 I have no financial disclosures. So this is a presentation of a case 69 year old male who presents with a mildly enlarging pinkish lesion of the superior contentiva on the right side. This has been ongoing for two years, completely asymptomatic, no irritation or pain. And before we go into a little bit more in the HPI, I just kind of wanted to show picture of what it looked like. You can take a look at that for a few seconds. And just think about a couple of things. First off, if you were looking at this eye on say a routine eye exam, consider whether or not you may even notice a lesion such as this. And also notice that it is on the superior conge. And so in order to kind of notice this sort of lesion, you would actually have to lift the lid and also consider how many times you may or may not do that on a routine eye exam. So what is this? So we could go into a brief differential. I just categorized these in a couple of categories. First off for contractile lesions, you can think of them at, you can think of at thelial origins. So on the left hand side is a papilloma and then CIN of course, with the gelatinous form, papillomatous and leukoplakic. Then you can classify them as melanotic lesions as well. So here you have anivis, relatively benign. You can see cysts. This is PAM. And here of course, this is much worse melanoma. And then there are vascular lesions of the congenitiva. So this here is a pyogenic granuloma. This is a hemangioma and this is Kaposi sarcoma. Some of these can look very similar and are difficult to differentiate clinically. And then the classification of lymphoproliferative disorders. So this here is lymphoid hyperplasia, lymphangioma and then lymphoma. Again, many of these are also difficult to differentiate as well without pathological assistance. So more on the HPI. In October of 2016, he actually had a congenitival biopsy on the left eye outside of Moran. And the diagnosis at that time was malt lymphoma. A PET scan was done and revealed mild increase uptake in the posterior orbits and so it was then classified as orbital lymphoma. And so the provider at that time discussed the options with the shields at wills and they offered a couple of different management options. One of the options was further excision with cryo. According to the providers and they felt this was too far posterior in the fornix and that the extension was probably too far posterior into the orbit. They also offered a low dose local radiation and this was based off of a recent paper at the time that had just been presented at the academy showing excellent results of very low dose external beam radiation of four grays and then systemic chemo if other areas were involved or if it had disseminated. At the time, the provider also noted subtle superior thickening of the conch on the right side but it was felt that biopsy would be low yield and so nothing was done for the right side at the time. And so on October 20th, he was seen by his outside hemonk provider and at the time he had no B symptoms, fevers, night sweats and no other involvement on the PET scan except for the orbits. And so the provider at that time felt that going further, including bone marrow biopsy was unnecessary. However, they did refer him to Radonk but he decided to come to Huntsman Group for a second opinion and they also offered him the low dose radiation and so he underwent low dose external beam radiation to the left eye at that time four grays over two fractions, two grays each. And so he then presented here where we were managing him as well. And so from the time of 2017 to 2019, the left eye after it had had that low dose radiation, no changes were noted and just mild scarring was noted. However, on the left side, initially there was some elevation that was noted of the condontiva. It then resolved the topical steroids and in 2017 appeared to be stable for the next two years and then in 2019 again, it started to look a little bit more suspicious. In terms of the rest of his history, pretty non-contributory except for the fact that he had had sinus surgery but that was for apparently chronic sinus issues and sinusitis and his father had actually passed away with pancreatic cancer, no known drug use or smoking just very occasional alcohol. Visuocuity was relatively good in both eyes. Pressure was borderline high. Everything else was otherwise normal. A little bit of MGD. He did have that elevated pink lesion on the right side and the left side had some scarring that was noted and a little bit of mild elevation as well on that left side. This is a 2019 exam. Fundus exam was normal. So these are pictures of the right side which had not received the radiation and this is the lesion that we were watching. In 2017, this is what it looked like here. In 2019, a little bit more elevated, a little bit more suspicious looking and this is the left side which was the side that had been radiated and here you can see kind of the peri-limbo scarring and actually in 2019, if you look at the two pictures, this perhaps could be a little bit more suspicious looking as well. So we decided to do congenitival excisional biopsy on the right side and so I'll show video how it was similarly done but we sent half in formalin and half for fresh for sent half fresh and then no concurrent crowd therapy was done but however, during the procedure, we did notice some significant underlying vascularization and so this is a YouTube video of a very similar case. Unfortunately, I don't have video of our case but we did demarcate the area very similarly like this and then it