Dr. Yale Fisher: So, my name is Yale Fisher, and I'm an ophthalmologist of--and I live in right now Florida, but I go back and forth between Florida and New York. And I've been in ultrasound for about 40 years, so that makes me very old, but very happy

And what we're gonna talk about today is something called distance measuring equipment. And that's what this is. We're gonna talk about pattern recognition, but we're gonna talk about distance measuring equipment

If you want, you can get an ear set--he's got it? Okay. Thank you

We're gonna talk about Contact B-Scan and how you would use it, and I'd like to make this interactive. If I say something you don't understand, you stop me. And if I say something you do understand and have a question about it, you can also stop me. If you want to give the talk, you can also do that, too

So, we're gonna go through this. I don't have any financial interest in this company. I don't have any stock. So, there's nothing really for me to disclose other than the fact they're gonna pay me to talk for an hour, which is okay, if they do. But, they may not, which is also okay because I'm more interested in that you learn something than I get paid

So, pattern recognition - we're gonna use pattern recognition, because over the course of years, what I've realized is that most people really do indeed make diagnoses from the patterns that they see on the screens. They may not even understand all of the reflectivity, but they understand what the pattern looks like

So, the reason I happen to like this particular machine, and there are many others that you can take, and I'm not sold on any particular one except for which one gives the best patterns. And right now, this company gives an excellent pattern recognition

I like it because you can store movies. And I no longer really take images that are solid or still except for the purposes of proving to the federal government that I've done the test because I don't get anything out of just a static picture

I always find it funny when people run up to me with a whole bunch of pictures and say, well, do you think this is a melanoma, or is this a vitreous hemorrhage, or is this a retinal detach--I have to see the motion, and we're gonna get into that in a minute

But, if you can store an image and take ten seconds of what the image looks like, hold the probe still and ask the patient to move their eye, you're gonna get the last ten seconds whenever you step on the pedal to stop the little probe from moving, you're gonna be able to review it, and you can review it with someone else. And all of my fellows do that with me

If they see something in the middle of the night--I used to wake up at three and come in. Now, I look at the pictures, look at the movies the next morning. It's a lot easier on me. And all they have to remember is where did they have the probe when that image was taken. You'll see why that's so important in a few moments

So, it gives you preservation, and it allows you to look at things remotely if you're tied in to the system, and that can be done. I personally don't do that, but I have done it for a few people in the world

The technology has changed since the 1990s. There have been scan converters, which really made everything go digital. And most of the physicians didn't even realize that this is an analog system which has been digitized

So, somewhere along the line, scan converters got better, and up until that time, they weren't. The digital imaging improved, and we got inexpensive memory, and we got image registration from cartoons, which I'll show you in a few minutes, and then we got web capability. And you'll see why that's so important so that if you don't get something during this talk, it's already on the web available to you any time you'd like, and it's free, which is even better. And there's no advertising. So, it's really the way the web was made

So, just by background, all of these distance measuring pieces of equipment, and that's what they're called--if there's any pilots in the group, you know, you were taught from a cockpit that the instruments in front of you, one of them was called a DME, a distance measuring piece of equipment. And that's what these are. They're all based upon time. And with ultrasound, we're actually waiting for an acoustic impedance mismatch, and in optical coherence tomography, we're looking at reflectivity

So, they are timing mechanisms for distance from which we get a group of A Scans and we put them into a bunch all together and we get B Scans. But, they're all time of flight devices. Trouble is sound travels slow, and unfortunately, light travels fast. So, there is a difference in what you can pick up, and the frequencies will limit your resolution

Many people have never seen ultrasound. Well, that's it. And these are Schlieren optic pictures. It cost about 2 million--no, $.5 million to make this picture. I was fortunate enough to be there when the guy was doing it, and I said do you mind if I take a copy. He said, I'm going to lunch, if you want to do that, go ahead and do it, I don't want to know anything

So, I did. I took it. And I've never charged a dime for it, and I've never used it for anything myself

But, this shows you what you can do to ultrasound. This is called continuous wave ultrasound. This is, however, what we use, pulse echo. And that's one pulse

