And so if you don't know, Jim is a professor in the Astronomy Department and part of the Astrology Program. All right, take it away, sir. OK, thank you for letting me barge in and give a talk on this. I've been keen to talk about some of the SETI projects that we've been doing for the last few years since I sort of got involved with AB. If you've heard me talk in one of these settings before, I've probably talked about stars and the active stars and all the things that makes Miles job hard, because I like the solid activity, which makes the data noisy. And so I'm sorry that my stars are so noisy. But it makes them exciting, yes. But I'm going to take a different approach today. And I want to talk about the SETI ellipsoid as one of the techniques that I'll share, which is sort of part of a larger project to bring SETI into the sort of modern era of what we call survey or data-driven astronomy. And so this is work that's being done with colleagues at sort of all the big SETI institutions that have sort of cropped up in the last few years, the Penn State SETI department, the SETI Institute, of course. This yellow ball here is the Berkeley SETI research program, which is mostly funded by the Breakthrough Listen. And recently, we also have a good collaboration started with the LST Solar System Science Collaboration, which is a mouthful. And so let me talk a little bit about this. This is the big motivator for me, which is this incredible facility that is being built in Chile, which is the Vera Rube Observatory, pictured here in CG, which will go online in about two years. First light will be under two years, like a year and a half, something like this. This is an 8.4 meter diameter monster telescope. So it puts it in one of the top 10 biggest pieces of glass that we've ever built. And it is a very short telescope, meaning it has a very wide field of view, which means it is used to survey large patches of the sky repeatedly for 10 years. So you've got a big piece of glass whose only job is to take repeated time series measurements for a long time over a large area of sky. This takes a huge volume of data. And so it's going to be good for all of your favorite astronomy topics, supernova, variable stars, maybe even exoplanets, and then everything else as well. And one of the big things we do here at UW, especially in the Dirac Institute, is work very heavily on the software that will drive this facility, both that will actually take the exposures and process them in real time, and then that will be used to make lots of catalog level explorations. So I hope you go tell all your friends, LSST, that's what the name is, the survey on the very observatory is the greatest thing that astronomers are going to be doing in the next few years. That's my biased opinion. You've got a 10-year survey that takes 30-second exposures. And so if we're thinking about SETI, the search for extraterrestrial life, intelligent life in the universe, so-called intelligent life, or technosignatures, as Rory said, there is a volume of parameter space that LSST and the very observatory would be very good at probing. And that is everything on the right side of this diagram. Anything that's longer than 30 seconds in timescale and up to many years in timescale, so here is up to millions of seconds, this program, the Legacy Survey of Space and Time, that will be conducted on the observatory, should be a great platform to study. Now this is a figure from a white paper about why we should look at high time series, so like nanosecond timescale stuff. There's lots of great astrophysics reasons why nanoseconds are interesting, but I'm not going to talk about that today, but I stole this figure from Shelley. So the right side of this diagram is what we want. You've got this massive data set. You've got sparse time series, but you've got 20 billion stars in this data set. This is like a profoundly large data set to study. You've got many targets over a long period of time, 10 years of study, and we have the capacity to do real-time monitoring. Within 60 seconds of the shutter closing, this facility will broadcast changes in the sky to the world. So we'll be able to do real-time follow-up and coordinated monitoring. This means it's a great observatory to use to trigger your follow-up facilities, your radio telescopes, your infrared telescopes, even J2ST at some point will be triggered based on this facility. So we need SETI projects. We need technosignature projects or life in the universe projects that can use this data. This is terrible data if you're used to things that astronomers have been doing like J2ST or Kepler or TESS or Spitzer, any of the things that we've talked about in this room with regards to life in the universe. This is like the worst data. The data, like the sun comes up and the data is only 1% photometry and it's in these big crappy filters. Like this is not good data if you really want to study the atmospheres of planets, for example. It'll be useless for you, I apologize. But it will still be a mountain of data for us to chew through. And so this is the motivating factor for me. We have this data. What are the techniques that we can find that might make use of it so that we can leverage it for the search for life in the universe? And then there's one good visualization of this from Jason Wright's work. This is the nine dimensional search parameter Haystack. Radio telescopes are somewhere down in here with 10 to the minus 18. I don't like this visual. Whatever, LST's on the top, fine. This is a better way of looking at it. Jilt Harder famously said that if all the parameter space we need to search for detecting life in the universe is equivalent to the volume of the oceans and water, then what we have searched for, at least as of 2000, was equivalent to a pint glass of water. That's how much parameter space we have actually searched when trying to find life in the oceans. And that is a precious small amount of water to infer the existence of like whales. Probably we're doing a bit better than that now. That was 20 years ago. Probably we're doing, Jason Wright says we're up to maybe a hot tub worth of water. So that's promising. Like you could actually find animals in the hot tub worth of water, probably not a whale. And I would argue that with some qualifications, this new generation of computerized, automated, large, data-driven surveys might get us up to a swimming pool sized volume of water. This is still tiny compared to the volume of parameter space you could possibly search in time and space and frequency and duty cycle and recurrence times. But I would put a lot more faith in a swimming pool than a pint glass. So I think this is an important step forward. Now there are many challenges when you're dreaming up a SETI program, as Woody can tell you from years of experience here. You have many things to look for and a range of believability or plausibility which you might search for. Sophia Shake has this great nine axis of signature merit that she describes. Things like are the signals long lived or short lived? Are they repeating or single events? Are they ambiguous or are they unambiguous indicators of intelligence or life? The same kind of arguments we make about biosignatures. Are they unambiguous biosignatures or are there many pathways to form them? Part of this also at the top of this nine axis are feasibility. It's no good if the signal you look for requires all of the money on earth to search for. That would be a prohibitively expensive search and so it's probably not a good signal to look for. So feasibility, cost effectiveness, can we actually do it? Do we have the data? These are important things. So there's what kinds of signals to look for but also important is when and where to look because it is an awfully large sky and we don't have unlimited amounts of time on telescopes. And it's that first bullet point. When and where should we look that the SETI lipsoid gives us maybe some help? This is a matter of signal coordination. If you were an extraterrestrial agent who wanted to get someone's attention and you were trying to beam messages in the hopes of being noticed, how would you get someone's attention? If all you knew was that maybe there's life out there, humans out there looking up, how would you try to rally their attention and stand out from all the other things that are happening in the cosmos? This idea of coordinating signals with natural phenomenon as like a game of sort of cosmic Marco Polo, if you will, has been around for a long time and this is one of the first papers I could find on this specific method from 1975. But let me put a cute animation that we have made up. Let's see, does this play? Come on now, this animation's more effective than it plays. Okay, okay, so you have, let's say, a supernova. Some kind of conspicuous event goes off. That information reaches another civilization and they say, great, here's something that we can piggyback and message on. Then the supernova reaches us. We say, great, a supernova. And then at some well-known amount of time later, this conspicuous other signal from another star system arises. So let's walk through this geometry one more time. You've got a conspicuous astronomical event. Let's say a supernova. You've got an extraterrestrial agent or civilization on some other star at some measurable distance away. And here we are with our radio telescopes or observatories watching the whole sky all the time looking for conspicuous events. We know the distance to things in the cosmos now. So we have some estimate of the distance to the supernova. We have an estimate of the distance to many of the nearby stars. Now I'll talk about that some more