to have an accurate UBM.  It has to be perpendicular. But the UBM measurements were much more accurate than were the white to white. When you're looking at the actual diameter of the ciliary sulcus. Thank you. I actually have a question. Dr. Wait, I know that you're doing quite a bit of ICL implantation. When do you approach it with patients in terms of having a discussion if there may not be a candidate for laser refractive surgery? Or if they may be a candidate for both how do you kind of broach that conversation with them? Well, first off, great presentation. Nice work, Cole. Okay, in regards to a patient coming in for refractive surgery, your job as a refractive surgeon is to first do what's the safest thing. So usually if a patient comes in and I'm reviewing everything with them, I'll usually give one recommendation. Here's what we're going to do in your case. So for example, patient comes in in their minus 10, you know, that we got one option, I'm not going to do Lasik in that case because I know I'll have actually more a safer result with better vision post-op using an ICL as opposed to Lasik. Those that are kind of on the border line, let's say they are a minus five and a half or minus six or something like that, they could go either way. Most of the time I'm leaning towards Lasik, but there are certain cases where for example, let's say they have inferior steepening or there's some question about their cornea, then I'll lean towards not using carotid refractive surgery and using an ICL instead. In regards to sizing, I'm glad you guys brought up about the white to white because that's really what people have been using for years, but you'll always have outliers. That's just the way it goes. If you use white to white, you will have outliers. And that's because the sulcus doesn't, doesn't match the white to white. So for the most part, you'll actually do pretty good. And the EVO is very forgiving in regards to bolt anywhere from, you know, say 200 to up to a millimeter, you're doing fine in most eyes. If so long as they have a deep anterior chamber. But if you can refine that, you know, you're obviously going to want to do that. So using a UVM or, you know, high frequency ultrasound, whether it's the ARC scan is another method that people are using, you're going to get it more accurate, but you're still going to have outliers just because the ciliary body is so variable in the size and the way, in the architecture of it. I was just, you're with Carrie Salmon, I was just down with him in Argentina in November visiting the Zaldobar Institute. And they're talking about using AI with not just measurements taken from the ultrasound, but videos taken from the ultrasound, where they can look at the architecture of the anterior chamber and start to make more accurate guesses, if you will, as far as the proper sizing of the ICL. And from their measurements, they've shown that they've been able to be within about 300 microns in pretty much every, every case, which is great. I mean, 300 is a big, that's a big number for the eyeball, but still that's much more accurate than we've been getting with, with white to white, for sure. So great job. All right. So yeah, great, great talk, Cole. I'm going to switch gears and kind of talk about a case presentation, a case that I had recently. That was a LASIK case, hopefully, can advance here. Okay. So this was just normal, normal patient, 33 years old, interested in LASIK. He wears glasses. He had tried contact lenses in the past, but he had a lot of trouble inserting and removing them. So he really never, never wore them. There's his refraction, kind of moderate myopia, some stigmatism gets to 2015, stable refraction in his glasses, normal exam, normal topography, normal PENICAM. He wants to proceed with LASIK. And I agree that that would be a good choice for him. So before I go into the exact things about what happened with this case, just wanted to review for all the non-refractive surgeons out there about what LASIK is. So LASIK starts off with a flap that's made in the cornea, typically used using a femtosecond laser. That flap is lifted, and then a different laser, an eczema laser reshapes the cornea to correct the refractive error, and then the flap is put back. And so that's basically it. And the way the femtosecond laser for making that flap works is there's a suction ring on that left picture that goes around the limbus and adds suction to the eye. And then the laser is actually attached to this aplanation cone. And the cone at the bottom of it fits into the suction ring and aplanates the cornea. And there's a vacuum that's used to really get a good dock. So that's what's going on with the actual flap creation. The femtosecond laser creates these very short pulses that are 10 to the minus 15th of a second, or femtosecond.  And that reaction photodisrupts the tissue and creates a resection plane. So again, so each pulse forms this little microscopic bubble. And this photodisruption occurs just at that little point, and the surrounding tissue is unaffected. So if you can imagine you've got these overlapping little pulses going across the cornea, you've got these overlapping bubbles that then connect in these separation planes. So I almost imagine like a postage stamp in 3D, where you've got these little overlapping pulses. So you just have to break these little mini connections between all the bubbles. So this is what a normal Lasik flap should look like. I'll just play this video here. And this is real time. This is only very lightly edited. Nothing sped up. So putting in the lid speculum, we get things focused, we put in a little more topical anesthetic. There's that suction ring going around the limbus. And we get good suction. And once you achieve good suction, then we bring the aplenation cone. Again, it's attached to the laser and that gets docked into the ring. So that docking is happening now. You see that surface aplenating the cornea. All those bubbles on the side are just kind of the vacuum building. And then once we have a good dock, the laser says things are good. We start the laser. And you see the flap being created.  And the gas gets vented out through that hinge, which is at six o'clock, which is really kind of superior for the patient. And so there's not much gas built up there. And that's the entire laser flap creation. Let's see. Let's get over to the next patient. So this is my patient. It's gonna be kind of a longer video. I'll speed through it. But he's very squeezy. He's got a really tight, help people fissure. And he's squeezing.  And the guy's really nice. I mean, he realizes that he's not cooperating. And he's really, really trying. And he's just apologizing the whole time. And we're trying to get him to relax. And we can't see his cornea. But there it is. Yeah, oh, major. So I decide like, well, he's got a tight fissure. And sometimes, even with the lid speculum opened all the way, there's not enough space for the, for the, for the suction ring. So sometimes I actually will take out the speculum, which is what I decided to do in this case, just because the speculum can kind of get in the way of the actual suction ring. But then we still have the same issues of him squeezing. So we get, again, this is right eye. So first eye, we're getting the ring in very carefully. He's trying really hard. And getting some decent suction there. And we get the aplenation cone down very slowly and gently. So it looks, it looks decently centered, not the best, but it's within the realm of what I'm happy with. And we'll start, I'll start the laser and you'll notice he's got a little rotatory motion because he's still squeezing a little bit. So there's a little rotation going on. But the flap otherwise is looking good. And that's it. So then, then we go to the other eye. And the other eye is really is, is worse. Just imagine like it's an even tighter squeeze. So there's like, at least five attempts of, of trying to dock. And I'm just going to speed things along because it's a lot of the same attempts here. So let's go without here. So I get to a point after like the fifth attempt of, of docking. And, and things aren't great. He's got some congenitiva creeping in on the side. There's a lot of opaque white, we call it OBL or opaque bubble layer kind of coming off along the limbis kind of right where that flap edge is. Not exactly sure what's going on there. So, so that's the flap. So I wanted to ask maybe refractive surgeons, what would you do, what would you do at this point? I would abort LASIK on this eye. Okay. You already made the flap, but I would abort the second part of it. All right. So if a patient's struggling this much, I think it's helpful to give them something like a ballium and, and you kind of have to talk them through the process as well. Oftentimes it's like, okay, just relax, open both eyes and look straight ahead. Because what he's doing right now, like with the, with the first eye, if it was his right eye, he's squeezing his left eye closed as hard as he possibly can and you're trying to get it in there. He has to open up both eyes and look straight ahead. Yeah, we, we tried talking. He's, he's trying and, you know, this is just what we have. Ballium can be helpful, right? Yeah. I saw this exact same scenario watching, I was, for one of the ESCRS meetings, I went to go visit a friend, Francesco Carones, who's in Milan. And in Italy, there's no cash pay in their healthcare system. So ophthalmologists who want to make extra money will do LASIK because there's extra money involved. So this was a retina surgeon who was doing LASIK on the side. And so, you know, when you dabble in refractive surgery, it just makes it really difficult because you don't have quite that skill set. So exactly the same scenario, exactly the same thing happened. If the conch comes over the side cut, you don't get a side cut. And so as he tried to lift, lift the flap, he got half of it up and the rest he just couldn't get up and he was just, he was just lost. As I'm saying, they're watching him like, you need to let this, you got to get this patient to relax, but I didn't speak Italian. Anyways, so fortunately he was able to get Francesco to come down and help me and kind of lift this flap, but had to get out some accrescent blade to cut that edge, to kind of create a side cut. But anyways, let's go back