For those of you who remember the Hunt for Red October, if you haven't seen it, go and see it. This is one ping only. And this is obviously slow motion. So, you're actually seeing the echo or should say the force go out, the wave front go out, and you don't see any return because it didn't hit anything, it's in water

You can put a little lens on the front and make it get thinner, and the edges from here to here would define your lateral resolution. That's why your lateral resolution's not great, not in B-Scan

This transducer wouldn’t be used because of those two side bars. But, this is just an image

This is what happens when there's an acoustic impedance mismatch. You'll notice that some of the sound comes back. We call that an echo. In an OCT, I find it quite funny that they call them echoes, as well

There's no echoes in OCT. It's light. It's not sound. But, I'll let them get away with it, and I don't mind. Doesn't really matter. It does tell you what's going on

So, this is what happens if you're not perpendicular. This is why perpendicularity in ultrasound is crucial to being able to make a diagnosis because it obeys the laws that make light change or sound change position

And you can see this completely misses the transducer. So, guess what you would see on the screen? Nothing

So, you've got to be able to make all of your images so that if you want to measure them in returning echo strength, you must be perpendicular to what you want to read. And you can have multiple signals coming back

It's amazing the thing works at all. But, it does. And it works consistently every time you turn it on

And if you're off center, even with all those echoes, it still obeys Snell's Laws of Physics. It gets bent in the water, and the acoustic impedance mismatch will go the wrong way. And with all those echoes, guess what you're gonna see? Nothing

So, it's important to start out this way and understand what ultrasound looks like. You can have parallel sides, which is what you get in quantitative A-Scan if you use just the A-Scan. Or, you can have a weekly focus B, which isn't quite as good for some things, but it gives you a B-Scan image, and that allows you to do pattern recognition

And this is more like an eye. The sound goes into the eye, and at the bottom, there's a piece of metal. And the metal rings, and that ringing you'll see again when we look at PFO left behind at the time of antrectomy

So, we all clear what ultrasound looks like? You're using pulse echo, ten megacycles. A megacyle's ten million cycles a second. That's a lot. And it rings for about 80 nanoseconds, and it listens for 300 milliseconds. So, it's listening a lot more than it's ringing, okay

Well, let's move on. How did all this begin? This is the guy that started it all. Well, not quite. The very first ultrasonographer was another friend of mine. I'll show you

But, this was an observer. He was in the church, believe it or not. He was known for his interest in animals and the preservation of the earth. Sound familiar

And he was doing work with predicting how animals would use sound. And he worked with this little guy. And that's your first ultrasonographer. It was he who said that these animals could fly without the use of their eyes, and he put cotton on their eyes, and they flew around the room quite easily

And of course, when he announced this, they immediately wanted to jail him as a heretic. How can you see without your eyes? And the answer is these animals were seeing with their ears. They have a special little voice box, which produces a sound wave, and their ears are quite large. So, they can listen and navigate and not hit a wall

They've gotten a pretty bad rap. They're not so bad. But, I'm not sure I'd want to have one flying around in here, at least not right now, maybe later on when I'm not here

So, how did this all begin? This is Jacques and his brother Curie. You may know the name from a woman by the name of Marie Curie who was not French. Most of you who are from Europe know that she was Polish. She was a student, and came to study under Jacques Curie's tutelage. And I guess the lab closed early some nights, and she was very involved with him, and she changed her name after she married him to Marie Curie. Her name was Sklodowska originally

And she was a Polish immigrant to France. She was sent there by his father because women were not trained in Poland at the time. And he was the great guy who was studying ultrasound

What's really interesting is almost ultrasound didn't develop at all. And the reason had to do with jaywalking. Jaywalking almost stopped ultrasound completely

Why do I say that? And most people don't even know this. Pierre Curie was a jaywalker. He liked to walk. And he didn't always look up

And one day, it was raining in Paris, it was cold, it was in the springtime, and he carried a very large dark umbrella closely over his head on--right near the Pont Neuf in Paris. And as he was walking, he didn't realize where he was going--and this is a picture that was redone. He was killed when this military type truck basically pulled by two horses rolled over him. He couldn't see the truck coming because the umbrella, which was over there, blocked his view. He stepped out from behind a cab, and Pierre Curie was killed