in a second. And so there is this growing ellipsoid with time where conspicuous signals might arrive. We call this the steady ellipsoid. Let me see if I can, there. There's this moment in time where if a signal were to arrive from another star at this specific delay time, that would be a very conspicuous coordination in time and space. And then this ellipsoid grows at time, eventually approaching a sphere. Okay, so here is the more technical schematic that was in one of our papers. All right, so again, you've got some coordinating source event in green here, earth here on the right. And there is this ellipsoid, this three-dimensional surface that grows with time that when it intersects stars, nearby stars, if a signal were to show up from that star, whatever the signal is, again, this is a when and where problem, not a what problem. If a signal were to show up, then it would be very conspicuously timed with regards to the supernova. Now these kinds of ideas are called shelling points. These are ideas about how you get someone's attention. It comes from game theory. If you had to find two people in a world, a video game, and you didn't know where each other was, you'd try to find some point of common reference, or commonality, or common communication. You'd find something to reference your attention around. And that's called the shelling point. And so this is one example of a time, a temporal, spatial shelling point. The upside of this idea is that we have all the pieces already. We see plenty of conspicuous events. Now there's a bit of observer's bias here, or human anthropic bias here. Like what do we consider rare, or conspicuous, or noteworthy? Probably things that happen once a day are not that conspicuous usually. We like supernova in our work because they happen relatively rarely, and they're very bright. They're good signal lamps to rally your attention around. They happen over one per galaxy per hundred years or something. But there are many other possible coordinating events that you could rally around. And it gives you, whether you like this idea or not, it gives you a very clear when and where to look. You still have to argue about what to do and how to get telescope time to look at stars. But at any given moment, there is a specific when and where you should look to see if there are conspicuous signals. And this cuts down parameter space a lot. The biggest uncertainty in this whole scheme, historically, has been the distance to other stars because we are governed by light travel time. We depend on understanding that the speed of light is the same in every direction. And so we need to know the distance that the light needs to travel so that we can build this triangle, this ellipsoid with time. And until recently, this has been the biggest issues that we don't have the distance to stars measured precisely. But thankfully, the Europeans have solved all of our problems and launched this beautiful telescope about a decade ago now called Gaia. And Gaia uses this very cool set of orthogonal telescopes that are fixed at a 90-degree angle from each other. It does this repeated scanning of the sky over a long period of time. And over many years, well, it doesn't really unfold the sky, but over many years, it creates the most precise, amazing map of the nearby universe of the Milky Way. And importantly, its whole job is to measure distances to stars. And it does it really well. It does it so well that 54% of the stars nearby have distances that are less than one light year. And astronomers don't often talk about light years. We talk about parsecs or other units of measurements, but I like light years because light year translates to year of uncertainty. If something has one light year distance uncertainty, that means we have a one year uncertainty in signal timing. And so our distance uncertainties directly translate into timing uncertainties. And so for a small percentage of the most nearby stars, we have distance uncertainties that translate into timing uncertainties down to weeks to months, which is actually really good. So the preferred target for this scheme over the last 30 years has been Supernova 1987A. This is a really important event. It happened in the nearby Large Magellanic Cloud Galaxy. Here is the most recent beautiful photo of it from the JDBST facility. You can see that it's beautiful. There's all these cool echoes around it from the interstellar medium where the light is reflecting off of stuff. There's cool shock physics going on. I'm not a supernova astronomer. That's everything I know about it. But what's cool is the geometry that we use to measure the structure of these rings and echoes and structure around it is the same geometry. It's the same math that we use in calculating the steady ellipsoid. But instead of light echoing off of dust, we're asking civilizations to echo signals at us. I like this figure because it's rare we get to see things so distorted to scale in astronomy. So if Supernova 1987A is at the center of this circle and we're at the right side, the information front, of course, is circular. The Supernova information front is a sphere. And the steady ellipsoid is this teeny, narrow, skinny oval. Okay, so here is an example of the steady ellipsoid for Supernova 1987A near us. Let me walk you through this diagram. In red are the stars that don't know that near us. Within a couple hundred light years, the stars near us that don't even know Supernova 1987A has happened yet. Like they haven't even seen it yet. You can see the curvature of that sphere as it's radiating outwards. Roughly half the stars in our neighborhood don't even know the Supernova's happened yet. It was only, you know, not even 40 years ago. This is like recent news in the galaxy. The stars in blue have seen the Supernova. So those are the ones, right? Obviously closer to the Supernova. We're at the center of this diagram at zero, zero. And the stars in pink are the ones that could have sent a message to us, right? They have seen the Supernova and enough time has passed that a message then could have arrived. And that is the ellipsoid.  And so at any given moment, there are something like 140 stars intersecting that three-dimensional space. And we know their distances very precisely, better than a few percent. And so we can target those stars, their telescopes. So if you have telescope time and you want to conduct SETI searches, this would be one way to go and know which hundred stars to look at. Don't look at the ones in red. They don't know anything about Supernova 1987A yet. At any given time, you can go look up, we can calculate very quickly which stars are intersecting this three-dimensional ellipsoid. Yeah, I like this point. 1987A, this Supernova is still super recent news. Most of the stars in our neighborhoods still don't know about it, which is amazing. Okay, this is just geometry, right? We're just drawing circles and ovals in space. And so what's great about this is we can calculate far into the future when this ellipsoid intersects more and more stars, right? And you can calculate this propagation to the shape in time. And so it won't be until hundreds of years later, 25, you're 2500, that most of the stars in our neighborhood have actually seen this. This means that any given time, even right now, even though 1987A was in the 80s, four decades ago, it's still a hot target to look for SETI signals coordinated around. It means that there's always gonna be lots and lots of stars that are just now seeing this signal and could be broadcasting signals in coordination with it. Ian, why the wiggles on the 2000? Oh, this, I just took a slice through the middle of it. So I'm just smoothing through the stars that are available in like a little narrow slice through the sphere. So it should be a perfectly smoothing, but I got lazy when I drew the figure. That's why I'm telling you. An honest answer. Yes, as an astronomer, I am always lazy in my figures, but colorful but creative. Now again, we haven't made any prescription about what the signal should be or what kind of stars should be sending these signals. And so if you take the astronomer's classic reference diagram, the so-called Hertzsprung-Russel diagram, what we call a magta diagram, you see the main sequence here is the big line in the middle. The sun is somewhere in the center of that. We've got main sequence stars. We've got massive stars, m dwarfs. There's even a few white dwarfs that are intersecting this ellipsoid right now. Again, we're not making any statement about what kind of star or what kind of signal you should be studying. There are arguments to be made about what the signal should be. We're just saying which stars to study. Okay, so that's the idea. This is the idea of the ellipsoid. It's a when and where kind of situation. Good for planning observations. So what do we do? Let's go make some observations. And so that's what we've been doing for the last few years. We've been going through databases that are active right now, such as the test mission we've just submitted this paper, going through tens of thousands of light curves that intersect the ellipsoid from the test mission, 20,000 alerts from the Gaia mission, 10 million light curves from the Gaia mission. So far we have found nothing interesting, spoiler, but we haven't found anything interesting. But what we have done is develop good code that can run quickly through lots of light curves to figure out when and where you should look through both patchy sparse light curves from Gaia and also exoplanet light curves from the test mission. So we are actively trying to deploy this code through other surveys that are running right now and are excited about