All right, welcome everybody to subspecialty rounds. Seems oxymoronic that we call it subspecialty rounds and it's comprehensive rounds, but best it is, we're just gonna spend some time talking about cataracts, makes us feel like specialists. Although we have Dr. Chia present, he's a glaucoma specialist, so he knows what that feels like. All right, today I'm gonna start with one case here. I haven't seen this in a long time, had a recent case, and so I thought that would be a good opportunity to present and also dig into it a little bit to see if there's anything new out there with regard to persistent corneal edema after routine cataract surgery. This case, patients, a 95-year-old female, reduced vision with specific complaints about difficulty reading, and so that's why we signed her up for surgery. Herocular history was otherwise unremarkable, so you had no past history of trauma or other prior ocular surgery. You can see her best spectacular visual acuties were about 2050 in both eyes. Otherwise, pretty normal exam. Pupils normal, confrontation fields, EOMs, IOP, all in the normal range, and no remarkable abnormalities in that regard. For pre-opsilit lamp and fundus exam, had some mild arcus to the cornea, but was otherwise clear there are no gutata or other issues. Deep chamber, normal iris, blends about three or four-plus NS, as you would anticipate in a 95-year-old who had not had FACO in the past. A DFE, normal exam, normal nerve macule, et cetera, so good visual potential based on the exam. So our assessment, of course, visually significant cataract with functional impact on reading, plan was for cataract surgery. Given the density, a few adjustments that I typically make in these cases will use viscotes as the viscoelastic, try and help protect the corneal endothelium. We use a balance tip with our Alcon centurion machine to try and improve the efficiency of nuclear removal, reduce the amount of FACO energy required for that, and then often use a burst mode. I'm just plugged in. Technical difficulties, hold on. Okay. Meanwhile, while we have everyone, just want to do a reminder that we do have our resident graduation this Friday, resident and fellow will be honoring of course, residents and fellows during this event. I don't know any details, although I understand this could be a roast to remember. All the subtle smirks and smiles of the residents as, at least anyone that's seen it, apparently this one could be legendary. So I'm doing what you generally shouldn't do, which I'm raising our expectations for it ahead of time, knowing that it's actually going to deliver on that. A couple other announcements. We do have our medical students who are going to be coming through soon. When our medical students come through, they are amazing. Just want to echo Judith's words. Please make sure and write down your thoughts, impressions and then send those right away. That really is the best way to get your thoughts together when they're fresh at the top of mind because they all do look pretty similar later. And then Megan, if you can just make him a co-chair, co-moderator so he can screen chore just so that he can do that. And you don't need to join up. All right, thank you. And so again, just a reminder, please write down notes impressions for the applicants. We will have an after interview open house just like we did last year in January, but that'll be our only time to meet our virtual applicants, those interviewing virtually. Thanks, Bill. All right. I came early and set this up, but I did not set it up properly. So thanks, Jeff. So back to the case. I promise you didn't miss anything on those slides that weren't very exciting. Everything I read was exactly was on there. So again, our plan is for cataract surgery. We talked about some of the adjustments we might make with the FACO machine and some of the instrumentation we might use just to try and make things a little bit more efficient. And of course, with somebody that's over the age of 89, we talked about independent risks for complications related to surgery. Obviously with the density of the lens specifically, we did talk a little bit about the increased risk of corneal edema, persisting for a little bit longer than typical with denser lenses with her age. So the actual case was uneventful, uncomplicated. I'd be perfectly honest. I thought it was a little bit smoother than I would have anticipated with that level of density of the lens. Her post-op, early post-op visits and see significantly reduced best spectral record acuity of 2040. The example otherwise, pretty unremarkable other than the substantial corneal edema. It's just 24, pupil is normal, out few is normal. The corneal of course showed substantial edema. There was no microcystic changes, just decimate folds with thickening of the stroma. Gracie was deep informed with about one plus cell, no fiber, no hypopion. Her eyewitness was round and reactive. Post-op chamber lenses well-centered, well-positioned. So our assessment is we've got a significant post-op corneal edema. So we continue, of course, the prednisolone. I had an aqueous suppressant just to try and help support the endothelium by minimizing any pressure associated impact on its functionality, although the IOP was pretty normal here in this case. In cases with significant corneal edema, there may be benefit to measuring with a device other than our typical gold manipulation tenometer because that can create a little reduction in the measurements because of the corneal edema. So you may need to add a few points in your head if that's the way that it was measured. And then we were gonna follow up in a couple of weeks to see if we were seeing improvements. In terms of the differential, with this amount of corneal edema, obviously you're thinking about a number of different things. So pass as was described here in Grand Rounds just a few weeks ago, pretty substantial edema, but usually you're gonna be seeing, you're going to see a more significant and your chamber reaction in terms of inflammation, which we did not see in her case. Doesn't mean that it wasn't maybe a variation task, but certainly wasn't presenting in that classic, very high, very significant inflammatory reaction scenario. Gouda less or Gouda less endothelial dysfunction. This was described in the early 90s in the literature or potentially you missed the Gouda, you can always look at the other eye to see if that is the potential case. In her case, there were no Gouda. There's always the possibility of a retained lens fragment so usually that's more focal in terms of the edema, usually the lower inferior cornea and usually you can see a small fragment in the inferior angle. Sometimes you have to do gonioscopy to identify it. And that's typically something that will show up a few weeks after surgery, usually as you're tapering off of the anti-inflammatory that the inflammation will show up and the edema will show up. Endothelitis obviously typically more severe, AC cell and vitreous inflammatory reaction more pain and none of what she was having. You can of course see this with a high pressure postoperatively, we looked for microcystic changes to sort of suggest that that's the case or that's present as we talked about measuring with a tonal pen or some other device other than the Goldman Appalachian Tenometer to get our best most accurate measurement of the IOP. An iatrogenic decimates membrane detachment also could present this way. You expect to see more bolus edema in that case. And so again, in her case, it appeared to be essentially a just significant postoperative probably fecal emulsification injury, maybe a butadolus and a field of dysfunction based on her presentation. Let's move forward here. So my working diagnosis that again, fecal induced and a field of dysfunction possible is that this is an anothelial dysfunction case without butata we haven't done or had not to this point done anothelial cell counts we wouldn't know for sure. So the plan of course has continued to allow time for recovery. We've postponed surgery on the other eye until this had a chance to recover and we're stable. We know what we need to do with that first eye to help her see better. We've got her on PRED, a BID. We stopped her topical onset after four weeks. Aqueous suppressant. I continue that for the first six weeks. The last IOP was 12 and thus we discontinued that and at eight weeks for edema is still grading out moderate about two plus. We've seen some clinical improvement, but it is persisting. So now what? Obviously this will be frustrating for a surgeon and for a patient waiting for this to recover in my experience. I don't have a ton of cases that have had this particular presentation in my experience. It tends to recover if you give it enough time and so try to preach patience. Obviously easier to do if you're not dealing with it. We continue PRED at a low dose at twice daily in terms of assessing the other eye and trying to figure out what might be going on and preparing or planning potentially for surgery in the other eye. A number of things that we can do. We can look at the endothelial cell count in the other eye to see if there's any abnormalities in terms of the cell count, the morphology of the cells as well and we'll see if it's suggestive of endothelial dysfunction or butadolous endothelial dysfunction. We can do an anterior segment OCT to look a little more in detail at the eye that is recovering to see if there are any abnormalities that might be suggestive of an etiology for the condition. If the edema does not clear within a few months, obviously we can involve our cornea specialty services to talk about whether a desecrademec would be indicated and timing on that. In terms of the other eye, whether you do a combined procedure, I think that would be of course based on whether there was evidence of significant endothelial dysfunction driving this persistent corneal edema in which case maybe a combined case would make sense. Other alternative or experimental treatments, I didn't find much in the literature. There was one paper on trans-corneal oxygenation which did show some improvement in terms of central corneal thickness as a marker for the effect from that versus no treatments. But other than that, there's really not much change out there. It wasn't great, but not much out there in terms of differences there. So unfortunately did not find anything or shattering or knew that we could add to this case. And again, it is recovering gradually. So the expectations will continue to see improvements that will likely take a number of months. Does anybody have any questions or comments on this particular case? Randy and then Nick. I don't see one eye. I'm not sure what happened to the two of them. How did the other? That's a burying in that. Burying in that, it's pretty good. So have you considered blocking? Blocking? No, I mean that, yeah, that's the other thing that I came across. I would change the level of the sound off. If you place something like this, this person is allowed to spread it well down and stop in that, try to get that out. It's not that series of words that you're getting and going on. But you're putting that together and going forward. You don't point