His wife went on. He had already received one Nobel Prize with her for radium and polonium, named after her native Poland. That's where it came from. And she had extracted this from material from the ground

None of this information gets known today. We all forget about history. But, I like it. It makes me feel the flavor

So, he died when the carriage went over his head. She went on to another Nobel Prize, one of the few people ever to win two Nobel Prizes, one in physics and one in chemistry. They won both, one together and one by herself alone

She became so angry that she would not talk to anybody. It changed her entire life. She was refused entry into the French Society and never gained access to it until recently when she was--must be French, I can tell--till after, oh, I guess within the last 20 years, she was elected to the French Society of Science

But, that's how it all went down. These were real people. And without him, we almost lost ultrasound

But, he had a fellow, and the fellow developed sonar. And he kept all the ships, all the submarines from coming in during the first World War. That fellow then grew up, had four children and eventually had a torrid affair with Marie Curie in the 1930s

And it was because of the torrid--sounds familiar, doesn't it? Petraeus, Pierre Curie - I don't get it, but whatever it is, it must be there. And for whatever it's worth, he carried on ultrasound

In the 1950s, ultrasound really began with the report of Muntin Hughes [sp], Oksala [sp] from Finland and Baum [sp] in Greenland, and I know this is Gil Baum, that's Oksala and Muntin Hughes

And this is what the original B-Scans looked like. You had to fill up water in front of the face and put on a big thing like that. Sometimes, they would even give you a straw and they would submerse you in a tub. When the water raised above your eyes, they could get images, and you would breathe through the straw, hopefully not your nose

And then, in the '50s, all this happened with a bunch of guys that I know. This is Jack Coleman [sp]. This is when he was about my age, about 40 years ago--no. And this is him now--Art Kenney [sp], who's died, and this is my mentor who taught me everything that I know about ultrasound, Nat Bronson [sp]

People forget about him, but the magnet that you use in the operating room, if you ask the nurse, the one that pulses the one you hold in your hand is called a Bronson Magnet. Nat Bronson did live, and he was a wonderful, wonderful guy

And after that, we used to give talks, hundreds of talks. Nobody listened. So, we would--it was kind of worthless

So, the physicians kind of got dropped by the wayside, and technicians kind of took over. And so, physicians were put in the position of never being able to do it themselves

I don't really care who does the ultrasound. All I care about is they do it well and express their findings to somebody who needs the information to save patients. The whole game is patients. There isn't anything else. That's all we exist for

So, I'll show you a little bit about an ultrasound. This is amplitude on the side, and this is the A-Scan. And if we put an eye in the middle of it, that's what your A-Scan looks like

This is called time amplitude. Time's along the bottom, amplitude's along the side. A little bit difficult to interpret, but if you take a whole bunch of them, a whole bunch of A-Scans and then let them kind of fall over just like match sticks, they'll come to the front surface, and they'll make the phosphorous glow on your little sets, and as little--well, they're LEDs or whatever they are now. And you'll see a B-Scan. And that's how you get a B-Scan

So, when you put on a simultaneous A-Scan and you see that little vector line come across, that vector line is just one of the A-Scans that's been knocked out and reshown as the original A-Scan that it was. So, when people talk to me about, well, I can't use A-Scan, I don't really understand, it's just a bunch of A-Scans into a B-Scan. It's pretty easy to do

And I go back and forth. I use simultaneous A-Scan so that I know where my A-Scan is coming from. I like to see a vector. It's not as pure as putting down the B-Scan probe and picking up a pure A-Scan probe

However, for me, I want to know whether I'm perpendicular, and that's one way to do it

This is how you do a good scan. I usually use it on the lid, and I will usually put it right on the lid with a white dot towards the nose. And it will give you, if you aim at the bottom of the eye, the retina, and the vitreous and the sclera and the choroid are all mixed together in front of the strong reflection from the orbital fat in Tenon's capsule

So, that's the image that you get. And if you know that this is the top of the screen, and that's the bottom of the screen, so this part is coordinated with that part and this coordinated with that part. You've got to know the registration of your image