the Rubin Observatory in a couple of years, where we're gonna have to be able to do this on billions of stars every night. We're also not limited to Supernova 1987a. Now I've just talked about this because this is the sort of hallmark event that has sort of captured our attention, but there's many other events that might be conspicuous and interesting. And in fact, there is another coordinating event just this last year that we've started to get excited about. And that is Supernova-223-IXF, the memorably named Type II Supernova in the M101 Galaxy. Now this was an exciting event if you care about Supernova, which I don't know anything about Supernova, so it was just another event for me. But it was very exciting for the Supernova astronomers because it was the nearest Type II Supernova in a decade. And so it's been very well studied. People pointed all the big telescopes at it to get benchmark data on lots of Supernova physics stuff. And so we said, this is great. There are people who are looking at this Supernova already with all of the big expensive telescopes that we can't get time on. And they're looking in the right patch of the sky. Let's figure out which stars within a few days of the Supernova occurring, which stars are going to intersect that ellipsoid. And so because we had the math already done, we calculated which stars from the nearby Gaia catalog, and that's these black dots. They fall in this little patch of sky, as you would expect, because the ellipsoid is very narrow because the event has just reached us. But there are already hundreds of stars. At the time of publication, there was 108 stars and a little ball right around the Supernova. And that ball will continue to grow for the next few years as people hopefully continue to study it. And so what's great, I think, is this is a model of how we piggyback, right? We're doing SETI work essentially for free with big error quotes on the word free because people still need to get paid to do this work for all kinds of other science. But we are doing SETI, or we are getting observations for free from the community who are looking for other reasons. So lots of other telescopes went and imaged M-101. It's a beautiful galaxy. Lots of other telescopes at different wavelengths imaged this and got lots of nearby stars. Now, we are also observing it with radio telescopes. And so we started with the SETI Institute and the Alan Telescope Array. We started a campaign to monitor all these stars for a few months. And so that work is ongoing. And again, I'm here to sort of advocate for SETI as a discipline with lots of surveys, with lots of studies, with lots of facilities. We should be running this on every other facility that you can think of. There is code. This is only one idea of many. This is part of a larger project to do what I would call Optical Survey SETI, or Survey SETI. Again, SETI, using these big data-driven time domain surveys. And so this is a new slide that I just made, which I'm really proud of, which is that we've got lots of papers now from many students, from many different projects, not just on the SETI ellipsoid, but also for other projects to see Kepler data, looking for laser lines and apogee. We're already starting projects with Annie Zanadakis, looking for rare stars in ZTF. We have lots of projects. This is just a slice of what's coming to publication now. And there are many future exciting projects with these surveys. One that I think will be a really big hit here at UW in the next couple of years is looking for unusual moving objects. We have a huge solar system group within the Dirac Institute that studies lots of asteroids and comets. And we'll be on the forefront of looking for interstellar objects, comets from other star systems. We know of two of these already. There is debate about whether or not one of them was artificial. I don't want to get into that debate right now. We can have drinks and hash it out later, if you'd like. But the point is, if a comet or a interstellar object makes a right turn, we should be there ready to watch for it. We should be able to determine that that thing made an unphysical change in velocity or in its trajectory. We should be able to detect that with our observatories and we should be able to track it. Similarly, if stars start exhibiting truly strange variability or patterns of variability or started blinking morris code to us, we should be ready with our algorithms to troll through our databases to find these kinds of signals. And again, I'm very excited about this project, which is harnessing huge spectroscopic databases that we already have. This is an example of high resolution spectra from a sunlight star in the infrared, from the ground. And looking for, I have colored on, an anomalous emission line. We have, from the Apogee survey, which UW was a founding member of at the Sloan Digital Sky Survey, we have something like 700,000 stars in our galaxy with high resolution spectra that we could use to look for anomalous lines. Now, of course, there's lots of caveats because the atmosphere is in the way. You're looking for weird things while you're looking through an atmosphere. So we just heard this is a problem, but we have a huge data set that we can draw from. And again, lots of good code that we can write to do this quickly. And so that's my conclusion. Is that the SETI ellipsoid is perhaps an efficient way to select which stars to monitor. I'm not arguing what you should monitor for, but if you want to do SETI monitoring, this is a good way to pick some stars to go after. And it keeps providing stars over time. Gaia is the transformative technology that makes this feasible for nearby stars because we can finally, with precision, measure the distance to nearby stars. Supernova 1987a, while it's old news to us, is still relatively hot, exciting new developments within the galaxy. And we haven't ruled out SETI signals from even stars than 100 parsecs within a few hundred light years of ourselves from coordinating signals, right? Only a small percentage of stars could we say haven't sent a signal. And I think this is just one of many, many projects in this new era of survey SETI. And I'll take any questions.


Hello everyone! My name is Anu Mandi and I am your instructor for this World Civilization course. Welcome! Many times students come into a history class fearing that they will be required to memorize a long list of dates and names to put down on the test. That's not the way to study history. In high school your history class might have been about finding answers for test questions. In college it's really about asking good questions about the human experience. World history is not simply a study of different regions of the world. I want you to understand that there is a fundamental difference between western civilization's courses and world civilization's courses. A western civ course typically focuses on the classical civilizations of the Mediterranean world such as Greece and Rome followed by the history of Europe and other western nations. This means that other parts of the world get very little attention. This world civilization's course focuses on the non-western world. I want to emphasize that world history is a shared history. This means that we cannot study a particular region of the world in isolation. Instead of the compartmentalization of the experiences of historical actors, a world civilization's course examines events from a global perspective and highlights the links and interactions among cultures. In this course we will focus on some of the prominent civilizations and key events that influence the early stages of human history. We will look at some common patterns of human development but also study the remarkable diversity of human experiences around the world. In general human beings don't like uncertainty and instability. The need to create structures or belief systems that provide some degree of stability is a common pattern in human cultures. Some civilizations attempted to achieve stability by focusing on political solutions. Other civilizations establish rigid social structures or religious practices and some other civilizations promoted freedom and mobility instead of focusing on issues of stability. So the first few topics in this course will examine basic questions about social structures and political institutions. Cultural interaction and diffusion is a common theme in world civilization's courses. We cannot understand a society without examining its culture that is the common beliefs, ideas and behavior patterns that are passed from one generation to another. Even today religious beliefs play a very important role in our societies and understanding different religious systems and beliefs helps us appreciate and respect the diversity of human experiences and societies because we need to have empathy and develop our ability to view the world from different perspectives. Ignorance of other cultures only breeds fear and violence. So an understanding of other cultures in historical context gives us the tools to break down the barriers and communicate with people of other cultures. Economic motives lie at the heart of many human activities from the quest for food to the pursuit of wealth. Economic factors have played a very important role in our history, driving some groups to conquer and rule other groups, extract wealth from them and impose their ideas on them. So in this context we will examine empire building and also study the impact of conquest and war on human development. History is meaningful for all of us and I hope that this course will inspire you to learn more about other cultures and broaden your perspectives. Thank you.