it out that thousands of years are an issue, it's not outside of the purpose of this. And it's just whatever you need, they need to have it on. And that's just, that's the value of it. Certain things are, and we'll see that that's totally up to you to get it on. So the second of my thoughts to the other eye, I'm going to use, you're not necessarily self-counseled but a lot of people have helped you know that, but I'm sure that probably you're just thinking. Yeah, I agree. The imaging's definitely planned to look at the other eye as you've noted, trying to help us figure out what's going on. Yeah, it's not the rock inhibitors with, when people do the decimates strip and just leave it to sort of heal secondarily, they use a rock inhibitor to help stimulate that. Nick, what he said? The only thing I would add is that only Dr. Olson can actually see guttodilus spooks, mere mortals can't see that at the sweat lamp. And we don't see that, but this would be a good one to get the pathology on. So if it does go to do on DMACC, make sure we get the pathology because we can actually see the diffuse thickening of decimates membrane in those little tiny, I don't know what we call them, gutettes that can show up micro-gutata. And so we'll be able to tell that on there. It'd be interesting to see what this specular microscopy in the other eye looks like. The other thing that we found in the past is when I've done specular microscopy every once in a while, I've looked at those corneas, they're crystal clear, everything looks normal, and they'll have a cell count of 600. And you just every once in a while, you'll get surprised and the cells that are there are just functioning, barely, barely functioning, keeping that cornea clean. It doesn't take much to put them over the edge. So I think a specular microscopy in the other eye would be helpful to guide you. Thank you, Nick. Just an addition on regards to that, I had one of those as well.  So you can get traumatic loss without any obvious sign with very low cell count and those can be fragile too. So good point, Nick. Mark. Hey, Bill, I'm sorry. I forgot what you were starting on 745, but do you have a specular for this eye? I don't. No, I'm arranging that. She's a patient from South Jordan. I don't have that out there. So it's arranging to get her up here to look at that. And how far out is this? She's about two months out. Yeah. I mean, I definitely would stall on EK because a lot of these eyes get better. And I think keeping them on low dose steroid is often a good, you know, like pred twice a day does seem to speed recovery. But I think that's the missing link.  And just so you guys know, the automated Conan, especially, don't even look at the number. Look at the picture. Unless you count the cells individually, the automated number is almost always wrong because it's just not, it's counting, especially if there are a goote, it's counting those incorrectly. But yeah, I mean, you definitely see this uncomplicated, easy FACO and then edema. You know, we see it in glaucoma patients, obviously. We see SLT patients. We see that there's definitely, you know, maybe an inflammatory component as well that's happening. And it's an uncertain kind of endothelial, I think maybe auto-immune thing that can happen as well, which may not be pre-existing. The last time I had a case, like it was a number of years ago and we shared this patient that had an eye stent with a FACO there. I mean, her lens was denser than this one, another mid-90s female. Yeah, definitely no question that angle surgery causes this corneal decompensation when there's no stripping of decimates directly. There's no reason for it. There's no hypotony, flat chamber, whatever. I mean, I don't know if Norm's here, but over the decades, we've shared multiple, multiple, multiple patients where it seems to be an auto-immune kind of process. And so, but yeah, the specular would be really helpful. Thanks, Mark. Anybody else have any questions or comments? Appreciate all those who have shared. If not, we can... And Dr. Chia is on now. Dr. Chia is on. Terrific. We'll turn it over to Craig. Hello, everyone. Can you hear me? You can screen share, Craig. Sounds good. You can hear me okay, though. Are you guys able to hear from where you're at? Jeff, I don't know if you can confirm if you can hear my audio. Yeah, audio, good, and video, good. Okay, sounds good. Well, I apologize to everyone for not being there in person after I managed to go three years evading COVID and it finally snuck up and got me this weekend. So I'm out this whole week and it's definitely not something to toy with. It's been rough for the last three days. I'm finally feeling a little bit better today, but I appreciate your attention. Bill asked me to present a few cases, some interesting cases. And so I'm going to present two cases, one on a fake Ocapsulotomy technique and then the 6-0 polypropylene flange technique. These are my financial disclosures non-relevant to this topic. And I just wanted to highlight to everyone, next month is Alan's birthday, his anniversary or his birthday. And just I want to acknowledge Alan for the work that he's done for our center. His legacy continues to thrive, both within our glaucoma division and as well as our cataract division, reminding us that we need to continue to always look for new and better ways to do things and to be able to challenge norms and to be able to get uncomfortable sometimes. And that's how we progress in the field. That's how we maintain our edge. And so I just wanted to acknowledge Alan for the incredible impact that he's had on my career and just the legacy that he's left behind our institution. For our early trainees that are coming through the program now that never had a chance to interact with Alan, I would recommend that you go down to external relations and pick up the issue that was dedicated to Alan, I think a few years ago. And it's worth the read. I actually have a copy in my office if you'd like to come by and read it. But it's just a reminder to me of the type of person that he was giving in so many respects and also pushing us to be our very best. So there are many strategies that we use to mitigate the Argentinian flag sign. And so maintaining high anterior chamber pressure is certainly paramount to any of these techniques. We also have the needle decompression.  As soon as I puncture into the capsule, I'm immediately pulling back on the plunger to aspirate the liquefied cortex. There's also the cortical milking technique by Sunpap Chi in Singapore, which is essentially very similar in the idea that you're milking peripheral milky cortex out to the periphery initially using a highly cohesive viscoelastic to indent the anterior capsule to overcome the intra-capsular pressure. There's also electrocautery with the Zepto unit where you can immediately perform a capsulotomy in just a matter of nanoseconds. Flags has also been considered as an alternative to overcoming the Argentinian flag sign. Micro forceps, Dr. Olsen et al. had published a series of cases using microutra as micro forceps in order to maintain that high anterior chamber pressure to be able to perform a capsulotomy through small paracentesis incisions rather than through a main incision. And then finally, the fecalcapsulotomy technique. Much has been written about this technique from Chris Tang. I encourage you to read his papers in terms of how that technique works. So I'm going to present this case. It's edited down to about 15 minutes or so. I'm happy to speed it up and pause it as we go along. I also want to acknowledge that we have absolutely outstanding chief residents this year. It's just been a joy to work with all of you. And I'm sorry, I probably won't be able to attend the graduation because I'll be in quarantine still until Saturday.  He's also the primary surgeon on this case. This is a roughly 58-year-old Caucasian female who presented to me with a white cataract. Ultra sound of the posterior segment was normal. And so I'm just going to let the case go here and kind of narrate as we go along. It was difficult for her to fixate and to maintain good achinesis. So we went ahead and did a subtenons injection there. Then I'll be using, I just used an optical zone marker to roughly delineate what the capsule rexis will look like. Heros and teases as incisions are made on either side in order to provide adequate access to the anterior chamber at all times. I'd like to use a small bubble technique for the tri-pan blue. I'll then inject the vision blue inside. And whoops, let's see what happened to the video here. Give me a second here. So there you can see the vision blue being displaced by the viscoelastic. And now a keratoma is made, a keratoma incision. Now for the keratoma incision, as you'll notice in this case, we struggle with the size of the incision. Initially, based on Chris Tang's paper, it was important to maintain high flow throughout the fecalcapsulotomy technique. But maybe I'll pause here for a moment and just leave it up to the audience to chime in about what their standard approach would be and why to overcome this milky cataract. Hey Craig, it's Nick Mamillis. I learned from Dr. Olson and Dr. Crandall to use the micro incision forceps through stab incision prior to making the primary incision and using a highly retentive OVD in the anterior chamber to keep that anterior capsule flat and to keep that liquefied cortex pushed down and knock wood. Using that technique, I've not seen an Argentinian flag sign now. When you've got, you don't make the wound because the viscoelastic can burp out the main wound. So you really gotta go through the side port incision with the microutrata forceps. And if you can keep that, disco visc or a highly retentive OVD like that in the anterior chamber and keep that from flattening out, you can keep that from extending. You start small and then spiral it out and as I said, using that particular technique I haven't had an Argentinian flag since then. So hey, this is Randy. Yeah, I mean, the big issue here is obviously when you get this intubus and cataract is that you've got increased intercapsular pressure.  I'm not only sure if it's been reported but it's lowering the pressure in the anterior chamber. And even though you can put a lot of viscoelastic in the anterior chamber to maintain that pressure with the main incision. And I've seen people with that that as soon as it burps out some viscoelastic, boom, there's the Argentinian immediately. And that shows that there's a very, very high pressure inside that capsule. So just having a single small side port and then with a highly retentive, I mean, Helan-5 was one that would work well, you just aren't gonna get, you've got enough, you're filling with the capsorectus forceps that I've just never seen it able to burp out through that small incision. And I'm with Nick, I mean, it's been a while since I've operated but I certainly did a whole slew of these since I had that series that I reported in JCRS and never had it. So I think it's an avoidable complication and that's certainly the way that I found was most effective. Craig, just one more comment.  