And then, that beam comes out of that probe just like that, and if you move it back and forth, you can see the image changing, all right? It's pretty easy so far

Now, what's not so far is how to interpret it, and what's not so easy, you have to spend a little time with it because how you hold the probe and where you're aiming is gonna determine what pattern you're gonna see. You remember, we all started with pattern recognition, all right

So, everybody who does ultrasound, as far as I'm concerned, needs to know the anatomy and pathology of the human eye. That's why the radiologists--are there any radiologists here? I have to be careful. No? Okay. We're all right

That's why radiologists get into so much trouble trying to interpret ultrasound of the human eye. They don't know the pathology, so they don't know what the cross sections are gonna look like. But, you do, and that’s the reason you win, because you can feel what a cross section of a particular item will be

All right. So, let's talk about resolution. You know that OCT does a really good job. You can get six microns axially. They don't tell you how much laterally, but I'll tell you. It's about, oh, I guess 15 microns laterally. But, you can only get it in a small area in the back of the eye

They all kind of pooh-pooh ultrasound, but that's okay. I accept that. I've been working with Euneusie [sp] all my life. He's my partner, by five years my senior. And I've learned to take a lot of guff. But, it's all right. I like it. It's good. It makes me work harder

The axial resolution of a B-Scan, because it's weekly focused and the fact we're working with sound, is somewhere between 100 and 150 microns. And the lateral resolution is not terribly good. It's about .2 to .4

Well, that's enough to be able to fall into an optic nerve head cup if you're subtle and if you carefully look at the head of the optic nerve. And we'll show you that in a little bit

But, you can look, unlike OCT, all the way out to the iris. And indeed, if you tilt the probe all the way forward, you'll see the pupil, and you'll be able to go back to the optic nerve

So, I have a regimen that I use, and that regimen is based upon how I do my exams. I always start at the top with the eyes open and the patient looking down. Why do I do that? Well, number one, if you close your eyes, I don' pick up the esotropias and exotropias. And if you don't know that the eye is not pointed in the same direction as the one you're looking at, you'll spend forever trying to find the optic nerve. It's like it disappeared. Well, it didn't disappear. It just moved, all right

So, if you leave the eyes open, you can see what the people have, and they don’t get so scared, and they'll look down--you say just look down at your knees, and you'll put the little white dot, which is my thumb, on the upper lid, and you push it down, just like we showed you in the picture, and you sweep the probe. And if there's nothing there, you're one quarter of the way home, all right

You do have to remember that the top of the screen, when you're in a position like this, is what? Well, the top of the--over there is always closest to the probe. Over here is furthest from the probe. Remember? Time and distance, right

But, the top of the screen is wherever the white dot is. So, if you're seeing a cross section on the screen and your probe is here, the top of the screen is gonna be down here. And the bottom of the screen is down here

And now you say, okay, I got that one, and then you do this. You go off to the side

Screen hasn't changed, but your registration has changed. What's the top of the screen like this? Superior and where? Nasal if you're looking at this portion, right? And the bottom of the screen? Inferior and nasal

Now, nothing happened except you moved the probe. And now, you're gonna move it again to here to do the top of the eye

Now, that's closest to the six o'clock. This is closest to the 12 o'clock. Look at my thumb sticking out. What's the top of the screen? Top of the screen is superior and nasal. Bottom of the screen now is superior and temporal. Screen hasn't changed. You've changed the probe

What we're doing is an exercise, and that exercise is to make you comfortable with analyzing and registering what you're seeing on the screen. If you don't know where the probe is, it's hardly even worth it to take a picture or even a movie because how's the person gonna know what you're looking at when you don't know what you're looking at? So, that's the game, all right

How do we make a diagnosis. And we're gonna get to some real stuff in a few moments so you don't get bored and go home, which you probably will anyhow. But, that's fine

You need three things to make a diagnosis. If you don't have this and you put down the probe or turn off the machine, you are dead. You can't bring them back unless you take a movie

The first thing you need is real time. What is the movement that is occurring on the screen

The second--in other words, retinas wiggle differently than the vitreous, okay? That's called real time. It just means you're storing movies rather than pictures