to this case. If the patient's not relaxed, you've got to get them in a position where they're feeling relaxed to really get a good femtosecond creation, flap creation. Yeah, agreed. All right. So one vote for aborting LASIK in this eye. Would anyone venture anything else? I mean, if you can go back to just before you did the, you've stepped on the pedal. Let's go forward a little bit. So what, what I noticed, sometimes you get something called pseudo suction where the laser thinks you have suction, but you don't. Yeah, he's got kind of some foggy. If you look at that red mark up at like 12 o'clock, look at it move. Yeah. You see it turning there. Right. So the laser thinks you have suction. And so it's saying you're green, good to go, make the flap. But look at that movie. Oh yeah. No, I knew, I knew this was actually, I kind of knew at this point I was going to abort because this was actually the best doc I could ever do on this eye. And I was like, I'm just going to go for it. And I, I can abort and come back and do PRK another day. Because I know I'm not going to, I'm, I'm not going to swap because it's just going to, you're just asking for trouble or going to have, I'm going to, I would have this half flap, you know, having to cut a side cut who knows what kind of stromal bed I would have had. So, so I boarded in the left eye. So I had a conversation. I told him like, you know, we got it, I think we got a good flap in the right eye, going to proceed with lasik in the right eye, but I can't do it in the left eye. We're going to have to come back another day and do PRK. And he was, he was amenable to that. So I'm just showing kind of the rest of the case with his right eye.  It lifted and oh yeah, this is the eye that was rotating a little bit. And so I was worried there might be some extra adhesions in the flap bed. And so it was a little bit stickier than normal, but it was, it was fine. The flap was a little bit sticky, but it lifted just fine. The bed actually surprisingly looked really good. So we proceed with the eczema laser treatment. And so, so everything went fine, flap got put back and, and that I went fine. So I'll, I'll kind of stop this and move forward here. So post update one, his right eye is 2020 plus two is flap was intact. And I plan for PRK in a couple of months just to let things heal at that flap. And, and because I never lifted that flap, I don't really have any qualms about doing PRK on top, just because it's going to be still the cornea, the flap isn't going to move at all with PRK on top. So I did PRK earlier this month without issues at post update five in that eye he was 23 year already. So he hasn't come back for a post up month one visit yet. But yeah, I just wanted to kind of show kind of a quick little case about what to do with, with flasic flaps and you can always change plans and there's always going to be complicated patients and he's, he's doing fine. All's well then as well. Can I ask a question, Dr Lynn? Yeah. How long did you wait between doing and not lifting that Lasik flap and then doing the PRK treatment? So two months, two months. I probably could have gone maybe one month, but just, just to be safe. I decided wait to. And then if it's like a patient with a larger myopic correction, like maybe a minus five that maybe you're worried about doing a PRK and treating through the flap, are you still able to do a PRK treatment or would you think about doing something else? I probably would have thought about something doing something else because then yeah, you're right. I would have lasered kind of through the thickness of the flap, which is not ideal. So I may have talked about ICL, but luckily he didn't have that big of a treatment. So it was just fine. So in the middle of you creating that flap, you saw that edge kind of become a problem kind of in the beginning, right, which we could now see in retrospect. I wonder, is it better to have stopped in the middle because you can take your foot off the pedal or do you finish it out so that you have a little bit more uniformity, even if you know you're going to abort after that case, which I mean, I think I would have done the latter and like what you did. But if I had seen that, you know, become a problem in the middle of the treatment, I might have been tempted to take my foot off the pedal. Yeah, honestly, if because I didn't never lifted the flap, I don't think it would have mattered if I had stopped like before I completed the flap, I probably wouldn't have stopped like right in the middle. Like I wouldn't have wanted to stop it right in the visual axis just in case there was any issues there. But let's say I stopped in like, you know, the first third of the flap creation, I think it would have been just fine too. Yeah, that is something to kind of understand with LASIK is that once you've docked and you've told the laser I'm going to make the flap, you then have full control over that flap progression and it takes about 15 seconds or so, 12 to 15 seconds, and you're holding a foot pedal down. So if you let off the foot pedal, it'll stop or if the laser ever detects that there's a suction loss, it will stop. And so I've actually had one LASIK flap where it made the entire LASIK flap, everybody, everything looked completely normal as I was going. And then the last two seconds, it just felt like it lost suction. And so it aborted just as it made the side cut. So I didn't, I had a flap with no side cut. And so we actually went back and made a second flap with no energy on the flap cut, we just made that super low so it can actually cut. And then it made the side cut at the end. So it's kind of a cool case that I had earlier. But yeah, you have full control over that foot pedal as you're going through it. Okay, it does have me up here. All right, I am nowhere near the photographer that Nick Mamelis is, but I've really enjoyed over the years of Dr. Mamelis sharing his photography with us as he has traveled the world. And every time we have a pathology lecture, I learned something about awesome cities around the world. So these are pictures of my tour of Utah using the dreaded icon pass that I joined this year. If you can't beat them, you have to join them. So this was up above snowboard last Friday. So how many financial disclosures? So I'm going to review, I've been trying to start this project where I'm trying to understand our Lasik and PRK refractive outcomes a little bit better, and trying to actually tabulate some of those things. So this is just kind of some very early preliminary data on that. So I'm working with Steve Christensen to try to understand a little bit better. And then we'll discuss some of the complications and I'm trying to tabulate that a little bit more, like how many complications do we actually have with Lasik and PRK. And then if we have time, we're going to review some of our current screening things. So this is essentially data from about 2015 on. And this is around 11,000 eyes between myself. I was still a fellow, so I don't have very many numbers in the early years. And then Dr. Lin and Dr. Mifflin as our refractive surgeons. This is looking at just uncorrected vision testing at distance. This is extremely raw data that just we just barely got just a few days ago, kind of pulling information out of Epic. So there could be some selection biases here, like we have some patients who at one year they're not doing their follow up for Lasik or PRK because they're doing awesome.  So you could have some selection biases here in different in various ways. But this is just the actual raw data showing our Lasik and PRK outcomes and by kind of months as you kind of look at this. So the top line is 2015 and better. And the very top one there and then 2020 is that second line. And so you have one week, one month, three months, six months and one year data. Those are typical time points that we're seeing these patients over the course of a year. And so those are kind of the actual outcomes. If you look at actual published literature out there, you hit it about 90% of patients. They're uncorrected, just complete uncorrected distance visual acutes. 90% of patients usually hit 2020 or better with kind of primary Lasik and PRK. And that's about where we're hitting on both of these surgeries. So looking at that a little bit closer. So this is kind of the data that is published a lot of the time is where patients at at one year. And so we are hitting it about 62% at one year 2015 and then another 30% or 2020 or better. So you just kind of tabulate that up. So 91% of eyes at one year with Lasik are seeing 2020 or better and about 99% or 2030 or better. And then with PRK slightly higher, but pretty similar 92% or 2020 of the year and about 98% with PRK or 2030 of the year and almost 100% or 20, 40 or better at a year. And again, Dr. Olson brought this up, but one of the key things to understand with a Lasik patient is what is their actual pre-op best corrected vision? Because you may have a patient that has like some mild amblyopia and they're only 2025 or 2030 at their best corrected vision before they have surgery. And so that could, that could skew some of these numbers. And then another thing that people look at is also like, what's their best corrected vision? If they're not 2020, you know, can they correct a 2020? And I don't quite have that data yet for our data set. So what happens in Lasik? So what are some of the issues that we come up with? So this is just kind of pulling in some data just to show published literature out there some of the complication rates. There's over and under correction. That essentially means that you had surgery and you're not seeing 2020, you're not seeing 2025, you're not happy, you want to have a correction done. And so the enhancement rates that are kind of shown out in the published literature are somewhere around 5% to 10%. Last time I was able to pull our exact data, we were somewhere around 3% enhancement rate. Infection is somewhere around one to two, one in 2000 cases. This is specifically with Lasik. There's a very broad range for that. You may have some published data that's like one in a thousand and some that's like one in 15,000. So quite a range there. Flab dislocations with Lasik is published at around one to two percent of those. And then you may have this inflammatory action called Diplomelo keratitis, dry eye, glare and halos, epithelial ingrow, thectasia. Those are kind of the things that we openly discuss with patients as we're consenting them for these surgeries. And there's there's kind of variation in how often those things are occurring depending a lot on your climate and where you live.  