All right. Hello, everybody. We're on for another awesome artwork piece to showcase from the in-person sessions at Reclim Open. I'm here with Alex Carney, who is an alum from Skidmore and is currently at Swarthmore College. Dartmouth. I'm sorry. I was talking to some Rachel Winchester from Swarthmore yesterday, so I apologize for that Dartmouth right now. Fun fact to you, Dartmouth is a domain of one's own school for us too, so it's all in the Reclim community. But if you want to just introduce yourself a little bit and talk about what your art piece was at Reclim Open, it was super cool. So I'm really excited to hear more about it. Yeah, absolutely. So thanks for the introduction so far. My name is Alex, and last year I graduated from Skidmore College, which is a small liberal arts college in Upstate New York. I studied math and physics, and then I graduated from there and then went over to Dartmouth College, where I got a degree in engineering, and now I'm returning back to Dartmouth in the fall to start a PhD program in engineering sciences and quantum computing. So I, at the start of last year, I was still at Dartmouth. I was doing my engineering degree, and I was part of this student organization or like club. I don't really know how it really classifies, but it was this opportunity on campus called the Dolly Lab, so D-A-L-I Lab, and that's an acronym for Digital Applied Learning and Innovation Lab. And actually the Dolly Lab is an opportunity for students who are interested in software engineering and computer science to build actual projects for people in the community. So how it works is people in the general Dartmouth community, whether it be like professors at the school or people affiliated with the nearby medical center, or even just somebody who lives in the area and wants to build a company or start a product, they'll pitch their idea to the Dolly Lab. And their ideas are almost always like a mobile app or some sort of website, some sort of project that falls under the realm of digital art or digital products. So something that a computer science student or a graphic designer could work on and build. So what happened was for the first time in the history of Dolly, a doctor from the nearby medical center, Dartmouth Hitchcock Medical Center, came in and said, I want to build a physical product with Dolly, with students at Dartmouth. I want to build a new type of microscope that does all of its processing digitally and doesn't actually rely on any lenses or light refraction or optics, essentially. And the people at Dolly who review projects that are incoming were like, okay, what are we going to do with this? I think what actually happened was he kept on coming back after being either pushed off or denied, and eventually the people at Dolly were like, all right, let's bring it on and just see what happens. We have no idea what this is going to mean for the lab because it's a physical product. So I was lucky enough to get accepted into Dolly Lab right before this project launched. And so I was on the project for its first term along with another developer and two UI UX designers and a project manager. So there are five of us. And on day one, we meet with our sponsor, who is this super excited, super energetic pathologist from the nearby medical center. And he has a couple of sketches and an idea and a pitch that's all we're given. And the pitch is essentially this. He does external research or through the hospital on using AI algorithms to act as sort of like a co-pilot for pathologists who are diagnosing cancer and other dangerous diseases from a biopsy. So how it works is you'll get a slide. Basically how it works is when you go into the hospital, they'll take a piece of your skin that could potentially be cancerous or have some sort of problem. They'll take it out, they'll do a bunch of processing on it, freeze it, and then slice it up into these minuscule slices of cells. Those will be put onto a glass slide. And that is where you end up with what you would traditionally associate with a microscope, which is a glass slide with some tissue on it. Then those are given to the pathologist. The pathologist puts that under the microscope and looks at it. Our doctor was doing research with these, this different way of managing that pipeline by digitizing those slides. And what that means is that they would get that physical piece of tissue off of your body, but then they would put it into this advanced machine that would take a super high resolution image of that slide. And so now when you have that image, you can put the slide away, you can freeze it, you can move it away, and now you have this super high resolution image that you can use instead. And his research was using AI algorithms that use convolutional neural networks as sort of like image processing to look at those high resolution images and see if it can detect any anomalies or more importantly simulate the effect of different tests on those or on those tissues. And what I mean by test is that if a pathologist cannot just look at a diagnosis and make a decision, they'll send it off to a lab and apply different chemicals to it in order to see different reactions that the tissue has. So, you know, if this tissue reacts with this color to this chemical, then that means that that's a potential marker for this cancer. And that's why they're professionals is because they know all of those different things. So they were trying to build AI algorithms that could simulate the effect of these tests, which would have numerous incredible benefits if that was possible to put into an actual production workflow. So he comes in and says, I want to use these AI algorithms to help me diagnose the cases quicker and not have such a large turnaround time if I have to send it off to a lab. But the only way to view these images, these super high resolution images of tissue is on a mouse and a keyboard and a monitor.  You know, each one is multiple gigabytes large. There are hundreds of thousands of pixels with a wide and height. And so you need to scroll in on your mouse to zoom in all the way and then you have to start dragging up and down. And he was just like, yes, it's not possible. So he showed us, he showed us some, some people that he had talked to in other departments, where other hospitals where their department actually paid the money to get all this software installed so that they could diagnose cases using the online mouse and keyboard and monitor. And the doctors didn't do it. They were like, no, we want to use our microscopes. That's what we're trained on. And that's what has been refined over hundreds of years to be the most ergonomic possible user interface for viewing cells using viewing glass slides with cells on it.  And so that's what the smart microscope is. It is a user interface for interacting and viewing with these high resolution images of tissue that makes no compromises. You have the exact, well, almost the exact same interface as a normal microscope, but everything that you're looking at is completely digital. And that's really hard for people to understand the first time when they actually use this thing. They would pick up the slide and say, like, there's just a red square on here. There's no tissue on here. Where's the tissue? Like, where's the slide? Is there a QR code on here? So how it works is there's a computer inside of the microscope, and that computer stores as many of those high resolution images as you want, let's say 30 on there. You can load up one of those tissues to look at on your little ocular device by using our separate tablet application. So our tablet application is essentially, you can scroll through it and then you can tap on whatever image that you want to view. It will show up on your oculars. Yeah, so you can see me looking through the oculars right now. There's actually a tablet on the other side that you can't see, but on the tablet, you have all the image, all the thumbnails for your different cases. You'll scroll through, tap on one, and it will show up in front of your eyes. Then to move the image, it's exactly as you would move an image on a normal microscope. As you can see, my hands are on the stage, and when I move the slide around on the stage, the image moves in front of my eyes. And how it's doing that is there's a little red square on that slide. And people are like, what's the red square? Is that a cell? No, that's just essentially a tracking system where there's a camera normally where the light would beam down on the normal microscope. So right above where my hands are, there's a camera there. Whenever you move the red square around, we use a computer vision algorithm to track the location of that red square and use that data to move the image in front of your eye. And what that ends up, the final result of that is a haptic feedback where you move the slide with your finger and just moving it around that stage, and the image will move around in front of your eyes exactly in tandem. And then the second thing that we developed was it's a little hard to see from this angle, but underneath the stage, there's a little spinny thing. We call it a turnstile. The reason that we have that is because on a normal microscope, you can zoom in and out using different objective lenses. So essentially, you'll be moving your slide around and you can flick the carousel over and that will move you to different zoom levels. We figured we're actually able to do whatever we want when it comes to redefining our user interface because we no longer have those lenses. And so our team of designers did user research, did user studies, and we actually found out that it was potentially more ergonomic to have the turnstile be underneath the stage instead. Because since it's all digital, you can have whatever sort of control that you want, meaning we had an amazing balance of trying to copy what a microscope already does and coming up with new ways of interacting with these cells just based on our own design. So we had a wonderful team of designers. The lead designer, her name was Lauren Goyette, and they figured out that if we had the turnstile be below, it might be more ergonomic and it's just a new way of doing it. So how it works is when you flick that turnstile underneath the stage, there's a system of lasers in the base that will track the location of the new state and then zoom you in or out based on just some sort of internal processing. So it's a combination of engineering and design. And that's kind of what I've enjoyed the most about working on this project is that it's a beautiful design and our designers were not only working on the UI of the application itself, like the tablet, which is what they're kind of used to, I guess, because that's what normally Dolly the UI team would work on. They would work on the user interface of an application or a website. But we also had like a product designer. And this was the first time in Dolly that we had a person who was applying those same exact design concepts