So we're going to talk a little bit about surgical technique, how to plan things, a little bit about what we do options for anesthesia for eye muscle surgery, touch on Botox, and a little bit about complications because as much as we like to think that our interventions never cause any problems, at times they do, anticipating them is good, dealing with them is better, and types of surgical procedures, weakening procedures, basically there's a whole bunch, depending on the muscle that you're dealing with, there are a lot of options. Recession, myotomy, myectomy, recession with anteriorization, mainly the inferior oblique, tenotomies, tenectomies refer mainly to the superior oblique, and a denervation, extirpation, that's a procedure done to the inferior oblique for people who cannot do recessions effectively and do horrible things to the muscle, and you'll probably not see anybody here do that but you'll read about it. And posterior fixation sutures where we're trying to differentially affect the function of a muscle at near, and not have as much effect at distance, or increase the recruitment of the contralateral muscle, an example of someone who's had an injured inferior rectus muscle after trauma, and we do a posterior fixation suture on the contralateral inferior rectus, remember with Herring's law you get equal innervation of both muscles, so you make it harder for my left inferior rectus to go down by putting a posterior fixation suture in, you pull the right eye down farther, expand the range where the patient can go into down gaze and keep single vision. And so let's try this, oh it works. Then strengthening procedures, resection, usually for horizontal muscles, occasionally for vertical muscles, advancement usually for a previously recessed muscle, and then tuck, which traditionally was just isolated to the superior bleak tendon where you fold it over on itself and sew it to shorten it, and a superior bleak palsy where you have tendon laxity, also has been popularized recently for horizontal muscles to use in place of a resection. The advantage is being that you're not cutting the anterior vessels, unless you encircle them with suture, and you decrease the risk of anterior segment ischemia. You will see some of those done in your time with us here in pediatric ophthalmology service. Now as far as special procedures, you'll notice in almost all of the adults that I do, one muscle is left on an adjustable suture. That allows us to anticipate variations in response to a given dose of surgery, adjustment usually being done, awake in the treatment room within a day or two of surgery, sometimes in patients who are very anxious, who can't sit still up to a week out, asleep again in the operating room, transposition where we're trying to use functional muscles to increase movement of the eye or change position, usually in the face of cranial nerve palsy, most commonly sixth nerve palsy, vertical shifts where we can take both horizontal muscles, rotate them up or rotate them down to change the vertical position of the eye. Kind of a handy thing to do to minimize the amount of, or the number of muscles that you're operating on. Now anesthesia, generally anesthesia is the most commonly used mode of, you know, making it safe and comfortable for us to operate on children. In adults, you have the option of doing retro-ball bar blocks. You can do most eye muscle procedures with the retro-ball bar. What that does do, on the other hand, is it limits you to one eye. And you'll find that when you're on service with me, most, if not all of the patients that we do, even on adults, I do under general, because a lot of the patients I do either have trauma, thyroid disease, or they're re-operations. And those folks, in terms of planning things, I want to be able to check for instructions, deal with scarring from previous surgery, and finesse things in the operating room to get the best outcome from the patient. On the other hand, I can tell you that when I operate, you know, it was a month ago in Nepal operating, and every single case we did was done with a retro-ball bar block with no nurse anesthetist or anybody else in attendance. Why? Because they didn't think we deserved one. The cases, by and large, went pretty well. Most of the patients are pretty stoic, and none of them got versed. You can do muscle surgery under topical anesthesia. I have done that usually with some sedation, and that's, you know, where you have patients who don't, you know, have some reaction to local anesthetics and have really high-risk airways in terms of sedation and general anesthesia. As far as injecting local, often if you inject subconjunctivally, it distorts tissues enough, it's really hard to make sense of things, but I've also done that in patients, again, where anesthesia was not safe due to general medical problems. At times you want to be careful with that issue with general medical problems, because when you try to save a very fragile patient from the harm of general anesthesia, if they're really anxious, often the trouble you cause with the anxiety can be just as bad as the general anesthesia. Now, when we're trying to operate, you want to have goals in mind. And what I mean by, if you take a child who's got infantile esotropia, you are not going to have normal binocularity almost all the time, so if that's your goal, you've got a goal you can't achieve. What you want in that patient to have eyes that are straight, give or take a little bit to give them the best chance of binocularity, but you're not going to change, you know, the underlying substrate in terms of their visual system and what it can accomplish. Generally, we want to try to establish competence, meaning that things are fairly well aligned in all positions of gaze. You want visual acuity to be equal, and often that's more important than getting the eyes lined up. Get rid of torsion if torsion is an issue. If torsion is present when you measure it, but it isn't an issue from the patient's perspective, dealing with it can actually create problems. If you decide to do a big tuck on a superior bleak muscle, which is probably going to change the torsional position of the eye, and the patient didn't have any subjective torsion, they're not aware that the other image is tilted after surgery.  The other issue are surgeon-specific issues.  The other thing to consider is after you've done a bunch of surgery, you'll find that looking at numbers and tables, what you get may not jive with that. You may find you get more or less. There is a lot of variation once you start doing eye muscle surgery in how sutures are placed, where you measure from, and all those things that can make a difference and make those tables not directly applicable so that you need to look at your own outcomes and adjust accordingly. Now, one of the things I always like to do is think about things from the standpoint of what's in it for the patient. How am I going to change their situation? Is this going to improve their life? Are we going to get rid of double vision? Are we going to make it so they can function effectively in school or work without being picked on or having somebody say are you looking at me or are you looking over my shoulder? Are we going to increase their chance of having normal binocularity? Are we going to decrease risk of amblyopia? And then there are mitigating factors. The child who's got severe neurodevelopmental problems, who's got large anglo-exotropia, straightening their eyes is probably not going to change their ability to interact with the world, their ability to interact with other people and may simply amount to picking on them at which point it's our job to say this isn't a smart thing to do even though the physical therapist thought it was going to change the world and allow them to do everything and make this child normal. It isn't going to happen and sometimes you just have to come out and say that. In the face of any neurologic disease, seizure disorders, I've got spina bifida or severe developmental delay after a hypoxic insulted birth, we vary the dose of surgery that we do for esotropia. Why? Because we get a lot more mileage out of it. If we do the appropriate amount of surgery for 50 diopters of esotropia in a child who's got a severe neurologic insult, you may wind up with 50 diopters of exotropia. So it isn't that our goal is different, it isn't that we don't want to get their eyes straight, but we may have to tailor what we're doing to get a better outcome. And then the other thing to think about is in the face of biomechanical factors in the orbit, are they proptotic? Are they enothalmic? Because they've had volume loss after an orbital injury and they've lost fat. The procedure you do can change the fore-aft position of the eye and make things look better or make it look very unusual. Anytime you do a resection, the eye is going to move back a bit so ptosis will be accentuated. By the same token, if you do a huge recession in a patient who's got thyroid disease and the eye comes forward, that can accentuate the ptosis they already have can actually cause corneal exposure problems. I'm not saying you shouldn't do that, but I think you need to be aware of it and sometimes we need to let the patient know. If you're going to do something that the patient may not appreciate and you tell them that it may happen ahead of time, you're smart and if they discover or their neighbor points it out to them, they don't think you're so smart. Now, what about this cosmetic versus correction of deformity issue? I have a lot of patients that come in and they have their child who's not got very good vision in an eye due to some problem inside the eye and we're trying to make the eye look straight so the kid looks as normal as possible. That is not cosmetic. Cosmetic is when you take something that looks fine or you know, and somebody wants it to look prettier because they think it's better. Correction of deformity is when you take something that is not the way that it is supposed to be and you make it look more like it's supposed to be so an individual can function more effectively in society and most of the things we do with straightening eyes out fall in that realm. The idea being that there's very good data if you look into the data on the psychosocial aspects of strabismus, strabismus correction and the effects of having strabismus on selecting playmates, on hiring people. My colleagues, David Coates, Neville and Pacey and Baylor took photographs of kids and adults and digitally altered them to give them strabismus and then they showed the kids pictures to other kids and saying, which kid do you want to play with? And with the adults, they showed them to human resources professionals who should know better. And it turned out that the kids selected the kids with straight eyes to play with and the human resources professionals wanted to offer jobs to the folks with straight eyes. So we do make it so these folks can function better. Now, what do we do in the operating room? We talk about planning things and having things ready to have a higher likelihood of having a good outcome. COVID-19 is the only thing that's