I'm not aware of any infections that I've had with it. I do see flap dislocations. I had a patient that really bumped my numbers up because she decided to dislocate both flaps about an hour after surgery. So my, what's that? I'll show you a picture of what she was doing in just a second. So my flap dislocation rate is 1.2%. I have one case of DLK that was pretty severe in one eye on a bilateral Lasik patient that eventually recovered to 2015 vision, but she was about 2050 for a couple of weeks with really bad inflammation. I did not lift her flap. I just treated her with topical steroids and it got better. I don't see as much glare in halos as a long-term complication. There's a unique complication with glare in halos with Lasik where you get what's called rainbow glare where when a patient looks at a light they actually see a rainbow spectrum. And that usually what we were finding happens is if you get an interface chatter event during the creation of that Lasik flap creation.  They're a little bit hard to see on some of the mapping, but that's something that's not as common anymore with the ablation profiles. And then dry eye, there's a ton of published studies out there. There's some published studies that show like 0% dry eye after Lasik. There was a military study that had one case of dry eye after Lasik in their study. You do not have dry eye. Yeah. So there's interesting, all the way up to 10%. I usually tell patients we're in a drier climate, so you're more likely to have that issue. But honestly, it's not a major problem after Lasik in my practice. I'm not aware of any ectasia cases with my Lasik. With PRK complications, pretty similar ideas about the different things that can happen. I tell patients if you want Lasik, you're signing up for all the flap complications. And if you're signing up for PRK, we get rid of all those flap complications. Those are kind of the main sort of decision points that patients are making here. Obviously, other things are very similar. One thing that's unique to PRK is haze formation. And then infections a little bit higher risk with PRK as well. For me, I have had one PRK infection, which is a really devastating case for me, which puts me at 0.007% in 1300 eyes. I see probably around three per year. I haven't tabulated this very well. I have not had to treat any patient to clear their haze. It just gets better on its own, meaning I haven't had to laser anybody. And dry eyes still do see it. Probably my biggest thing that I don't love about PRK is that patients complain about kind of a recurrent erosion syndrome. They're like, I'm doing fine throughout the day, but I still wake up a couple times a week with pain. It feels like something's tearing my cornea. So they're essentially having these minor recurrent erosions. And then I tell patients that glare inhalers are less common with PRK. The ablation profiles are the exact same, but you lose that LASIK flap interface as a potential cause of glare inhalers. Okay, so this is the patient of mine that had bilateral flap dislocations. And when I went to pull her video, I was like, I wonder how good this is going to be. I'm just going to show it. I don't know how good this is going to go. I don't remember anything detailed about problems making her flaps or anything. But as I went back and reviewed this, she was like the perfect patient, like zero squeezing, just open her eyes super wide, had no problems docking, really good aplination. And her LASIK flaps were about as smooth as they get. So no chatter, no OBL. So chatter is kind of the linear lines that you'll see. OBL is if you see like this big burst of white kind of down at the hinge area, but her LASIK flap just super smooth and made really well. And the same was true for her other eye. So we did her right eye first and then her left eye, and both LASIK flaps went really well. We currently use the Alcon suite of the laser. And it's been the only laser that I've actually used. So we've had it for, I think about 13 years, 12 years. I can't remember now. I wish Mark was here. I can't remember when we got it. We got it here at this building. And then when we opened mid-valley, we moved over there. So this one actually does have a little bit of OBL. So that's kind of that whitening that you're seeing a little bit more dense at the bottom. That's essentially as gas is trying to escape through that venting incision. It doesn't escape fast enough. And so it stays in the flap interface. And sometimes it'll make a more sticky flap. But that went really well. And then this is her flap. So you kind of mark the flap before you lift it so that you know where to put it back and essentially get her flap lifted up. So you kind of initiate a little at the side cut. You kind of initiate down to the bed of flap. And then you come across with this lacy spatula to lift it. And just a really nice consistent flap on this case. And then a lot of this was just approved to myself that I did get her flap in the right place at the end of surgery. And so you kind of irrigate the flap. You float it as we call it. So you're kind of putting a bed of fluid under there to rinse any debris out. And then we kind of milk the flap down into position with a really wet wax cell. And I think eventually you can see those marks come into view where they're just perfectly lined up again. We use that prednisolone to kind of initiate anti-inflammatory treatment. But also it kind of helps you see the gutter as we call it. Let me pause that for just a second. So if you look at the actual side cut all the way around, we're kind of looking to see if it stains that area white just a little bit. It's just that pred orte kind of pooling in the side cut. And that's one of the indications to understand is this symmetrically laying back down. And so that looked really good. And so we did her other eye. I think we'll just skip the other eye because it was the same. No issues there. So this was what her flap looked like. I don't ever take pictures of my own refractive patients. It's kind of like this weird thing where we have to charge them, but then we don't. It's like it's hard to get pictures of them, but I wish I would have had pictures of her because she had about a four millimeter gutter in the bottom of her cornea. So that meant that her LASIK flap pushed up four millimeters and it was all wrinkled. Just kind of sitting about halfway through. And I see patients about an hour to two hours after LASIK because that's when their flaps dislocate. It tends to be in those first couple of hours. And so I went to get her from the waiting room and I'm like, how are things going? And I'm looking at her and I'm like, both your freaking flaps are dislocated. Like I don't even need a slit lamp to see this. Yeah. I was like, oh my gosh. And she's like, yeah, they hurt. It feels like something's in both eyes. I'm still pretty blurry. And it's like, sometimes it's hard because it's pretty painful to have LASIK. The first couple of hours is pretty light sensitive. And so I said, well, so tell me what's been going on. And she's like, well, I don't really know. My friend's been helping me put my drops in. And I'm like, so how has she been putting your drops in? And she's like, she has been grabbing my upper lid and just pulling it up. And so her friend essentially just dislocated both flaps. And so she was about 2100. And so I just said your flaps are out of place. We just need to get it back in position. And kind of varies how I do this. Sometimes I'll do this at the slit lamp. I'll just re-clean them, just get betadine washing them, make sure they're nice and get that betadine all rinsed out. So there's no betadine in the flap because you can get DLK if that happens. I think in her case, I actually took her to the minor room. We were still at the laser center. So I just took her in there because I was like, both eyes was going to be a little bit tricky. And so I just did a full complete reprep and refloated them. And I just saw her, she actually moved to Seattle about six months after surgery. And I saw her this like two weeks ago and she was 2015 flaps looked really pristine. So if you can get to these early, they're not good. Yeah. Yep. We talked about that. You definitely are going to have really good outcomes that earlier you treat these. So I had a patient that had kind of a similar thing happen. I actually saw her at about a five hour post-op. And she was looking fine. Had a really good vision. Flaps were in position. And then her flap dislocated at some point in the next week. And when we saw her, she had kind of that similar idea where there was some horizontal striae. And I had to relift her flap, but it wouldn't flatten out. So I had to de-epithelialize it, flatten it out. And she's done fine with that, but a little more aggressive. Katherine Who and Mark Mifflin have their hands up. Yeah. Who do you want to go first? Dr. Mifflin. Hi. Hi. Can you guys hear me? Yes. Sorry, I'm not there. I'm home recovering from shoulder repair. But I wanted to comment great presentations, good comments. And just on the dry eye thing, I think that Katherine may be chiming in on that too. But I think that Austin and I wrote a letter to the editor and I think it was Corny or JCRS. I can't remember. But one thing, we have a prospective dry eye study going between LASIK and PRK right now. And I think what we find is that the symptoms tend to be worse in PRK and the findings tend to be worse in LASIK. So there's an element of hypoesthesia verified by esthesiometry readings and corneal staining. In terms of actual effects on the patient's quality of life, they both tend to be very low, even in our very harsh conditions here environmentally in the Salt Lake Valley and the surrounding areas. And so generally, outcomes are good in, quote, controlled dry eye patients in either group. And I think that's where the military study is a very interesting one because they didn't really look at findings. They just looked at symptoms. And if you can't feel your dry eye, then it's not there unless it