And this is one that's really interesting if I think about, you know, if I was, if indeed, you know, we can arrive at a place where this is consistent, there's a known and very low rate of complications. This is what I would call kind of a mere mortal being able to go in and just open up a capsule straight away for capsule rexess. Clearly you have to get the fluidics right. The two times I did this, it worked out well. It still makes me a little uncomfortable only because it's unfamiliar but I think it's technically certainly easier than the kind of tried and true, you know, methods that Randy and Nick have outlined whether or not it's safer and better long-term, that's the question. Sounds good, I'll let the video play. I did want to add that I did apply a highly retentive viscoelastic and now I'm just going to pause for more just to highlight the settings and also just to point out a few things. Normally I operate through a 2.4-ish incision and I use a pink sleeve on our centurion fecal platform but here I've decided that I'm going to go through a slightly larger incision and I'm going to use the same needle, not a larger needle, but the same needle but I'm using the purple sleeve which should allow for better flow, inflow into the eye. I've also cranked up my infusion pressure. Normally I operate with an infusion pressure or IOP of around 40, in this case where we've ramped it up to about 80 to 90. So I've got more flow coming into the eye. I've got more flow coming around the needle and according to Chris Tang in his description we're using a low vacuum setting. So this is your typical sculpt mode. I'm using somewhere between 80 to 100 millimeters mercury. My standard power settings on my fecal aspiration roughly 20 to 25 or so. So this is a sculpt setting that I'm using to initiate here or that Sean is using to initiate. So now the technique is such is that you just have to plunge immediately and immediately start aspirating. You're combining the idea that you're constantly infusing water into the eye and then you're also aspirating immediately the liquid cortex. So here we're burying in and boom, you can see that opening and there's a little tag there and surprising that tag is still maintained. Sean is gently aspirating the liquefied cortex and then he'll actually use the fecal tip and actually finish off the last tag there. And there you can see just before he withdraws there's still more liquid cortex. So we're putting highly retentiviscal elastic to maintain the chamber before we come out. And then now you can see this case almost proceeds relatively normal here. And in some cases where you feel like there's still a significant amount of pressure inside the eye you may actually start to see the capsule rex as one or run out. But I would say for the most part as Sean is propagating this capsulotomy it's behaving normal. There's not a lot of run out. There is still some minor liquefied cortex as you can see emanating from the opening but we're not seeing any runouts here and it's very controlled. In hindsight, what some things that I would have done differently I certainly would have used a tighter incision. I think I had the wrong keratone that was maybe a three millimeter rather than a 2.75 so it didn't match up nicely throughout the case. I'm gonna go ahead and let this case run and just point out a few other things throughout the case that I think Sean did extremely well. But here you can see we've got a great capsulotomy opening and we'll go back in and we'll start to do our fecal. As you can see this is not just your white cataract it's also burnescent as well. We're using a standard sculpt setting here and then we'll actually do kind of a double sculpt we'll sculpt distally and then we'll rotate again to be able to get that some incision a little bit better to be able to get down to the plate. So now I've done a few cases or one more case since this fecal capsulotomy case that I'm showing you here and now I've just decided to maintain my normal pink sleeve 2.4 millimeter incision. I will ramp up the settings and then allow the needle to immediately penetrate and then aspirate the liquefied cortex. Here we're using this is a throwback to Allen. This is a pre chopper. We just felt like we were able to get better leverage down at the plate because our fecal and second instrument weren't able to give us the leverage we needed to be able to crack the plate. So we're using both ends of the pre chopper here the rounded side we can get all the way down to the plate and touch the plate without risk of perforation through the plate and through the bag. And then now we'll proceed with just our simple chop technique here. We're dividing the pieces up and then Sean's doing a very nice job here of chopping those pieces and maintaining safety. I'll speed up this case. The case went very routine from this point on. One of the things that I had to do throughout the case though is that we had to place some sutures because I mentioned to you that I used a keratone that was not normally in my set. I thought it was a 275, but turned out it was by closer to a three. And so I had to place some sutures throughout the case to reduce the risk for surge. And so we'll go ahead and just advance here and get down to the last nitty gritty here. So we're down to the last chip. I've placed two or three sutures actually to close the wound up to keep it a little bit tighter. We don't have any sleeves larger than the purple sleeve for our standard fecos. So you do have to just place an interrupted sutures to close up the gap and limit the amount of egressive fluid. So polishing, not much to polish in this very dense lens. This galastic lens is placed in the bag. And then at the end of the case I've actually replaced some of the sutures and we'll just place two interruptants to close this incision. Because of the density of the nature of the lens that I went ahead and injected some dilute trimesinolone which we use for vitreous stain. And usually if I'm planning on injecting it into the anterior chamber for inflammation control I'll ask our pharmacist to mix it a little bit more concentrated than our standard dilution for vitreous stain. So that is the fecal capsuleotomy technique. I was very surprised at how controlled it was and that by maintaining a high pressure infusion pressure we're maintaining that anterior chamber space and overcoming intercapsular pressure in order to mitigate against the Argentinian flexion. Questions before we move on to the next case? Comments or comments? This is Dr. Olsen. I think it's the same concept, really. I mean, as long as you're maintaining good pressure inside the anterior chamber and the main incision is being supported by the sleeve and the rest so that you're, and then you've got the inflow. And yeah, I mean, it's great. It's neat and people don't have to learn how to use a microcapsulotomy forceps. So I think it would probably be very effective. It makes sense. Yeah, I think one of the issues as I've traveled around the world, micro forceps are still a luxury item for many parts of the world. Certainly they're used to using, I know San Duke Rui, when I watched him do cataract surgery in Nepal, he was using an assistotome on an infusion line. So he essentially was doing the same thing through a micro incision coming. Actually, he didn't even make a paracentesis. He just punctured it in through the peripheral clear cornea, running it through an infusion on an IV pool in order to maintain the chamber space. So I think you can get creative here. If you didn't have access to microutratas and micro forceps, I think this is a reasonable technique to be able to overcome the complexities of chamber shallowing. Hi, Craig, this is Marissa. Two questions. Could you just do this with your normal wound size, your keratome and the normal sleeve? Like I guess, why do you have to change both of those? And then could you describe what you're doing with the foot pedal as you enter? Are you going into FACO just to break through the capsule and then backing off so you're only aspirating after that? Yeah, so great question. So to answer your question, after this case, Sean Collin was still on my service and we did another case where I just used my normal pink sleeve, 2.4 incision sleeve. And but I still ramped up the infusion pressure closer to 80 to 90 to really push in more fluid. I made sure that the incision was tight. We went in, you know, I think we really tried to keep the incision as true as possible to the particular size of the sleeve to reduce the amount of egress coming around the sleeve. In terms of the foot pedal position, so you're going immediately into FACO 3 as soon as you touch the capsule and you're maintaining at least into position two to be able to aspirate the liquefied cortex. In this case, there was a small little tag that we actually, I don't remember exactly. Maybe Sean, if you remember, I feel like we just aspirated the tag and then just ripped it off rather than actually FACOing the tag off. So I don't think I used any additional ultrasound power to remove the tag, but you definitely would need to maintain position two in order to continue to aspirate the liquefied cortex. There was also a point in the video where Sean is kind of bouncing the lens in order to try to milk out that liquefied cortex that's behind the lens in order to bring it forward. Hey Craig, it's Brian Zog on Zoom. So two questions that I have. Do you run risk of wound burn with this technique or is it short enough that you're not worried about that? And then the second question is, but when you create that FACO opening, what do you do if you create like a perfectly round opening with nowhere to continue or initiate, I guess, a tear to complete the rexis? Yeah, great question. So wound burn at the very beginning, although we did use a highly retentive of viscoelastic to maintain that space, we did aspirate a little bit above the cortex. I think the risk that we run with a wound burn is if you're FACOing under viscoelastic for a significant amount of time. So we did aspirate a little bit above the capsule in order to be working in a dome of BSS rather than just viscoelastic alone. And then your other question was about, what do we do if we actually need to, if we create a perfectly round rexis? So I'm gonna go back to it here and just show you here that that's exactly what we have. We had a perfectly round capsulotomy opening. So we're just aspirating there and then we're ready to plunge. And then immediately we're in position two at least to maintain liquefied or to aspirate the liquefied cortex. And there's a tag here still and we'll remove the tag. And then what we're left with is a perfectly round capsulotomy. So there really was no tear for me to then initiate, but as you can see with the utrata forcips here, and I think part of it is also with the tri-pan blue staining in order to make the capsule just slightly more brittle, we're able to actually just grab the edge and then start the tear. And that was able to be propagated around and successfully completed. Other questions? So I don't think it really matters. We were using a fully torsional setting rather than longitudinal. I don't use continuous FACO on my Sculpt setting. I use a high pulse rate of like 40 pulses per second