been shown in any ophthalmic procedure that will really affect the number of species in colony forming units and decrease risk of post-operative infection. Question of intracameral antibiotics and I think there probably is good evidence for that but as far as prior to surgery, a drop of betadine in the eye and that work was done actually by a pediatric ophthalmologist, a guy named Sherwin Eisenberg in Los Angeles working with patients in Kenya who published information about that and kind of got everybody going in that direction. The traction sutures, I think the traction sutures are very helpful to get good exposure to allow you to do a better job. There are some of my colleagues who think the traction sutures are kind of like training wheels on a bicycle and I don't share that viewpoint. I'd urge you to use them. You want to plan an effective congenital incision. You want to think about where you want to sit, where you want your assistant to sit and how you want to organize things have good lighting, good magnification. I would urge you to use loops. Many of the individuals I work with in developing countries and I do that several times a year do strabismus surgery with a microscope. They do it because they're all doing cataract surgery and it's easy for them to just use the same microscope, have them bring the patient in and do eye muscle surgery. The problem with the microscope, I mean it works okay for horizontal surgery. When you start doing vertical muscles, when you start doing oblique muscles, the positioning with the microscope is very inflexible and it is difficult to get good visualization of the muscle and do an effective job. And so I have switched many of the people that I work with to using loops and headlights. Now, here we go. We're not going to belabor this. You can look up amounts of surgery to do in various procedures. And this is for esotropia. The A got left off by the way this thing got put together. But these are basically the numbers here on the left for Marshall Parks for increasing amounts of esotropia in the amount of medial rectus recession, lateral rectus recession you would do on one eye, or medial rectus recession you would do on each eye for esotropia. And my mentor Jean Halveston measured things from the limbis. These are the amounts for the kind of the small, medium, and large approach to life under a year of age and over a year of age. And some of those numbers may look familiar. I use a lot of that information still today and I think it works darn well. For intermittent exotropia, again, you can look these things up, but ultimately you will arrive at your own numbers. I would imagine for most of you that have worked with me in the operating room, you've probably never seen me pull a table out and look at it in the OR. I did that for probably the first 10 years I was in practice. And I didn't even know where the table that I put together, I had a little chart that had all these things on it in case I wanted to refer to it. And now, you know, you reach a point where you know what you want to do in a certain situation and how to factor in the fudge factors. And this, again, another, this is Dr. Parks' approach to intermittent exotropia. These refer to bilateral lateral rectus recessions. And we'll just go back. How do we go back? Previous? There isn't a way to do this with this mouse otherwise. Now, if you're doing a patient who's got severe vision loss, we've got a large optic nerve coloboma or optic nerve hypoplasia and finger counting vision. We do larger, look at these numbers, they're much larger, larger amounts of surgery. You also do that in the 40-year-old who comes in, who grew up with large angel exotropia and has never had surgery. So that long duration and poor vision will change things as well. And then there are A and V patterns. A and V patterns, when we talk about patterns for business, we're talking about a disparity in the amount of horizontal deviation between up and down gaze. And basically, for those, you can, if there is inferior oblique or supere oblique overaction, weaken the corresponding oblique muscle to collapse the pattern. And we'll talk about shifting the horizontal muscles if there isn't oblique overaction. For vertical surgery, if you weaken the supere oblique muscles, you're going to change the vertical position by somewhere in the 10 to 15 prism diameter range. If you do a tuck, you're going to affect it by about 15, but you may get up to 25 prism diameters of correction, it depends on how much of a tuck you do. The way tucks are done, it isn't a matter of looking in a table saying, I have this much deviation and I'm going to tuck the muscle this much. It is more based on feel of the tension in the muscle because the tendons will vary as far as how much laxity is there and if you do too much, you'll limit movement of the eye. With the inferior oblique, again, you can plan on getting about 10 to 15 prism diameters of vertical change in primary position and will vary with the supererectus and inferior rectus with recessions of getting, you know, about two and a half millimeters will get you about eight prism diapers of correction and the most you want to recess the superior or inferior rectus muscle is about five millimeters with the exception of severe trauma, scarring, thyroid disease, all of which, in those situations, I think those of you who have operated with me will see us do, at times, huge recessions. You have to do what the patient needs. Those situations can be very complex and you probably need somebody who's been there before with you to do them. And then, again, we can go through, I'm not going to belabor the tables and nobody's going to ask you when you take OCAPs to recite somebody's table, but they more likely would ask you what would be a reasonable procedure for this patient and the problem they have to see if you can think your way through what needs to be done. Now, complications from surgical procedures, alignment issues are the most common. You know, what I tell patients when we're going to do a first time strabismus surgery is that we've got across the board somewhere in the 80 to 90 percent range chance of getting alignment to be acceptable, give or take a little range where we're happy with things, about a 10 to 20 percent chance that they will need additional surgery. That means if I'm doing, you know, 10 patients on Monday at Moran that I could expect that one or two of them were going to need to have additional surgery at some point. So I always tell them that alignment issues which may result in diplopia, those are things that go with the territory that may happen. The things that we usually do not see are perforation sclerosis, serious infections and things of that sort. And we don't want to see serious scarring, congenitival cysts, suture granulomas happen. People at times react to vicaral, realize that all of the absorbable sutures that we use absorb because they incite a local inflammatory reaction. If that is an intense reaction and somebody's got a very active immune system, you can have a granuloma result simply from the inflammation that usually will go away. Sometimes you do need to excise them. Now, what about refractive error change? If you do a large resection on a muscle, you can induce a fair amount of cylinder. It is usually temporary, so you want to avoid making huge changes in the patient's glasses in the first couple of months after surgery. But you want to be careful with that and think about it in a child who is not seeing as well after surgery. Let's say we're in the operating room together and I'm having you do your first scleral pass with a muscle and you feel a big pop. And I kind of go, and we pull that out and there's a kind of a little dot, a clear liquidy stuff coming up through the hole. What do we do? What's going on? Where did that needle go? It went into the vitreous. The stuff coming out through the hole is vitreous. And so the question is, what do you do? And knowing and having a plan ahead of time is always better than making it up on the spot. And if you really don't know what to do, call somebody else who does know what to do. But in this circumstance, it isn't that uncommon for people to wind up in the suprachoroidal space, but going through, if you've got vitreous, if you've gone through choroid, you've gone through retina, you're in the vitreous and there is a communication that will first of all allow things to get inside the eye, but more importantly, allow liquid vitreous to get under the retina and cause a regmetage of retinal detachment, which the patient won't be grateful for and your retina colleagues won't be grateful for. So the thing to do is to stop operating, dilate the pupils, take a look in the back and deal with the issue. And, you know, lasering around the break in the retina, which is basically what you've created, is an appropriate way to deal with it and then go ahead with the muscle surgery. I, in the past, before the days of laser, when there wasn't an indirect laser, believe it or not, once upon a time, we used the cryoprobe and you would gently cry out if you're going to use the cryoprobe, be cautious, you're nervous, you really want that fixed and everybody's tendency is to do too much cryo, at which point you can actually cause, you know, traction on the retina and further problems, but that's something that you need to have a plan for particularly in patients who've had trauma, patients who were highly myopic within sclera, that would include a fair number of the patients that I operate on after they've had a sclera or buckled placed, maybe removed and they were highly myopic to start with, they got perforated a couple of times during their sclera or buckled placement and then I'm trying to do muscle surgery and it can be very, very challenging. Infections, any time we've done eye muscle surgery and you get a post-operative infection, in my mind, that is always orbital cellulitis. When we talk about preceptile cellulitis, you're talking about infection in front of the orbital septum, any time we've opened the intermuscular membrane, you've got access to whatever process is going on posteriorly. The other place you want to think about access, where were my sutures? Was any of those, were one of those sutures deep? You know, do I have endothelitis? We've lost one eye here, one of my colleagues had a problem with a patient where they didn't recognize that the patient was infected, didn't recognize the patient had scleritis and subsequently did not recognize that the patient had endothelitis and an eye was lost.  And I think that we're dealing with complications after surgery that you've done. I'd urge you to think in similar means. Other things that we see at times, fat adherence. Staying out of the fat, you'll hear me when we're operating on the medial rectus telling you to stay right over the muscle.  It is the vitreous of eye muscle surgery. We don't want to encounter it. And once you get into the fat, I may never be able to fix the scarring that results. The other issue is dealing with conjunctiva. And I know that my retina colleagues like to use the Q-tip and push things every which way.  