So, Laura is going to be, is going to be showing us some cases later on in this talk. She said, yeah. And so, I'm just going to talk a little bit about visual field testing. And some of you may have heard this talk before, because, you know, we are on a two-year cycle now, and previously on a three-year cycle. Some of you may have heard the talk before. Some of you, it's all new. So, let's without any further ado. So, what I'm going to talk about is how to do visual field testing, how to record visual field testing, various testing strategies, and testing artifacts in automated perimetry. And so, you all remember the visual system, okay? I'm going to just take that as given. But there are a variety of ways in which you can test the visual system. A lot of people sort of conceive of the visual field as sort of this mountain of vision in a sea of darkness, right? And the point of this mountain is that the vision is not as good in the periphery, and then it gets better and better and better towards the center. And so, this rising peak here indicates better and better and better acuity. And so, what you can do is you can sort of enter into the field of vision with various sizes and brightnesses of objects and expect them to be seen progressively closer towards the center as they get smaller and dimmer, okay? The most common way of field of vision testing is confrontation fields. I prefer confrontation rather than confrontational because I think confrontational implies, can you say this? Okay, so here you are.  When you're doing count fingers vision, you don't really need to have it carefully aligned with a patient's eye.  And then it gives you both hands free. So some people do one or two. Some people do one or two or five fingers of counting. It's important to make sure, and this is something we start off with the medical students, which is coming up on Monday in a couple of weeks, to make sure that the fingers are not aligned like this. How many fingers? I don't know. Is that one or two? I can't tell. So you're testing in all four quadrants, not out here. And we make the point with the medical school, testing somebody in there is teaching the medical students to do the semaphore version of visual field testing, but nobody admits it. So the other way of doing the visual field testing is with some sort of more formal testing method, and they all employ some kind of a bowl representing visual space around the patient. When you're talking about kinetic perimeter, it's a moving target coming in towards the center, and you have a certain specified brightness and size of stimulus that is brought in from the edges, and then you join up those dots representing what they call an ice doctor of visual field. And in static perimeter, you're shining different brightnesses and sizes of objects in various locations, and the brightness is going to be variably detected as you get closer towards the center. So kinetic meaning moving, and static meaning not moving. And so in kinetic perimeter, you get these ice doctors and static perimeter, you just get this sort of graded mountain of vision. We also have the beloved tangent screen. We use that a lot. It is not just a way of decorating the walls. There's one at the VA. There's actually a regular one at the VA somewhere, but that got moved. But the one down in low vision surface is just perfectly fine. As a matter of fact, it's the fanciest one I've ever seen. It's very, very nice. And the nice thing about the tangent screen is, unlike all the other methods with the tangent screen, you can vary the distance of the patient from the screen rather than just the brightness and size of objects. So in recording the field of vision, the right eye goes on the right. The left eye goes on the left. This is the only thing that is different in entire medicine where things are reversed. Everything else is as if the patient is lying on the page and you're looking at them. In the visual field, it's as if the patient has the field and is just kind of burning it. It's like Superman burning it into the page. One of the most successful ways of determining which visual field you're looking at is I but looking at the appearance of the physiologic blind spot. And you want to double check in a Humphrey automated perimetry that where the machine thinks the blind spot is actually where the blind spot is turning up. There's a little gap in the printout where the blind spot is intended to be on a Humphrey visual field. And if it's not turning up where the blind spot is, then you may be looking at a patient being tested on the wrong eye. So moving on to some of the automated perimetries, there are a wide variety. Almost everybody now is going with some form of CETA. Does anybody know what CETA stands for? Threshold Algorithm? Something, something. Algorithm? Threshold Algorithm, Swedish. These are interactive, actually. Not integrative, interactive. And so what's interesting about CETA testing is that basically the machine assumes that a certain visual field exists. And then as the test is being done, that field is being modified and updated during the testing. And so before that, basically, the stimuli were presented at a certain speed and a certain brightness, regardless of what the patient was doing. And with this interactive, the machine does a few preliminary tests and decides how the patient is seeing and how quickly they're responding and adjusts accordingly. And so what that results in is a huge variation in the amount of time that it takes to do a test. So you guys all need to be aware. So full-threshold testing is really nice. But it can take up to 20 minutes per eye, which is agony. That is not a fun thing. So the regular CETA standard, if a patient is doing well, can take five, six minutes per eye, which is way more tolerable. And the CETA fast, which has a commensurate slight decrement in information, is usually five minutes and under. So you can really speed up the situation by changing your algorithm. So of course, neuroephthalmologists never trust anything. But somebody's done some testing and comparing CETA to golden visual fields. Because we were all raised on golden visual fields. Goldmans are preferred by the patients, I think mostly because you can chit-chat with the examiner while you're doing it. You cannot do that during a CETA test. You have to really maintain your attention. But on the other hand, having a little chit-chat can help to keep you awake. So it's not an unreasonable thing when a patient is a child or an elderly person or somebody's had a stroke or falling asleep to switch to a Goldman because of that chattiness. CETA is way faster. It's much more sensitive. It's CETA is at least as good as a full-threshold. So the testing has been done. It's pretty good for picking up defects. And they concluded that it was a useful alternative. I just wanted to mention some of the variants. And I've heard that this kinetic fixation is actually going to happen. Basically, all of the other tests, there is a central fixation target and the spots appear around it. In this kinetic fixation perimetry, the fixation target is moving around. And then the testing spots appear around it in the same proportion. And I think it's much more comfortable. I think that we all get complaints about, well, I was looking at that dot and it totally disappeared. Or I saw five dots in the center. Or I thought I saw the dot, but then it seemed to totally go away. Or all kinds of hallucinatory experiences. I mean, the human eye is not intended to stare into a bright, white bowl for more than a few seconds. So I think that this sort of thing might actually come up. This is a printout of one of those early tests. The other thing you guys need to know about is that there are a bunch of screening tests out there. These are a money-making proposition. Some patients, when they go to their eye doctor, they sort of offer to menu, what would you like to do today? Do you want some photographs? Do you want to visual field? And some people will say, yeah, sure. And I've actually seen patients with a visual field defect picked up because they said, yeah, sure. And they had no idea anything was wrong and off they went. But these screening tests are extremely efficient. This is one of them where you have a sort of sinusoidal grading that's sort of moving. And so the patient will tell you that they were looking into a little viewer and a little kind of flickering thing appeared all around in their peripheral vision. It's only 16 test points for this particular one. And so it was specifically designed to try and capture M cell, neuronal death. I don't know that it really does, but it's nice because you don't have to be in a dark room.  