and 100% all torsional power, no longitudinal power at all. Some people feel that I think it would be, I guess theoretical that maybe a longitudinal might be better because you're just going forward and backward and just really cookie-cuttering that capsulotomy rather than going to and fro with the torsional movement. But in this case, we didn't have any issues with any radial tear-outs. Okay, we'll move on to the next topic. We live in the land of pseudoxfoliation and it's just amazing the amount of pathology that comes in our region because of that, both from a glaucoma service as well as late dislocation of IOLs. Nick, I don't know if you're, I forget the statistic in your paper that you and Liliana did a series of patients who had IOL dislocations and postmortem it, I think it was maybe something like 30 or 40% had on or were never categorized as pseudoxfoliation, but postmortem you were able to see that on staining. Is that true? I don't remember the actual percentage. Maybe the mic's not on for you. Yeah, we got the mic now. We found a very high percentage in the spontaneous dislocation of IOLs in our first study. We found that 50% actually had exfoliation but was interesting. Got a further large group of specimens from Northern Germany, from Thomas Conan, who's an outstanding clinician. And of those that we saw, we found that two thirds of all of the spontaneous dislocated IOLs within the bag were found to have associated pseudoxfoliation. And what was interesting about that is they only recognized about half of them ahead of time. And this is a department chairman, outstanding clinician. And so sometimes the findings of exfoliation syndrome can be quite subtle. So we were very surprised when we found out that actually half of the ones had unrecognized exfoliation syndrome. And so here in Utah of the ones that we see here, it is somewhere between 50 and probably 66% of all cases of spontaneous dislocation of an IOL within the bag or associated with exfoliation. Yeah, wow, that's incredible. But it's definitely matches with our clinical experience patients who come in with a spontaneous dislocation of their IOL and with no prior history, no IOP spikes and no obvious signs of phenotypic signs of pseudoxfoliation. So in any case, one of the challenges that we have with fixating these IOLs is what techniques do we have available? Historically, we've used non-absorbable sutures, typically EPTFE or also known as Gore-Tex or polypropylene. Yes, in full disclosure, Gore-Tex on its packaging says not for ophthalmic use and I think they're just trying to cover themselves. But many people have found that this is really one of the gold standard sutures that we use for non-absorbable sutures for skeletal fixation, whether it be for IOLs, CTRs or capsule retention segments. Finally, we have the double-flange Yamani technique, which many of us have adopted in order to fixate patients who fixate lenses that don't have capsule bags. So I just wanted to highlight that, this polypropylene technique has been something that's evolved over the last several years, primarily since Shin described his double-flange technique kind of Brava, McKabe, Mahler, et al. Many have actually described using polypropylene suture and flanging it for skeletal fixation. Recently in JCRS, last a couple of years ago, there was a nice series by Ehuda Asia on the 6-0 polypropylene flange technique. There's a part one and a part two series. I encourage you guys to read it. It's his case series, talking about the outcomes of his particular population, but also goes into some of the fundamentals of how to use 6-0 polypropylene suture. So now I'm gonna just switch to a different screen here. Just this video is gonna be better suited. So now I'm gonna let this play. This is a patient probably, I wanna say around mid-70s to late-70s with a spontaneously dislocated IOL. I'm using an optical marker here, or sorry, a Mendez ring in order to mark the visual access. This is prior to dilation or maybe the patient received one set of drops but wasn't dilating very well. Another clue that this is likely related to suit explanation. I can't see the video, Dr. Chaya. Oh, okay, let me see. It's still on the original one. Okay, let me just get out of this. Let me share it again. Is that better? Yeah, we can see it. Okay, so this is a Mendez ring that I'm using to mark the visual access and I'm gonna mark my zero and 180 but I still don't know exactly how this lens was oriented in terms of where the haptic-optic junction is. This patient actually just a little bit more feedback about this is actually a patient who has a prior bleb. I mistakenly forgot to add that as part of the history. You can see he has a shallow bleb here superiorly. So a patient with known suit explanation who had a bleb, existing bleb with a spontaneous dislocation of his eye well. So this galactic is injected. I'm gonna make my main incision and then in a little bit we'll place some iris hooks just to understand. I knew that the lens was not a toric lens. So I wasn't as concerned about having to maintain the orientation to maintain the astigmatism correction. So my plan was to fixate the lens at the horizontal meridian in order to avoid trauma to the blood. And so what we're gonna do here is after we create our incisions I'm gonna just advance this a little bit. We're gonna place our iris hooks in order to be able to locate the haptic-optic junction. So I don't think there's anything wrong with using ML. You can ring in this instance if I do like iris hooks just to be able to sequentially move them where I need them. And sometimes I don't need all four. Sometimes I just need to have enough exposure to be able to see where the haptics are. So maybe I'll just pause here for a moment and then just open it up to the group again about what would their preferred technique be for suturing a capsular bag IOL complex here. Or if you would even maintain this lens. Certainly there's a good argument to say why not just remove the entire bag and start all over with the Yamani technique or another scleral fixation technique of choice. Hey, Craig, it's Randy again. I mean, it's been a while since I was actively surgically engaged but I used to lead these and would suture my making sure that I last through the haptics in the bag and suture the bag haptic complex and bring it back in under a little Poffman pocket so that the sutures were hidden down and I follow those patients for, I've now got some 10, 15 years, they were very stable. I used to use Nino polypropylene but we know even that sometimes will degrade. So I think the Teflon would also work but I don't see many people doing that anymore but I thought it was quite effective and it minimized the amount of surgery needed because you just had to place the sutures and I know people complain how hard it is sometimes to get those sutures through the capsule and some secondary cataracts. So I would always put a sharp needle from the outside and they use my suture needle against that sharp opening so that you could between the two control exactly where the capsule was and pass then the needle through the capsule underneath the haptic and then into the opening of the needle and bring it out inside of a Hoffman pocket and you just had to do the other one as well and that last suited and brought it in in good position. So an old technique, I know I don't hear many people talking about it anymore but certainly the patients that I'm so following that I've seen, they look good and stable, so.  Then as you suture your complex, those sutures are passing through the pocket and you'll use a snare either a kuklin hook or micro forceps in order to be able to externalize the sutures on top of the cornea where you'll tie your knots and then advance them down into the pocket. So the advantage of a Hoffman pocket is it allows you to not have to create a pyrimony and to be able to bury the knots of the sutures easily. Others, I'll go ahead and let the video play here. Again, we're identifying, so my video is frozen, give me just a second. And so here you can see that the haptic bulb is here and so I have a good sense now of where this haptic optic junction is but because I mentioned that this patient had a superior bled, I'm prepared to have to rotate the entire bag complex. We're performing a limited anterior tractomy here just to make sure there's no vitreous in the anterior chamber, a little bit of vitreous stain just to look as well. And then just to ensure that there's nothing in trapping the complex. Now I'm gonna grab the edge of the capsule in order to bring it back towards the center. I'll use a push pull here as well. And here I can see the other location of the haptic optic junction. And I brought that up above the iris plane in order to just secure it a little bit. And then I'll reposition the iris hooks, actually trying to get this in the capsule itself to hold it in place, but it's not very successful. The capsule is quite fibrotic and I just don't have enough space there in that location. Putting viscoelastic behind the lens in order to give me a little bit of safety in case the whole lens complex wants to drift Replace the iris hooks and now I'm gonna be marking the sclerotomies in the horizontal meridian. My first anterior most sclerotomy is roughly two millimeters from the end of the blue-gray zone. And then the second sclerotomy marking is three and a half millimeters back from the blue-gray zone.  We don't need a needle for the needle on the suture for this. We're just simply gonna place it in the eye and dock it into these needles. I'm bending the thin-walled 30-gauge needle. This is the same one that we use for the Yamani technique. Then the suture is placed in the eye. I'm an opposite paracentesis. This patient's having a little bit of difficulty, so we'll do just, I think, a cut down here in order to give him a subtenon's injection. So I like to make the first pass posteriorly, so I'm cradling the lens from posteriorly. Just in case the lens wants to drop back, I have an option to levitate.  