But if you treat conjunctiva delicately, gently, don't cause undue trauma to it, things will heal better and you'll have less restriction. You may also, in planning surgery, want to think about whether you want to actually bring conjunctiva back to the limbis. If before surgery, things were very tight with four-structions and an eye has been esotropic for years and years and years, once you get the eye straight, if you bring conjunctiva right back up to the limbis, the conjunctiva alone may pull the eye back in so you may have to recess it. Another thing to put on your list of things to wonder about and then change is an eyelid position. The most common there would be with inferior rectus recession because the lower eyelid retractors sit right next to the inferior rectus. That is the reason we try to free up those attachments, you know, from Lockwood's ligament. No matter how much you free those up, to some extent, if you do an effective and a fairly large inferior rectus recession, the lower eyelid is going to drop a bit. So I always warn patients about that. When we do thyroid patients here, the order in which things are done are orbital surgery first, muscle surgery second, and lid surgery third. And that way if I need Dr. Patel or Dr. Crumb to go in, put a spacer in the lower eyelid and bring the lower lid back up, they do that after I've done the large inferior rectus recession. And then slipped or lost muscles. Slipped muscle basically refers to a muscle that has moved back within its sheath. So it may be that sutures were put in very superficially and the sheath of the muscle is still attached, but the muscle has moved back in it. Another variation of that is the eye where the muscle has moved back and there is scar tissue attached to the muscle, making it look like it's attached where you wanted to put it. That is called slipped scar or stretched scar, a woman named Irene Ludwig kind of popularized that terminology. Lost muscles, the muscle has become detached from the globe and has disappeared somewhere back in the orbit. And when I was a resident, somebody talked about this and I said, well, wait a minute. I mean, it's somewhere there.  It didn't go out the back of the patient's head or out their left ear. It's in there.  You know where it is. And I didn't have a clue how difficult it is to find it. If you wind up in a situation where you think a muscle, you've cut on the wrong side of the sutures in a resection and suddenly the muscle just disappears, please don't dig around excessively. Call somebody like me to come help you find it right there in the operating room. Because that is absolutely the best time to find it. There are simple things I can talk into doing over the telephone that I have talked a number of my colleagues here into doing that will likely let you find it. Tip what that involves is locating, the muscle will never be right along the globe. It will be, it goes back through its particular the medial rectus muscle, which is the most commonly lost muscle, through its sleeve and tenons layer. And you find that by looking for where it's bleeding. You follow it. You put a forcep through there gently, open it, grab it and pull out. And it's like pulling a rabbit out of a hat, but often that muscle will come back out of there. You can put it back where it belongs. Everybody's happy. The worst thing in the world you can do is have somebody dig around in the fat. Because once somebody has been going all over the place with a pair of scissors frantically trying to fry in the muscle, I'm not going to be able to find it. There are ways of going in with the ENT surgeons taking out the medial orbital wall, locating the muscle posteriorly, putting suture in it, threading it anteriorly along the medial orbital wall. Those are GWIS procedures. They never result in normal motility. I mean, they're, you know, people are really impressed when they can put it back together, but it's not a good thing. Now, bradycardia, oculocardiac reflex. In the literature, it'll tell you that the medial rectus muscle is the most common muscle involved. That's only because it's the most common muscle operated. Where you want to think about cause and harm is in somebody who's got a very fragile cardiovascular system. They've already had an MI or a stroke, and they're not going to deal with severe bradycardia or hypotension for a long period of time. And where I've seen the most trouble personally have been in young, healthy adults operating on vertical rectus muscles. Almost every patient that I've personally had prolonged episodes of acystole in the operating room where the anesthesiologist has jumped out of their chair saying, what are you doing? And there's just a blank screen. Has been a young, you know, like teenage or 20 year old, in the 20s person where we're pulling on the superior rectus muscle. So think about that when you're doing that, and basically if you back off on it, you let go of the muscle. Their heart rate will come up. They can give them something to compensate for it. Why would I mention this? My other purpose in mentioning this is if you're going to do adjustable sutures, you pull on the muscle, and you're doing it in your office, in clinic. You need to have a plan to deal with a patient who suddenly has a heart rate and blood pressure of zero.  That's the reason, if you look in pediatric ophthalmology clinic, all of our chairs there lie flat, and I did that purposely so that if one of my colleagues wanted to do an adjustment there, they can do it. I think you need to think about that whenever you're doing procedures, because of the chance of eliciting an ocular cardiac reflex in clinic. I do all my adjustments in the procedure room at the Moran OR so that there are anesthesia and nursing personnel around to help take care of things if bad things happen because I've gotten burned before. Who here has seen a case of MH? Anybody been involved in it? I think by the time I was, as a second-year resident, I had a kid develop full-blown MH doing muscle surgery. It didn't have a good outcome because dantraline, the medicine that they used to deal with it, they allowed hospitals in Michigan then to share the supply, and it was at the other hospital. Every patient we do at primary, there is a sheet in the patient's chart that has all the medication doses based on their age and weight for resuscitation and for MH. They have an MH cart. They do the same thing here in the OR. I want you to be aware of it. You may be asked to kind of put your I'm a regular doctor hat back on and help resuscitate a kid if you have an opportunity to go through and keep ACLS current keep PALS current if you haven't taken PALS and you want to do it when you're on our service we can try to make arrangements to do that. I would urge you to do that so that you can help anesthesia resuscitate your patients. It may save a life. What about Botox? Botox is botulinum atoxin was developed by an ophthalmologist, a guy named Alan Scott at Smith Kettlewell, San Francisco.  We used it both for blood for spasm and for strabismus early on. That would be in the mid-80s. It prevents release of acetylcholine. It is fragile. The fact that it's bound to tissue 30 minutes after injection is significant because when we inject it into eye muscles we position the patient so that if it leaks from where we inject it the tissue that it becomes bound to is likely tissue that we would like it to be bound to and not something else, particularly the levator, so you don't wind up with complete ptosis, particularly in a child. The maximal effect occurs about three to seven days out from an injection. Wears off about two to three months out and I still occasionally do eye muscle injections but for most people doing strabismus work on a general basis unless you're in the UK where you can't get access to the operating room, Botox is not in general use. Subacute, meaning I'm not getting better as quickly as we'd like, paralytics for business, almost exclusively six nerve policies where we inject the ipsilateral medial rectus muscle to prevent contracture is still useful for some patients. There's small-angle horizontal deviations and overcorrections and undercorrections almost no one is doing this anymore. I've not seen anybody try to use it in graze disease in years. The first paper published on acquired nystagmus in an adult using Botox. Gene Helveston, I think my name wasn't on the paper, I did the work but my name isn't on the paper. Gene and I think one of the residents in Indiana, their name is on it. What we did was to take 25 units of Botox which is 10 times the dose that we use in a medial rectus muscle and injected it retro bulbar to see if we could keep an eye still in a patient with acquired disabling nystagmus and indeed it kept the patient's eye still. So in that series of N of 1 it appeared to work my roles I got called urgently to an examiner saying, do you know how to do a retro bulbar injection? And I said, sure, give me that and that was that because Dr. Helveston had not done a retro bulbar in years and could not remember how to. And it, again, the situation where you're going to use that with nystagmus is it has to be a patient where you're trying to make it so they can sit still and watch television.  That eye is going to sit still but their other eye is still doing all kinds of things so they're going to have to patch the other eye. You've made them a one-eyed patient who's going to have to target their eye wherever they want to look and that is a big discussion to have before you do that. It is helpful to those patients where their nystagmus is so overwhelming their suicidal when they come in the office often. That is a big problem. Now let's go to and see if I can get this other thing to let's see, this we close, right? And then we go back to this. How do I get rid of this thing? There we go. Has anybody here been involved seen a Botox injection? Other than for blepharospasm? I mean, blepharospasm are simple. When we were doing them in the study, I did a bunch of blepharospasm injections but they're boring. I didn't really find the blepharospasm patients to be folks I like to hang out with so I stopped doing them. I also was of the opinion I think someone quoted me that you could teach a chimpanzee to do the injections. I mean, they're very simple and you just do these injections and it's not what I want to do. Now we're going to go through some patients this is where we get the audience participation time to wake up and see if your coffee worked. This patient, the first patient is a nine month old who has been esotropic according to parents since birth and when they look they have equal fixation they'll look equally with either eye and their deductions and versions are full they've got a normal anterior segment a normal fundus and they've got minimal refractive air and this is their motility assessment. When you're looking at this thing right here, this is primary position up gaze, down gaze, right gaze, left gaze measurements. We don't have the oblique measurements for this kid very difficult to get those in a small infant. What does this child have? Give me a diagnosis. How about a differential diagnosis? Child's esotropic, nine months old don't have significant refractive air this would be a very typical OCAP question. Make it multiple choice. Do we is this spasmus nutans accommodative esotropia bilateral six nerve palsy or congenital esotropia. And this is kind of a quintessential congenital esotropia patient.  