was removed with Westcott scissors and then underlying here, very similarly, we actually noted a fair amount of vascularization that did seem to be relatively abnormal compared to normal congenitival tissue but the lesion was completely removed and was then sent for histopathology and flow cytometry and then in this case, the congenitival defect was large enough that they use amniotic membrane which you can use to cover the resulting congenitival defect in our case, the defect was not large enough so we left it alone. So doctor, should I be worried? This is basically the first thing he asked the next day after surgery which of course, we did not have any results to give him at that time but we did notice that we had those abnormal vessels and with his history, there were a couple of things that he could have been worried about and so eventually the biopsy results came back highly suspicious for low grade B cell lymphoma especially extra notomarginal zone lymph lymphoma of mucosa-associated lymphoid tissue. This term is also used to describe malt lymphoma so is this a new malt lymphoma versus a recurrence versus previously noted disease before that was not previously addressed and so in terms of his clinical course, he went back to Huntsman and ended up getting four grades in two fractions to the right orbit this time. Follow-up MRI so far has shown no intraorbital disease extension. He did have an incidental right parotid gland mass that turned out to be a cyst. His congenitival has healed and currently doing well and we are watching both eyes very closely. We may need to continue looking at the left eye as well. So a little bit about congenitival lymphoma. Incidence is pretty low, female preponderance around ages 50 to 70 years old. It's a third most common congenitival malignancy besides SCC and melanoma. Usually it's a primary neoplasm but it can be associated with disseminated lymphoma and the most classic location is usually in the inferior fornic so though in his case it was in the superior. The majority about 80% are malt lymphoma and these are non-Hodgkin's lymphoma. Usually presents as a salmon patch colored painless mass and usually B symptoms are pretty rare unless it's disseminated. Histology is the most important prognostic factor. Malt tends to have a very good prognosis. Filicular is almost as good and then the mantle and diffuse B cell versions are much worse prognosis. Recurrence is actually very common, approximately up to 40% in malt median recurrence two years in one study. And so in terms of treatment, we already talked about some of them, brachytherapy is also a possibility and then it's been studied, intralesional rituximab or interferon has actually shown some good results as well and then systemic chemo for disseminated disease. Intralesional being subconge. These are just some sample slides. Here you can see it's basically a lymphocytic infiltrate on H&E and then on staining, these are typically CD20 staining which is characteristic for B cells and usually a little bit more negative for the T cell stains. This is five, 10 and three actually. So I went looking for that paper that was apparently presented at Academy at the time and I believe this is it, which interestingly enough, one of the main authors was one of my previous tendings at MD Anderson, Dr. Ismaili. But this paper was a retrospective review of 22 patients with B cell, what they call B cell ocular adnexal lymphoma, which included malt mantle follicular. And so basically we know that radiation can be very devastating to the eye in higher doses causing things like cataracts, radiation retinopathy and optic neuropathy in even very low doses. Cataracts can form in doses as low as one to two grays and radiation retinopathy typically around 15 to 20. And so this study looked at giving very low dose radiation for grays to the orbit into two, two gray fractions. And they got this from studies showing good results in primarily palliative patients. And so in this paper they looked at clinical response which they defined as clinical resolution or radiographic resolution in orbital or eyelid lesions. And most importantly, actually 100% of the patients that they showed some form of response and many of them achieved a full clinical response in this study. And very few adverse effects over the period of two years that they looked at just one patient with dry eye. And I just wanted to point out they did have one patient who later developed contralateral recurrent malt in the other eye a little less than two years later. So was clinical response meaning complete resolution? That's how they defined it as complete resolution. However, they did look over the period of two years and whether or not they might have recurrence. And 75% of the patients at two years, I'm sorry, 25 of the patients at two years actually did recur in some way, either same eye or contralateral. And this is just a picture showing what external beam radiation could look like to the orbit. Usually you have a lens shielding the eye because it can actually help prevent cataract formation but they actually didn't do that in the study. And then this is just another review. I just kind of wanted to point out characteristics of malt lymphoma in particular. In this study, they looked at 262 patients and almost 70% of which 262 patients with congenital lymphoma and almost 70% of them were malt lymphoma and bilateral incidence was 18% of those with malt lymphoma. Recurrence was actually pretty high, almost 40%. However, if you look here, many of them either achieved complete