And it can tolerate a ton of blur. So refractive error is not so much of an issue. And this would be the printout that you get. This is like a perfect test result. And it's this little sort of strip that gets spit out of the machine almost like when you've done a lensometer, the automated lensometry. And so you can sort of see that there's the little black dot over here in the left. Eye is over here on the left. And then it goes all the way out to 30 degrees nasally. So it is intended to screen for glaucomatous problems. It takes a couple of minutes per eye. The screening one is 45 seconds per eye. It's fast. It's compact. It's portable. It's inexpensive. It can miss neurologic deficits because the stimuli don't respect the vertical. The targets are large, so small. Scutomata can be missed. But Dr. Wall, a neurothemologist in Iowa, did some data on this. And he concluded that it was actually quite sensitive for optic neuropathies. It's original intent, glaucoma. But it doesn't do very well with hemianopias. I have seen hemianopias picked up, but it's not very sensitive. So the advantages of automated perimetry, now we're moving into the artifacts. The advantages of the automated perimetry are lack of observer bias. So a golden visual field, for instance, in an experienced hand, can make show almost any defect that you think it should. So it's very easy as a voleman to find a defect that you intend. The Humphrey perimetry doesn't look at any of these pretest biases. It's very reproducible. And almost everybody in the country has Humphrey. The major alternative is octopus, which is a very nice test. But unfortunately, since the color print out doesn't fax very well, as my printer doesn't fax at all. But the other nice thing about the automated perimetry is that there are a bunch of different test strategies. And you've seen us in clinic doing testing with large, bright stimuli with bi-sized stimulus, et cetera. There are a lot of ways you can go about doing the test, even with automated perimetry. And I would say that in most cases now, a streaming or seed of fast will be faster than most goldmans, except for a goldman that's intended for driving. So driving valuation, goldman, which is a single-size stimulus, a three-size stimulus, the 35E, can take literally 30 seconds. You can get that done. The other thing that's nice about automated perimetry is very quantitative. And so if you're trying to follow a defect, then it's quite helpful. The disadvantage is that it's run by a machine. So there's no chit-chatting. There is adaptation for the patient, but not very much. And it is prone to artifacts. And we're going to go over some of those. So the players in inducing artifact and automated perimetry are the patient, the machine, and the technician. So the patient, pupil size matters. With very small pupils, you're going to get constriction. You do have to have accurate refraction. You do need the near add, because the bowl is at about 14 inches. It's pretty close to the patient's eye.  People have high myopia, or better off, using their contact lenses, or even their glasses, because the machine has a lens in front of the patient's eye that those can need to artifact as well. Tosis on the part of patient, concentration, reaction time, neurologic data, so it can all play a role in your reliability of visual abilities. So if they're going to wear their contacts, do you just do a little refraction over them? Yeah. And the near add, whatever the near add might be. So patient teaching. The technician, whoever's doing the visual field, like Rhys here, these men in the visual field do today, you have to know what the patient's up for, right? If you don't understand the test, then you can't tell the patient how to do the test. And they need to tell the patient how to do the fixation, how to respond, even to dims stimuli. They have to be redirected during the test, but not too much, because if you're constantly hovering on the patient and moving your chin around and poking it in the back of the head and things to try and get their head aligned, then the patients can get very frustrated and annoyed. And sometimes they'll say that that was the best visual field I've ever done. And sometimes they'll say, that was so annoying. So the machine can be stopped in mid-flight, right? If you just hold down the button, then the machine stops. And so if the patient is told that they need a rest, and they need artificial tears, oh, my bad. They can stop the machine as it's going, and then just resume. Yes? Oh, here it is. I thought you were asking a question. I don't know what I was doing. Some patients simply cannot do pump-free visual field testing. Every time they do the test, it gets worse. And they start getting anxiety attacks and things. It's moderately stressful. The machine issues. You have to choose the right protocol. You have to know what you're looking for. You have to choose the right stimulus size, and the correct parameters have to be put in. There's a lot of information that has to get entered into the machine before the patient can even get started. And they have to put in the patient's age, the right correction, the pupil size, and they have to test the correct eye. So here's a classic artifact in visual field testing. What's going on here? It could be a rim artifact, or it could be ptosis. So both have to be looked at. In this case, the pupil is 2 milliliters, OK? And that's just not going to work. And so after the patient's dilated, you can see a lot better response. What happened here? Anybody have any suggestions? Any suggestion about the patient? Trigger navigating. This is too darn bright. They have very, very, very good vision, or they're just pressing a button willy-nilly. And unfortunately, the machine can tell. But look at that fixation losses. They're looking around. It's just not a very reliable false negative. It's not none. So they're just really going to town. And so what about that one here? Fogul threshold there, what's that? One decimal, right? That can't be good. That's just too dark. You can't do that test. So this is not a problem with the machine. It's a problem with the choice of the test. So with the three size there, they can't do much with the five size. You can actually maybe be able to follow that. So the one on the left is a three size. One on the right is a five size stimulus, OK? What's the deal here? Mostly. Yeah, it could easily be. What's this one called? Cloverleaf. Everybody see why? It's so lucky day. OK, so the cloverleaf is your fellow. I want to explain that a little bit. So the machines are kind of interestingly designed. The first thing the machine does is test these four little spots at about 10 degrees, which is, I put this in an amphibre. If you put an amphibre in the back of the hole, the four spots that are tested first are the one out of about 10 degrees, OK, which Amzard is out there. So those are the four testing spots. These other guys in the middle are as close to centrifugation as the machine gets, which is interesting. But so you can see here that so the physiologic blind spot starts at about 10 degrees. So here's where the physiologic blind spot would start, and so these testing spots are about 10 degrees. So you can actually have a reverse cloverleaf. This is where the patient didn't get the test. They didn't understand what's going on during the initial primer phase, and they just missed all four of the initial testing spots. So that tells you exactly, it's like a reverse cloverleaf. It tells you exactly where those first rounds of testing are occurring, right at about 10 degrees. OK, what happened here? Could be ptosis again. And so you can take the lid and get the ptosis out of the way. What happened here? Rim artifact, yeah. See how mechanical that looks? Just doesn't look like anything sort of physiologic, especially the one on the right. That's pretty impressive. So rim artifact, most often what's happening is that the lens is actually put, it's on this little standard, and it's put right up against the patient. And then over the course of the testing, the patient like that. And so they're looking sort of through this little ring. So it's best if you use kit lenses, but if you can't come up with the astigmatism correction that you need, then using the patient's own glasses as long as they're correctly positioned. Keep the patient awake and keep the head up against the force.  They're only an inch away, but this feels like they're... Okay, what happened here? The vertical position was on. Does anybody know how that would happen? I can tell you that it almost never happens in the other direction. Does that help? I've never seen it with the physiologic line spot displaced superiorly, never ever once. You want it, you want it? Okay, so this is looking into a comfrey individual field bowl, okay? This little thingy over here is the little camera that's watching the fixation. And so down at the bottom of the printout, there'll be that little line that shows how well the patient is maintaining eye position. So this thingy down here, this is the test that the machine uses to detect bogeal threshold. It's this little set of diamonds and it's a progressively brightening, kind of like a gringe colored stimulus and it's down below. So as you're doing a bogeal threshold, and that takes like maybe 30 seconds per eye, very, very helpful tests.  