Somebody come up with a plan I want to hear maybe three different plans, two different plans that are reasonable with this patient having equal vision. Let's say for a first surgery what would be the most reasonable thing to do. Absolutely and now let's say we'd already done that and this was the patient's measurements. What would the second procedure be? Absolutely very good. Now we're going to change things up a little bit with this next one. Notice the difference here is that now we're 20 ET in up gaze we're 50 ET in down gaze. So this is a V pattern my eyes are more in when I'm down they're less in when I'm up that's where the letter V description comes from and this patient if we're doing initial surgery do we need to take this into account if you know in planning our surgery well if we want to get rid of that disparity between up and down in addition to straightening things out yes and in this patient and there is no oblique overaction here we're going to shift the muscles vertically in addition to recessing them doing that bilateral medial rectus with a V pattern we always shift the medial rectus muscles towards the apex of the pattern whether it's V or A and we always shift the laterals towards the open end you can take that to the bank that always works now how much you shift them is it a half or a full tendon width depends on the amount of disparity there's not general agreement on that that's one of those things that you're going to have to figure out or I can guide John if you're going to do it for the first time call me and we'll chat about it so now we're going to move on this is a similar patient notice that the difference between up and down very similar but now we've got right hyper and left gaze left hyper and right gaze and we got 2 plus infir oblique overaction so where we've got infir oblique overaction and a V pattern it turns out that infir oblique overaction commonly goes along with V patterns why because remember one of the functions of the infir oblique is abduction and in its field of gaze which is up gaze you're going to get some abduction which causes there to be less estropia with the infir oblique overaction to collapse the disparity between up and down gaze there we're going to weaken the infir oblique muscles in addition to doing horizontal surgery for the primary position deviation so put that together and give me a procedure please of both eyes absolutely that makes sense if not I mean say something because it needs to make sense and now this is a different situation this is a patient who's got constant leftisotropy patient's got optic nerve hypoplasia that's not going to get better they're not going to have normal vision in that eye patient has 45 prism diopters of esotropia at distance and near this is a little bit of a trick question and the parents they're kind of ambivalent about doing something but grandma is there and she's looking at you saying I want this fixed I want this fixed now I don't like the way that eye looks what procedure do you do paid attention on the service that's good no that's absolutely right your strong obligation at that point is to tell the parents that operating on that child at that particular moment time at nine months of age is absolutely totally ridiculous and you shouldn't do it and grandma needs to get her act together and quit being a problem and the idea at times is that grandma's devastated that her grandchild has his crossed eye on the side doesn't see and every time she sees the eye crossed it bothers her that's why she wants you have to understand why she wants it fixed I'm not trying to take on grandmoms in general but the bottom line is that if going back to the what's in it for the patient this patient isn't going to see any better out of that eye and at nine months of age their sense of self their self-esteem isn't going to come from anybody grandma being worried about that eye crossing and it isn't affecting their ability to interact with other kids so we follow the child and prior to starting school you want to make that eye look straight and that's the time to do that somewhere between three and five and then you straighten out and if we're doing that now we're let's say we're four years old they're back you put safety glasses on them to protect the the right eye from from injury and they still got about 45 to 50 prism doctors vastropia what surgical procedure would you do right who would do surgery on the right eye nobody yeah and not me either and what you may see with this kid is this kid may actually have some nystagmus bilaterally and you may find that they've got a little bit of a face turn and this right eye they prefer to keep it in adduction I'm still not going to recess that right medial which would tend to move that null point that they've developed closer to straight ahead but operating on that child's only seeing eye you really have to be pushed to do that and and that's a frank discussion to have with the parents you say I'm not going to you know likely to have a little bit of a face turn still we're going to make the eyes look nice and straight but the other thing you have to tell them is the thing that keeps those eyes looking straight is seeing a lot of each eye and using the eyes together and they're not going to do that so that I may drift but it's important because they probably have a neighbor who's told them that somebody said you have one chance to get it right it has to be done by age six and after that you're toast that's a kind of a common thing for neighbors to tell people and I'm trying to be helpful and the parents are terrified and so you say you know if this drifts at any age you do more surgery and make it look better and that's a good thing for them to take home and understand about that so that they're not terrified now shifting gears we've got this three year old who comes in and about four months ago they started crossing and they finally decided yeah it's really there they want to come in and have it looked at and the exam they've got equal fixation behavior they've got about 40 prism diapers of esotropia but it varies a little bit and you've got this cycloplegic refraction what's the patient have what's the diagnosis accommodate of esotropia meaning as they focused to overcome the hyperopia their eyes cross that's different than the normal situation I mean this is not this is at the upper end of what we had accepted in a child for the amount of hyperopia but most kids with five diapers of hyperopia focus and keep their eyes straight kids with the cognitive esotropia cross when they do that and so is the right thing to take this child to the operating room and straighten them out not unless you've got a boat payment do you know and unfortunately I see that happen it's very disturbing but the right thing to do that lets you sleep at night and feel good about what you're doing and feel you're doing a good job taking care of patients is to put the child in glasses you put them in that full psychoplegic refraction and so we see them back in two or three months their eyes look nice and straight with the glasses on do we operate at that point no we say you're doing great you know come back and see me in four to six months or something and follow them along as long as you've got their eyes straight they're going to do fine now this is the same patient but instead of looking straight they come back and they've got 25 prism doctors of ET in primary it's equal and up and down gaze it's also the same at near what do we do here make sure the glasses are right so you check the psychoplegic refraction that is an excellent idea I like that and the glasses are right so what's your next move okay and they say gee my neighbor said they patched their child's eye and it's straightened out why aren't we doing that well because patching doesn't straighten eyes we use patching to treat amblyopia we do not use it to straighten eyes it doesn't straighten eyes and so this patient needs surgery now do we do surgery for that full you know large amount of estropia or do we do surgery for this amount of estropia what are we trying to correct the 25 prism doctors so that with the glasses on the child's eyes are straight that will result in the most stable alignment that will give them the best chance of developing normal binocularity now this patient shows up and they've got estropia since birth and they just their pediatrician told them it would go away they saw somebody at Walmart that told them it would go away and they show up in your office 20-30 acute edgi they've got no significant refractive error they've got this and they've got dvd 3 plus it's really noticeable sometimes one eye sometimes the other eye and the question is what to do and there are kind of two issues here one is the estropia the other is the dvd dissociated vertical deviation so for the estropia what would be the most and this is equal at near as well 45 prism doctors what procedure would help the horizontal misalignment absolutely now and in both eyes get things straight and then the the issue is what do we do for the dissociated vertical deviation and we separate our thinking like the issue of A and V patterns with and without inferior bleak overaction if you have dvd and you've got inferior bleak overaction you're gonna have to do something with the inferior bleak to get it fixed and the most common procedure done is an anti-replacement procedure where we instead of simply recessing it reattach it further forward on the globe where you change the inferior bleak from an elevator to a depressor popularized by a guy named Jim Mims who's a pediatric ophthalmologist in San Antonio, Texas and since written about by a whole bunch of people but the idea is that that in that circumstance as long as you don't do too much is a good thing if you do too much you will actually, if you're doing it asymmetrically limit upward movement of the eye because of restriction and then you'll wind up with a secondary deviation the other eye way up here and that becomes a big problem trying to fix and in inferior bleak overaction now what about if we have no inferior bleak overaction what would be the procedure of choice there and this again is a fair game OCAP kind of question so worth knowing about the most reasonable thing done in that circumstance is superior rectus recession okay the third line thing done by some people self not included is inferior rectus resection and some people will advocate that I have never found a patient combination of either dealing with the inferior bleak or superior rectus with DVD that I was not able to fix which is why I have not gone ahead and done that I think that now with the superior rectus again it's easy to say that if you're going to try to do it and you've never seen the superior rectus except you know when you're