The second is grayscale. How strong is that returning echo? And you've got to be perpendicular to it or you're gonna miss some of it, sometimes all of it, sometimes some of it. You need all of it, okay

So, that's grayscale. And if you had an A-Scan on at the same time, the strongest echoes would be the one with the greatest height, but only with the greatest height if you're perpendicular to what you're measuring

So, you say, well, that should be easy. Yeah, it's easy if you know how to do three dimensional thinking. That’s the last part

How are you gonna put together an image in your mind of what the inside of the eye looks like if you can't take cross sections and build them into a larger image? To do that, you have to be able to know what images you're seeing and what things would look like in cross sections

Again, this is where you guys win if you're all ophthalmologists and the radiologists lose, because they don't know the anatomy. And we're gonna go through a couple of these in a few moments. But, basically, it comes down to interpretation of expertise

Let's do one, all right? We're gonna pretend that this is an entire eye, all right? Are you in it? Are you with me, all right

Up there is the cornea. Back there is the optic nerve. And we've got a total retinal detachment within this area. There's a big round thing in here, looks like an ice cream cone. Can you see it? All right

I'm the probe. I'm outside this wall, and my head's a transducer. So, they've taken my probe. We're not going right through the cornea, because that goes through the lens. You don't want to mess with the lens - screws up your ultrasound. And I'm gonna pass this thing right through the inside of the eye from this side to that side

Now, I've chosen something that's symmetrical. A retinal detachment's like an ice cream cone. We don't have to worry about any asymmetry here. It's a total detachment. The optic nerve is there

And here I am, and my head is a transducer, and all I'm doing is this. That's what's happening, all right

So, I can't see the optic nerve on the screen, can I, because I'm not pointed at it. I'm pointed this way

So, I jump inside the first space, and what space am I in? Where am I? If the total detachment's in the middle of the room, and I jump through there, and I'm inside the eye, what space am I in if the retina's detached? We're in the sub-retinal space. And in front of me, I'm gonna see something coming towards me, and then it kind of goes away from me, and it kind of goes away from me down there, and I'm looking up and down and I don't see anything else

So, on your screen, the first thing you're gonna see is the curve of a circle, half of a curve. And then, if I jump inside that thing, I see the other side of that - again, a half a circle away from me. So, it's gonna look like that, right

And then, I jump outside the eye. And fortunately, the eye is symmetrical, so you're just gonna see the normal size

So, the cross section of a retinal detachment that's total is a circle or an oval if you're a little off center or if it's not a perfectly round thing

We've just done the very first part of three dimensional thinking. And you need that, or you can't survive in ultrasound. You need to know what things look like inside an eye

Well, you already know that. You know what choroidals look like, you know what detachments look like, you know what traction detachments look like. You guys are solid for this, solid. But, you need good images. You need the best image you can get

And right now, there's a few companies that will manufacture that. One of them is Ellex. If you want the other ones, I will tell them to you, no problem. They're not paying me enough not to. But, they do make a great product, and I've used it for years

So, if you'll look on the website, you'll see that most of the images come from Ellex. I don't deny it, and I don't say anything. And I talk to anybody that'll listen to me about ultrasound

Why? I want to help the patients. And at three o'clock in the morning, there's nobody around. And the residents and fellows need to know this as soon as they start their practice

So, let's see if any of these pictures will play, and they probably will--they may not. We'll see

There it goes. So, this is a person who--this is what real time is. You see something wiggling? That’s real time, okay

This is a person with endophthalmitis. And unfortunately, this person was one of the people that got an injection that developed an endophthalmitis. And what you see here is the back wall of the eye. You can see this granular material here, or so it looks like

And I like to call that minimal to mild reflectivity. It may be a little bit stronger down here because this is the form vitreous, and that's the liquid vitreous. And you can follow them along

So, this is a case of endophthalmitis. And what do you think this is the beginning of? Anybody? A choroidal, because the pressure's dropping, because the eye's being toxified

So, we know what choroidals look like, and this must be a view from the side or a view from the top or the bottom. But, it's not 360 degrees. It only involves this portion of the screen