And then what's supposed to happen is the patient's supposed to move their fixation up to the central fixation target, okay? And that is literally right straight ahead of you in the bowl. And if you don't do that, then the whole test is typically done with the patient looking at the little diamonds here, down below. And that's, again, it's about 10 degrees off fixation. The blind spot is displaced inferiorly and you'll often get these spurious upper visual field defects because of course you're testing way more peripheral vision than the machine is intended. Make sense? It's a mechanical problem with fixation. And it happens all the time. And patients will say, well, I thought it was kind of weird, but you know what, I just did what I was told. Or the tech will say, well, I know it all looks right ahead, but they just seem like they weren't fixating properly. And machines go nuts because they can't find the physiological blind spot, et cetera. So what happened here? Is this patient radically getting worse over time? There she is. She's got a pretty nice visual field on the right there and her little meningioma, is it like expanded and just gotten dramatically worse? You can see there's generalized depression there. And is it worse? Could be. Let's do another MRI. Or we could check the parameters here. Somebody put in her date of birth incorrectly. Right? And the machine thinks she's only 40 years old instead of 50 years old. And so she's being judged much more harshly, right? A 40-year-old and a 50-year-old will not have the same field of vision. And these machines are calibrated for age. So you're compared not against, you know, 25-year-old lab rats, you're compared against your peers. Are they in, like, 10-year intervals, usually? Or how is that? I don't think that one or two years is probably gonna make much of a difference, but a decade would. And I don't know the answer to that question. I'm sure it's out there, but. I didn't know that. And I don't know. I don't know if it's bend or if it's a continuous variable. I'm not sure about that. But definitely a decade is gonna make a difference. So in automated pre-treat, there are patient-related artifacts. You have to prepare the patient. You have to coach them. You have to monitor them. Position them, dilate them, refract them. Take care of their ptosis and choose the right test. Right? You're not gonna be able to get a good result if you ask for the wrong test. And they're machine-related artifacts. You have to choose the right test strategy. You have to check the parameters. The demographics, the lens position, the stimulus size. And I say, be one with the machine. Right? You have to really understand how the test works. Because when patients come out to you and say, you know, that he's all making mouths in there, well, maybe they're not totally nuts. So I think, I encourage everybody to actually have a visual field done on them because it's a very interesting and somewhat unpleasant experience. Okay, so let's go over some cases. All right, so the first case was a 65-year-old guy who was referred by his neurologist to evaluate his vision. One year prior to when he came to us, he had had a hemorrhagic stroke. And since then, he noticed that he'd frequently been bumping into objects on his left side. And he was describing mycropsia and macropsia. So for him, when he would walk down a hallway, it would seem like the walls were getting bigger and smaller and bigger and smaller. So his acuity was 20-20 in both eyes. He had no APD. His motility and alignment were normal and his slit lamp of the anterior segment and his funnest exam were normal. Okay, so here is his Humphrey visual field. So how would you describe this field defect? Anybody, this is an easy one. What? Quadrant, very good, okay. So where was his hemorrhagic stroke? Right parietal, okay, so here is his skin. There it is in the right parietal. So I found this, I didn't create this diagram. So I don't know if this is against the rule, but I thought it was actually really nice, whoever did make it, describing kind of where the field projects onto the retina and then anatomically where that goes back, right? So he had a left lower quadrant tenopia, right? So it projects up here onto like the supranasal portion of the retina and the supratemporal here, right? So he's gonna come down through the optic nerve, cross through the chiasm, go back in the right optic tract, synapse in the lateral geniculate nucleus, come up into the parietal lobe through the optic radiations, right? I'm gonna say I'm on this side. Okay, so what other symptoms do you think this patient might have? This is some board review stuff. Let's say, what if it's his non-dominant hemisphere as most right-sided parietal lesions are put up here? I know, it's hard to look it up. So they get spatial disorientation, they can get dressing or construction apraxia.  So you have to really be able to appreciate the spatial relationship of the pieces and the parts of the clothing. Construction apraxia is when people have a really hard time either repeating a drawing or creating even a simple structure, like popsicle stick type stuff. If it's the dominant hemisphere that's affected, they can have dysphagia or aphagia, apraxia, and then Gerstman syndrome is a good thing to know for boards because they'll ask you about that. They have a hard time doing basic calculations, writing, finger, agnosia, sorry, that's misspelled, is out and they can't recognize and name the different fingers that they have and they have a hard time telling right versus left. And hemispatial neglect usually happens from a right-sided lesion causing left-sided neglect and that's because the right-sided space usually has redundant processing from both the right and left hemispheres, but for most left-brain-dominant people, the left-sided space is just processed by the right hemisphere. Okay, next case is a 21-year-old woman who came into triage. This was just before Thanksgiving because she'd been noticing a gradual loss of vision in her right eye. She thinks maybe somewhere like the past one to three months has been pretty slow. She's not had any changes in the left eye and she's been noticing some headaches several times per week for the past month and they last sometimes the whole day and she gets fairly light-sensitive with them. And she was seen here back in 2012 in Dr. Vitale diagnosed her with mutes in the right eye. There was a question of maybe whether or not it could be a multifocal coriditis but she felt like, well, it doesn't really matter if it's gonna go on its own so she just never came back. So her acuity was 2020 in both eyes. The technician that saw her and then dilated her thought that she maybe had an APD in the right eye and her motility and alignment were normal. Her anterior segment was unremarkable and on dilated exam the report that you get is that the left optic nerve is maybe a little hyperemic. So what would be the next step now? So somebody's called you and they're like, oh, I have this person sitting here, I'm not sure what to do. I've already dilated them. Revealed! Very good. So I put up here her confrontational field and even though she was dilated, we decided to just go ahead and get one and see what pops up. So how would you describe this? A homonymous, right? Yeah, yes, that's very good. So where would you expect to see a lesion? Or what part of the visual apparatus? Could be a lot of places, right? Like basically sort of anywhere behind the chiasm. It's somewhat Congress, maybe not, but what would you want to do to evaluate this? Sorry, did you say her complaint was her left eye? Her complaint was her right eye. Was her right eye? She didn't feel that there was anything going on in the left. Okay, so what would be the next step? Imaging. Imaging. What would you order? Okay. This is what came up on the MRI. So this actually turned out to be a hemangioperisitoma. So she just had that resected and she's still, she's in rehab now actually for that. So interestingly enough, so because she'd been having the symptoms for like one to three months and it was really gradual onset. I didn't, I thought stroke was less likely and so I thought it's fine to do the scan as an outpatient. The radiologist actually came out and talked to her as they were doing the scan and sent her to the ER because she's got this big left shift there, so. Okay, so I pulled this back up just to kind of reiterate the anatomy there. So this, her field defect was like this, right? So it's gonna be these on the retina, right? So then these are gonna come back in here and this comes all the way back here. So this is kind of, you have to think about this diagram being reversed in terms of the imaging, right? So this is the left side. Okay, the third case was a 43-year-old woman who was sent for a visual field defect found on automated pre-metry. So she had gone in to see an optometrist three months prior to when we saw her for an annual exam. I mean I say annual but she hadn't been to anyone for a long time but she just thought maybe she should get her eyes checked out. And the optometrist found bilateral optic nerve power and did fields and found these field defects. She herself has not noticed any changes really.  