a resident doing things don't do that for the first time your first week in practice call me we'll talk through it because it's a quick way to get yourself in big trouble because you have to pay attention between the relationships between the superior rectus and the superior bleak and deal with all those issues to do it effectively you always want to hang the superior rectus back so that you're not putting inadvertently suture through the superior bleak tendon which can be difficult to find if you've ever looked for it it can be quite a challenge but it's a very effective procedure and but that's an easy one to kind of talk through but without inferior bleak overaction superior rectus recession with inferior bleak overaction you do the inferior bleaks the question is well do I do both eyes or one eye let's say it's just one eye to see the parent see going up if you see any DVD on the other eye you have to do bilateral surgery even if it's not apparent to the parents because if not two weeks after surgery they're going to call you saying doctor the other eye is going up now and you're going to be going back to the operating room to fix the other eye so you want to look carefully for that and I'll often recheck them if I'm planning on doing unilateral surgery for DVD the day of surgery and tell the parents I'm ahead of time that I'm going to check it and I may ask them to let me do both eyes right then and there if I see any because I don't like to be surprised with that stuff and then we've got one more we'll look at and then we'll kind of wander on so this is a patient who's been five year old and the parents tell you that they see the eyes turn out mainly when the kids sick mainly at the end of the day if you ask for a percentage they say 25% of the time and kids got good vision and when you break the child down you're seeing about 30 prison doctors of intermittent dexatropia and it's comatant up down right left and when I say fusion abilities are estimated as good what I'm talking about is that when I stop covering I look to see how quickly the child pulls things back together and if they pull things right back together that's good if they wait 5-10 seconds they pull things back together that's in the fair range and if they just sit there that'd be what you'd call poor and so in this patient who's turning out 25% of the time are we going to operate in this patient now? I'm not because the patient's probably straight 75% of the time that's assuming I agree with what the parents are telling me about 25% understanding that parents vary hugely in their ability as observers and one of your jobs as a parent is to get used to how your kids look now if that patient and we'll go back to this now is turning out 75% of the time let's come up with a reasonable procedure to do because at 75% of the time the child is at risk of losing vision in an eye developing amblyopia at risk of losing binocularity if you let them become constantly misaligned and we worry a lot anytime they're misaligned more than 50% of the time if we're going to do surgery here what would we do? lateral rectus precession bilaterally is probably exactly what I would do in the operating room let's say the child had had amblyopia in the left eye and we are now at 20-30 and 20-40 right and left would that change anything? yeah I'm assuming that 20-30-20-40 was the result of the patching let's say they started at 20-80 very good question again she's pinning me down in the details here the bottom line is yes you want to and that's an excellent question the idea is you deal with amblyopia first why? amblyopia basically having equal vision after you've done treatment or as close as you can get it will improve your chance of maintaining good alignment and reestablishing normal binocularity and so if they respond as expected amblyopia treatment and they'll do it now sometimes parents don't and you wind up operating anyway after you kind of get pushed into a corner but in that circumstance I am honest with the parents you know, yeah we're going to operate but we haven't done as good a job with the patching as I'd like we're kind of between a rock and a hard spot and the results of surgery are not going to be as predictable nor likely as long standing as if we'd actually done that you know and I try to lay things out so they know what's going on and if I'm worried about something I let them know about that so they know I'm worrying about it don't just say everything's going to be fine we'll get this fixed I can't tell you the number of patients I have we're talking about doing surgery that want to know what kind of guarantee comes on the procedure and I just say well the same one you came into this life with you know guarantees come on toaster ovens and microwaves not people in operations and all I can guarantee is I'll do my best to get your child fixed or to get your eyes straightened out and you know and be honest with them and that's where we are now what questions do y'all have about this otherwise get out here and have a good day


The paper reviews the current state of knowledge on the distribution of corals in marginal and extreme environments, including latitudinal extremes, shallow reef systems, and reef-neighboring environments such as upwelling in CO2 vent sites. The authors also conduct a synthesis of abiotic data collected at these systems to provide a collective assessment of the range of extreme conditions under which corals currently persist. The paper highlights that corals can persist in suboptimal physical-chemical conditions and identifies commonalities in coral taxa able to do so. It also provides evidence for key mechanisms required to support survival and or persistence under such conditions. The authors suggest that extreme and marginal coral environments may provide potential refugia under changing environmental conditions and outline priority areas for future research on these environments. They also discuss additional management options that could be provided by these environments, such as genetic stocks of stress-tolerant corals to support proactive management strategies. This article was authored by Emma F. Camp, Verena Shope, Peter J. Mumby, and others. We are article.tv. Links in the description below.


Hello, can you hear me? Yes, Minister. Thank you so much for taking your time. I can hear you very well. That's great. That's great. So let's get started Yes, um before we start is it fine if I record this because then I can focus on speaking? Yeah, of course and just in case the vote the voice is not getting through very well I'm recording on my side also and at the end of the interview you can choose whether we publish this as a Transcript after 10 days of editing or maybe we upload it just to the YouTube after a date that you specify Yeah, yeah, I think and you know actually my my plan would be to use it for short articles So just use sort of excerpts of it for an article But it's just you know for me it's easier to to heaven recording because then I don't need to take any Yeah, and I would love to love to talk about two things actually The first part would be sort of more generally about data data protection also the upcoming GDPR here in Europe And then in the second part I would like to speak about AI, which is what I cover mostly So yeah, so if I you know that my first question would be next week Europe is Or the GDPR will take effect finally on the 25th Do you believe that Europe is taking the right step with You know this updated set of data protection laws. Yeah, definitely so Taiwan has our privacy act very closely resembles that of the previous version of the European Privacy Act and We have also added Parts of it that we feel that are very important such as the user's right to be empowered to interrogate the data Operators and so on and and that those parts are also not just in GDPR, but further enhanced And so we think it's totally in the in the right direction and the National Development Council here in Taiwan has already Allocated a whole website section just for GDPR compliance And we've worked with all the relevant ministries to publish guidelines for GDPR compliance So we're totally supporting it Mm-hmm and when it comes to I believe it's called PIPA right the the acronym of your own data protection act from 2010 originally if I'm not mistaken that that's exactly right. Yes Yeah, when so when it comes to this act I mean, you know data protection is something that's in flux and these rules need to be constantly updated and so on Would you say that you know in future revisions of your own act? You you might draw inspiration from the European approach because it is very comprehensive. Yeah, of course, so There are of course exceptions to The privacy guarantees and different jurisdictions Emphasize different things, right? So I think all of us encourage academic use But for some European countries, there are exceptions made for historical research for the archivist and the Histo historiography here, but we don't make an exception for the history People here, but instead we make exceptions for for example criminal statisticians and criminal investigation and things like that So so there are different social norms is what what we're saying but there are parts of it such as data portability and The other more technical aspects of it that we're already Installing on a regulation level Not necessarily on the law level, but already on the regulation level and I think GDPR is a great Opportunity for us to choose parts of things that we already do on regulation level and on our next law revision Put it in and also in addition, for example, the data protection authority at a moment each ministry in Taiwan is a DPA for all the commercial entities registered under that ministry That's usually not a problem, but for platform economy and more companies We are seeing that one operator may fall under the jurisdiction of multiple agencies or ministries So some harmonization of that is great And we're seeing that in Japan also they used to have each ministry acting as DPA But now they also have a central agency in charge of harmonizing the different interpretations of Data protection laws within all the different ministries. So the National Development Council is now also taking charge of that and we're kind of reshaping the Department for Information Management Into potentially the Department for Digital Development So that it can be more Kind of a oversight of all the different ministries. So so we see it as a positive opportunity It's there's there's talk here in Europe about the GDPR potentially becoming a model for the world Data protection. What's your what's your reaction to this? How do you feel? Could it be a sort of a role model? Well, I mean there's parts of the GDPR That I think are very advanced and that we should definitely Learn about I think in particular the requirement for the data operator to To explain in understandable terms Instead of, you know, just a request to explain at all in any technical terms I think that is a real innovation and that's the one that I personally feel very important And I could call that a model of the world But I think