to a physical product and having it 3D printed. So we were looking at here is all completely 3D printed and then just pushed together with screws and it's in a full assembly. So sorry, I was just gonna say that's super cool. On this side, I grabbed this photo from your submission. Ben Harwood at Skidmore sent me this photo from the Instagram. So I just thought that was a really cool visual to kind of show show what we're looking at. But then I want this is what we had a reclaim reclaim open on the ground and Brian Alexander breathing fire and brimstone as the smart microscope is paving the way for the future analysis and artificial intelligence. Yeah. Yeah. So I'm super interested if you want to talk more about that 3D printing aspect of the of the microscope that that's really cool. Yeah. So essentially how it was working was we were really I think we really lucked out with the team that we had for this project. And I think maybe the Dolly hiring squad kind of figured like, oh, we've got a physical product coming in. Let's try to hire people who are not only, you know, not only of the skills that we're looking for normally, which is, you know, computer science web development and UI UX like app development, but also maybe some people in the engineering department. And it just happened to work out that I applied and I had digital electronics knowledge. And that other lead designer that was talking about Boya applied. And she was interested in product design and had taken product design courses. And so what that means is that she was using SOLIDWORKS, which is a 3D like computer aided design tool that almost every engineer knows. And how SOLIDWORKS usually works is you would design some sort of machine part out of metal to be milled out in a machine shop. But now with the rise of 3D printing, instead, you can directly export a SOLIDWORKS file, which is just some sort of computer aided design file or rendering that you build in software, you can directly export that to a file that can be read by a 3D printer and just print it right there. So Dartmouth has a makerspace and conveniently it was adjacent to the Dolly lab. So we would just go back and forth between, well, actually, I guess we wouldn't really go back and forth. I stayed in the lab and did my coding on my computer and Lauren was and her design team was in the makerspace planning things out on SOLIDWORKS with these huge engineering like blueprints and then sending it over to these massive 3D printers that would print everything piece by piece. And then she came up with the ways of like using screws to assemble everything together. So there's an assembly step as well. That's not just a single, there's probably like five or six that are all put into a final assembly. So Alex, one of the things I'm wondering is so you got this person, they came in, they gave you the pitch, you both or the team went back, they built this pretty remarkable instance. And I love the way you talk about the ergonomic ability turnstile to switch. How did the sponsor or the person who came to you asking you to build it when you gave them the prototype or the actual smart microscope? What was their reaction? Like, were they like your geniuses all hail? You know, the team, how did that go? Also really quick, does my mic sound different now? It does. Okay. And it's, I assume it's better. It's better. Okay. So unfortunately, I guess the system defaulted to using my webcam as my mic rather than my actual mic on my headset. That's all right. But anyway, you sound great both ways. Okay. But anyway, so yeah, what was his reaction to this? I mean, this guy is so excited and so high energy that I think that has been one of my favorite parts of working on this project. I mean, you show him literally anything and the guy will just start like bouncing with glee. And that's not even an understatement. And so it really made it, I mean, it made it a real treat to work on this project because he knew what was a big contribution. He kind of understood the magnitude of what we were doing and he understood when we were presenting what we did during the week during our weekly sponsor updates, he could pick up on exactly what was a major contribution, what took a lot of time, and what was a big thing to drive the project forward, which is sometimes rare because those contributions would be like some computer science thing like, oh, I was able to use this package with this package to make this thing work that normally a sponsor who's not really as integrated into technology and software would say, okay, why didn't that take five minutes? You know, it's kind of the there's kind of a running joke in the software world where sponsors and program managers have these crazy requirements and have no idea what it takes to build things. And it makes it difficult to work with because like, you know, maybe a project manager will say, oh, that should only take five minutes, right? I mean, that doesn't sound that hard. Or like a sponsor will say, I want this, this, this and this and this and this without knowing what's really possible when it comes to software. But although our doctor was not a software engineer or did not really have a software engineering background, somehow he knew enough about the field and as a whole where he was able to know exactly when we were making big contributions, even if it didn't sound like something or when maybe we needed to pick up the slack a little bit. And maybe we were falling behind. And so I know that the the super high energy and excitement was maybe a little bit of a deterrent to other people on the team because we were full time students doing this. This is just a project, we were getting paid. This is a paid position what the Dolly lab offers. But you're taking a full load of courses, you're trying to pursue your degree, trying to have fun, you know, so for a lot of people, it was a little bit of extra stress to have somebody so invested in this. And it's like, well, I'm not that invested in this. And so we actually had some some pretty high turnover rate with students coming in and off of the project. But for the people who stuck along the whole time, I think it really was his excitement that that kept us so engaged with the project. Because you could you could literally see that this is we're doing something that matters. And I'm still working with him now over the summer, because we are going to we're going into our first round of clinical validation study. So he is preparing a set of cases that are going to be used by doctors on three different mediums. So the microscope, the smart microscope, a traditional microscope, and the mouse and keyboard. And he's going to put it into an actual paper and go from there. And what that means that this was not just an idea from him, like this is something that he has put money, time, a lot of energy into the passion project that he thinks, and now the rest of us think can really, really take off. And so having a passionate sponsor is is just who believes in the project just kind of trickles down to the whole team. It's funny too, because that passion seems to have found its way into your presence in general at Reclaim Open. I have commented on before I will again, I mean, you were a great presence. You brought not only like amazing fair art fair project, which we're looking at, but also a great talk on Reclaim Cloud, and how you use that in the students. So what was and even I think you ran into by coincidence, certainly not by design, a histologist, who probably saw your project and what you were doing and was like, you know, this is another way. It was an interesting coincidence just to kind of remind us that there are people in this space who have immediate interest and possible need of what you're creating. So what was Reclaim Open like for you and like the energy for the work you're doing? Like, how did that work, you know, for you? Yeah, so coming to Reclaim Open, first off, actually, I think the story of being invited to it is also funny. So I'll start there. So basically, there was my, so I graduated from Skidmore two years ago at this point, and I had this senior project that I had built as a web application for the physics department to use to aid their research. And I kind of built it. I deployed it on Reclaim Cloud. Some of my professors were using it, but the project kind of not really died down, but I kind of, you know, forgot about it, especially once I started working on the microscope. I had a friend at Skidmore who was a year younger than me. His name was Sten, and he's like just as passionate and excited about like everything as I am. And what happened was he, without me knowing at all, him and Ben like sent in that my senior project to Reclaim Open like as a here's something that we could present as Skidmore. I had no idea. I had no idea. And then I went and visited Sten for his birthday, and he was like, Hey, do you want to go to a conference?  And he was like, Yeah, I took your senior project and me and Ben, we submitted it to this conference and it got accepted. You can go present it. And I'm like, I was just here. I was dumbfounded. I thought he was joking with me, but Sten's the kind of person who was just so excited about everything that he'll do that.  I'm not even to go there. And I was like, Okay, that is okay. We have a word for that in American, right? Like it's getting thrown under the bus, right? Yeah, it's getting thrown under the bus. But like, if the bus is an awesome opportunity that I would have never known about in the first place. So I guess it's like a good getting thrown under the bus. I don't even know. You didn't make a new catch. You didn't make a new idiom just for that. And so I was like, Yeah, let's let's do this. I mean, when in my life is something like this just going to be presented to me without me even knowing that it was presented to me. And so Ben and I started preparing and we came to reclaim open. Well, actually, before that, I was like, Okay, if I'm going to do this, I might as well also talk about what I was doing a year before, and what I'm doing currently, and what I'd like to get more help with when it comes to using cloud computing on the microscope. And I guess I can talk about that a little bit later on kind of the future of the project and how cloud can continue to have it go into its next step. So I come to reclaim open. And I don't really know what I was expecting. I had never really been, I had never been to a conference before. And I thought, I mean, I had all these ideas in my mind. I thought it was going to be like a kind of like a massive convention with like people like different companies with like stands everywhere to just like walk around from the different stands and just like introduce yourself. I don't know. I mean, maybe some conferences are like that. But reclaim open turned out to be more of like a community meetup of a lot of people who had connections to each other through all these sorts of ways. I mean, Ben knew a lot of people