Then I'm gonna locate where the haptic optic junction is and with counter traction, you use a micro forcepsin in order to puncture through the haptic optic junction. The 6.0 proline suture is then docked into the needle and then externalized. I think what's important here though is as you externalize the needle, you do still have to maintain some counter on the lens. Otherwise you could just continue to tear off more zonules. So a little bit of gentle counter traction there. And then that suture is externalized and then flanged. Now personally, I prefer a larger flange just to make sure that those flanges are visible but flush with the sclera and definitely buried underneath the conging type of antenons as well, ideally. And the other end of the suture is then folded on itself and brought back into the same paracentesis. And then we'll go through the anterior most sclerotomy here with the same needle. Perpendicular to the sclera as soon as you puncture through then you can level off and then docking that suture into the needle. So this needle has not passed through. It's simply just in the sulcus space above the eye wall complex and then we'll remove the other end of the loop. So that's one end of the complex and we'll repeat the same thing on the opposite side. Again, folding over, docking the anterior most. One of the advantages I like about this technique is rather than simply lassoing around the haptic where there could be a risk of having the suture slide off the haptic as it cheese wires through the back complex. This is very secure. You're going through the actual lens material itself through the haptic optic junction. And then here you can adjust the tension on both ends of the suture in order to get the eye wall back complex as close to the center as possible. And I will flange the anterior most at the very end and adjust. And what I'm looking for is kind of a snap Mac sign that as I put tension on the suture and here I'm constantly just adjusting and trimming. And I do this multiple times to in order to get the right tension that I need. Here we'll make sure that that's buried underneath and then we'll do the same thing to the opposite side. I haven't figured, this is really just more art than anything and just a feel for how much suture you need to trim off. There is a theoretical risk that you could pull the polypropylene too hard and actually cheese wire through the haptic optic junction. But I think it's a lot tougher to do with 6-0 protein. I actually feel like it's more likely to happen with a thinner caliber suture where you can actually cheese wire through the lens material. But 6-0 protein is quite sturdy. And there we've done our double flanges for both sides. And then we're now removing our iris hooks. A little bit of anti-retractomy at the end just to make sure there's nothing that has prolapsed. We'll suture the incision and then the case is completed here. So in summary, the 6-0 protein technique, polypropylene flange technique has been used in a variety of techniques not only to fixate an Iowa bag complex. It's been used for capsular tension rings or capsular tension segments. It's also been used in iris reconstruction for urinalysis repair cycle analysis class. And also I've been using the same similar technique, the 6-0 polypropylene flange technique for iris prostheses as well. So a very versatile technique. Are there some issues or some cases where maybe I wouldn't want to use this technique? I think patients, if they're very astute, they may notice the small blue rivets above the sclera. And for some patients that could be cosmetically unacceptable for patients. And so maybe EPTFE or Gortix suture would be more appropriate for those patients where hiding the suture color would be most important. Now, I have found that these are very small flanges. I don't want to give you the impression that these are like massive blue dots on the sclera that are noticeable across the room. You really have to get close. And I think even with a slip, I have to be able to see them in detail. But these are things that need to be followed over time. Liliana had a nice editorial a while back talking about some of the complications that can occur with this flange technique. And one of them is conjunctival erosion and nebulomitis. So I do think it's important to be meticulous and how you flange these. I do think that a little bit tighter to get that snap back sign where you see the flange pulling back into the sclera is essential to keep these flanges from eroding through the overlying conjunctiva. But overall, since I've used this technique in the last six years for a variety of techniques, both for Marr fans work and Irish reconstruction, I have not seen any conjunctival erosions at all. But I do think that you need to be prepared to address those as they come and make sure patients are aware that if they notice any injection, form body sensation, irritation that they be evaluated promptly in order to make sure that that complication is not occurring. Thank you for your time. I'm happy to entertain any questions or discuss this technique further or other techniques.


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Fumizum Dabi labels her man as her strength. Celebrity couple Nkobi Shota and Fumizum Dabi have been together for more than a decade, but are closer than ever. The couple who are usually guarded when it comes to their private life, occasionally give fans a glimpse into their romance. And, when they do we're all here taking notes. Fumizu shared a picture of her and Shota from 2008, and proudly declared that he is her rock. 2008, still today, you are my strength when I don't have any.


We have the Brady Campaign to Prevent Gun Violence on Think Tech here. I'm Jay Fidel. This is Community Matters, and we're talking with Erin Davis, who is a daughter of Hawaii, if you will, who is practicing in the gun violence, you know, gun violence practice in Washington. Welcome to the show, Erin. Thank you so much, Jay, for having me. It's my pleasure to be on, and it's always a treat to talk to people about what I consider my real home, which is Hawaii. Of course. And we will always consider you a daughter of Hawaii. So, you're doing really important, interesting work with the Brady Campaign. Can you tell us, Zoe, we'll understand what is the Brady Campaign? How did it get started? What does it do? And what do you do for it? Absolutely. And before I start, I just want to thank you for having me on and allowing and lifting up this issue on your show and lifting up Brady's work. It's really important to us for people to be informed about the issue and support our work, and Jay, thank you for that. So I work for an organization called the Brady Center to Prevent Gun Violence, and this is a gun violence prevention organization that has been in existence really since the 70s. We started off originally as hand-violence handgun control with the name of the organization, and then after Jim Brady was shot, Jim Brady was Ronald Reagan's press secretary, and after he was fatally shot in the attempt to assassinate President Reagan, he suffered injuries that left him permanently paralyzed, and him and his wife Sarah Brady became huge advocates in gun violence prevention to try and change the law. And what they did was they worked with the organization that later became named for them, which is Brady, and they passed the Brady Bail, which is one of the most important pieces of legislation that has ever come to be in the gun violence prevention movement because it required federal background checks to occur when you sell a gun. You could no longer just walk into the store and buy a gun. You had to go through a background check, so it was the first substantial federal law related to gun safety, and it was a huge, huge accomplishment by them. And to honor them and to honor their legacy and to honor the work, our organization was renamed for Jim and Sarah Brady. Now what I do at Brady, I mean Brady is a large organization. We work across Congress, courts, and we work across the communities to really raise awareness about gun violence and ultimately save lives is our goal. And what I do is I am the senior counsel for trial and appellate litigation, and I work on a legal team that has been established for about 30 years. And what we do particularly is we bring impact driven litigation against different actors in the gun industry. So what that means is that, you know, every major social issue has been reformed through impact litigation. So what Brady does is we bring important cases, we create important precedents, and we pave the way for private lawyers to bring lawsuits on behalf of victims of gun violence. So the goal is to do this impact litigation to really change the industry, to change the practice of how gun industry actors and hopefully make our community safer. You know, a lot of people think that the federal government is broken, Erin. They think that Congress is broken. Even the gun bill that was passed two weeks ago is, it's not strong enough. A lot of people think that. And, you know, they worry about the courts. They worry about some of the judges who've been appointed in recent years during the Trump administration in the federal system and in the state system. For that matter, they worry about those judges too. And they worry a lot about the Supreme Court given its recent decision, including in gun control.  What's your level of confidence in that? I am traditionally an optimist and I am encouraged and I hope that, you know, even within the political landscape, that good can be done both legislatively on the federal level. I think the Bipartisan Communities Act was a wonderful starting point. It accomplished a lot. And even though there was a lot that wasn't included, it will definitely save lives. We definitely have more work to do. And certainly the court system presents its own challenges, but there are a lot of good judges and there are some good laws out there. And our hope is that bringing these cases will continue to reform behavior. You know, if you had, if we all had a working Congress, a Congress that would be sensitive to, you know, the tremendous gun control problem we have in this country. A lot of the issues that you deal with in the courts would be resolved by statute. Isn't it true? I mean, I know that you wouldn't mind having, you know, those issues resolved in Congress. But what would you like to see in Congress, assuming Congress, you know, was more sensitive to the issue? Absolutely. So, you know, there are a handful of different bills and initiatives that are sitting in Congress waiting to be voted on or waiting to pass. A really important one is universal background checks. I think universal background checks is a crucial bill, as does over 90% of the country want universal background checks. Right now, many states have requirements in which you are required to pass a background check if you're a private seller. But it's not at a federal level. And given that, you know, with the exception of Hawaii, most of the United States is continuous and somebody can buy a gun somewhere else and bring it in, it's important that some of these laws become federal law. So, what about the Brady Bill? You mentioned a few minutes ago that the Brady Bill called for background checks. What's the difference between a background check in the Brady Bill and a better background check, a better statute on that that you would seek now? Absolutely. So, the bill that's currently in Congress is basically to close the loophole for private sales. So, federally, if I wanted to sell you, Jay, a gun, I could sell you the gun without you having to undergo a background check.  