gets really severe. Just to comment on our laser, we've had our EX500 laser. I can't remember for sure when Mid Valley opened. I think it was 2013. So we got it just a few months before we opened Mid Valley. Before that, we had the EX400, or not, it wasn't called EX, but we had the Allegretto 400. And then we had a 200 before that. And then we had the Vizix laser before that. So that's kind of our history. I think that's all I had to say. Thanks. Thanks, Mark. Hope you're doing well. All right, Catherine. Yeah, I was going to say, can you guys hear me? Yes. We're connecting from AUTO. But yeah, in the order of who do you unmute first, definitely Dr. Mifflin first. But yeah, I was going to mention our dry eye study. And we're looking at corneal asezometry as well as staining and also questionnaires for symptoms. That's the fellow study. And one thing I was going to ask you, Brian, is how did you keep track of this data? Because as a new attending surgeon, I've been just manually tracking my outcomes through like red cap, because you can do that as a faculty member, set up your own database. And that's been relatively easy. But just wanted to kind of know in terms of both cataract and refractive, I've been tracking my own outcomes, sorry, outcomes, but wondering if you have a better idea. I know that other practices will have like veracity, other built-in systems, but wanted to get your perspective on that. Then also the most shocking thing that I learned from the ScranRounds is that you have the icon pass now. That was the thing that I was very surprised by. I know it's sad. Can't beat him. You got to join him. So as far as data goes, I have learned this last year that there are data miners that work for the university that are kind of there for you to kind of request this information. And they can get stuff really quickly, especially with kind of how Epic is set up. And so Steve Christensen is who I've been working with. And we'll add you to this data set. I don't think you're in it yet because you're just getting started. But I can show you how to get access to it and stuff. I'm going to add a quick point. I think we got our new iterations of our lasers in 2016 because we had a big flood at Mid-Valley that ruined our half a million dollar lasers. And so we had them replaced within three weeks. So we were down from the laser. I think it was during your fellowship, no? Yeah. It was a little disappointing time. 2016. It's worked out. It's worked out. There was a flood in the pipes in the ceiling. So we got a new laser. It was great. But it was the same one. So I am typically seeing patients at the slit lamp, like I said, right after surgery. So I checked their eyes right after we've left the laser suite just to make sure everything looks okay there. I had one patient that as I was taking the lid speculum out, I was like, did her flap just dislocate? And it actually did. Because she kind of just squoze at the right time. And so we just repositioned that really quickly. And then I'll usually see them within four hours and then a week later. So when we're doing, I wanted to go into just really quick just a few minutes of how we screen refractive patients. So as you're seeing a patient or talking to friends about it, you know, what are we looking for? So lifestyle considerations come up a lot in deciding, you know, is this something that's useful for you or if you just wear contacts and glasses? Obviously their correction level, how much of their cornea we're leaving behind is the residual stromal bed. We're looking at actual changes in the shape of the cornea. And then age and stability of refraction comes into play. And then just underlying ocular and systemic pathologies. There's a random and risk calculator. I don't physically like put patients through this. But it's something that we all use as refractive surgeons to kind of understand how risky this patient is. So if they collect four points in this calculator, they're high risk. Four points is if you have an abnormal topography. And also if you have a residual stromal bed less than 240, which not, I don't think there's very many surgeons that are going that low. And this is kind of older data. Like we're not really doing laser refractive surgery on somebody that's greater than minus 14. But that would give you a lot of points. And then it just kind of goes down from there. So three points is if you have inferior steepening a skew pattern on topography, if your residual stromal beds like somewhere around 250 younger ages get high risk factors because you don't know what their cornea is going to do over time, the chemistry readings less than 500 specifically less than 480 in this case. And then two points, it just kind of ticks up a little bit. So the older you get, the less points you collect, the thicker you get, the less points you collect, the lower your refractive error, the less points you get. And so this is kind of where a lot of us live is that we're not going to put people down below 300 on a residual stromal bed. We're typically waiting for patients to age a little bit before we're doing surgery, and we're not going above a minus 10, typically with a laser refractive surgery. Zero points. This is telling you, okay, this patient's a pretty decent candidate for refractive surgery. They have a stigmatism, but it looks symmetric. Their residual stromal beds above 300, their age is over 30. Their pychymotry is above 510 that treatments less than minus eight. So that's typically a good candidate. Some of the numbers that we use to figure this all out, if you have a percent tissue altered that's greater than 40%, it puts you at high risk. We measure this essentially by looking at their pychymotry, looking at how many diapters we're going to correct and use this formula to try to predict that. You can also plug it in the laser and the laser will tell you what it's actually going to remove with the treatment. And then there's some things about corneal flattening that if you flatten the cornea too much, it degrades their quality of vision. And so those are kind of the main things that we use for it. I had a bunch of cases I was going to take you through, but we're going to skip over that because we are out of time. But it's something I just literally pulled up like last Monday's clinic and just pulled up every refractive surgery screening that I saw that day and threw them in this presentation. It's something that we deal with every single day of like, how do I figure out what this patient is able to have and what do they want and lifestyle choices. And it's just kind of a discussion of hear your options. I'm going to consent you for all these different options and we take them through what like Dr. Wait said that we feel is the best and safest surgery for them. So refractive surgery is a lot of fun. I'm hoping to keep tabulating kind of our systems outcomes and data and complication rates. So thank you. Appreciate Amy for putting this together. Any questions? Yeah, Dr. Wait. Okay. I think to answer Catherine's question too, how do you track this? When you're doing LASIK and PRK, you want to be using a nomogram that can help you put the best numbers into the laser that will give you the most accurate results. I use IBRA, but also surgery vision has another one as well. Do you guys use that? Wellington. Okay. So Wellington's a paper nomogram. And the nice thing about this is it's kind of like using AI to figure out, okay, these are the results I've had. How do I tailor down the best results? And so it can be helpful, but then also you can go back and track your numbers. You have them all put into the system. So you can look at every single patient from the beginning to the end kind of a thing. I agree in regards to PRK, definitely RCE symptoms are one of those problems here in Utah specifically. They wake up with pain in the mornings. But I'm curious if you guys have noticed a difference in between your enhancement rates with LASIK versus PRK. I couldn't quite hold the data this time, but when I looked at in the past, they are slightly higher with PRK. Okay. Same here. My enhancement rate is higher with PRK than it is with LASIK. And I have to assume that the reason why is because the epithelium itself has a certain amount of refractive air built into it that we can't really take into account with our current technology, our current diagnostic equipment. And so we're making certain assumptions and then we assume it's going to heal how it's supposed to, and then it doesn't, and then you end up having to do an enhancement. And so my preference is if the corny is normal, I'd much rather do LASIK because I know that'll be, I have a lower enhancement rate, it'll be a quicker recovery, right? And then, oh, the last thing. Okay. In regards to flap dislocations, I don't know if this has necessarily statistically made a difference for me. I went to go to Dan Ryanstand's course in London a few years ago, which is phenomenal. He's a good teacher. At the end of the case, what he'll do is he'll put him up at the slant like you're doing, you're checking them. And then you use a Miracell sponge and you kind of, you massage out any fluid top to bottom to the sides out of the flap and you'll see actual fluid coming out of the flap. So you're laying that flap a little bit more securely to the cornea and you'll see that that gutter that's around the edge will actually disappear. You'll bring the edges to each other to touch. Since starting to do that, it's been amazing just seeing the flaps afterwards, how they heal with minimal gutter, very low dislocation rate. But I think, of course, if you're mashing on the cornea, you're going to dislocate any flap, regardless of how you put it down. But then again, even on, I know you're seeing them a few hours, then you'll see them a week later. I think completely appropriate. I usually will see them at the one they post up. You can still, there's still some motion in the flap. So if there were a little Microstria, you could actually use a Miracell to kind of push it out and get those to the edges. But that, massaging the flap after the case, I think, is the last step of LASIK, the surgical technique. And I think it's worthwhile to do that. For me, I think it's made a big difference and make sure the flaps are perfect before they even walk out the door. I'm done. Thank you.