And she told us that actually at age two she fell out of a second story window and she was in a coma for 90 days. And then she thinks ever since then the left eye has just kind of drifted out. And she hasn't had, you know, she's not had close follow-up by any means. So she thinks that she may have seen somebody maybe like 10 years ago, maybe it was like 20 years ago, so it doesn't really know. And a few weeks ago she started getting headaches a few times per week. So because of the field defects and the way that her nerves looked, the optometrist had her get an MRI and we had the read on it, not the images, but it was normal. So her best corrected acuity was 20, 20 in the right eye, 20, 70 in the left eye. She had a small relative efferent pupillary defect in the left eye. She had a very large left XT. That was very commentant. Her anterior segment was unremarkable and her nerve, so she had a little bit of rim that was pink, left superiorly and inferiorly and then temporally and nasally, there was no rim. So I'm sorry, I don't have a photo of that. So I'm just pulling this up to show you it was very thin. Okay, so here was her confrontational field. So what would you like to see next? Her Humphrey. So there it was, so how would you describe this? Yeah, bi-temporal field defect. Okay, so where would you expect to see a lesion? Right, somewhere near the chiasm. Okay, so the MRI, which was done specifically to evaluate a bi-temporal field defect was normal. They saw no pituitary tumor, so now what? Very good. What other things, let's assume that it's not like a terrible radiologist that just missed a huge pituitary tumor, because that would be pretty unlikely, right? What's that? Like other medications. That's good, she's not on any medications. What other things could give you a bi-temporal field defect besides a pituitary tumor? I know it's the one you think of right away, but what? You would probably see it by the aneurysm. An aneurysm, very good, anything else? What? No, I'm saying besides a tumor. Forget a tumor in that area. But that's good, yeah, if it was coming up from below. Other kinds of tumors. Other kinds of tumors, yeah. No tumor. Very good, you can get a chiasmitis from that. Yep, very good, you can get it from sarcoid. And what else? What other disease that's autoimmune can cause inflammation of the nerves that maybe could also cause inflammation of the chiasm and you? MS, yeah, very good.  And also, and I don't know if you guys will come up with this, I certainly did not. This woman has this really significant trauma history, right, she fell out of a second story window, she was unconscious for somewhere around three months. Is there any way that that could give you a field defect that looks like this and how? So you can get a sheer injury to the chiasm from blunt trauma like that. So we requested the images to look at them. And I'm not sure how well this is gonna show up, but she had these cystic spaces like surrounding the chiasm, so that's CSF there and this is just another little slice and like here and here that confirmed the suspicion that she'd had a sheer injury to the chiasm back when she was a kid and that's why she didn't notice any changes, whatsoever in her vision. Because you'd think that if it was really new, you would notice something like that. Although to be fair, most patients don't. A lot of times they don't notice that they have trouble with their vision until they're using monocular viewing and trying to read the eye chart and they can't read the right half of the eye chart with their right eye or the left half of the eye chart with their left eye. That's true. So to be fair, you know, with both eyes together, you can often see pretty well. Don't tie it off again. Exactly, what is? All right, so we'll actually come back to that too. Okay, so the fourth case is a 44 year old guy who went in to see his optometrist at the end of October because he noticed this black caterpillar in the left super temporal visual field. So it was just kind of like sitting right there. And they found that he had swollen optic nerves on both sides. So an MRI was done which revealed an occipital tumor and that was resected and it was found to be a meningioma. But he's coming in to see us because he's had blurred vision in both eyes since the surgery. And he thinks maybe it's getting a little bit better but he's having a really hard time like reading and he's a very smart guy and he can't really do his work right now. So his central or his corrected acuity is 20, 25 in the right eye, 20, 20 in the left. He had no APD. His motility was fine. He was orthophoric. His confrontational fields were full. His color vision was a little bit down. Sanctuary segment was normal. And on fundus examination, his nerves are like this. Okay, so now what? What kinds of things will you ask him about? Okay, good. His only medication is capra. Thanks. He gets headaches like occasionally, like maybe once or a couple of weeks, but that's it. He's had a couple of those that he's noticed. It's not happening very frequently, but he has noticed that. What? Yeah, he's noticed that a few times. He thought it was like raining outside and then realized that he was just hearing something in his ear. Okay, so what's the next step? Visual fields. And here's what they look like. Okay, so how would you describe this? Let's start with the blind spots. What would you say about that? Yes, they're both enlarged, right? And then what else does he have going on there? They kind of are seco-central, right? They're sort of, you know, right there. But I think, and it's a little bit hard to tell, but you can kind of appreciate that there's a little bit of like a homonymous nature to that there. But so could you get a seco-central scatoma in the enlarged blind spots based just on his disc swelling? What? Not usually? Yeah, so that'd be really unlikely, right? So remember we talked before about how with papillodema or discodema from that, it's like really unlikely to get central vision loss until it's really late. So it'd be very odd to have everything else in the periphery fine and then just the central one. So that, just looking at that right there should make you think, oh, that's probably something besides just disc swelling. So if we say, okay, yeah, there's a little bit of a right homonymous, a little bit of a left homonymous, where do you expect to find a problem? Something on both sides, right? It's probably behind the chiasm, but. And it gets central, it gets central in the entire face. Right, so pretty far back in the occipital lobe. Okay, so I'm gonna show you his pre-op scan. So that's his meningioma there, more in the right occipital lobe. And this is a coronal view. So what I wanted to point out here is how it's sort of enveloping and surrounding the confluence of sinuses there. And this is post-operatively. So I don't know how well it's really coming up there, but so you can kind of appreciate, this is a flair image, that he's got something going on here and something going on right there. So he's had, what, I heard a whisper. Does anyone know what's happened to him? Yeah, so he's kind of, so he's had bilateral occipital strokes. So they've removed that huge tumor, and then luckily he was just left with pretty small strokes, but sin both occipital lobes there. So, but he's still got all that disc swelling, right? So what's the deal with that? Yeah, so we wanted to also look at the sinuses and see what was going on there. You know, as you remember, it was all kind of wrapped around the turcular, so he would be definitely at high risk for getting some thrombosis there. So this is the sagittal view, and I don't know if you can appreciate there.  So we put him on anti-quagulation, and we'll see how he does. He's still walking and talking, and he's alive, and he's not really miserable, so I thought that was really surprising. Okay, so. I would just say, though, that blurred vision, that was his complaint with blurry vision, and you know, you might think, well, maybe the blurred vision is from this pamphlet human, but it's the visual field that told us that, no, this blurred vision is not a pamphlet demon. This blurred vision is related to this sensual visual field defect, and because he had it on both sides, he had that inferior, homonymous defect in the right and then on the left.  You can kinda see how this could happen, and the bigger field defect seems to be, well, it was in his, his right eye was the bigger field defect. Oh, oh my God, yeah. Well, where's my thing, dang it. Back, back, yeah, there. I think they're both bad, you know, because they're right there, so anyway, but it's bilateral. It's a very nice case, though, to how the visual field really, really helps you go, wow, well, this isn't his pamphlet demon. This is definitely something else. Okay, so I, I know we've seen some patients like this, and I was going through trying to find them, but I couldn't, so I can't show you their specific fields, but can anybody think of a scenario where one brain lesion can give you a homonymous hemianopecia, optic discontrophy on both sides and a relative efferent pupillary defect? What? Would that give you an efferent, what? Yes, the tract, the tract. So can you tell me which side the efferent pupillary defect would be on? Like ipsilateral or contralateral? Yes, why? What are the fibers across? Yes, it's very good. And what would the atrophy look like? Yes, can anybody explain why? Sort of, but not exactly. So that was... That's the, that's a lot of make-up notation there. Okay, so I thought I also didn't make this picture. I don't know if I'm allowed to put it in here, but I just thought it was a really nice illustration. The best one I could find, so. Actually, it was stolen from Bill Lloyd's paper. Was this one from his paper? Jim Hara has taken this drawing from Bill Lloyd's semi-optic triple-plusia article of 1968 or something. So don't feel bad about it. Okay, so let's say, so this is, we're gonna say this is the right eye, okay, this is the left eye. So here's the right nerve, the right tract, left nerve, left tract. So let's say you have a lesion here in the left tract. So the fibers that you're gonna hit from, let's say the left eye, it's gonna be the temporal retinal fibers, right? They come back here, they come back here. So temporal meaning temporal to the phobia. So these fibers come here and they come into the disc superiorly and inferiorly here. The fibers that you get from the right eye are gonna be the ones from the nasal retina, right? The ones that will cross here and go into the left tract. Nasal meaning nasal to the phobia. It's gonna be the papillomacular bundle here. Then these are the temporal retinal fibers coming in and then here's the other nasal retinal fibers coming in. So you'll get atrophy here and here, which is why it's called the bowtiatrophy. Does that make sense?  