So, really, the hope of the background check bill is to close that loophole for private sales and that same law applies for gun shows. You can walk into a gun show and buy a gun in many states without undergoing a background check. You can also buy a gun online. There are certain websites, one of them is called Armsless, which is essentially Craigslist for guns where you can post a gun and buy a gun and there's no accountability and no background checks that are done. So, the universal background check would require everybody to have a background check if they're seeking to buy a gun. So, why would I go to a gun store anymore? It sounds like gun stores have been cut out of the equation. It's so much easier to go on the web and buy it off a website without the background check. It's almost like, why do I care about gun stores? Yeah, I mean, it's an interesting point you raise. I mean, I think that there is a, most people, most gun owners are lawful gun owners and they want a gun for the sport or because they feel entitled to it and they know and they take safety classes and they know how to handle a gun in a safe way. So, those type of individuals would absolutely go to a gun store to purchase the gun because they have the most selection and biggest types of guns and well-priced guns. But if you're in the criminal marketplace and you can't get a gun through legal means, people often seek getting a gun through private sales. They seek going on the internet to buy a gun, like a Lego kit that you can put together yourself called a Ghost Gun. They can buy a gun through, like I said, Arms List or one of these organization and one of these other types of websites or they can buy a gun through a licensed dealer through illegal means like a straw purchase, which is illegal. So there are plenty of ways for criminals to try and get guns and our hope is that some of this legislation can stop that and cut off the different black market ways in which a criminal could get gun. And certainly my goal in this interview is not to tell criminals how to get a gun but there are certainly many loopholes that exist. And I think states, especially states like Hawaii are looking to try and close some of those loopholes for citizens, which I think is wonderful. You know, I remember a TV movie about a news segment about a gun show in the South. And in Hawaii, we don't have gun shows that I know about but this was a gun show apparently that happens on a regular basis in many places in the South. And it was huge, huge. It was the biggest haul you could imagine. And there were truly thousands of people buying and selling guns. It was the biggest swap meet you ever saw. And I didn't realize until I saw that movie just exactly what kind of a problem there is in terms of trading, selling, buying guns in this country or without background, yeah. Absolutely. So like I said before, background checks are a really important bill that Congress could pass. Another bill, if you wanted me to bring up another one that Congress could pass is the Assault Weapons Band. And this was asked as recently in July of this year in the house with bipartisan support. So, you know, it's waiting to be brought up in the Senate but an Assault Weapons Bill really could stop a lot of the mass shootings that we're seeing in this moment of time. You mentioned the Lego guns and I wonder if you could help us understand what that is and how dangerous it is and what if anything could be done in Congress or by law enforcement to limit the number of Lego guns out there? Absolutely.  So every single gun that's sold through lawful means and really every gun starts in a lawful way. It's manufactured, it's sent through a distributor, it's gone to a gun store and then at some point, if it enters into a trafficking or a legal way, it enters into that. But it all starts for the most part through legal ways and all of those guns are serialized which means that if that gun is used in crime or recovered in crime, what the Bureau of Alcohol, Tobacco and Firearms can do is they can take that serial number and they can figure out how the gun got there. So it's called a trace. They can trace that gun back to the dealer who sold it, the distributor, to the manufacturer. So you can really keep track of how these guns ended up where they are and organizations and regulatory agencies like ATF can look at that data and use that as an enforcement. The difference with ghost guns is that they're not serialized. So individual companies on the black market are creating guns that don't fit within the definition of a firearm, that fits within the definition of a firearm it has to have a serial number. They're building these guns that have different parts of the firearm but they're not necessarily assembled together. So what that means is that you could go online and order one of these guns haven't delivered in most states. Hawaii actually has passed a wonderful law against ghost guns. But prior to that, what you could do is you could go online you could order one of these guns. It would arrive in your house in a box that looks like an Amazon box, although they're not from Amazon.  They're not traceable. So if they're used in crime, they can't hold anyone accountable for how they got there. So it's real and what's interesting is ghost guns if you look at the statistics, they're not showing up where you can easily get a gun in the black market. They're showing up in markets like Hawaii or California and their crime scenes because it's an easy way to get a ghost gun in states that have pretty serious regulations that who can have a gun and the type of gun you can have. And they'd be seen by TSA if you walk through an airport security station. Yes, I think most of them can.  Obviously they have guns that you can, you know print on a 3D printer that are made of plastic that might not register in that way but the ghost guns in general that I'm referring to are typically made out of modern parts which include being able to be picked up through a metal. Any other statutes you would support in Congress to limit gun violence? Yeah, so I mentioned expanding background checks in the assault weapons ban. The third one that I would mention which is also still pending is an enhanced background check. And this one closes what's called the Charleston loophole. And what the Charleston loophole is is the Charleston loophole is a loophole that exists that basically says if you go to buy a gun and your background check is not completed within three business days, that dealer can choose to sell you the gun even though the background check is not finished. And what that means is that, you know most good dealers, most safety conscious dealer will wait until the next background checks come back. And once they come back, it'll give you either what's called a proceed or a deny. And what a proceed or a deny is as they say a proceed means, you know legally they've passed the background check and assuming there are no other red flags for the purchaser, you can sell the gun. Whereas a deny means there's something that came back in the background check and you absolutely cannot sell the gun. So, but oftentimes, you know it takes Nick's and the FBI a bit of time to look at your record. Most of them come back very quickly but there's a few where there may be something that they need to double check to see whether someone might pass a background check or not. So what they do is they put you into what's called a delay status which means they don't have an answer right away but they're looking for it. Now the way the law is currently written is if that background check has not been completed in three business days that dealer at their discretion can legally sell you the gun under federal law. I mean, certain states have closed this loophole on a state level but on a federal level, it means you can sell the gun. And that loophole was how the Charles in the Charleston church shooting several years ago how that shooter got his gun. So closing that and making sure that you have a concrete proceed or deny prior to transferring the gun is really an important law. And all of these laws that I've mentioned the assault weapons ban, the enhanced background check closing the Charleston loophole and universal background checks are all things that gun safety advocates and gun owners all agree on as really low hanging fruit in terms of things that really could continue to stay more alive. So that's one of the reasons why they're important pieces of legislation and hopefully there will be some movement on them at some point. The bills have been drafted. They're sitting there waiting for some sort of vote and hopefully that vote is passing them. Why is it so hard to get them through Congress? There seem obvious that the fewer guns in the country the less gun violence, especially when you're talking about guns that are manufactured for war scenarios not self defense by any stretch. And why is it so hard? Who is opposing? And I think I know part of the answer here anyway. Who is opposing all these gun control measures? The gun lobby is extremely strong and the gun lobby is best served by people buying guns and that includes citizens buying more guns and it involves law enforcement needing to buy more guns to protect citizens. And it's an industry where the gun industry profits as long as guns are being sold and they have a tremendous lobbying, they have effort and they fund these politicians which sadly is a disconnect between what their constituents actually want in those cases and the money they're getting in political fund rates. So it's a tricky issue. It's certainly not a new issue. The gun lobby has been around and quite strong for a long time and it's gotten more strong and more extreme in recent years, certainly in this market. I was encouraged I have to say by the fact that there was in response recently both to the Ubalde shooting and the Buffalo shooting which were both just horrific that there was a moment that caused everyone to pause and not listen to the political lobbyists and actually get together and pass bipartisan legislation. So I am hopeful that if they weren't able to do this I hope it doesn't take more people dying to get to that moment. But I am hopeful that there will be additional efforts on the federal level and certainly on the state level we've seen a lot of exciting important bills being passed and being worked on in the state. And Hawaii is certainly one of those states that leading the charge in terms of passing really important gun safety bills. So my hope is that even if it takes longer even if it's a long game on the federal level that hopefully some of these states will pass a really important legislation in the shorter term. Mark would you know New Zealand and Australia have a statute that called for the return the repurchase of guns and pay you a fair price for your gun and you turn it in. And if you don't turn it in you go to jail and just a lot of carrot and stick kind of encouragement there. And it has worked. People have turned their guns in, no surprise. And in fact, the number of incidents of gun violence in both of those countries is down to a tiny fraction of what it was before and certainly what it is in the United States. Is there any chance that you see going you know into we're all old and gray. Is there any chance that issues the of statutes like that here in Congress? I think the gun violence problem in the U.S. sadly is very American and very unique the U.S. I think given you know certainly some of the protections of the Second Amendment and some of the interpretations of the Second Amendment which you know we'll have to do it. We'll have to do another get together on whether exactly interpreted or not certainly we could do an entire session just on that but given what the Second Amendment stands and given the gun culture in our country I don't necessarily see a parallel situation to New Zealand but I am