Now when studying the crucible Reverend hell is another really important character that you need to become very familiar with and Memorize key quotations. Now Reverend hell at first is part of the establishment He arrives from a different city or rather a different town He is seen as the voice of reason and authority and his arrival confirms that there is indeed witchcraft at a foot And at first when he arrives he almost arrives with this air of arrogance around him He believes that his ideas really infallible. There's no mistake to him And of course he also declares that Salem. There's a lot of witchcraft. That's happening However as the play progresses and he starts realizing a lot of the hypocrisy and he also starts noticing that key characters like Governor Danforth really are using this process as a way to just amass more power rather than actually genuinely having an interest in Protecting people from a religious standpoint from witches. He actually becomes very disillusioned with the process now Rather than maybe using his power to convince the governors that you know They need to stop this whole process He actually towards the end even if he becomes disillusioned and really starts talking down on this process and really seeing all the wrong Things with it He still places too much energy and emphasis on trying to get other characters like John Proctor To falsely confess in order to save their lives rather than denouncing the entire process of Witchcraft and witch hunting Okay, so he's a really interesting character in that sense and whilst at first he's part of this Establishment he supports the whole process of witch hunts and witchcraft and of course he has blood in his hands He ultimately becomes very disillusioned with this process now the first quotation to relate to Reverend Hale is The stage directions when he first arrives in act one and he's setting down his books and there's ellipsis here Okay, so this is the stage direction setting down his books And of course you want to focus on the verb setting down. He has us there of the authority.  He believes he can make no mistake then he states They awaited with authorities who's talking about the books And of course this is tying into how he is supposedly an expert in spotting witches Okay now in this and what he says the word level analysis you want to do is the alliteration of W so weighted and with and of course this illustrates at the beginning that Reverend Hale is really a figure of authority That's part of the establishment now the second quotation to bear in mind with his character is When of course he comes in and then he asserts the devil is alive in Salem and of course here It's interesting because on the surface this quotation is simply stating a fact from his perspective that there's Definitely the devil here. He's causing women to you know become witches However, we can also when we're looking at word level analysis You could actually see this as a metaphor the devil being alive The devil is a metaphor for people with dishonest intentions people who are basically they have devilish reasons behind why they're Causing all of these innocent people to die as a result of being denounced as witches And so perhaps this is a metaphor more so not so much as the you know, the witches that are there It's an evidence of the devil being there However, this could be a metaphor to relate to key characters again Governor Danforth Even Reverend Paris to an extent these characters are very corrupt in their intentions even think about the Putnam family and therefore You could state that this quotation actually foreshadows the devilish actions that these characters do in order to just simply further their own interests Okay, now the third quotation to bear in mind with Reverend Hell's character is when he states and he's asserting You know why his work is so important and how it's very sometimes hard to tell the witches amongst them He refers to the Bible and he states until an hour before the devil fell God thought him beautiful in heaven And of course this imagery especially talking about beauty this connotes and Ties into the idea that the majority of people who are denounced during this time or women this idea that women Deliberately use disguise to mislead men. Okay. Now here the word level analysis You want to focus on is the oxymoron so opposite words devil and God and of course this is tied into how Reverend Hell Really generally at this stage believes that there are witches and he sees women as threats Especially women whose sexuality is very unfettered The other quotation to bear in mind with Reverend Hell's character is when he states in act force and now this is when he's changed He's become very disillusioned with the process and he's trying to get people to confess their sins in order to at least save their lives He's now trying to see what he can do to maybe not let innocent people die Now he states let you not mistake your duty as I mistook my own and here you can say that he's actually very Self-recriminatory he can see some of the mistakes that he made being part of this entire process that he's now realizing is a very corrupted Process now the word level analysis you want to do for what he says here is the pronouns you You're when he's talking particularly for example to Elizabeth He's saying that it's her duty to try and get John Proctor to lie in order to save his life And she shouldn't mistake the role that she plays in saving his life much like he unlike him who mistook his role He thought he was coming in as a good person to you know spot all the witches and then he realizes now It's all a mistake. He was just part of a very elaborate political scheme Also another word level analysis you want to do is alliteration of M. So you've got mistake Which is repeated twice and of course you've got my okay now here, of course We can see that Reverend Hale has really changed She's become very disillusioned and he's now becoming very worried about all of these innocent people who are dying at the hands of essentially hypocrites people who are using Puritanical faith and religion as a very thin veil for their own self interests Okay, so that's really it when it comes to key quotations to remember for the character of Robin Hale


On Wednesday, the U.S. stock market took a nosedive. Oil held near $30 caught between demand loss and supply cuts. Fits Powell said the economy may face extended period of weak growth. We found out that the UK GDP shrank by a record 5.8% in March, and that there may be a harder COVID hit ahead. Welcome to the TICML Update, I'm Kiana Daniel, the founder of the Investeva movement. Make sure to subscribe to the TICML YouTube channel and support us by liking and sharing this video with your forex trading friends. On Thursday, we have some economic data from Eurozone countries, the U.S. weekly jobless claims, and a data dump from China, including their retail sales and unemployment rate. Today I'm looking at the Aussie yen pair, which appears to be in the process of forming a double top bearish reversal chart pattern. On the 4-hour chart, it's already penetrating the Ichimoku Cloud. The neckline of this double top is setting at 67.84. However, if the Ichimoku Cloud supports the pair, we could see more gains going to next week towards 70, putting the Aussie yen pair into a consolidation. Do you think the Aussie yen pair is ready for fresh losses? Hit over to the comment section and let me know. Of course, trading in the financial markets involves a risk of loss, and you should only trade the money that you can afford to lose. If you liked this video, give it a thumbs up, subscribe to the TICML YouTube channel, and I'll get back to you with more updates tomorrow.