I happen to know I took this picture from the side. So--and I was aiming nasally at the time, so this is an inferior nasal choroidal

So, if you give the injections and they come back the next day and this is gone or this is more liquefied, hey, you feel better, they're getting better - pattern recognition, but you knew the registration of the image - critical, real time. Reflectivity is called grayscale, and then three dimensional thinking

If I move the probe back and forth, I can make this disappear because I'm gonna get out of it. I'm gonna be pointing more at the optic nerve. You won't see it any more. So, complete scanning of each quadrant is critical

So, this is the next day. You think we're doing better, or you think we're doing worse

Choroidals got bigger. My probe was in the same place. You want to follow what's going on. This at least is getting smaller. More of this is more liquid now. Believe it or not, even though the eye is toxified, it's getting better

And this is another image. I'm not gonna show it

I meant this one to go first because you just guys--or some of you were here for glaucoma lecture. You remember? Yeah, he was awake, I could tell

But, believe it or not, this is the head of the optic nerve. And I'm gonna make it play for a minute so that you can see that you really can fall in to an optic nerve end cup that's large enough

How big? Well, depends how much you want to cheat because I can make it happen that I can keep the sound in something long enough for it to show up, and I'll pick up to about .3 optic nerve head cups with just a plain old neural [sp] 10. Better if you got a 20 megahertz, but I can still do it, and I can tell you whether an optic nerve disc cup with what you're working with in your places

I don't know how many machines you've got, but it's not absolutely interchangeable. I hate to say it. Ellex has a really good product. Because it makes me feel like I'm pushing them--they have a good product, you know? It's like trying to change somebody if they like Heinz ketchup. You can find other ketchups, but it doesn’t taste the same, right

Now, let me go back one and see if I can make this play. And I'll tell you why this is important. Can you see the cup now? You couldn't see it until I put it into real time. See me go back and forth? I'm just moving my hand just slightly, just touching the probe back and forth

And you'll see that the cup shows up every time as a little indentation right on the head of that optic nerve. And I know that's a .6 cup with my machine

Now, I say my machine because I'm used to it. If you take me to another place, I usually will use my eye to judge what my eye looks like with a different machine

We're coming down to the end. Don't get nervous

I thought I'd show you this one because most of the time, you don't get to see a vitreous face separation, and this is one. There's the face of the vitreous gel

And so, this person has a vitreous face separation. This is the solid gel, and this is all liquid. And you can go back and forth. People come in and say, well, when are my flashes gonna stop, doctor? I don't pick up an indirect because I can't see the vitreous except for the Wisis [sp] ring. I'm looking to see where they have any tears

And I didn't tell you that I do longitudinal studies on everybody

Flashes and floaters, number one thing - I'm picking up an ultrasound probe. I don't care about the indirect right then because they're gonna have to dilate. I can't look [unintelligible]. If you look too early, even if it's three o'clock in the morning, you don't want to wait around. You've got to know, do I need to call the OR, do they have to not eat that morning, do I have a detachment that has to be operated on, or do they have a retinal tear

At Bask and Palmer [sp] where I work, most--during the wintertime, I teach the residents, look, you bring in a retinal detachment. I use the ultrasound probe. You use an indirect, and we'll compare our maps, and I'll do a retinal drawing

Where are the tears? Where is the detachment? And I use schleral depression, okay

We've got a couple more to show you. I think you'll like it

Anybody have any idea what this might be? What are these comets? I don't know if any of you have ever done any vitreoretinal surgery, and if you've put in any heavy fluids like perfluorocarbon. But, that's what they look like. And once you put it in, I don't care what you do, you'll never get it all out

And every single patient that gets PFO in their eye winds up with a few little bubbles somewhere inside the eye which look like foreign bodies. They're ringing. The sound gets into the bubble of the PFO and goes back and forth. And if you measure the distance from here to here, that's the size of the bubble. It's just ringing like it just normally would because it's got a difference of what? Acoustic impedance mismatch to water. And the eye's filled with? It’s not chop chicken liver. It's water, okay

