 So, thanks to everyone that had a chance to take a look at Mr. Bates. He's sitting in the back. He wanted to listen into the conversation, so I appreciate anybody's input from what they saw and their thoughts on the exam. His initial exam is about a year and a half ago he presented to me with, let's say, acute vision loss, but relatively sub-acute vision loss with a sublux in the bag, single piece acrylic toric intraocular lens. He had some slit-lap finding suggestive of pseudo-exfoliation. His gonoscopy shows just a very mild SEM-PEL-SE line. The exam also demonstrated basement membrane dystrophy in both eyes. He had normal intraocular pressures at that point. His optic nerve exam showed some mild cup-to-discase symmetry, but there wasn't any notching or thinning thought to be present at that point. But obviously the emphasis or focus of the exam was on the assessment of the subluxated lens and surgical preparation and planning for repositioning of that lens. So surgery was performed. It was scleral fixated via a technique that's been popularized by Gary Condon. Those of you who use this technique know that the needle point on that is not necessarily ideal for this technique. Ideally, it would be just sharp at the tip and then smooth along the edges. There is a little bit of a tapered component to the needle that's currently used with this. And a little bit of cheese wiring of the inferior pass of the suture. Not enough to necessarily abort the technique, but it resulted in a modest decentration of the intraocular lens. It's very well fixated. It doesn't move. There's no denesis or other abnormalities with that. But that did result in some mild decentration of the lens. It was very stable. It was uncorrected vision. Even with a toric lens, we were able to get that reasonably well positioned relative to the original targets. And so it's uncorrected vision is 2030 with manifest refraction of spherical equivalent less than a half diopter. And his astigmatism is consistently less than a half diopter on manifest refraction. His IOP continued to be normal through this process. But despite this recentration of the intraocular lens, he still felt like the vision quality in the left eye was never as good as the right eye. And so it was somewhat of a conundrum for me trying to figure out, well, what is the issue here? Is it this modestly-decentred lens? Is this really causing this type of visual complaint? Could it be the basement membrane dystrophy causing some of these issues? So we did a soft contact lens over refraction, which improved his vision to 2020. At this point, we decided, let's do some medical therapy for the ocular surface and see if we improve that ocular surface. Maybe that'll help improve the visual complaints. And then down the road, we could certainly consider secondary surgical intervention for either the basement membrane dystrophy or the de-centered intraocular lens. In the meantime, so we did that medical therapy to this point. It really hasn't made any difference. In the meantime, started to notice an elevation in his intraocular pressure, and that triggered a decision to form a glaucoma workup. In that, we'll go through the testing and why I think the glaucoma may be a significant issue in terms of his visual complaints. But he still feels very strongly that that intraocular lens issue is a significant component of his visual complaints. He felt like the vision was fairly normal or essentially normal before the lens de-centered. And so one of the reasons we're here is to listen into the discussion and get some input from other individuals to allow for that discussion to be helpful in terms of your opinion and assessment of the cause of his visual complaints. So I'll show you just a few things here. So we've got his topography. You can see there's some irregularity of the anterior surface. This is the OPD-3 for those who aren't familiar with it. The axial topography there in the top center. I see just, again, a little bit of inferior steepening and some irregularity related to the ABMD. This is present in both eyes and probably has a similar impact on vision in both eyes based on topographic analysis and his soft-content lens refraction. So this is the original RNFL that was performed when his pressure was spiking up. You can see he's got significant thinning inferiorly in that left eye. The right eye, fortunately, looks pretty good. It's hard to appreciate when you look at the nerves. He's got small nerves with a lot of nerve tilt and inferior peripapillary atrophy, which makes it a little bit more challenging to assess the nerve on exam. This is 24-2, which was performed just a few months ago. You can see the left eye, again, a significant superior field loss. It's sort of a variant arcuate, a dense arcuate change. There are hemifilte change. And this is a 10-2, showing the central impact of that visual field cut that's present in that left eye. We've got him started on Latanopros, which has lowered his pressure from the mid to high 20s down to the mid teens, 16 or 17. The question in the discussion here is, what impact do you think, with regard to his visual complaints, what impact or contribution are we getting from the basement membrane dystrophy from any of the IOL decentration versus that glaucoma field cut? And based on that assessment, would you recommend anything treatment-wise for the basement membrane dystrophy or surgery for the IOL? Or do we