Does that make sense? How do I explain this? Okay. All right, quiz time. In the analysis of an automated static central 24-2, a Congress incomplete homonymous hemianopia is least likely to result from a lesion at the one. Which of the following visual fields is the best one to perform? Confrontational, tangent, Humphrey, Goldman, any. A patient with 20-20 vision in both eyes has a right afferent pupillary defect, localized pallor of both optic nerves and a partial right homonymous hemianopia. The most likely explanation is, everybody have a paper copy? Like, is it totally pointless for me to do that? There are some that don't? Yeah. Okay.  Does it be else missing a copy? Put your heads down and get to work, kids. And we'll go over this with the answers. If I can remember anything. They're kind of tricky questions. Is somebody missing the second page? No, please. Oh, yeah? Can I tell you? I can't, I don't want to explain what I'm doing. Do you have page two? So remember, I'm a neurologist. So we don't listen to the patient, I just said. Do I read it to you? Dear Ray. Ha, ha, ha, ha, ha, ha, ha. Dear Ray, I'm doing great. I was in the hospital for a while, but I'm back now and everything seems to be just fine. So you just won't let me drive. I don't even quite understand why. Ha, ha, ha, ha, ha. They tell me I had a stroke. But I feel fine. Much love. Hope to see you at Christmas. This is an actual letter from an actual person to my actual letter. Ray. Okay. Charmingly giving you. So, a congruous, incomplete, non-saminopia is least likely, I hate the least likely questions. So what do you guys think about number one? Congruous, I think this is good. Complete visual field, complete heminopia. I wouldn't tell you anything, right? Because you don't get the congruity that's complete. It's all complete heminopias are totally congruous. I don't know what you think of it. So I think in the greater principles of things that are more posterior than more congruous, so all I was trying for here is the furthest forward. So I would go with object tracking. So which of the following fields is the best one to form? Anything, anything. It's okay. Okay, and then write it down. So 2020 vision, a right APD, localized power. Partial heminopia, the most likely explanation. I mean, many of these are possible, but the most likely, the nice way to put it all together. Pardon? B. B, B, sorry, I thought somebody was saying something. Okay, a congruous, homonymous, superior co-identitonomy, it may result from any of the following except. I love the gradations. I should stop answering questions all out. Well, so parietal should give you more inferior, right? So it could be a temporal lobe, right? But these are, I don't know, somehow the one that I sent you, I corrected it, so the written one is better written than the, than those ones there. So it could be the optic radiations, right? And so you could get a lesion in the optic radiations from the explosives, a nice, co-identitonomy from the posterior pole, and it includes you from the MCA. What's the conclusion of the MCA? Could you add more conclusion on the MCA? Of course. So, yay! I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. I got it right. Yeah, so the optic radiations in the parietal lobe should be a few in here. That's the only one that does the test. Good. Okay, a monocular visual field effect. And why is, why can you get a monocular field effect in the monocular field effect? How can you get a monocular field effect in this box? What about the temporal pressives? Yeah, exactly. What part of the exit but a lobe would be hit? The most anterior part of it. So there's a lobe on the box. The fixation in the right visual field where the optic mirror vanishes the eye. Right. So that's E, B. All right, so the most likely region, painless sudden onset, middle-aged woman, otherwise normal. And so, now in this I'm, you know, it's like most likely painless sudden onset. And I'm talking about sudden onset. Now there are two possibilities. How long is that to her that she never said what we're saying? To me? To me? I would say to her. It could be nerve or retina, but what's more common? Okay, so what about the actual defect itself? Does that give you information? Yeah, you have a nasal, inferior means of stuff and then a superior also, you know, like partial, almost all of them are superior. Yeah. So theoretically, the retina is gonna give you less likely, is less likely to lose something that crosses the horizontal meridian because of the vascular supply kind of stuff. You can leave that there. And then this is the line spot of the water. This line spot is in water, does another thing. And I would venture to say that interesting doctor, roughly maybe more common than retro-watered illusions. So I'm good with no appearance. Okay, Rhys, what do you think about this letter? You're right. I don't know. I can't tell from the picture what it's trying to show, but I'm not sure if it's supposed to be like a neglect or something. Yeah. I was gonna say opposite at all. Okay. What? I gave you the whole explanation about having neglect.


Hello everyone and welcome back to theCUBE's day one coverage of cloud native security con 23. This is going to be an exciting panel. I've got three great guests. I'm Lisa Martin. You know our esteemed analysts, John Furrier and Dave Vellante. Well, and we're excited to welcome to theCUBE for the first time, Eve Sanford, the CEO of com division group who's coming to us from Germany. As you know, cloud native security con is a global event. Everyone, welcome. Eve, great to have you particular. Welcome to theCUBE. Thank you for inviting me. Eve, tell us a little bit before we dig into really wanting to understand your perspectives on the event and get Dave and John's feedback as well. Tell us a little bit about you. So yeah, talking about me or talking about a combination real quick. We are in the business for over 27 years already. We started as a SaaS company that became more like an architecture and cloud native company over the last few years. But what's interesting is, and I think that's really interesting when we look at our industry, it hasn't really, the requirements haven't really changed over the years. It's still security. We still have to figure out how we deal with security. We still have to figure out how we deal with compliance and everything else. And I think therefore it's more and more important that we take these items more seriously, also based on the fact that when we look at it, how development and other things happen nowadays, it's everybody says it's like open source is great because everybody can look into the code. We, I think the last few years have shown us enough example that that's not necessarily solving all the issues, but it's also code and development has changed rapidly when we look at the cloud native approach where it's far more about gluing the pieces together versus the development pieces when I was actually doing software development 25 years ago and had to basically build my code because I didn't have that much internet access for it. So it has evolved, but even back then we had to deal with security and everything. Right, the focus on security is incredibly important and the focus keeps growing as you mentioned. This is guys, and I want to get your perspectives on this. We're going to start with John. This is the first time cloud native security con is its own event being extracted from and amplified from KubeCon. John, I want to understand from your perspective, break down the event, what you see, what you've heard and cloud native security in general, what does this mean to companies? What does it mean to customers? Is this a reality? Well, I think that's the topic we want to discuss. And I think ease background and see the VMware certification. I love that because what VMware did with virtualization abstract that from server virtualization kind of really changed the game on things. And you start to see cloud native kind of go that next level of how companies will be operating their business. Not just digital transformation as digital transformation goes to completion, it's total business transformation where IT is everywhere. And so you're starting to see the trends where, okay, that's happening. Then now you're starting to see that's cloud native con or KubeCon or AWS re-invent or whatever show or whatever way you want to look at it. But in the past decade and past five years, security has always been front and center as almost a separate thing in itself, but the same thing. So you're starting to see the breakout of security conversations around how to make things work. So a lot of operational conversations around what used to be DevOps makes infrastructure as code. And that was great. That fueled that then DevSecOps came. So the cloud native next level is more application development at scale. Developers driving the