The cartoons follow us So we're in our basement in the new house Got everything set up for the most part. We got to do the walls yet. There's our big sign That's my office right there Back here's Theo's plater. We've probably already seen this because I probably released a little tour already But I'm gonna wait a little longer till everything set up. Oh, I didn't realize she did put up all the wall stickers already That's awesome. We've got a little play area back here got all his toys and all his books Got his couch Looks like Cookie Monster's a little bit All over the place right now, but that's okay. So my Project for right now is My office I got to put my desk together and arrange everything in here I think that table is going back to my mom and dad's basin Oh Sounds like somebody's not going down for a nap without a fight Yeah, that's what I'm gonna be working on. Oh, you're right here. I didn't hear you come down You're tired man. You just want to watch cartoons all day, don't you? So it was no go on the nap. He's not going down for a nap. So we're gonna run our errands now We have to run around town Get a whole bunch of stuff done got to go pick up our Keys for our new mailbox and stuff got to go get a new shower head for the downstairs bathroom here That's that's my bathroom my mom bathroom and Then tonight we're gonna work on this office and we're gonna get caught up on all my vlogs Because as of filming this right now, I haven't edited any vlogs of the move yet. I haven't even released them edited them Nothing I haven't even released the last video of me getting home from my last trip yet because I put everything on hold so we can Get this all done Now I've got to play some catch up and get some videos released to you Oh, so I don't know how that's all gonna turn out, but I do know that tonight. I am getting this office set up Oh, I have a closet. I didn't realize that I haven't had any time to really explore It's just one project after another after another after another we got the fence done outside yesterday with my dad Thank you dad so much There's nothing that he can't do I told him I needed a fence and Pretty much snaps his fingers and there it is. I Don't know how he does it. Oh And okay, I can't open this whole I forgot my coffee was here Some shelving in there. I'll show you that later. I guess And a big thank you to my mom and my sister Cheryl as well Who came and helped us move get everything moved in get everything unpacked helped Britt get everything in its place upstairs while I was doing other things You know Every time you move or every time I move anyways, I really realize how great of a family I have I have to give a special thank you to Jerry and Cynthia as well We're here to help unpack things as well on our move-in day like all around both sides of the family Well, can you say what's the word for it? Blessed? kind of I've got a great family and Britt's mom Kathy and her boyfriend Gary are coming down tomorrow so they get to see the house then and Excited to show show them it as well. I think some more family members are showing up tomorrow. So big thank you Everyone who helped make this possible This is a we're very happy exhausted, but very happy That a lot a lot to do and there still is more to do we can't Sit still and I got a pack away and get the whole garage organized Yes, so we can get Britt's vehicle inside the garage yet for the coldest part of winter at least right? Oh, we need to get a heater for in the garage as well. That's right It's insulated, but you need to have a me a separate heater for it Can't forget we're going to town now to get a few things Guess I've got to put on people pants if we're going out in public Not just my sweats Who am I kidding? I wear sweats at the public all the time But you never see me Going on in here Nice Change the outfit though. You love it. All right. So here you can see the fence from yesterday outside See Just close off the back end there and all the way around But all the bottom blocked off.  You guys don't want to go outside wiener. Let's go outside Go outside Place is so much bigger. We got to go find the dogs He was asleep You sleeping buddy such a big house. I have to come find you. No, no, no outside is not that way, buddy This way there you go. No, no, that's not outside either That's that's not outside All right guys, I'm gonna take you up real quick Wonderful wonderful Further away from the house further away from the house little guy If I let one of you pee near the house all of you are gonna appear and pee near the house What are you doing back here lagging behind you get into the yard, bud Into the yard. There you go. There you go So you got to scare them away from this little area here Otherwise, of course, it's cold out right so they come out here and they want to pee right here And what do the other dogs do as soon as they smell that they all come and mark this whole area here and then right by the house It smells like pee so Be calm Bring that stuff over there Well, look at this the way like this has got to be four times the sizes of our other yard at least three times One two three like one this way one there one back there.  See this is just temporary. So don't Judge us Just temporary we had some dad had some extra wood. We just sealed up the bottom And in spring we're getting the rest of this fence done. So it's going to match all the rest It's going to be six foot. It's just going to continue from there all the way around back here to there So we're getting that stretch done with a rolling gate in the center here. I think it'll be here But it's going to roll that way, right? And this tree was dead when we moved in so we've got to transplant that or not transplant it But take it out in spring as well. We want to plant a new one in there But yeah, this is 36 and a half feet Again, it'll do it'll do until spring when we get the professional to come in here and Close it up and make it look pretty What do you think diesel? What do you think? What do you think? I'll place them here Oh shoot, I better not have these here. They're going to run right into these Uh, I gotta Here, I better fix this There They might still run into the side of it, but at least it's not going to poke their eye out, right? Is that wouldn't be fun, right chef?  They have to sniff every square inch of this property Chevy's pretty much got all of it all of it down the rest of these guys Well ease this place. I didn't even know this outside existed Is your yard now Frank? It's all of us Good job, Chevy You can have that tree. It's dead I'm gonna get a new one Kanaki tire Canadian tire we found ourselves here. So we got our keys for our new mailbox And uh, we also Got new little booties that we're waiting in the mail for this little guy So now we gotta Go and find a whole bunch of stuff in here. We're looking for curtain rods a towel holder Uh Anything else we find that we like Maybe Stinks out here. You smell that? Oh, she's taking pictures of them Such a mom takes like 5,000 pictures a day until the sun goes down that she takes another 10,000 It's good though. Better get out there. I'll carry him.  Okay I'm not sitting in there talking to you guys wasting time Lock these doors It does smell it here.  Somebody cleaned out their barns near town. You got them? Yeah, he's getting heavier and heavier Want me to take him? No, good workout. Okay. Yeah, that's season everybody Two of them. Oh, they're on sale Oh sign Should I get four? I'm just kidding. All right, we're back home We got the little guy here jamming out. Hey bear. It's always a hit Those of you who have uh young kids Am I right?  Hey bear. It is like catnip The babies look at this guy just loves it. I don't want to get copyrighted from that music.  It's that time of year. The sun goes down so early It's uh depressing It's only 6 30 And and oh in a couple of days we do that that Daylight savings time You guys do that where you are too. Most places do right? Daylight savings time. I hate it because tomorrow Day after tomorrow whatever whenever that switches switched It'll be that dark outside at 5 30 in the afternoon It's the only bad thing about this Christmas season, but at least you have Christmas And you know, that's why people set up Christmas lights even if you're not, you know of the faith to celebrate Christmas Christmas can also be a secular holiday as well for all the rest of you the reason people light up their houses And light up their trees and everything during Christmas Is that's right near and around the winter solstice the shortest daylight hours of the year You light up all your lights to cheer people up and to remind people that Longer days are ahead longer daylight hours are ahead you keep them careful light up their life So get out there and get those Christmas lights on your house Don't turn them on until after remembrance day or veterans day for americans But after that actually wait wait wait in canada After remembrance day november 15th fair game turn on all your lights because it gets dark outside so early That way it'll cheer up your neighbors. They'll see your lights Makes up a little bit for being dark so early, right? If you're in the u.s. If you're an american Wait till after Thanksgiving Totally understand that you guys do your Thanksgiving in november We've already done ours gotten that way out of the way So it's all christmas for us now right after remembrance day So remember remember to say veterans days come out make sure that you take that time to honor and remember All of the fallen soldiers and all of the currently serving soldiers Here in canada and also with our allies abroad That was weird they just started filming and that speaker started doing something Interesting Who are you? Oh, it's my wife's phone is hooking into my speaker One second Hey hun Your phone is hijacking my speaker Okay If she connects to my bluetooth speaker the next time i turn it on automatically connects to her phone And she already has her music playing upstairs So shuts off her music upstairs and then sends it down here to my speaker You're gonna be careful because those hey bear songs will get stuck in your head All day You like your new home Diesel this is our home This is our home. What do you think? This is our forever home Yeah, we're never moving again I will do everything in my power to make sure we never never move again. I'm glad you got to see it I was worried that He's getting old. He's uh 12 years old now and he's having a hard time I kind of have to help him get up the stairs when he wants to go up Looks like he might want to go up now No, he's chasing this tail. He's good He has a little bit of a hard time getting up the stairs now already sort of have to help him up I'm hoping that's just because we've never had stairs before And we lived in such a small house with a smaller yard that he just needs the exercise I think he wants to go diesel. You want to go upstairs? You need me to help you? Yeah, I'm good man. I'm good. Come on, kiddo. Stop telling people that man. No, oh 12 is like the new seven Okay, you say so But uh, I am glad that he got to see this home yet Before it was too late Yeah, we've been together every day for a long time me Two buddies two buds two brothers two bros Yeah All right, I gotta keep doing my office here man.  