from like Twitter just and never had met them. And it was it was more of this is of a community meetup where everybody has similar values and things to share. And it was a really, really wholesome environment to learn. Now, me coming in as a complete outsider, not really knowing anything about the web before like, you know, 2019, I guess, and not knowing a lot. It meant that the first couple, the first day and a half was like, really overwhelming, because I was like, what the heck is WordPress? Like, I've heard of WordPress. I've made my website with Domains of One Own. But like, why are these people talking for so long about like WordPress and blogging and all these arguments about these different platforms that I didn't even know existed. And then I very, very quickly realized, wait, these people have the same exact passion that I do for the things that I'm interested in, and they have a lot to share, and I have a lot to learn here. And so I started, well, I was always going to the sessions, but I started really, really appreciating what everybody was doing in their own sphere of the internet. And I realized that it affects a lot of people in ways that I would have never expected, because I've kind of had such this, such a bubble that I was in of just, you know, other students, and being like, oh yeah, let's build our own applications or whatever, without realizing that in the educational space, there's a whole entire world out there that I had no idea of. So this was an amazing opportunity for me to get a glimpse into, you know, just, it's not just my generation that has enjoyed and has contributed and has had the internet be a massive part of our existence and our identity. And that has been a thing for decades now. And it was a little bit, almost like a culture shock, but I was really, really glad to learn so much and see so many passionate people and talk to so many passionate people and hear about so many cool projects and listen to the amazing keynote speakers. And yeah, I mean, it was an incredible opportunity and I having an amazing time. And I'm glad that my presentation was at the very end, but I'm glad that I was able to get acclimated to the culture and meet everybody beforehand because that meant I could be totally, totally comfortable during my presentation and be like, yeah, I mean, I can just, I can be just as passionate to everybody else because I'm just mimicking what I've already seen so far. So all that passion and all that excitement that I had in my, in my presentation at the end, that was just mimicking everything that I had seen before. So. And you nailed it. I mean, absolutely. Like you, you sold the cloud better than we did. It was, it was pretty impressive. So we have a couple of minutes here left. What is your vision of the cloud in the future and what are some final words we can get from the ever insightful Alex Carney? Yeah, so the cloud offers infrastructure as a service. That's one of the very many things that it does. And what that means is that you can have these computing devices that don't have much power at all on their own, but can be hooked up into a network that handles the computing for them.  And you can access that from any device through the cloud. And I'm working with, you know, the smart microscope, it's a Raspberry Pi. It doesn't have the capability of running AI algorithms on its own. But that's what the cloud is for. Having a network up there and being able to sell this infrastructure, have all these microscopes connect through the cloud. And so there's a variety of things that the cloud brings. But I think really offloading the infrastructure as computing needs become more and more and more demanding. You can have smaller and smaller computers like Internet of Things in your home that connects to a cloud database. You can just kind of reduce the amount of physical computing that you need in the moment, but have decentralized everything that you need. So, yeah, I think the infrastructure is really the biggest thing. So that's basically how the smart microscope is going to be working, right? You have very affordable, reproducible Raspberry Pi running the code that you developed. And then you're offloading a lot of the hard GPU CPU number crunching, etc. to the cloud, which is then just taking that work and reproducing it for the user. Does that make sense? Is that fair? Yeah, exactly. It's awesome. You marry innovation, 3D printing with the cloud on top of just an amazing learning experience at the Dolly Levitt Dartmouth, which is commendable. And you talked extensively about it at Reclaim Open, and we loved you for it. I mean, that was great stuff. So, again, I just want to personally thank you for coming, but beyond that, for being such a kind of a bullion, fun, really open and amazing presence. I mean, in some ways, I said it at the conference that I'll say again, you kind of, for me, personified the joy and the possibilities of dreaming of Open. So, again, thank you for coming. It was great, Alex. Yeah. And once again, thank you so much for having me. I never could have, like, I totally could have never imagined what sort of experience I would have had, but I had an amazing time and I learned so much. Right. All right. Amazing. Yes. Are we going to wrap it, Meredith? Yeah. So, we've got some awesome more repremiers of all the sessions at Reclaim Open starting this coming Friday. So, after this premiere is Friday throughout the month, we've got the rest of the sessions coming up and some awesome keynotes throughout the month as well. So, stay tuned. And thank you again, Alex, for coming on to talk about the smart microscope and your experience at Reclaim Open.


Good morning. Good morning. So this morning we have Dr. Hansen, our neuro-optimology fellow. It's coming to talk to us about the visual quality of life in migraine patients. And she did her training at the University of Cincinnati and then joined us and has been here for well. It'll be a year in July, I guess. Feel welcome her and she'll have some time for questions. Alright, thanks for having me. This, originally there was going to be two presenters, but now it's just me. So I added this talk on which is pretty brief, but I'm also going to be presenting an interesting patient that we saw in clinic. So this is a project that we're doing in the neuro-optimology department looking at the visual quality of life in patients with migraine. So just as a quick update on the background, as everybody knows migraine is a neurovascular clinical syndrome. In which patients get recurrent episodes of head pain that do not serve any warning purpose. It's very common, globally at least 11 percent of the population, but in some populations it's up to 20 percent. As everybody knows, frequently patients get light, sound and odor sensitivity and up to 30 percent of patients get an aura. Most patients are photophobic during an acute attack, but there were two really important papers that showed that patients with migraine are actually more light sensitive than the average person in between the acute attacks. So the IIH TT looked at visual quality of life in patients with IIH and they used two different questionnaires, the NEIVFQ 25, which is the National Eye Institute visual functioning questionnaire. There's 25 questions and the neuro-optomic supplement to the NEIVFQ 25. And interestingly, the scores were actually pretty similar to scores that patients had at MS and optic neuritis. And they found that patients with worse visual acuties and worse pain symptoms also had worse visual quality of life. Not that surprising, but one of the reviewers questions and one of their biggest critiques were that we couldn't say how much of the decreased visual quality of life was related to migraine because there's a huge overlap of migraine in IIH. And essentially that answer just wasn't known, hadn't been looked at. So we decided to use four different questionnaires and the first two on the list look at the visual quality of life and the second two look at the impact of headaches and the headache severity. And I'll just show you a screenshot of each one to give you an idea of what they're like. So this is from the NEIVFQ 25. As I said, there's 25 questions. They're all Likert scale questions, but they ask things like how much trouble do you have driving because of your vision and how much trouble do you have finding something on a crowded shelf, that sort of thing. And this is a screenshot from the neuro-optomic supplement. It's 10 questions. Again, they're all Likert scale questions. They ask things, questions about double vision and blurred vision and pain with eye movements and lip position, things like that. This is the migraine specific quality of life questionnaire. So all of the questions are asked relative to how much migraine has affected them in the past four weeks. And it asks things like, you know, how much have migraines interfered with your ability to do your daily work activities, stuff like that. And this is the hit six questionnaire, six questions.  So we separated participants into three groups, those with chronic migraine, those with episodic migraine and a control group. So our inclusion criteria were patients who had migraine headaches that fulfilled the ICHD third edition criteria. And if they had migraine headaches for at least 15 days out of the month, they were put into the chronic migraine subset and we just did adults. So we excluded patients that had a history of other neurologic disorders and those who had a history of eye problems causing vision loss. So, of course, dry eye does affect visual quality of life. But if we excluded any patient with dry eye in Utah, we would have zero patients in the study. So we just excluded patients who are actually under a physician's care for it. So this is just a table of the results in terms of the demographics of the groups. So there were 29 participants in the chronic migraine group, 37 in the episodic and 32 in the controls. There were more women than men in the migraine group. And I have the average age listed of the patients there. So this slide I know is a little bit busy. The table at the top shows what the average of the composite scores were for the NEI VFQ25 and the 10 items supplement for each group. So in these questionnaires, greater scores indicate a better quality of life. So what you can see from the table is that the controls had the highest scores than episodics than chronics. And these two tables here are just showing what the results of the unpaired T tests were. So there was a significant difference in terms of the scores of the chronic migraine compared to controls, the chronic migraine compared to episodics, and the episodics compared to the controls. So the chronic migraineurs had significantly worse scores than episodics who were worse than controls. And this was true for both questionnaires. And this is showing what the scores of the hit six questionnaire were.  