there's other parts that we will have to Adjust based on the social norms here. For example in in Taiwan the special sensitive Personal data we have actually more strict protection Than the GDPR one for example the medical records Health records genetic information and also criminal records and things like that We are actually putting into a much more stricter provision and so we're not Looking at GDPR is that we can relax those, right? So so they are part of it that we we need to harmonize within our practice But generally I would say it's on the on the right direction So I'm slowly now shifting towards AI as I said and and I mean of course, you know Data and AI are closely related AI doesn't work without data There was the last month the European Union Released its own strategy on AI and in a nutshell, you know sort of summarized in a nutshell what what what the EU Said it's like its idea is to become a leader when it comes to ethics of AI and to sort of preserve Fundamental rights along with the rise of AI and you know that the idea is that this will make the continent Competitive in the race where right now we have the US leading, but China catching up very quickly Wait, um First question is like how what do you think about that this approach? well, I think Any any public discussion is a good thing because the the scenario that we don't want to see is that a researchers Stop publishing and starts, you know working in cabalas and conspiracies that would be to the detriment of everyone, right? So so we want to encourage our researchers to work in the open and to work out AI safety and Ethic norms with the whole society with the other stakeholders and in fact this just this week We're going to push a new legislation to our parliament. It's called the AI mobility sandbox and I see that Germany is Setting a kind of AI ethic for autonomous vehicles that puts human first animal second and and some Very interesting ideas about non-discrimination of any race and as density and things like that when they consider human life And so on which I think are very good guidelines But in reality what people care about is not only such top-down philosophical guidelines, but very practical thing like When a AI driven vehicle runs into something not necessarily people when it runs into a building, for example How do we interrogate that vehicle and see the world from its perspective so that it can communicate with people and This process we already have a word father is it's called domestication, right? But I think just like the wolves and earlier humans co-domesticated each other So become modern dogs and modern human We also need a way for the early AI vehicles to not just be subject to some top-down ethic standard, which is important I'm sure but also interrogate its integration into the society case in the example is that For example, the MIT media lab has this class called persuasive electronic vehicles or PEVs and they're automatic Vehicles, but they're tricycles. They are very slow driving tricycles, but it can still carry cargo and it can still carry people And we have that because it's using the right of throughout just as pedestrians We have that running around Taipei in the social innovation lab And we recorded a lot of interaction of these vehicles with people because it's slow enough if it runs into people It doesn't really hurt anyone We were able to gather because it's open source and all the data is shared We were able to have the local university college students tweak it so that we can try various different ways For it to signal its intentions and for the human to signal its intentions and maybe merge the worldview so that we can view a playback of the incident from the vehicles viewpoint and so on and We were able to do that because Taiwan is a place that values experiments And I think in the AI mobility sandbox what we're doing is I will have the local regional governments Declare their social need that could be fulfilled by a limited testing of AI vehicles And it's not just driving but it could be ships. It could be drones and then but slowly Maybe under a speed limit or something to experiment with the business model But the important thing is not some top-down rules But for the society through this kind of experimentation gain a first-hand understanding of how to commit co-domesticate with AIs and then write up such multi stakeholder Opinions and reflections into something that could in turn inform the interaction design of the Vehicles so that they can explain themselves and integrate better So what I'm trying to say is that with the AI mobility sandbox We're taking a grassroots approach instead of a few legislators and few zero Rations and a few computer science ministers. That's me Declaring there's such and such thing is good and ethical from a AI standpoint We're going to using a slow speed limited area sandbox and for the Society to to work out with the individual vendors and at the end of experiment if it's click declared a good first Society will just incorporate part of it into the regulation and if it's not a good idea Well, at least it doesn't really hurt anyone and we can demand Extra restrictions of the future experimentation. So we already have some success with the fintech sandbox with AI banking Right. So now we think and mobility should be the next sandbox after it the AI banking one I'll get back to this in one second, but I want to ask one other question If you know if you look sort of the global Landscape when it comes to artificial intelligence at the moment You have the US which is still leading and the US follows traditionally a very business-centered approach where the expertise is with the big tech Companies, you know, sir. That's where it happens. We have China which Wants to catch up very quickly and follows, you know provides companies with data is also you know what I would Describe as a surveillance state and then Europe that wants to play what's to come up with this third path And they say, you know, we need to be sort of a place where people know that their data is being You know used safely whether they can still to that and in this sort of like tableau of three different kind of Broader, what do you see? What do you see Taiwan? Well, I think it's the oversimplification because I just returned from The the valley and I talked with the open AI folks and the open AI as you know is a charity and It's explicit goal is to work out safety Lost for the generalized artificial intelligence and I would not say that they're profit-driven at all that they were all very Interesting AI researchers trying out all the different branches trying to reach generalized artificial intelligence before a maliciously Intent actors do so and I think their charter There's part of their charter. I think can still use some More conversation and explore more deeply Because the regulatory co-creation I think is very important But I think their open AI charter strikes a pretty good balance between what you said as human rights Interests and the private sector interests. So I don't think they're necessarily competing with each other I mean the the US and the Europe Approaches I would will not comment about the compatibility between the surveillance approach and the other approaches So I think in Taiwan because my domain is not just digital But it's also open government and social innovation and especially social entrepreneurship what I always try to Encourage in in the constituents and also in the civil society is to not think about human right or environmental causes or any other social justice as opposite to profit or to business or commercial interests with the right design of social entrepreneurship you can use the for-profit motive for social good You with the like the b-corp movement and other movements So I think AI only takes off if there are incentives from all the stakeholders to not just share the data But also publish what whatever they learn because frankly speaking there is no generalized theory at a moment guiding the field of AI It's it's just random. I would say random walk from all the different kind of applications and trying to solve Practical issues and that's not necessarily applying to the field that it's Experimenting but sometimes, you know just playing go or playing Amiga games can carry over to some other field So what I'm trying to say is that we we have to align carefully the the social benefits and the private sector for-profit motives, which is why why Taiwan's AI plan, which is in AI dot Taiwan dot GOV dot TW Strikes the balance by saying we are going to have the small and medium enterprises Find out which part of their work can be automated and that's obviously a commercial motive But then for the academia and the people working on research to try to as part of solving this problem Also find out ways that's social innovation. That's to the benefit of everybody's through regulatory co-creation so with the industry proposing solutions and academia and the civil society refining the solutions to be acceptable by the General public. I think we have to strike a balance between the private and the civil society interest And I think that is actually what most of the large companies that I have interviewed with like Microsoft or Google Is doing anyway. They they because of partly GDPR But also because of a collective Awareness of the potential damage that AI can do to the human society You will see that once they roll out AI product, they very quickly rush to say Oh, by the way, Google duplex will declare itself is a bot and she will refine its interaction So that it can integrate with human society without deception and things like that And we don't usually see that kind of prefixes in the previous product announcement So that to me is a signal that they're also taking this balance approach Yeah Speaking about this you you recently you as in Taiwan the country Managed to attract a couple of American companies to to to come to come to Taiwan and and Open up their own AI divisions there. That's right So this is I mean, I understand a lot of the expertise is there here in Europe We have a similar phenomenon here with them opening their divisions here and their politicians here and lawmakers who are Concerned about a brain drain on our own territory, if you will So that you know that that talent is going to the US companies so that a lot of the expertise still remains with them Is that something that you are concerned about? Well, I see AI mostly just like the invention of fire The more democratized it the more safe it is It's true If it's just a handful of people in a society can use it and everybody else treat as a black box Then we run the risk of a lot of social catastrophe because of people's misuse, but it's just like fire, right? It's dangerous. It has been entire cities, but we teach how to use fire In a safe and responsible way from when people are like four years or five years Oh, right as part of the cooking class. So what I'm trying to say is that we're in our K212 Curriculum we're explicitly saying AI access to ICT media literacy Criticism thinking it's not just some two hour or four hour class that all