I got you. I got you buddy. Come on. I got you Good job Chef you want to come downstairs with me now? Come on He was super scared to go down the stairs because he's never done stairs before right? And then once he mastered he did it once now look at him. Come on, chef Like a boss. No problem When we first moved in he uh, he couldn't go down the stairs I almost literally had to push him down the stairs like I wasn't gonna like Hurt him and push him down, but I had to like Aggressively encourage him to you know, just do it man. You can do it Oh now look at him Look at him You want to go back upstairs? The one who likes to be downstairs with me. They don't want to be upstairs with mom Thought I was the fun parent more treats. That's true Well, I got feel so Look at this guy Every day's got me. Hi Don't show me your new noises so Your turn No, your turn You got it Here look at the volume bag on here. There you go. There's your cat in it another vlog edited and done. I'm just taking a look here on my Computer here in my office. I have an office. We Let's see how many do I have left yet? I got another one coming up Us cleaning the house. Yep that now and I have one there I have another one here Okay, it's another two Or three There are two or three of us here at home yet before I uh head back on the road So I look forward to seeing you my next one. Thanks for hanging out with me Yeah, this is a big sort of moment a big week in our lives. This is a move is always uh A big change and a big life event You know, I always remember the day that's the day we move in and so we got it all on on film now So thanks for being a part of it and being a part of our lives I gotta get to editing these other videos now. So I hope you enjoyed this one If you did, please hit that thumbs up button consider subscribing And stay tuned. There's more coming


The Mutual Broadcasting System, in cooperation with Family Theatre Incorporated, presents Ms. Ethel Barrymore in a dramatic narration of The Passion and Death. Ms. Barrymore will be introduced by tonight's host, Guy Madison.  The Passion and Death is a love story, a true story. It recounts events in the lives of men and women who lived many years ago. But the events of their lives are as real today as if they happened only yesterday. These events give meaning to the sufferings in life, give meaning to sacrifice in our lives, because they are an inspiration to lift our sorrows and crosses out of the hopelessness and despair you hear so much about today. Yes, only love gives meaning to sacrifice. For centuries, this story has inspired men and women in all parts of the world to give themselves generously and unselfishly in service to their fellow men, and in charity to all. We present Ms. Ethel Barrymore in a dramatic narration of the greatest love story the world has known, the story of God's love for men. Before the festival day of the past, Jesus knowing that his hour has come, that he should depart out of this world unto the Father. Having loved his own who were in the world, he loved them unto the end. Then they were gathered together, the chief priests and ancients of the people in the court of the high priest who was called Caiaphas, and they said among themselves... But this man doth many miracles. Yes, they speak of one four days in the grave whom he has raised to life. For three years now he's gone throughout the towns and villages of Palestine, healing and helping the sick, speaking his message of brotherhood. Do you not see that we prevail nothing? Behold, the whole world is gone after him. Then we must apprehend him. No, no, not on the festival days, lest there be a tumult among the people. We must apprehend him and put him to death, for it is better that one man die for the people so that a whole nation will not perish. And the chief priests and Pharisees gave commandment that if any man knew where he was, he should tell them that they might apprehend him. Then came one of the twelve apostles who was called Judas Iscariot to the chief priests and magistrates, and he went in and disgust with them, saying... What will you give me and I will deliver him unto you? You? You will deliver him? Are you not one of his disciples? What will you give me? Silver? Yes. Then we will give you thirty pieces of silver. And having given his promise, Judas from henceforth sought opportunity to depraise Jesus in the absence of the multitude. Now on the first day of the feast of unleavened bread, Jesus gathered his disciples to eat the past. And while they were at supper, he took bread and blessed and broke and gave to his disciples and said, Take ye and eat, this is my body. And taking the chalice he gave thanks and gave to them saying, Drink ye all of this, for this is my blood of the New Testament, which shall be shed for many unto the remission of sins. And when supper was done, he riseth and layeth aside his garments, having taken a towel girded himself. After that he puteth water into a basin and began to wash the feet of his disciples and to wipe them with a towel wherewith he was girded. And after he had taken his garments being set down, he spoke to them, Know ye what I have done, you call me Lord and Master, and you say well for so I am. If then I, being your Lord and Master, have washed your feet, I have given you an example that I have done to you, so you do also, for the servant is not greater than the Master, for the disciple greater than he that sent him. If you know these things, you shall be blessed if you do them.  Now there was leaning on Jesus' bosom, one of the disciples whom Jesus loved. Peter therefore beckoned to him and said, Who is it of whom he speaketh, Lord, who is it? And Jesus answered, He it is to whom I shall reach bread dipped. And when he had dipped the bread, he gave it to Judas' scaliot, and after the morsel Satan entered into him and Jesus said to him, That which thou doest do quickly. Now no man at the table knew to what purpose he said this unto him, for some thought because Judas had the purse that Jesus meant he should buy these things needed for festival days, or that he should give something to the poor. He therefore having received the morsel went out immediately, and it was night. When Judas therefore was gone out, Jesus said, A new commandment I give unto you, that you love one another as I have loved you. Peter loved in this no man hath that a man lay down his life for his friends. He that hath my commandments, and keepeth them, he it is that loveth me. And he that loveth me, should be loved of my father. Amen, amen I say to you, if you ask the father anything in my name, he will give it to you. Ask and ye shall receive. You have heard that I said to you, I go away, but I will come again unto you. Now I have told you before it come to pass, that when it shall come to pass, you may believe. Arise, let us go hence. They therefore went forth to the Mount of Olives, over the brook Sidron, to a place which is called Gethsemane. And when they had come into the garden, Jesus said to them, All you shall be scandalised in me this night, for it is written, I will strike the shepherd and the sheep shall be dispersed. But after I shall be risen again, I will go before you into Galilee. Now sit you here while I go yonder and pray. And he taketh Peter and James and John with him, and he began to grow sad and said to them, My soul is sorrowful, even unto death. Stay you here and watch, pray lest ye enter into temptation. And when he was gone forward a little, he fell flat on the ground and prayed. And Peter and James and John spoke among themselves. Peter? He speaks of our being scandalised and scattered. Though everyone be scandalised in him, I will never be scandalised. I will never leave him. You will not deny him, Peter? No, though I should die together with him, I will not deny him. But he said this night before the cockroach, thou shalt deny him thrice. I am ready to go with him both into prison and to death. Peter? He is in an agony. We will go to him. No, it is better not. He asked us to stay here and watch. Listen. He is praying to his father. Father, all things are possible to thee, if thou wilt remove this chalice from him. Nevertheless not my will, but thine be done. And being in an agony, he prayed the longer, and his sweat became his drops of blood trickling down upon the ground. And when he rose up from prayer and was come to the disciples, he found them sleeping. And he said to them, Why sleep you? Could you not watch one hour with me? The spirit is willing, but the flesh is weak. Behold, the hour is at hand when the son of man shall be betrayed into the hands of sinners. And while he was still speaking came Judas, who knew the place because Jesus had gone there often together with his disciples to pray. And with him came a multitude of swords and clubs, and the chief priests and the scribes and the ancients. But how shall we know him? They are grouped together in the dark. Which one is he, Judas? I shall go up to them. Whomsoever I shall kiss, that is he. Hold him fast and lead him away carefully. Hail Rabbi. Judas, does thou betray the son of man with a kiss? And then they came up and laid hands on Jesus and held him.  