standards with developer first thinking shifting left. I get all that. But down in the lower ends of the stack you got real operational issues. DNS we've heard in the keynote. We heard about the kernel and Linux kernel. Things that need to be managed and taken care of a secure level. These are like, seem like in the weeds, but you start to see that happen. And the other thing that I think is real about cloud native security con that's going to be interesting in the watch is Amazon has pretty much canceled all their re-invent like shows, except for two, re-invent, which is their annual conference and reinforce, which is dedicated to security. So cloud native Linux, the Linux foundation has now breaking out cloud native con and KubeCon. And now cloud native security con. They can't call it KubeCon because it's not Kubernetes, but it's like security focus. I think this is the beginning of starting to see this new developer driving, developers driving the standards. And it has IT implications, what used to be called IT ops. And that's like the VMware's of the world. You saw like all the stuff that was not at developer focus, but more ops becoming much more in the application. So I think it's real. The question is, where does it go? How fast does it develop? So to me, I think it's a real trend and it's worthy of a breakout, but it's not yet clear where the landing zone is for people to start doing it, how they get started, what are the best practices, machine learning is going to be a big part of this. So to me, it's totally cool, but I'm not yet seeing the beach head. So that's kind of my take. Dave, our inventor and host of breaking analysis. What's your take?  I think when you look back, let's say 10, 12 years ago, the need for speed far trumped the security aspect, the governance, the data privacy. It was like, yeah, the risks, they're not that great compared to our opportunity. That has completely changed because the risks are now so much higher. And so what's happening, I think there's a major effort amongst CIOs and CISOs to try to make security not a blocker, because it used to be, it still is. Okay, I got this great initiative, give it to the SecOps pros and let them take it for a while before we can go to market. And so the huge challenge now is to simplify, automate, AI comes in, the whole supply chain security, so that companies cannot be facing so much friction. And that is non-trivial. I don't think we're anywhere close there, but I think the goal is by, within the next several years, we're going to be in a position that security we heard today is wasn't designed into the initial internet protocols, it was bolted on. And so increasingly, the fundamental architecture of the internet, the cloud, et cetera, is seeing designed-in security, and that is an imperative or else the business is going to come to a grinding halt. Right, it's no longer, the bolt-on no longer works. Eve, what's your perspective on cloud-native security? Where it stands today, what's in it for customers, whether we're talking about banks or hospitals or retailers? What do you think? I think when we look at security in the modern world is we need to, as Dave mentioned, we need to rethink how we apply it. Very often, security in the past has been always bolted on in the end. If we continue to do that, it will become more and more difficult because as companies evolve and as companies want to bring products and software to market in a much faster and faster way, it's getting more and more difficult if we bolt on the security process at the end. It's like developers build something and then someone checks security. That's not going to work any longer, especially if we also consider now the changes in the industry. I mean, we had Stack Overflow over the last 10 years. If I would have had Stack Overflow 15, 20, or 25 years ago when I was a developer, it would have changed a hell lot. Looking at it now and looking at it, what we had in the last few weeks is like where nearly all of my team members say, it's like, finally, I don't need any script kitties anymore because I can go to ChatGPD and it writes the code for me, which is on one hand great because it enables us to solve certain problems in a much higher pace. But the challenge with that is if the people who just copy and paste that code don't understand the implications of that code, we have a much higher risk continuously. And what people thought is challenging with Stack Overflow, imagine that something in one of these AI engines is actually going ballistic and it creates holes in nearly every one of these applications. And trust me, there will be enough developers who are going to use these tools to develop codes. It's the same as students in university are going to take this to write their essays and everything else. And so it's really important that every developer team basically has a security peer person within their team and not a security at the end. So we build something, we check it to go through QA and then it goes to security. Security needs to be at the forefront. And I think that's where we see Cloud Native Security Con where we see AWS. I saw it during re-invent already where they said it's like we have reinforced next year. I think this becomes more and more of a topic. And I think companies as much as it has become a norm that you have a firewall and everything else, it needs to become a norm that when you are doing software development and every development team needs to have a security person on that needs to be trained. I love that chat comment, Dave, because you and I were talking about this. And I think, you know, that is going to be the issue. Do we need security chat for the chat bot? And there's like a recursive model there. The biases are built in, I think, and I think, you know, our interview with Palothin, it was co-founder Dave, when he talked about zero trust as a structured way to start things. But he was referencing that with Cloud. There's a chance that we think or do a do-over in security. So, you know, I think this is kind of to me where this is all going. And I think you asked Pat Gelsinger, what year? 2013, 2014, is security a do-over? I think we're in that do-over time. I mean- He said yes. He said yes. He was right. But yeah, eight years later.  But how do you organize and redo security? Because to me, I think that's what's happening here. And John, you heard near Zook at Palothin Network said, yeah, the word security and architecture, they don't go together historically, right?  Well, is that because there's too many tools out there? And people buy- Yeah. For sure. For every tool? Yeah, well, first of all, a lot of hardware and then yeah, a lot of tools. You even see IIoT and industry 40. You see IoT security coming up as another stovepipe and that's not the right approach. And so, you know, I mean- Let me ask you a question, Dave and Eve, if you don't mind. Because I was just riffing on this yesterday about this. In the ML space, you're seeing the ML models, you're seeing proprietary models versus open source. Is security going to go down this proprietary security methods and open source? Because that's interesting because the CNCF is run by the Linux Foundation. So you can almost maybe see a model where there's more proprietary security methods than open source or is that non-issue? I would, let me, if I jump in here first, I think the last, especially last five or 10 years have clearly shown the whole, and I invested early on in the end 90s in several open source startups in the Bay Area. So I'm well behind the whole open source idea and met Linux and others back then several times. But the point is, I think what we have seen is open source is not in general more secure or less secure because code is too complex nowadays. You have millions of lines of code and it's not that either one way or the other is going to solve it. The ways I think we are going to look at it is more is what's the role to market because only because something is open source doesn't necessarily mean it's going to be available for everyone and the same for proprietary source from that perspective, even though everybody mixes licensing and payments and all that all the time, but it doesn't necessarily have anything to do with it. But I think as we are going through it and when we also look at the industry, security industry over the last 10 plus years has been primarily hardware focused and a lot of these vendors have done a good business out of selling hardware boxes, putting software on top of it, whereas in reality, those were still X86 standard boxes in the end. So it was not that we had specific security Essex or anything like that in there anymore. And so overall, the question of the market is going to change. And as we are looking into cloud native, think about someone like an AWS, do you really envision them to have a hardware box of every supplier in their data center and that in every availability zone in every region, same for Microsoft, same for Google, et cetera. So we need to have new ways on how we can apply security. And that applies both on the backend services, but also on the front-end side. And if I could chime in, I think the answer is no and yes. And what I mean by that is if you take antivirus and known malware, I mean, pretty much anybody today can solve that problem. It's the unknown malware. So I think the yes part of the answer is yes, it's going to be proprietary, but in the sense we're going to use open source tooling and then apply that in a proprietary way with specific algorithms and unique architectures that are going to solve problems. For example, XDR with unknown malware. So, and that's the hard part. Somebody said, I think this morning at the keynote, it's all the stuff that the SecOps team couldn't find. That's the really hard part. Well, the question will be, is the new IP, the ability to feed chat GPT, some magical spelled insertion query string that does the job is unique. That might be the new IP, the question to ask. Well, that's what the hackers are going to do.  