the student must go through It is actually to be ingrained into all the different fields so that the students these AI is just a another tool To to simplify their life while being very critically thinking about Biases and and other things when they learn all the different disciplines. It's not just for their computer science Discipline and we have integrated into the curriculum starting next year So what I'm trying to say is that if there are many AI researchers doing cutting-edge research in Taiwan I think it will increase the public discourse on AI because we will have Thousands of people who are knowledgeable enough about us who can participate in our democratic process And once the K212 people and all the children in Taiwan because broadband is a human right here Have easy access to GPU computing or other air computing clusters I think this this is actually what Causes the reverse of the brain train right it's causing that everybody is becoming AI aware And I think in a few years we will not think about AI as some very special thing It would just be part of the automation just like office automation. It was treated as something magical But but now it is just part of their life That's right. That's very interesting also the analogy with the fire. I have two more questions One would be that is sort of looking at the US there was and the White House held an AI summit last last week And from what I heard from my US colleagues the the administration the Trump administration signal to the companies that they That they you know won't Regulate massively at this point in time because they say for for AI to foster growth There should be little regulation at this point And what do you think it is that the right approach? Should there be regulation? How much regulation should there be for AI at this? No, as I said, I think the model is for co-regulation, right? So our regulatory co-creation and so if a company come to us saying, you know AI banking is currently outlawed by the you know Vintag laws of the financial Minister instead of saying you were doing a light touch or we're doing a heavy touch We instead say okay, right up exactly where does our regulations have hampered your growth and have a multi-stakeholder panel look into it As long as you don't cross some red lines like I don't know funding the terrorists or money laundry You can't do experimentation of that, but other than those things you can do an experimentation They challenge the existing laws and regulations without the regulators and lawmakers have to commit one way or the other We can through six months of experimentation have everybody affected by this new AI banking service or very soon AI mobility service Deciding whether it's a good idea or not. I think it's also part of what we just called the media literacy or AI literacy idea Because if it's co-regulated with the civil society everybody learns a little bit about how the machine views the world But if it is just a handful of regulators then everybody ends up non-the wiser So so I think it is Easy to say that we need to uphold some standards on freedom on freedom of expression assembly and freedom France surveillance from coercion and from censorship, but other than those basic freedoms I think all the norms of interacting with AI cannot be done in a broad brush It has to be very specific to specific air implementations and specific to a county even And on how the people there want to react and maybe the county nearby doesn't want to react the same way, which is great I think there is a lot of diversity of how to incorporate Domestic animals even into human populations and we should use a very similar analogy when incorporating AI into everyday life of people Especially if they're upgrading for our assisting role to a autonomous role My last question would be you know again sort of looking back at Taiwan and Europe Where do you see very broadly speaking for AI? Where do you see the potential for Taiwan and Europe to cooperate? Right. I think in Taiwan the research into AI safety and AI What we call trust trustable AI explainable AI interpretable AI there's a lot of interest in it, but I think Not just GDPR by the recent declarations I think it provides a model because for example, if German has passed a certain law that translate into algorithm On the automakers doing self-driving cars in Germany, then with our AI mobility sandbox We don't have to start from scratch, right? We can incorporate those same algorithmic Oversight and accountability into our Co-creation system and start from where Germany has started. So we're not seeing any competition between those Norms because essentially this is codifying our social expectations Not usually into law anymore, but into code, right and and code has the The property that it transcends jurisdictions You can take the same code and compile it into different languages and different regulations Even that part is being taken care of by AI. So I think At the end we will have a set of abstract Code and algorithm and parameters and our regulatory co-creation will be the society's Tuning of those parameters and hyper parameters, but the end result will be shareable Among all the different jurisdictions and for example, just take another non AI example just recently The ministry of transportation and communication here has regulated that shared driving And so a coupling is limited to like two times To commute and commute back and if you start charging people for those two trips, you're still coupling But if you're doing it more than two times a day, then from the third time onward, you're essentially doing You know a uber like rental car service and and you start being eligible for taxation and whatever above the third Trip and I can easily imagine that in other jurisdictions in Europe using the european platform economy laws It's not two trips or four trips or whatever But but I think the the structure of the argument will be the same and so we will be able to co-create on the code-based Norms that the society can up in or up out and tune the parameters like two trips or four trips And we're going to see very much the same thing About AI banking and AI mobility and other applications Minister, thank you so much. Um, this was really really helpful and thank you also. I know it's late in taiwan already So thank you for no, no, it's just great. Yeah, so so I yeah my I you know, I'm I want to Actually, I want to publish it as fast as possible. Um, but it's it's not entirely in my hands But no editors Brussels, but I I will keep you updated. I will send you an email as soon as I know I mean, I'm sure it's going to be out this week. This is really my my right So after it's published, would you would you mind if we just publish this youtube video? No, absolutely. Yeah, for sure. For sure. So I'll post it as a unlisted video. So it's not Searchable by anyone else. I'll pass you the link and you can review it And once the article is published, you just let me know and we'll flip it into public Okay, that sounds great. That sounds really good. Thank you very much for your time and you know, have a great day Thank you for the great questions. Thank you


Going on everyone Sam here late in sports card drip in 23 tops chrome baseball hobby jumbo 8 box makes number 18 random team style So look again at your random results as always you can find those on the website under the results tab as well as the link That's currently in chat a little bit further up, but it is it is there. I can Tell you that for sure. Yeah, Jonathan pretty solid got the Orioles In the random that'll be solid. Hopefully you can pull you an Adley or a gun or auto that'd be cool Guys got NT tomorrow national treasures football tomorrow comes out long-awaited NT football Volpe rookie refractor drew waters rookie. That's Corbin Carroll. There's a story Reese to 199 seal lava for these base Manoa refractor ready fast can see no Ozzy albis just trying to play for it You you yeah My dad is Alvarez prism a lot of you Of course, it's one of your buddies. I know I do it, bro. I really don't Thanks, Jonathan friend requests That was so funny. That was awesome. Glad he sent you a friend request. That's pretty fun. That's pretty great. Pretty great Contra Base auto is yander. Yes, that'll be going to the Astros grads used it nice one Even small Oscar for last There's a Cabrera as Waldo that is How stellar is prism together gosh young rookie I'll show up after just crash it Prism von Grissom Grissom come in just start yelling One eye Green sonar Ryan Mountcastle to 99 there you go Jonathan Myer and Alex call. I'll come in at like 12 30. That's the thing. It'll start yelling sticks out Even Kwan Yeah, good to be back Jonathan. Thank you. Thank you. I was so dude last night. I was so excited to come come back I couldn't wait Nolan Gorman rookie Even I was playing Fort LaShawn today.  This is all card ship as well Zegel Tova And base. All right second hobby box now boom Guess again tonight We get there. Yeah, it's gonna be big That's Goldie James Outman Rookie O'Neill Cruz bow nailer Blue sonar to 1 at 25 George Springer nice color match from blue jays Oh, yeah, yeah people staying with you. Oh, she's in the apartment. Yeah. Oh man. Kodai Senga That is gonna be comfortable. Yeah Yes, it is. Thank you Jonathan. Thank you Yes, it is Actually, it is my birthday today. Yeah, the 364 days here when we say that No Uh, Jose Miranda prism. Yeah, it's in Riley green Prism Stephen or uh refractor Stephen quantrish and cossus Yeah, just five group break spots left tonight. Everybody pretty solid Gunner Henderson rookie got crown royale Uh tiered random team style as well as optic choice full 20 box case tiered random teams So just five total group break spots Left on the night. Prism Riley green nice one there We'll check to make sure that that is correct Harper taking a tiered spot in choice. So we're down to two and two now Two and two four group break spots left on the night everybody Torkelson Two to go Sean's dropping that link right now. Thank you Sean. Lee over preguero rookie auto grads pirates Nice one there the base auto O'Neill and mookie Sean Murphy refractor Brandon Hury Yankee legend Brandon Hury Tucker Moreno Miguel Vargas Francisco Alvarez rookie refractor negative JD Martinez Grats on that Dodgers potential silver slugger Surely the Red Sox and then let him just walk that'd be crazy Taylor Ward prism Joe Ryan Brian Bale My arch nemesis on the Yankees right now. I was freaking Carlos Rodan What he's so bad Christopher Morell Well, we signed him for like all this money like over 180 million. I think it was something like that And thank you Bobby. What up Bobby appreciate that man Bobby and he to start off missed the first Two and a half months of the season with injury After hurting himself in spring training then came back and went one in four with uh over almost a six ERA Now he's back on the aisle Riley green Waste of money, dude Dude, honestly, I honestly remarks. I don't know how much you're gonna agree with this But I really do think Rodan could go down as the worst cashman signing.  