So, that's what PFO looks like. This is fun stuff, I hope

All right. This is a longitudinal view, which means I didn't have the white dot up or towards the nose. Instead, I put the white dot--my hands aren't right--right towards the cornea. So, if the cornea is the--now becomes the top of the eye, the bottom of the eye's gonna be further back in the globe. And you're gonna see the optic nerve

Now, why do I want to do that? I want to walk along the vitreous vase. I want to see where the tears are. And the tears all occur right where the vitreous is still attached

If it's a round tear, the operculum will come off and float on the back surface of the solid vitreous. I don't care about that tear. It's not gonna detach. The only ones that detach are usually the ones that have traction on them

So, why do I show you this picture? Let's see if we can see it. I thought you'd like to see a retinal detachment occur. Most people never get to see this in their whole lives

There's the tear sticking up in the air, and that's how it pulls when the vitreous gel sticks on it. Look at it again, because you can see the wallpaper literally being pulled off the wall. Watch it careful

So, I was telling this guy--this was about six o'clock in the morning when I got into the office. And I said stop wiggling your eyes. I did it--I did this once or twice, and I told them stop now, you're not dilated, but I know you've got a detachment

If you want to get lasered, stop pulling your retina off. He says, how do I do that? And I said, I'm gonna cover your eyes. And I did. I made him sit there with blinders on both eyes so he wouldn’t wiggle any more so that we could get a laser as soon a he was dilated, and it's helped him. I can't say that he wouldn't have been like this even if I didn't do anything. But, every time he wiggled his eye, more of that retina was coming off as the vitreous pulled it

And that's how you get a detachment. You won't see this again, most likely. I was just lucky. The guy was even luckier

Remember, I told you there was a big detachment in an eye that was complete? There's one, but you can't tell it until you put it into real time. These little cysts tell you how chronic they are, and you can see that there's no movement as opposed to the previous picture where you could see things flopping around

You want to try and fix this? Good luck. You can probably fix it, but you're gonna wind up with a little postage stamp of neuro-sensory retina right around the head of the optic nerve

I've got exactly four more minutes. That's it

Some people use silicone, and they stick it inside the eye, big in Europe, and they love it. Trouble is you've got to take that stuff out if you can. And most of the time, you can

Guess what? You can't take all that stuff out, either. Every time you put any PFO or silicone inside an eye--tell me what this is, Brucker [sp]

Mr. Brucker: It's stuff floating around in the eye

Mr. Yale Fisher: Silicone - you can't get it out. It's just--even when you extract it and you wash it and do all this other stuff

These are all the iatrogenic foreign bodies, part of a lecture that I give as a talk, for what happens to all that stuff we stick in eyeballs

Now, if you leave the silicone in for a while, this is what it looks like. If silicone's in, look how big the eye gets. Why do you figure that

This is what it looks like if it's emulsified and there's bubbles in the silicone, and this is the eye. This is a normal eye down here. What happened

What happened was sound doesn't travel so fast in silicone. It slows down. Remember what I said - time is distance. If it takes longer for the signal to get through it and to get back, the machine's gonna read that as a bigger eye

But, at the bottom, this was not a complete fill. This person had a hemorrhage still. And the question that was posed to me is they could see through all these bubbles, not so well, but they could, but they couldn't see through the blood that had been crushed down to the bottom of the eye by the floating silicon. And they said, is the retina attached or detached down there. They know they can see through here

So, if you're tricky and you can get around this little bit, and I'll have to show you how to do it, but it's doable. It's a little bit more advanced than we want to go into now

But, in real time, you can watch down here and you won't see--you see a little tiny little flicker down here, but nothing that's a detachment. So, we told the person who had done the surgery that, indeed, it was my partner, Spade [sp]

And I said, Rick, you're all right. You did have a little bleed, but it's okay. You're gonna have to take that silicone out, anyhow

How about this one? I showed you a big long eye. Now, I'm showing you, what? A little short eye. And suddenly, all the orbital fat's disappeared. Well, you can see some of it up here, but all this is gone

So, what's this? And what's all this stuff? This is an eye that's had a hemorrhage in the past, chronic uveitis, hypotony, it's shrinking, we're going into phthisis, and this is calcification of the choroid, perhaps also the sclera and maybe even some of the retina