optimistic that some of these gun safety laws will ultimately save lives if we can get them passed and hold those you know accountable under all those who are selling guns to people who shouldn't have them we can hold them accountable. Well you talk about accountable but your practice is a civil practice. You're not involved in prosecuting anybody or for that matter I suppose defending them and in gun control cases the use of guns. So I'd really like you to you know help our audience understand what the civil practice of gun control is like. Who are your clients? I mean don't tell me their names please. Who are your clients? What has happened that makes them wanna go to court and who do you wind up suing and what kind of reception you get you know in terms of the outcomes? Yeah absolutely so all of my clients are primarily victims of gun violence and they've all been through you know the most horrific trauma that they have ever gone through like most you know civil tort victims and you know we have a variety of different types of cases. You know I have some cases on behalf of family and children who are unintentionally shot because you know the gun industry is not regulated by the Consumer Product Safety Commission so they're not required to have mandatory safety features or their products can't be recalled in the same way that a water gun or a Nerf gun would be. So I have certain cases that are product that liability cases against the gun manufacturers. I have cases on behalf of victims of gun violence against gun dealers for selling guns and trafficking in the legal straw purchases. I have, I represent victims of gun violence against the gun manufacturers for their negligent marketing of cases that encourages people who are prone to violence to you know buy their types of guns and those are some of the high profile types of shootings that we've heard about in recent years. And then we also work on behalf of you know cities and states to hold the gun industry accountable. We have a case currently on behalf of this city of Gary, Indiana which is holding you know the gun industry accountable for all the carnage that it's caused in the city. So you know impact litigation is really a tool to hold the gun industry responsible the same way you know big tobacco was able to be held responsible and it became a public, it created a public health campaign and it really caused them to ultimately you know change their practices and change the voice in the country. So that's a lot of what our impact litigation is driven at and you know the other thing I would mention is that you know like I mentioned before the gun industry has certain special protections because of their lobby and they have in they were able to pass in the mid 2000s in an immunity statute which limits gun violence victims from being able to have their day in court. So a lot of our work is geared at overcoming that federal statute and creating a good body of precedence that gun violence victims have access to justice. How do you do that? If they you know the good manufacturers have immunity how do you get around that? So the immunity is limited and it certainly is limited and there are certain exceptions carved out of it. So you know we bring cases that you know established precedence showing what these exceptions are and we also argue that this statute is unconstitutional. So obviously you know our policy team is working to repeal it in court and we are working to develop a body of precedent that paves the way for gun violence victims to have their moment in court. So are your cases frequently jury trial cases and if they are what kind of reception do you get among juries and is that geographical and do they you know give you walloping verdicts because I tell you I'm volunteering now Erin I want to be on one of those juries. I know what to do. Jay I would love to have you as a juror on one of my cases truthfully. You know what's interesting about jurors in this case is even gun owner jurors even gun owner jurors and you know I have a national practices. So I have cases in urban cities and I have cases in very rural areas where the vast majority of the jury is a gun owning jury. But really at the end of the day you know lawful gun owners want the same thing they want their community to be safe. They don't like people and they don't like actors that break the rules. For example if a gun dealer sells a gun and then the legal straw purchase you know it makes it harder for them as you know a lawful gun owner to be able to use their firearm in the way that they choose. So in general it's been really interesting that jurors really do line up behind the idea of gun safety and holding those accountable who break the rules and endanger their community. What about ammunition? I remember that after one of those massacres was it Hay Mart or Walmart announced they weren't going to sell ammunition anymore or a certain kind of ammunition. Can you attack the rash of gun violence that we have by attacking the availability of ammunition? I think the ammunition is certainly a problem. In particular I think these firearms that have high capacity ammunition aren't even bigger a problem.  If you have ammunition that you know a 10 round magazine you can't do nearly as much carnage. So I certainly think the amount of ammunition you can hold in a magazine is also an important area where you can you know create some gun safety laws and rules around that. So when you say impact you want to have a social legal, national, social, legal impact on this whole phenomenon that we have in this country with our 400 million guns. And are you getting there? And how do you choose the cases? I mean what cases would you not take when you are you know dedicated to having an impact? Yeah so I mean what I have found from doing impact driven litigation is that you know filing a case makes it really has a big ripple effect. So when you file a case even if it's only on behalf of one victim you know gun dealers around the country who want to do the right thing. And I would say that most gun dealers do want to do the right thing. They don't want to sell guns off the books illegally in trafficking. There's a handful of bad apple gun dealers who sell a lot of crime guns know they're selling a lot of crime guns and continue to sell a lot of crime guns. But most of them I would make the argument do want to do the right thing. And when they hear about incidences where gun dealers are doing the wrong thing or alternatively they hear about incidences about gun dealers performing their practices and changing their practices to have safer practices. That really can have a ripple effect on gun dealers and they hear about what other gun dealers are doing or they hear gun dealers come out and make public statements about gun safety and they copy that. And so it does really have a ripple effect is what I found in my experience. And certainly I've been against large corporate dealers and corporate dealers who have large stores in a big footprint if they change their practices that really does have a wide impact as well. It reminds me of some stock brokers who impact stock brokers who would tell you never ever buy any stock in any capacity or never buy any fund that held any stock in guns. Seems to me that you can get impact that way too if everybody followed that rule. Yes, no I definitely think that there is a role for corporate America to play in terms of holding the gun industry accountable for their role, absolutely. I think that I hope that more companies lift up their voices and do things like that and really sort of put pressure on the industry and in other ways that would cause them to sell guns safely and then back your guns with safety features and be accountable for when they don't. This strikes me that anybody who is dedicated to doing impact in this area is going to have a secondary impact. That is if people know that there's lawyers out there like you who will take these cases and will pursue these cases, will lose a draw.  So it has, I'm sure as you said, a ripple effect around the whole community. So my last question to you, Aaron, is there are other errands around other Brady projects around that are doing the same thing? And because we need a lot of you, we need you to be a wave of accountability, a wave of litigation as the best choice to have impact on this. And I wonder if you have friends, associates, colleagues who are doing the same thing and whether they are having an effect and whether it is a growing area of practice, I'm hoping that it is. Yes, and I think, I mean, unfortunately the rate of gun violence continues to raise and remain stable in our country. So there are no shortage of cases and Brady does a lot of cases and we've certainly paved the way but we also work really hand in hand with the private bar and I encourage private attorneys to bring these cases and if they don't know how to pick up the phone and call me and I'll tell them how to do it and sort of walk them through ways that they could be successful. It's really important for us to empower the community, the private bar to keep bringing these cases because they're important. And certainly Brady views itself and wants to be a thought leader but this is not something that we can solve with the footprint of our organization. And so our hope is that we inspire other lawyers to work with us, bring cases because it really isn't an important issue. And Jay, if I may, I would definitely like to tell your viewership about our email address if you have any questions about my work or about Brady's work, our website is www.bradyunited.org and if any of your viewers are interested in the topic we always appreciate additional supporters of Brady. There are so many ways to get involved in the issue well beyond just knowing about it. So we have a really interesting podcast as well which I hope you don't mind that I lift up on your show because it really touches on a lot of these different issues and certainly looks at many, many different aspects of gun violence that it's called Red Glue and Brady. So if any of your viewers are interested in learning more about what we do or about different issues, we have detailed podcasts. I have a bunch of them on different cases that we've handled and that I've handled at Brady and we've also have detailed deep dives into all of these policy issues as well as what we're doing from a public perspective as well. Well, it's clear we're gonna have to do another show also, Aaron. We're gonna have to come back and drill down on some of these points we discussed. Aaron Davis, the Brady United organization for gun control, we really appreciate your work, appreciate your coming on the show and appreciate your contribution to the country. It's much more, much beyond just ordinary practice of law. It is practice of law for the benefit of everyone. Thank you, Aaron. Jay, thank you for having me and thank you again for lifting up our issue.  So thank you for having me. I would love to come back another time and certainly continue this conversation. Absolutely. Thank you, Aaron. Aloha. Thank you. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, Twitter and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.