They're going to start. So guys, let's take this conversation up a level. I want to get your perspectives on what's in this for me as a customer. We know security is a board level conversation. We talk about this all the time. We also know that they're based on, I think David was the conversations that you and I had with Palo Alto Networks at Ignite in December, there's a lack of alignment between the executives and the board from the security perspective. When we talk about cloud native security, all talked about the value in that, what's in it for customers. I want to get your perspectives on, should this be a board level conversation? And if so, how do you advise organizations whether it is a hospital or a bank or an organization that is really affected by things like ransomware, how should they be thinking about this from an organizational perspective? Well, I'll start first because we had this conversation during our super cloud event last month. And this comes up a lot. And this is the CEO board level. Yes, it is a board level conversation for security as is application development as in terms of transforming their business to be competitive, not to be on the wrong side of history with this wave coming. So I think that's more of a management. But the issue is they tell their people, go do it. And they're like, because they get sold on the idea of, hey, once you transform your business, never it's going to be data-driven and machine learning is going to power your apps, get new customers, be profitable. Oh, sign me up for that. When you have to implement this, it's really hard. And I think the core issue is where are companies in their life cycle of the ability to execute and architect this thing properly? As Dave said, Nick Zer said that you can't have architecture and security. You need platform. So I think the replatforming and the refactoring of business is a big factor. And that's got to get down into the organizational shifts and the people to do it. So are there skills? Do I do a managed service? How do I architect it? Are there more services? Are there developers doing applications that are going to be more agile? So this is not an easy thing. And to move a business from IT operations that is proven to be positioned for this enablement is just really difficult and it's expensive. And if you screw it up, you could be on the wrong side of things. So to me, that's the big issue is you sell the dream and then you got to implement and that's really difficult. Eve, give us your perspective on based on John's comments, how do organizations shift so dramatically? There's a cultural element there as well, but there's also organizations that have competitors on the rearview mirror and there's no time to waste. What are your thoughts on that? I think that's exactly the point is like as an organization, you need to take the decision between the time, the risk and all the other elements that we have into this game because you can try to achieve 100% security but that's exactly the same as trying to protect gold or anything else 100%. It's most likely not going to be from a risk perspective anyway, sensible. And that's the same from a operational perspective. When you look at building new internet services or IoT services or any kind of new shopping experience or whatever else, you need to balance out between the risks and the advantages out of it. And you also need to be accepting that you potentially on the way make mistakes, but then it's more important than ever that you are able to quickly fix any mistakes and to adjust to anything what's happening in the market because as we are building all these new cloud native applications and build up all these skill sets, one of the big scenarios is we are far more depending on individual building blocks. These building blocks come out of open source communities which have a much different way. When we look back in software development back then we had application servers from Oracle WebLogic whatsoever. They had a release cycle of every three to six months. And now we have to deal with open source where sometimes release cycles are on a four week schedule in between security patches. So you need to be much faster in adopting that, checking that, implementing that, getting things to work. So there is a security stretch from that perspective. There is a speech stretch on the other thing companies have to deal with. And on the other side, it's always a measurement between the risk and the security you can afford because reality is you will not be 100% protected no matter what you do. So you need to balance out what you as an organization can actually build on. But I think coming back also to the point it's on the board level nowadays. It's like nearly every discussion we have with companies nowadays as they move into the cloud, especially also here in Europe where for the last five years it was always it's like it's data privacy. Data privacy is no longer, I mean, yes for certain people it's still the point, but for many more people it's like, how protected is my data? What do we do in case of ransomware attack? How do we do in case of a denial of service? All of these things become more vulnerable where in the past you were discussing these things with a batting page or like a stock exchange.  And all of the sudden this now affects nearly everyone in their storefronts and everything else because everything is depending on it. I think you're right on it. You think about how cultural change occurs. It's bottom up top down or middle out. And what's happened with security is the people in the security team cared about it. They were the, everybody said, oh, it's their problem. And then it just did an end run to the board kind of mid early last decade. And then the board sort of pushed that down and the line of business is realizing, holy cow, my business, my EBIT can be dramatically affected by this so I care. Now it's this whole house, cultural team sport. I know it's sort of a cliche, but it's true. Everybody actually is beginning to care about security because the risks are now so high and it's going to affect not only the bottom line of the company, the bottom line of the business, their job, it's virtually everywhere. It's a huge cultural shift that we're seeing. And that's a big challenge for organizations in any industry. And EB talked about ransomware, general service, every industry across the globe is vulnerable to this. But how can maybe John, we'll start with you. How can cloud native security help organizations if they're able to embrace it operationally, culturally, dial down some of the vulnerabilities that just seem to keep growing? Well, I mean, that's the big question. The breaches are critical. The governance is also could be a way to anchors down growth. So I think the balance between the governance compliance piece of it is key, but making the developers faster and more productive is the key to me. And I think having the security paradigm where they're not blockers, as Dave said, is critical. So I love the whole shift left, but now that we have more data focused initiatives around how you can use data to understand the security issues. I think data and security are together. And I think there's going to be a data operating system model emerging where data and security will be almost one thing. And that will be set up by the security teams and the data teams together. And that will feed guardrails into the developer environment. So the developer should feel no pain at all in doing this. So I think the best practice will end up being what we're seeing with supply chain security, with making sure code's verified. And you're going to see the container security side completely addresses been in KubeCon. We just, I asked Scott Johnson, the CEO of Docker, and I asked him directly, are you guys all tight on container security? He said yes, but other people are suggesting that's not true. There's a lot of issues with the container security. So there's all kinds of areas where there's holes. So cloud native is cool on one hand and very relevant, but if it's not short up, it's going to be a problem. But I think that's where the action will be at the developer pipeline in the containers and the data. So that will be very relevant. And if companies nail that, they'll be faster, they'll have better apps, and that'll be the differentiator. And again, if they're on this next wave, they're going to be driftwood. Dave, how do they prevent becoming driftwood? Well, I think cloud has had a huge impact and a cloud by no means of panacea, but let's face it, it's dramatically improved a lot of companies' security posture. Now there's still that shared responsibility. You know, even though an S3 bucket is encrypted, it's still your responsibility to make sure that