So as you would expect, patients with chronic migraines had the greatest impact on their life. And again, this was statistically significant. Chronic migraines were the worst, worst, and then episodics and then controls. And then these are the results of the migraine specific quality of life. And it's broken down into three sub-scales. The role function restrictive are questions that assess how the migraines limit their social and work related activities. The role function preventative questions assess how migraines prevent the activities and the emotional function questions assess the emotions associated with migraine. And again, these are not surprising results that the chronics were the worst and then episodics and then controls. But they're really important results. So, and these were all statistically significant. And one thing that we thought was very interesting, the scores for the visual quality of life, questionnaires in patients with chronic migraine were similar. They were not different than published values for patients who had other neurophthalmic disorders, like ischemic optic neuropathy and ocular myosthenia and thyroid eye disease. So diseases that you would expect would really have a significant impact. Patients with chronic migraine were just as bad. So we're still in the process of analyzing the data. And so we want to find out whether or not there's a correlation between decreased or a greater impact of headaches and their visual quality of life. We expect that there will be. But the biggest conclusion that we are taking from it right now is that migraine has really significant effects on the visual quality of life. And if you see patients with migraines in an eye clinic, you know that that's true. But this is just kind of proving it to everybody. And their quality of life has really decreased. So we understand a little bit about why that happens, but we really need to look further into what actually causes the decreased visual quality of life. And the other important issue is that when clinicians are assessing the overall disease burden of migraine, they really need to include what their visual quality of life is in that. So that's it for that part. These are the references. Which items on the EFQ-25 were they lower on? Was it across the board or were there specific ones? That's a really good question. It was across the board. I think the worst, the most decreased scores were actually with driving and near activities. I think were the most significantly decreased, but they actually were all the way across the board. But that's a really good question. So last week, the trick that I learned from Eileen is that if you want people to pay attention to your presentation, you should show them a picture of your brother. So I thought, oh, I could probably find a nice one from my wedding this past year. But what I found out is that I cannot, and there are actually only three pictures of him from the entire wedding. And he also might be a little bit insane. So I thought, oh, so this is my brother, Caleb. And this is the second picture that I found. That's Caleb eating dinner. And the third. That's literally the only picture that was from the wedding. Okay, let me switch over. All right, so this is about a patient that we saw in the clinic. He was a 53-year-old man that presented with double vision. He'd been seen by an outside ophthalmologist and referred in. He'd had three months of constant double vision that started fairly abruptly. He was on a long drive through Wyoming at night. And he had noticed since the time of onset that it was constant vertical binocular depopia. He reported that it was progressively worse as the day went on and a little bit better after a nap. So when the double vision would get really bad, he would go rest his eyes for a little bit or go take a nap for a little bit. And he would notice that his left lid appeared to be drooping when he got really tired. He wasn't having any trouble swallowing or breathing. So he really had no past medical history to speak of, but he also didn't follow regularly with a primary care physician. His neighbor is an instacare doctor, so if he would have problems, he would just kind of like pop over there and he would help him out. So he didn't really find the need to go see anybody. He also had no past ocular history and he'd already had an MRI of the brain and orbit, which was read as normal other than some sinusitis. And so he went to his neighbor's house and they talked about it and they decided to do a course of antibiotics and prednisone to see if it would help. It did not and he had just finished the course at the time of his visit in the clinic. So on examination, his acuity was normal with some correction. His pupils were normal, his fields were normal, his color vision was normal, his pressure was normal. He had some asymmetry in terms of the positioning of his lids. His MRD1 was 5 on the right and 4 on the left. And other than that, his slit lamp exam and his dilated fundus exam were very unremarkable. And this was his motility and alignment exam. So what I'll point out is that he had a left hyper that seemed to be worse in right gaze and worse in left head tilt. He also appeared to have some up-shoot in adduction of the left eye and wasn't quite able to get the right eye elevated fully. So I will just throw that out to the group if anyone wants to throw out the answer. What typically will give you a left hyper that's worse in right gaze and worse in left head tilt? Yes, good job. Yeah, a left one. Okay, so I'll let you think just for a second about what would be in the differential for that. And I came up with some ideas myself. So probably most commonly top of the list would be congenital or traumatic fourth nerve palsy. You could get a microvascular fourth nerve palsy, although that's not very common. If you had a little schwannoma on the fourth nerve or another tumor pushing on it, he could get it. Maybe it doesn't have anything to do with the fourth nerve at all. Maybe it's myasthenia or thyroid eye disease. You could get a vertical deviation with a skew, although you probably expect that to be a little bit more comatent, or maybe demyelination or aneurysm. So we actually think that there should be another thing on the list that you might not initially think of. And I didn't want to give this away before, but I'm going to show you a photograph of him. So it's probably most obvious, or it's jumping out to everybody, is the asymmetry here. So he really has Halloween of the superior sulcus. And it's a little bit hard to tell in the picture, but this is actually much more full on the left eye than here. He also has some pseudo-retraction, and I'm sorry, the hooding with the dermatical aces really doesn't let you see it, but the lid margin is just a bit higher relative to its position to the limbis. And then I don't know how easy it is to appreciate, but he had about two to three millimeters of hypoglobis and two millimeters of enulfthalmos. So at this point, we thought this was very suspicious for silent sinus syndrome, so we really wanted to get a look at his images. So this is a coronal T1 fat-set image, which confirmed our suspicion. He's got an opacified and collapsed maxillary sinus here, and you can see that the orbital floor is depressed here. So his inferior rectus is just kind of hanging out there. And this is a slice from his CT that was ordered by the ENT after he saw us, and I'll point out a couple of other things on that later, but I thought it just kind of nicely showed the difference in the contour of the floor. So at this point, we were asking ourselves whether or not he had more than one problem causing the double vision. And, you know, we thought, is all of this related to the silent sinus? Is any of it related to the silent sinus? Could he have a congenital fourth that he no longer can control because of the hypoglobis and enulfthalmos? But if you look back at the image here, you can compare the size of the superior obliques, and if he had a congenital or a long-standing fourth, you would really expect the left to be smaller, but we thought it looked very symmetric. And in addition, his vertical-fusional amplitude was five prism diopters. So what we took from that is that he needed four to correct his deviation, and then he could fuse one additional prism diopter after that. So we thought that his vertical-fusional amplitudes were not increased, and essentially we did not think he had a congenital fourth going on. And we looked at the rest of his scan and didn't see anything like, you know, a tumor or other demyelinating lesions or something to suggest that he had something else going on. But we really couldn't say that he didn't also have something like miastinia or thyroid eye disease. So we did decide to test for that. And actually at this point, Dr. DeGree, she made me bet, like, place a monetary wager on whether or not I thought he also had miastinia.  But yeah, she made a lot of money from that. It was illegal tenders, what that is. So the testing was negative. So at this point, we were pretty confident that all of his vertical-what's that? That's irrelevant. It's irrelevant. Yeah, I lost. I lost. But so we were pretty confident that it was all related to the silent sinus syndrome. So it is a progressive enophthalmos and hypoglobus due to collapse of the orbital floor in the presence of asymptomatic chronic maxillary sinusitis. So it was first described in 1964 by William Montgomery, who was an otolaryngologist. He described two cases of double vision and enophthalmos with maxillary sinus, a case of pacification and collapse. And after that, there were several more case reports, but the term silent sinus syndrome was coined by Charles So Parker and his group in 1994. And they described 19 cases of hypoglobus and enophthalmos with asymptomatic maxillary sinus disease, meaning they did not have symptoms of the chronic rhinosunusitis. And so it typically occurs in the fourth to fifth decade of life. The largest review of cases had 84 patients. The average age was 39 and there were slightly more males as compared to females. So the underlying pathophysiology involves hyperventilation of the maxillary sinus due to obstruction of the osteomyatocomplex. So the first thing that happens is that you obstruct the sinus osc. And in 62% of patients, they have a lateralized middle turbinate, which we'll come back to. It can also be triggered by a deviated septum, a mucosil, a polyp, or even just chronic secretions. And interestingly, the underlying pathophysiology of silent sinus syndrome is considered to be very analogous to the pathophysiology behind chronic eustachian tube dysfunction and the resultant tympanic membrane atolectasis. So this is just a little diagram describing what happens in the course of silent sinus syndrome. So as I said, the first thing that you get is occlusion of the sinus, which eventually leads to development of a negative pressure. And it's not really entirely understood why some people who block off the osc develop negative pressure and some people don't, but it's thought to lead to development of negative pressure because the gas that's within the hypoventilated sinus gets resorbed by the capillaries of the closed sinus. And so then you get this negative pressure. So Eric Cass and his group proved that there was a negative pressure. They took an 18-gauge needle with a transducer attached, stuck it in there, and showed that they had sub-atmospheric pressures on the affected side. So then they get an accumulation of secretions within the sinus.  