Hey everybody, welcome back to my Star Wars channel. My name is David and today, we're going to look at the Micro Galaxy Squadron. We would be honored if you would join us. Hey everybody, welcome back to the channel. Thanks for being here. You like that? I changed that setup over there.  It's been on the floor in my closet and I keep kind of like moving around it and I don't know if it doesn't work structure-wise to be something that sits on the floor. So I said it's got some height to it, kind of like the ad-at. So I got that over there and then I also got a little Rocket Fire Jet Pack. Boba Fett there, that's a little Boba Fett guy from Galaxy's Edge. He's one of my fun Boba Fett figures and I got some of my cups. I got a new cup, so mug, right? It's a new Boba Fett mug from Christmas, but we're not talking about that today. Today we're going to talk about the Micro Galaxy Squadron. Let's look at them. So I'm sure you've seen these already from other YouTube videos or seen them in the stores, right? But I just got these for Christmas. The way Christmas kind of goes at my house, I'm one of those adults that buys toys all the time and I kind of always buy little knick-knacks and things for myself all year long. And so when my birthday rolls around or on Christmas rolls around, being 55, people go, I don't know what to get you. They always say, I don't want to get you. So I always tell people, just get me Star Wars stuff. You could literally get me anything Star Wars and I'll be over the moon. So I think I was in Walmart and I saw the Falcon, right? I saw the Falcon and I picked it up and I was like, whoa, that's really cool. And my wife kind of made a mental note of it and she ended up getting me several of these. And so we're going to bust each one out for you one at a time. Nice and close up, right? I'll show you nice and close up. And I got a question for you. I got a question for you about these afterwards. So stick around to the end. All right. So we're going to move over here to my table just so you can see things a little bit more close up. You like my best dad shirt? I think I have three of these. So Mando, maybe Yoda, obviously. There's a father-son thing there. I have a Django Fett one, right? Obviously, because Django Fett is dad too. Boba Fett. And then I have a Darth Vader one. So yeah. And I'm a dad. Kind of silly if I had these. I know it wasn't a dad, right? So here's the one I had over there. And it's the Darth Vader's tie advanced. And as you can see from the picture, there's a little cockpit. There's a Darth Vader figure. I'll take different stills for you so you can see what it looks like. And the backside shows some of the other ships. Over here, this is Obi-Wan's Starfighter from the prequels. This one I do not have. Look at that. You got a little tear up there. It's probably from wrapping paper and tape. So hey, if you're giving Star Wars gifts to people, don't put tape right on the packages, especially if you think your friend won't ever open them because, yeah. Well, yeah. Don't do it. And the next one I have is the X-wing, right? And so with that, you get a little X-wing pilot. You get R2-D2, which is going to be Luke Skywalker. So this is red five. Obviously, you got the five red stripes on the wings. And it shows you that the cockpit opens. You can stick Luke inside. The back design doesn't have any tape marks. There's also a tie fight over here that where the wings flatten. So I don't have either one of those two. So I don't know that they were released with the first set, although this says number 15 in the corner. Does that mean there's 15 of these? Really? I mean, these say launch edition. So I kind of thought that these were the launch editions. That was my, that was limited to this amount, but I could be wrong. I don't know. So here's the X-wing. And so here's the one that made me say Ula-la, right? Because look at the Falcon. Like, come on, look how big that is. Remember when we all had micro machines? I mean, look at that size. They're all your characters. Got all the Han and Leia and Obi-Wan and Chewie. A little mounting radar dish. And I believe the gun is right there. Oh, underneath. So yeah, gun's right there. So then on the back side, more ships I don't have. Look at the chicken walker. I want the chicken walker. I don't have the chicken walker. I got to put that on my wish list. The transport, imperial transport, like that'd be another good one to get too. So lots of fun. As far as I originally thought, well, maybe they've got like the little, remember the little acrylic stands that micro machines used to come on? You could stick them on. These just have landing gear. Okay. So no stands come with these. They're a full-out landing gear. This even has a little ramp, well, you know, the famous ramp for the Falcon. But yeah, if you're thinking they might have come with acrylic stands, that would have been cool. But they do not. And so let's do a side-by-side comparison. All right. So this is the old school hard die cast micro machine from days of yore. This is my vintage one, right? So the year on this is not there. Oh yeah, this is 1979. So it has a little landing feet, right? So it has a little swivel radar dish, a little swivel gun. This is from Galaxy's Edge. So this is the Galaxy's Edge prop and it makes noise. Can you hear that? It has landing feet. I believe it makes different noises. Yeah, gun noises. Right. You can see size-wise how big those two props are. And if you bring in the new one, you can see how massively bigger the new one is compared to the two previous models. This is big. And we've saved the best two for last, right? Because gotta have the slave one, especially, especially I do, right? Because I have all things Boa Fett. Even if I didn't have anything else, gotta have the slave one. And over here in the corner, it's obviously from the new Boa Fett Book of Boa Fett series, because it's the newer Boa Fett look. And you've got a Phoenix Shand over there as well. And on the back, you have the same ships we saw from previous. And that is gorgeous, right? It's gorgeous because it's got all the battle damage. Got the paint exactly like it should. Color scheme looks dead on, right? And still says launch edition in the corner. And the Razor Crest, which is quickly becoming one of my very favorite Star Wars ships. I love the Razor Crest. I wish I had the Razor Crest Lego. I wish I had the large, big toy Razor Crest. Those things are awesome looking. And I'm so, so, so sad that he does not have a Razor Crest right now. I'm hoping they're bringing one back, because the design of the ship is absolutely awesome. So you get a Dinjarum, of course, and Quill and an Offworld Jawa in the corner. And back shows your Blueprints and some of the other ships in the series. Alright, so I said I had a question for you. Here's my question. If you've watched other YouTube channels, you've watched people unbox these, or at least show you what they look like out of the box and all of their features. As you saw from my video, they are still in the box and partially because they don't have stands, right? They have landing gear only. And I don't have any place to put them. Right now, they are at the top of this shelf alongside other things that are also in boxes on top of this shelf. But what should I do? I don't know where to put them. If I took these out of the box, they would be really big and they would take up a lot of space. And right now on my display shelves, I really don't have any place to put them. So I kind of think that until I have a space, I should leave them in the box where they're protected. I think one day I will open them, right? You got to open these. I think they need to be opened. But as of right now, I think they're going to stay in a box until I have a place to put them. So my question is, did I make the right choice? I guess. What would you do? Tell me what you do. All right. So that's my collection. That was all of them. And what do you think? Which one's your favorite? Tell me which one you like the best. And I know there's some new ones that have come out since these. So which ones am I missing? Which ones am I missing? Have you got one?  So what's a new one I should add to my collection or stick on my wish list, right? So when my birthday comes up this year, what are some ones I need to add? So let me know down below. Thanks for watching, guys. I made the force be with you. I'll see you next time. Bye.


Going on everyone Sam here with late and sports car trip at 22 Eponini flawless football hobby 1 box break number 11 Random left-side serial numbers to look again at your random results as always find those on the website under the results tab as well as link in check Good luck organizing, so I know who is where sword rain Oh Okay Okay, ooh, that's cool like the first one here. Do I see a color? I like potentially Empty starting off with a Randall Cunningham. That is gonna the 10 spot 10 of 20 Phil K Say for color patch. Oh his name Sean his name Sean God going to the nine spot nine of ten is gonna be Christian Watson Miles H on the nine spot See on Frank L 5 of 15 that is gonna be game-worn Jarvis Landry Congrats Frank javas Juice Landry the jungle nice one here going to the two-spot two of three Andre Johnson going to Miles H. Congrats, buddy That's awesome two of three Andre Johnson Three of ten going to the three-spot John D. DeMarcus where DeMarcus over there Congrats on that Three-colored patch auto that is game-worn DeMarcus where that's actually pretty cool nice one here It's gonna be 14 of 25 Drake London rookie auto going to the 14 spot Zachary. Oh congrats Zachary The guy who is on the chat or on the track And that's it up Fluid And go to the three-spot John D. That is gonna be a three of five Daryl Green Nice one there on the legendary signatures from 2016 Panini flawless right here Sean 2016 Panini flawless Daryl Green This haven't been signed yet five of 15 Chris Jones going to Frank L at the five-spot Grats Frank Nice one there, buddy Frank L. We've got 25 of 25 going to Brett W at the 25 spot Brock Purdy Patch patch Jersey patch like sock patch pushing me to a Chris Between me Jake Everybody And Going to the one-spot that is an on-card Joe Nameth Super Bowl champion signatures. Yep One of three going to mark am congrats mark. That's cool. That's really cool All right, not gonna do a recap on this. Thank you all again for getting this filled up coming up is number 12