Yeah, it's Jordan Walker rookie. Nice one there Javier Assad Walls the fracture Farewell, go Harris. That is a green of hunter green a green green to 99 green wave Irish spring green green green The youtuber does that No Don't do it. Here. Don't do it around here What's up, Bobby? Purple manoa to 250 No one warming Biggest bot that worked there IP Jake big Jake Just know how he was Already well past due the time. Yeah Juraq's music and refractor He better have a haircut before he goes to the concert Is he gone?  Yes leak. We've got uh Like six or seven basketball just doing baseball and basketball tonight because of nt tomorrow presum Contreras So we've got just four group break spots two to go an optic choice tiered Uh and two to go in crown royale tiered Brian haze now. It's unbelievable dude verlander refractor. It's really unbelievable remarks Unbelievable George Steinbender's roll over is great. He is josh young disgusted. He is not happy For sure. How are they doing in my franchise? Anthony Volpe base auto michael toglia. I'll be going to the rockies That's colorado It might be jake Yeah, tovahre Trying to cool us in the Joe I put Joe up there Joe definitely Corbin carol I have to say both your son and matt my son for sure matt 1 million percent Kyle for sure. Yeah Kyle's like Donnie That's like my it's every time I walk in at like three thirty or two thirty when I come in And I go in and it's already in shipping and it'll be like Dylan matt chris like jay like jaden and like donnie And everyone will just go oh man like that when I walk in adley rutchman christian yelich and I'll always be like Like man, they really got to change the hiring process here I last time I came in I was like man, you really all you have to do is have a pulse and you can get in my job here What's your zombies out there? Tyler stevens into 199 teal lava. I know I'm so pumped for nt bobby riley green and goldy Yeah, nt is gonna be freaking awesome, dude Uh, josh young nice one there on the refractor rookie for the rangers Hello, anneal, uh, jordan walkeroo Shohei refractor Michael harris Gabriel marina Starling martin Kyle stowers as Waldo cabrera Abyssal garcia dranhalo stanton chris over morrell We're getting banned from a lot of tick tock lives Yeah, man Dagonizing people kind of boy Based on a bone nailer nice one there for the guardians It's so easy, dude. All you got to do is ask people if they have leg mud and that's it It's all they have to do Mike trout frism. It's so funny Because either somebody won't understand it and you hit them with it or somebody would be like not falling for the causes Oh my god, it's so glad your screens captured. Oh my god, james outman rookie. It's the funniest thing in the world Oh me. I always ended Oh my god, it's awesome. I love my burner Masataki or shita. That's a gold drawer in karnassi own rookie to 50 grads on that miami Here you go marlins Prism austin riley uh prism avon herrera Cody plemins lebertor I'm kind of happy Bobby wit refractor Shea langlears It's torpleson future stars gunner henderson rookie and dj le mayhew and choiza. All right jumbo time be empty romper bell does Fresh off. There's no hitter Logan o' hoppy rookie. It's prism austin riley And deal hall refractor That is a green hunter green irish spring green green green to 99 I saw in there future stars for the reds anthony rizzo So happy everybody gets to see a reaction now. It's awesome So funny adley base rookie Michael Harris makes this so much better now George springer cedric mullins jeter downs. You agree with that? No Hey, thanks jerry appreciate that. Thank you. Thank you, man. Appreciate that very much uh neat eaton Nice one there for the royals bassata Because this is how do you like that one? Sean o'neill cruise that's stick Don't show it with me kyle It's a long way to go here. All right. Josh young can't tap out yet Zach gallon jake mccarthy prism and anthony rendo Do a gold wave Ellen gorman gold wave Will brennan to 50 nice one there guardians 24 50 Congrats cleveland and shawn murphy Here's um, there's an alvy francisco alvarez Ezekiel dovar deal hall prism And Yeah, today's my actual birthday up the 8th Today is my actual birthday. That is chrispher morrell. It's nice j rod to 199 on the teal lava color match for the mariners kershaw engine mccuchan no one gorman rookie That's green wave shintaro fujinami to 99 still for the a's in this of course Pre-trade to the orioles starling marté marté party And they actually say that to be fair. That's I did not come up with that. I'm just reciting that To be fair to be 100 fair Uh john carlo stan jersey card for the yanks going to vaughn perfect guy for this to go to to 99 Here you go vaughn Vaughn just tell me hey happy a late birthday josh Kyle talker uh prism oswald perazo and chrispher morrell Greg picking up the jets tomorrow alexandros with a tiered uh choice spot Thank you alexandros and thank you greg appreciate you guys And grab your nd spots tomorrow everybody national treasures football release day one of the best releases of the year Trying to get to 100 likes for sam's birthday. Let's go. Yes, sir. Yes, sir, please miggy Refractor bryan serban rookie auditor 499 Halfway there and you darvis appreciate that josh. Thank you, man And my grandfather's birthday was the 7th as well Yeah No, he's not Again down to just one spot to go three group rake spots left on the night everybody That is it That is all codide senga james outman In goldie or as rookie prism for the mezz and christine elch and that says Wheeler got a purple mini diamonds coming up here. It is cori lee to 299 for the stroves That's houston 141 out of 299 cori lee that wheeler gossas Langleers or the gunner rookie uh prism shaw and murphy and a hobby by as refractor Aaron judge josh smith prism rookie j smove and bow nailer refractor rookie Strider akunya andres hymen as refractor Hey, dude, I am pumped to rip some empty tomorrow. I got me and shaw again tomorrow night You got five streams tomorrow everybody bow guards bladdy junior prism for the lujas trish and cossas refractor rookie for the red socks spence astia uh christopher morrell that is a david vr base rookie auto for the giants and robbie rey Riley green rookie that is a green wave jake up the grom to 99 that is going out to the Rangers yeah And tyler o'neill that that's that's that's a red on dean dean's going straight to the red dean out Dean's going straight to the red today We got so many people yellows and reds today alvarez. That's our second red guard. We've issued Purple jady martinez to 250 That is jeter downs and mike. Yes Mr. Yastremsky Moreno Jordan walker gosh young base auto shade linglears I saw in there for the ace of that case. All right. I'm in a little bit of a scuff on the bottom I'm going to send an empty box and wrapper with the ace also a refractor of linglears There's a little with Oakland That case I'm all right with it dean That case very that's the whole different story then Morelle rookie got another jersey card Plemons liberator that is flat america railroad jr. Game used jersey card for the blue chase Rats on that there a toronto Awesome riley clayton kershaw and seah And guys just one to go on Optic choice. There's still two to go in crown realm drop you guys a link to that real quick two to go Gonna be a fun one for sure the next one Going kaboom hunting as well in Brown everybody adley rookie Gorman rookie. Hmm. Cal Mitchell refractor rookie. He's doing out there right now Oh, that is a ultraviolet all-stars vlademigaro jr. Nice one there on the short print for the Blue jays. What's up jake? Different jake logano hoppy prism and hermon marquez not our jake jake lakers 23 michael harris Goldie purple brian bayo Cool one there to 250 for the red socks crats on that boston one of their late like Big inning eating uh relievers no one are not from walker Prism Kyle Tucker and nicoladolo Now they're nice they're sick Y'all have to show me that's the bellinger prism Ryan bale those are nice Those are sweet Yep, bulky rookie corbin carol rookie Yeah, they're sweet brah prep 80 rookie tovar Prism buxton and logan web. Oh hoppy rookie gunner henderson future stars And brand new yakey legend brand injury That is prazzo the castianos and joseo poove City connect jersey on there. They're playing right now. Actually they're losing To nothing to the orgs That is a brace to rang the 199 on the aqua the rookie for the brew crew and dermis garcia refractor rookie You go cabrera cal stevensson base auto Going out to the a's nice one there oakland riley green refractor rookie I don't think it's an auto though quit josh jung It's gonna be a starling marté 35 of 50 you can call that a gold marté partay right there prism cori seager and jose braves Right no Pedal on so josh young base auto there you go rangers nice one there Lee comes back nice and healthy right before the playoffs. That would be awesome Nathan why pick it up a spot in Crown royale random rows and rainers around to just one spot to go and crown and two to go and one to go in choice. I believe We double check definitely one to go in crown and choice has One to go two group break spots left on the night everybody. That is it That is all shon. That's it. That's all baby Volpe rookie corbin carol rookie christopher morale prism and mukibets Oh, yeah, it's up here my glares Yeah, those are dope Okay, kibali rookie refractor, right Uh, that's a breath baby yentos. Oh hubby Bloody james outman prism for the Dodgers and gunner henderson refractor rookie. There you go jonathan The oaves uh no one gorman rookie base auto is cal stevensson Hey, what's up candler? Thank you, buddy appreciate that man. What up? What up? Appreciate that my friend All right, riley green rookie Tyler stevensson and garret michael refractor rookie Kirby soto and marina refractor Josh young That is riley green we got refractor jason alexander to 499 grads on that aka george castanza Grats on that brew crew and dj the mayhew the machine bow nailer prism my trout refractor Here's pew pew Jordan walker teal law but a 199 nice rookie there 24 24 candler o'neill cruise and miguel vargas Oh, you got a nice hit for your team. Do you got a john carlo stanton jersey card coming your way my good my good man adley ruchman no one gorman rookie George sprayer joey meneses and dalton varcio You got yourself a number to 99 green Jersey card coming your way my friend that's pascantino shame a clan of hands to 299 Yeah, that's valid valid jordan walker fun goes. I'm sure I'm assuming it's player awards. He's never seen in any game Very very valid very valid I got a teal wave auto to end us off here. Come on. Let's make it a big name. Why not? Oh, it's bregman will Benson. I just won there 199 for the guardians And christian yelch Do a quick recap here guys pretty solid overall, I would say Definitely a good little break Got a base autos cal stevensson josh young cal stevensson Shea langlears david br knee eaten bow nailer michael toglia leover baguero yaneir diaz refractor to 499 jason alexander brian serban teal wave to 199 will benson to 250 we had brian bayo 299 cori lee and gold 250 will brennan That is gonna do it for the break guys. Thanks again for the fill coming up next is breakers delay