And that leads to chronic subclinical inflammation, which kind of like continues this loop, and eventually you get maxillary sinus atolectasis. So all patients will have enough thalamus, usually two to six millimeters. About half patients will get hypoglobis, usually one to six millimeters. Most have double vision. The most common late abnormality is pseudo-retraction, but you can also get pseudo-tosis. And radiographs are an essential part of the diagnosis. You must have maxillary sinus shrinkage and a pacification. You'll get a depressed orbital floor. And then you may see areas of bone demineralization of the orbital floor. It's a little bit controversial because it's not always seen. And in fact there are some case reports where the maxillary walls actually were thickened after. But a lot of people think that the demineralization, as a result of the chronic inflammation, predisposes you to collapsing the floor. So this was an interesting case series where they described the radiographic findings. And there were only five patients, but they all had an enlarged middle miatus and all had varying degrees of lateralization of the middle turbinate. So this is the CT scan from our patient, so I thought I would point out you can see how lateralized his middle turbinate is.  And you can use CT or MRI to diagnose it, but a CT scan outlines the anatomy a little bit better and can, from what I read, help you differentiate other possible causes better. So this is a list of some, most, but not even all of the items that would be in a differential diagnosis for silent sinus syndrome. So I'll point out a couple of things that are really important to consider. Like a malignancy can cause chronic obstruction of the ass, so you'd want to rule that out when they have a procedure. I'll talk about that a little bit. Sometimes it's just congenital asymmetry. Sometimes it's orbital fat atrophy or bone growth arrest if they've had external beam radiation. So this was a really important retrospective observational case series. And this group included 19 patients that have been sent to them with the diagnosis of silent sinus syndrome, but they didn't actually have silent sinus syndrome. They did have spontaneous asymptomatic enabthalmos, like asymptomatic meaning other than the double vision and that. So this is a list of what it actually turned out to be. So in the majority of patients, they'd had unrecognized orbital floor fractures. A large amount actually had Perry-Romberg syndrome or linear scleroderma, they're on the spectrum. It's hemifacial atrophy. And three of them, it was congenital facial asymmetry. Two of them actually had thyroid eye disease. One of them had HIV-related lipodystrophy and one had an asymmetric facial atrophy from Barakir Simmons, which is a rare acquired lipodystrophy syndrome. And one had metastatic breast cancer in the orbit. So just some important things to think about that may not be as obvious as it seems. So there are two main goals of treatment. The first is to relieve the obstruction and improve maxillary sinus drainage. And the second is to restore normal orbital anatomy. So the first goal is accomplished with a sinus procedure. The Caldwell Luke involves fenestration of the anterior maxillary wall, so they actually go up under the lip. But that's an older procedure and has fallen out of favor and people primarily use FESS now. So the two aims are to reestablish normal drainage of the maxillary sinus and then to aspirate in culture secretions and you can also do a biopsy if you're concerned about malignancy. Functional endoscopic sinus surgery. So this involves using an endoscope to go up through the nose. So they may or may not start with a septoplasty to improve access.  So the need for and timing of reconstruction of the orbital floor is in some ways, some people think it's a little controversial. In this series of patients, 22 out of 23 of them had resolution of their symptoms after just FESS alone. But not everybody resolved with FESS alone. So there are a couple of different timing options. You can do a single stage procedure with the FESS or you can do it two to six months after the FESS or not at all. The implant choices, implants that have been used successfully are varied. So you can do titanium plates. You can do implants. You can do the septal or castor cartilage. Another interesting option is using hyaluronic acid gel. So this is a group out of Greece and they injected like two CCs into the intracronal and extracronal spaces and had good, they had improvement of the patient's enaphthalmos for about six months. But this wouldn't be expected to really do anything for hypoglobis. But it's an option. And I thought very interestingly you could also do an inferior oblique myectomy on the contralateral side. So David Geithen wrote this up in 2010 a patient who's a 41 year old man who presented with double vision and he was found to have a silent sinus syndrome on the right and causing an apparent left superior oblique palsy. So they felt that the depression of the orbital floor resulted in tightening of the ipsilateral inferior erectus and inferior oblique and then loosening of the ipsilateral superior erectus and superior oblique and then that mimics fourth nerve. But they actually also had the apparent inferior oblique overaction on the left side just like our patient had. And so the guy in the case had already undergone FESS and didn't have complete resolution of his double vision. So he was going to have reconstruction of the orbital floor but then somebody sent them to this clinic so they thought let's try an inferior oblique myectomy and it worked. So I thought that was very interesting. That's it. Any questions? Which MRI scan didn't show the sinus? It did. It just was an MRI scan. Yeah, that was the MRI that I showed was from the outside hospital. We just got it sent in. It's hard to know everything but it really depends on your fellow physicians with expertise like in radiology and your nose and throat to help you out when you're in a bind. So you really feel screwed when you send somebody for an MRI and they don't read it. And so sometimes you just have to do it yourself. In fairness, a lot of radiologists have never heard of the silent sinus and I've heard that a lot of you ENTs haven't either. How long does it take for resolution if they are adequately aerating that sinus and how long does it take for the orbital and the avenue to do it normalize and make the double region better? That's a really good question. I have no idea what the average amount of time is but I know that typically people will give it up to six months. Dr. Patel, do you have any more experience with that? Let's make it representative to the 22 out of 22 normalize of the silent sinus syndrome. If you look at it, we don't found most of it. We can double read the symptoms. So if there are patients who present with dryness and the common radiations, at least if they are medical products on that side. So it's a combination of pseudo-infection and pseudo-physicists. If you look behind the side of the eye, there's no major component of the mechanism. So that is a really controversial because you never rest along the aeration of the ability for developing the symptoms of the sinus with the natural normalization. So what do you do about six months and then you do a new product with the normalization? Sometimes you have a different measure to do that on the product and so on. So that's the one component of the mechanism. They only look at symptoms with the sinus. So I think the question of normalization is that if you look in this show you make a video of the sinusitis, which if you make a custom holiday you can show the sinusitis in a different way. It's the sort of normalize the normal. None of those videos show the sort of normalization. And our patient did have the fest and he felt like his double vision was a little better but it's not resolved. So he's actually good to see you and why he's so excited. So Any other questions? Yeah, good question. Are there any rotational aspects of the double vision? No. Yeah, no. There was not a cycloportical indication of any questions. So that brings to mind what to do with fixing. And you know, I have a lot of respect for doing a guide one. But if you recess the contralateral into your bleep you're probably going to give it some portion. So the thing to do is that we're going to discuss if it doesn't get better, which it may well do gradually. You want to check the worst actions in the operating room. If that gypsilateral inferior rectus is tight, I mean, keeping in mind you've got left eye higher than right, your options are either to bring left eye down, this is what you're going to accomplish with your bleep recession or bring right eye up, which is what you would do if you'd be inferior bleep. On the left, if you recess the right inferior rectus, you'll bring the eye up. You'll help normalize the position of the eye. And if that's tight, it'll turn out to have been the right thing to do. Probably a decision you can't really make in the operating room, but that issue of torsion is kind of key to do. If you do an inferior bleep recession and a patient that does not have torsion they're going to come back saying, yeah, things are kind of okay, but now this image is twisted like this doc and then you're kind of playing the catch-up trying to fix that by doing offsets on additional muscles you're operating on which won't be the best thing. So the smart thing would be for the patient to get better than I've ever had. The right-hand space was that the patient had not had a certain of the muscles served. Right. He had a FES. Yeah, so I think your steps should be your FES can be ordered to the natural rectum before you do FES. It's just like a thyroid disease. Absolutely. It's the old syndrome, if you go through a rectum surgery they'll fix you right away. It's a more common approach. It didn't come up in any of your in any of the articles you cited, but I've got a patient I've been following for about 10 years now who just doesn't want to take the time out of his schedule to do strobism surgery. So we've been managing him with prisms and he's been currently happy with that. That works too. Good. This guy's deviations probably works in common. Just don't look right. And he's slightly better already. Didn't you talk to him? Not entirely. But quite a bit better. And that's just, he's only close to like 6 weeks or something like that. Yeah. All right. Nice job. Thanks.