But, calcification's like what? Stone. So, you figure you're gonna get ultrasound through that? No way, Jose

So, it doesn’t look like there's anything in the orbital fat, and this is classically described as shadowing. That's what it means - pretty easy

So, I thought I'd show you this one. This is a person that had silicone in their eye. Perfectly good view in, absolutely clear

We do a little ultrasound. What do you think it shows? That, same eye. Remember what I told you about those little bubbles? You say, wait a minute, I could just see inside this eye. Where's all that stuff coming from

Well, if you didn't know that silicone could be left in the eye and it does demonstrate a Ralay [sp] phenomenon, you want to go look it up, it's on the internet, it's under Wikipedia. Ralay was an English guy, I think. I think he was English. But, I know he was from Europe. Where was Ralay from? Do you know? Oh, he's a physicist and described what happens when large frequencies hit small objects. That's what happens

So, I went back to this picture again. I don't know if she has it. Yeah, she does, but I can't make this go away. Oops, let's see if I can go back to it. There's all the bubbles. See them? I'll go back one more. See all the bubbles popping up? Like champagne in an optos [sp] picture, all right

So, what we've taken you through--I don't care who does it - physicians or technicians. As long as your technicians know anatomy, I'm fine with it. If they don’t know anatomy, I'm not fine with it. You're gonna get these ridiculous reports, and you're gonna look at it and say, well, I don't know what to make out of this

That's why it's a good idea for you to know how to do ultrasound. If you want to go on the website, we started one in 1996, the idea for it was there. And it has gone a long way

In September 2009, it's called Ophthalmicedge.org, Ophthalmicedge.org. It's free. There's no advertising. There's a whole series of lectures much longer than the one I've given you

I've got to stop because they've got someone else going on here. And it's a great tool. It's around the world. It's in 101 languages, 156 nations. And just for your records, there's 196 places in the world that we consider to be countries

So, it's really made a big progress, and it was launched as an ultrasound alone. I got tired of doing slides, so I gave up and I decided to do this instead. And I just want to show you that--what it looks like now

And there's one other thing you should see, and then I'm gonna stop. This site now has enormous bandwidth. It can handle anything. You guys want to contribute to it? You send it to me, either in New York or in Florida. You can find my address on the website. You put your name on it. We'll put it on the web

This is all cloud technology. And I thought you'd like to see a cloud room because they all tell you it's a cloud. It's not a cloud. It's a room. I don't know why they say it's a cloud. But, it is. I mean, the technology--and if y'all talk to the people that don't wear ties--that wears suits and no--and sneakers--anybody around here with sneakers

But, anyhow, these guys are really different. I mean, they--I can't--and they're like--they're in math, right, and I'm not, which is fine. We need each other. That's a cloud room. That is the cloud room for something you know as Facebook

Now, if they knew I had this picture, they'd probably shoot me, but that’s it. That's what it looks like

And this is the website as it stands now. Once you go on it, you can read about it. But, go to resources. And we've put on not only ultrasound, but how to do a buckle in real time, how to do a vitrectomy, how to do endoscopy, how to interpret fluorescein angiography, OCT, ICG. I'm gonna make this into a Wikipedia of the eye with people that hopefully we can all keep this thing current

Don't need a publisher, don't need anything - I can load your stuff. You retain the trademark. If you want it back, you can have it. We can take it down in 24 hours

Ed Ryan [sp] did the buckle. He's from Minnesota. He's done about 15,000 buckles in his lifetime. Steve Charles did the vitrectomy. He's down 3,742--speaks very quickly. I'm sorry, Steve, if you're hearing it

And, oh, the endoscopy I did. Bob Flowers [sp], who started ICG in part, has done the ICG part. Rick Spade's gonna do the auto-fluorescents

I'm gonna make this thing good. Trust me. It's the only thing I want to leave

And if you're ever in New York or in Miami, come and see me. I'll give you my cell phone at the end of this little talk, and you can come and talk to me. And I'll teach you how to do sound. It's not hard. But, you do have to concentrate. Thank you for sticking around

If you've got any questions, I'll stay here for a few minute