believe that glaucoma field cut is the primary cause of the vision complaint and focus specifically on treatment for that and minimizing the risk of progression or further loss of visual function? Based on the testing, my working diagnosis is that glaucoma field cut is the cause for the vision change. But I don't want to necessarily take that without listening into some of your thoughts. So does anybody have any comments for those who were able to see the patient and assess him? Jeff and then Susan. All right, we'll ask Dr. Churna. Well, one thing I did notice is he does have an NAPD on the lip. Does small nerves or you start out with a small nerve. You don't have much tissue there. Any amount of cupping is significant, I think, if you look at both, compare the nerves. I think there is a lot more cupping there on the lip. And then glaucoma is notoriously difficult for patients to describe the symptoms of. And he will tell you that himself. He wishes that we could see what he could see. It's like looking through wax paper, the nation flying kind of a thing. And so all of that together makes me also agree kind of with your assessment that I think the glaucoma probably is a large part of what he's never seen. I appreciate that. That is something that he's certainly, and I've heard that multiple times, when you try and give him to describe it, it's difficult to describe it, which you can look through and to see what it is that I'm seeing. That's a better appreciate. Yeah, I completely agree. And we know that in eyes that don't get good signal from glaucoma that optics, at least optical abnormalities, aberrations, they have a greater effect. I mean, there's a reason why glaucoma is a contraindication for multifocals. People do horribly when they don't get that crisp, clear image in one focal point right on the retina. And so certainly, I think glaucoma is the main issue here, but anything that could be done to correct optics could potentially help. No, I wouldn't mess with the IOL. I mean, that's in my mind, almost a home run as far as getting that electricity, at least in an axis that is helpful. The ABMD is interesting. I mentioned upstairs, perhaps letting him walk around at the contact lens for a couple of weeks to see if that might make a difference for him if he's functionally noticing a change. Then I'd consider some sort of ABMD treatment, but short of an improvement with the contact lens trial, I wouldn't do anything with the optics. Well, I think that this really illustrates the fact that pseudotelation has on the zonus or his dislocation of the IOL within the capsule bag in person. And we've done lots of studies in our laboratory showing how pseudotelation is the most common cause of this spontaneous dislocation. But interestingly, we had a whole bunch of specimens that Lillian and I received from Germany, where they were sent from a very reputable place with the German people who are very German and really do good examinations, and they found exhalation in a third of the patients. And when we actually did the topology of the specimens we found in two-thirds of them had exhalation. So even in the hands of a really good observer, you can still miss exhalation. So whenever you see spontaneous dislocation within the capsule bag, you really gotta take exhalation first of all. But the second thing is in this case with the toroid lens, I'm really impressed that you've got the results that you've got. Because with those toroid lenses, when you're trying to suture them in position, even if they're off 10 degrees, 20 degrees, you can lose a lot of the effect of the touristy plus the tilt of it. And no matter how you suture them, they're still gonna tilt. I wouldn't touch that lens because chances are not only of not matching this result, but of making things worse by trying to reposition the lens that's in them. So I would leave it alone and treat it like all men and attempt to treat the base of memory disease. So I like that contact lens with the 2020 vision. I suppose with that, that is one more thing to do, but get used daily lens and put it in the days you want it. Don't worry about it the other days. That's a simple approach. Yeah. Make something a lot of sense. Thanks, Joe. As you're saying, when you're stressing the, I guess the great air crowd here is that contact lens is great. And it makes a big difference. And the softness of it, and the hardness really, that surface and the hard provides. And yeah, the physics is sharpened right up. They say, I love this. You know, it's a hassle to put a hard contact. They will pay you to do that with that visual quality. So I think that's really easier than the rest of the approaches that you could try to contact Lundra for. Bill, with the ABMD, it seemed like it wasn't really that central. I think it's pretty peripheral changes. Yeah, I agree. And the challenge with doing a superficial care technique is the refractive shifts that you're gonna get. And you don't really know how much sill you're gonna induce and aberrations. I mean, you assume it's gonna be better, but if you could shift a couple diapters in this refraction, then it's uncrected visual drop. So yeah, it can take six to 12 months for it. Yeah, hard to know. Stabilize. Yeah, it's not an ideal option, but certainly not rushed into that. Any other thoughts? I appreciate your input, and Mr. Bates also appreciates your input to be able to hear that conversation. Thank you.