it doesn't get decrypted by somebody who has access to it. So there are things like that, but to Eve's earlier point, that can be, that's done through software now. It's done through best practices. Those best practices can be shared. So the way you don't become driftwood, as you stepped back, rethink that security architecture, as we were talking about earlier, take advantage of the cloud, take advantage of cloud native, and all the rapid pace of innovation that's occurring there. And you know, you don't use, like it's called before, the audit is the last line of the fence. That's no longer a checkbox item. Oh yeah, we're in compliance. This is a business imperative and because we're going to reduce our expected loss and reduce our business risk, that's part of the business case today. Yeah. It's a huge, critically important part of the business case. Eve, question for you. If you're in an elevator with a CEO, a CFO and a CISO, and they're talking about security and cloud native security, what's your value proposition to them on a say a 30 second elevator ride? Difficult story. I think at the moment, the most important part is we need to get people to work together and we need to train people to work more, much better together. I think that's the overall most important part for all of these solutions because in the end, security is always a person issue. If we can have the best tools in the industry, as long as we don't get all of these teams to work together, then we have a problem. If the security team is always seen as the end of the solution to fix everything, that's not going to work because they always are the bad guys in the game. And so we need to bring the teams together. And once we have the teams work together, I think we have a far better track on maintaining security. John and Dave, want to get your perspectives on what Eve just said. In all the experience that the two of you have is industry analysts here on theCUBE, Wikibon, SiliconANGLE Media. How do you advise organizations to get those teams together? As Eve said, that alignment is critical, but John, we'll start with you. Then Dave, go to you. What's your advice for organizations that need to align those teams and really don't have a lot of time to wait to do it? That's a great question. I think that's everyone pays hundreds of thousands of millions of dollars to get that advice from these consultants, organizations out there doing the transformations. But I think it comes down to personnel and commitment. I think if there's a C level commitment to the effort, you'll see the institutional structure change. So you can see really getting behind it with their wallet and their support of either getting more personnel to support and assist or manage services or giving the power to the teams to execute and doing it in a way that's well known and best practices. Start small, build up the pilots, build the platform, and then start getting it right. And I think that's the key, not the magic wand. The old model of rolling out stuff in six month cycles. It's really get the proof points, double down and change the culture, but also execute and have real metrics and change in the architecture, like having more penetration tests as a service.  So like, it doesn't make any sense. You got to have that built in almost every day, every minute, so these kinds of new techniques have to be implemented and have to be tried. So that's why these communities are growing. That's why I like what open source has been doing. And I like the open source as the place to have these conversations because that's where the action will be for new stuff. And I think people will implement open source like they did before, but with different ways. Better testing, better supply chain on the software side, verifying code. So I see open source actually getting a tailwind from this, not a headwind. So I'm bullish on the open source piece here on all levels, machine learning. Lisa, my answer is intramural sports. And it's because I think it's cultural. And what I mean by that is you take your best and brightest security, and this is what frankly, a lot of CSOs do, an example is Lena Smart, MongoDB. Take your best and brightest security pros, make them captains of the intramural teams, and pair them up with pods of individuals across the organization, which is most people who don't know anything about security and put them together so that the folks that understand security can realize how little people know what the worst practices that are out there in the reverse, how they can cross pollinate. And they do that on a regular basis, I know at Mongo and other companies. And that kind of cultural assimilation is a starting point for how you get security awareness up to your question around making it a team sport. Absolutely critical. Eve, I want to kind of wrap things with you. We've got a couple of minutes left. When you're really looking at the cloud native community, the growth of it, we talked about earlier in the program, cloud native security con being now extracted and elevated out of KubeCon. What are your thoughts on the groundswell that this community is generating around cloud native security, the benefits that organizations will achieve from it? I think overall, when we have these security conferences or these security arms a bit spread out and separated out of the main conference, it helps to a certain degree because especially in the security space, when you look at other like black hat or white hat conferences and things like that in the past, although they were not focused on cloud native, a lot of these security folks didn't feel well taken care of in any of the other conferences because they were always these, it's like they are always blocking us. They are always making us problems and all these kinds of things. Now that we really take the cloud native piece and the security piece together or like AWS does it with reinforce, I think we will see more and more that people understand is that security is a prominent topic we need to cover but we need to bring different people together because security also has compliance and a lot of other components in there. So we will see at these conferences moving forward also a different audience. It's not going to be only the cloud native developers. And if I see some of these security audiences, I can't really imagine them to really be at KubeCon because there is too much other things going on. And you couldn't really see much of that at reinvent because reinvent by itself has become a complete monster of a conference. It covers too many topics. And so having this very, very important security piece separated also gives the opportunity, I think, that we can bring in the security people but also have the type of board level discussions potentially between the leaders of the industry to also discuss on how we can evolve, how we can make things better and how we can actually, yeah, evolve our industry for it because let's face it, that threat is not going to go away. It's a business. And one of the last security conferences I was on the ransomware part, it was one of the topics someone said, it's like, look, currently on average, it takes a hacker group roughly around, they said 15 to 20K to break into a company and they on average make 100K. It's a business. Let's face it. And it's a business we don't like and ethically, it's no discussion that this is not good, but that's something which is happening. People are making money with it. And as long as that's going to go on and we have enough countries where these people can hide, it's going to stay and survive. And so with that being said, it's important for us to really build an industry around this, but I also think it's good that we have separate conferences. In the past, we had more the RSA conference which tried to cover all of these areas, but that is not really fitting cloud native and everything else. So I think it's good that we have these new opportunities, the cloud native one, but also what AWS brings up for someone. You know, Yves, you just nailed it. It just comes down to simple math. It's a fraction revenue over cost. And if you could increase the hacker's cost, increase the denominator, their ROI will go down and that is the game. Great point, Dave. When I'm hearing guys, and we can talk about technology for days and days. I know all of you, but there's a big component that the elevation of cloud native security on its own, AscendLand is critical as is the people component. You guys all talked about that. We talked about the cultural chains necessary for that. Hopefully what we're seeing with cloud native security con 23, this first event is going to give us more insight over the next couple of days and the next months or so is to how this elevation and how the people can come together to really help organizations from a math perspective, as Dave talked about, really dial down the risks there, understand more of the vulnerabilities so that ransomware as a service is not as lucrative as it is today. Guys, so much appreciate your time really breaking down cloud native security, the value in it from different perspectives and what your thoughts are on where it's going. Thanks so much for your time. All right, thanks. Thanks Lisa. Thank you. Thanks Yves. All right, for my guests, I'm Lisa Martin. You're watching the Q's day one coverage of cloud native security con 23. Thanks for watching.