Then Jesus said to him, put up thy sword into its place, for all that take the sword shall perish with the sword. Thinkest thou that I cannot ask my father, and he will give me presently more than twelve legions of angels, where this is done that the scriptures of the prophets might be fulfilled. And now you come out, as if it were against a thief, with swords and clubs. When I was daily with you in the temple, you did not stretch forth your hands against me. But this is your hour, and the power of darkness. Then the disciples leaving him fled, but Peter and another disciple watched from afar off, and the band and the tribune and the servants took Jesus and bound him and they led him away. And they brought Jesus to the house of Caiaphas, the high priest, where the scribes and ancients were assembled together. When therefore they had gone in to where they sat in judgment, they questioned him. What witnesses bring you against this man? He has called himself the king of the Jews. We know that in secret he is perverting the nation to set up a new kingdom. That is true, because he has refused to pay tribute or to visit the temple. He said that he will destroy the temple of God, and after three days rebuild it. You are not a sorceress, thou nothing to the things that are charged against thee? You see, he cannot answer, he is guilty. He called himself a prophet. Blindfold him and let him prophesy who struck him. Va, if he were a prophet, he would know who it is. Is this the promised one, the redeemer, the Christ who is to deliver his people? As high priest, I adjure thee by the living God, that thou tell us if thou be the Christ the Son of God. I am, and thou shall see the Son of man sitting on the right hand of the power of God and coming with the clouds of heaven. What need we of further witnesses, for we have heard the blasphemy from his own lips. What think you? He is guilty of death. Let him be crucified. Away with him. And they led Jesus outside to the court of the high priest where Peter had entered that he might see what would happen. And Peter sapped with a servant at a fire warming himself, but one of the maid servants seeing him in the light began to say to the bystanders. This man is one of them. You, are you not also with Jesus of Nazareth? Me? I neither know nor understand what thou sayest. Surely thou art one of his disciples. Did I not see thee in the garden with him? By all that is holy I am not. I do not even know him. Never truth thou art a follower of his. For even thy speech doth discover thee as a Galilean. Have I not said I know not the man of whom you speak? Must I swear by oath?  And going out Peter wept bitterly. And when morning was come the chief priests and ancients of the people who took counsel against Jesus they might put him to death. And having bound him they led him away from Caiaphas to Pontius Pilate the governor. Now Judas who had betrayed him seeing that he was condemned repented and went back to the chief priests and ancients. Judas, I would speak with you concerning Jesus. It is finished. He is condemned to death. But this man hath done no evil. He has been judged guilty. I have sinned and betraying innocent blood. If you have sinned, Judas, then look you to it. What is that to us? I will return the money. It is not lawful for us to take it because it is the price of blood. I have betrayed him. Here! He has become as a madman. This money it shall be used for the purchase of a burying place for strangers. And with the money they bought the potter's field that is called the field of blood even to this day. One was fulfilled the word spoken by Jeremiah the prophet and they took the thirty pieces of silver, the price of him that was prized and they gave them unto the potter's field. Jesus was brought before Pontius Pilate the governor, the scribes and ancients went not into the hall. They might not be defiled on the festival days. Pilate therefore went out and spoke to them saying. What accusation bring you against this man? If he were not a malefactor we would not have delivered him to you. He is guilty of death. Why? What evil has he done? We have found him perverting our nation and forbidding to give tribute to Caesar. Thus thou hear the accusations they bring against thee? Answereth thou nothing? He stirreth up all the people teaching throughout all Judea beginning from Galilee even to this place. He says that he is Christ the king of the Jews. Art thou the king of the Jews? Art thou a king? And Jesus answered, thou sayest that I am a king. For this was I born, for this came I into the world. That I should give testimony of the truth. And having questioned Jesus, Pilate spoke again to the Jews. Find no cause of guilt in this man. I will chastise him therefore and let him go. He has been judged guilty, but you have accustomed that I should release one on to you at the past. Do you not wish therefore that I release on to you the king of the Jews? We have no king but Caesar. Crucify him. Shall I release Jesus or Barabbas, who is a judged thief and murderer? Release Barabbas. This man must bless thee. He calls himself the son of God. He's destroyed the temple. Crucify him. Why? Crucify him. Why? What evil hath he done? Find no cause of death in him. I will chastise him therefore and let him go. No more. Then therefore Pilate took Jesus and delivered him to the soldiers. They led him away into the court of the palace and called together the whole band. And stripping him they scourged him and clothed him with a scarlet cloak and plaited a crown of thorns. They put it on his head and a reed in his right hand.  And when the hour was come Jesus went forth bearing the crown of thorns and the purple garment. Pilate therefore went forth again and spoke to the ancients. I bring him forth unto you that you may see I find no cause in him. Behold the man. Let him be crucified. I find no cause of death in him. We have a law. And according to the law he should die because he made himself the son of God. Pilate your wife wishes to speak with you. Yes. I have done nothing to do with this just man. But I have suffered many things this day and a dream because of him. Let him be crucified. If thou release this man thou art not Caesar's friend. For whosoever maketh himself a king, speaketh against Caesar. Bring me a basin of water. I shall wash my hands of this deed before the people. I am innocent of the blood of this just man. Look you to it.  Then therefore Pilate delivered him to them to be crucified. And they took Jesus and bearing his own cross he went forth. And there followed after him a great multitude of people and of women who bewailed and lamented him. When Jesus turned to them said daughters of Jerusalem weep not for me but weep for yourselves and for your children. But also two malefactors led with him to be put to death when therefore they came to the place which is called Golgotha which is the place of Calvary. They gave him wine mingled with myrrh but he took it not. It was the third hour and with the robbers one on his right hand and the other on his left they crucified him and Jesus said father forgive them for they know not what they do. Save thyself. Let him come down from the cross that we may see and believe. See the inscription above his cross. Yes. Jesus of Nazareth the king of the Jews. See the thieves on the crosses. They are talking to it. If thou be the Christ save thyself and us. That is enough. Neither dost thou fear God seeing thou art under the same condemnation and we indeed justly but this man has done no evil. Lord remember me when thou comest into thy kingdom. When Jesus said to him amen I say to thee this day thou shalt be with me in paradise.    The temple was rent in two from top even to the bottom and the earthquake to the rocks were rent and the graves were open and many bodies of the saints that had slept arose and coming out of the tombs after his resurrection came into the holy city and appeared to many. Now his friends from Galilee stood afar off beholding these things and all the multitude of them that were there came together to that site and saw the things that were done returned striking their breasts of the centurion and they that were with him watching Jesus and having seen the earthquake and the things that were done were so afraid and said indeed this man was the son of God and in the hearts of the disciples who had watched on the hill of Calvary they echoed the words of Christ father forgive them for they know not what they do little children a new commandment I give unto you that you love one another as I have loved you greater love than this no man hath that a man lay down his life for his friend. Thank you Miss Barrymore for an inspiring performance the passion and death is a fitting family theater program because it is a story of sacrifice a lesson of love yes and in a family sacrifice and love go together every mother knows what it is to give up things for her children every father makes sacrifices for his wife and family keeping a family together and happy demands continual sacrifices sometimes the things you must do and the things you must do without are almost too much to bear that's why a home needs God's help that's why a family needs family prayer only when you pray together as a family do you know the wonderful help that comes through family prayer if you've never turned to God before turn to him now and this will indeed be a joyful and happy Easter for you and your family your family will be united together with God's love with this help and this realization a family that prays together stays together this is Guy Madison saying good night and God bless you our thanks to Miss Ethel Barrymore for her performance this evening and to Max Terror for his music the script was prepared by Mark Carney this production of family theater incorporated was directed by David Young others who appeared in tonight's play were Norman Field Janet Scott Victor Perron Edward Coleman's Charles Maxwell Herbert Rawlinson Bob Purcell and Howard Culver next week our family theater stars will be Gene Crane and Robert Walker in Little Boy Blue your host will be William Gargan series of the family theater broadcast is made possible by the thousands of you who felt the need for this kind of program and by the mutual broadcasting system which has responded to this need be with us next week Tony LaFranco speaking this is the mutual broadcasting system