remission or were alive with the disease, 24% were thought to be dead directly from the lymphoma. So very good prognosis overall, which is why observation is still considered a good management option. And that's about it. That's a nice review of all the lymphomas. One thing that we wanted not to forget, even though these are low-grade, mostly malt-like D-cell lymphomas, there can be systemic association with lymphomas. And especially Kovac was in New York 30 years ago. He had a large group of patients with this type of lymphoma that he followed long-term. I mean, even out in 15, 20 years, and what they found was that the further I could get from the initial diagnosis, the more chance there is of finding systemic lymphoma. And so with these people, we want to keep an eye on them at all times because when he went out, I mean, initially less than 20% of them had systemic lymphoma associated with this diagnosis. But as they went out more than 15 years, it went from 50 to 75%. So you really want to follow these people very carefully for that systemic involvement that can occur. Absolutely. Okay. Just while we're changing over, I'll just add to the late side effects, the radiation of various forms and also vitamin C in the spectrum of the dry eye that occurs, but the sclerolation, melting, those kind of things, sometimes with these higher doses that people get, you'll see that within a few years there's going to be more of a problem. Basically the blood vessels are damaged and there's just no healing whatsoever, and they can be really, really hard to fix, graft stuff, things like that, avoiding these high doses. Yeah, the fact that this lordose radiation has been successful as is, is used up because I remember the day when they were sitting up there at that 50 grade, you could just about depend upon the fact that it was going to be destructive to the eye. Hi, a presentation. I did mine on cataract surgery in the management of the stigmatism. This is a relatively basic topic, but I thought it was very relevant, something that a lot of us see every single day. So this particular patient is of a 55-year-old male. He was complaining of ghosting of images, a monocular diplopia of the right eye since he had cataract surgery with a toric lens about five months ago. Of note, he had a history of retinal detachment in that right eye, had a vitrectomy, and also was noted to have EVMD in both eyes and then his toric IOL in that right eye was done for a near target. So on exam, in his right eye, as you can see, he was purposely left near-cited, but he still has significant stigmatism, is best corrected to 2020, but still complaining of the ghosting and monocular diplopia on the exam. It was pertinent for the findings of EVMD in both eyes that was affecting the visual axis. And then upon further examination, the toric lens, it was intended to be placed at 133 degrees, but looked like it was about 20 degrees off at 155-ish. So also topography and tomography was done. This is a pentakium showing both the pre-op images on the right and then the current images upon presentation next to that. And it's showing a similar pattern, some irregular astigmatism, particularly inferiorly. And then it looks like the astigmatism is maybe slightly getting worse. So options for this patient are obviously the most conservative is glasses, but he was still having monocular diplopia complaints. He was also previous to the appointment told to increase lubrication, and this has not helped him. So other things that we can consider are a superficial keratectomy for the EVMD, and then surgical options would be rotating the toric, IOL exchange of piggyback lenses. So after a discussion with the patient, it was decided to proceed with superficial keratectomy. This was decided not only because it was the most conservative option to start with, but also it would help increase the accuracy of the IOL measurements in the future if he needed further intervention. So the top picture is of the irregular cornea, same similar pattern to the pentakium pre-opt for the superficial keratectomy, and then the inferior picture shows it's more regular astigmatism, and you can see with his refraction that the axis has shifted a little bit after three months after the superficial keratectomy, and also he has better best corrected vision. So taking a step back when you see a patient for cataractyval, it's important when you're deciding to whether you need to take steps prior to the surgery. You can, you know, you need to obviously assess whether it's affecting the vision. Look for particularly pay attention for EVMD, sub-epithelial fibrosis, salmons, particular whether it's in the central six to eight millimeter optical zone, also really take a look at the topography, specifically looking at the Myers, seeing if they're irregular like in this picture. Also look for biometry inconsistencies as well. And then after, if you decide to move forward with a procedure, then it's important to be patient and delay surgery at least 30 to 90 days after treatment of the cornea to get fable measurements. This is my, I tried to make a picture illustrating something on word. So basically this is trying to show salmons and nodules and basically the red line is trying to show that those can really flatten the cornea overall and then once you remove them, the cornea can undergo a big myopic shift and so they can be very visually significant. And then dry eye is something that we all see every day and that's really important to manage prior to surgery. There was a few studies that actually showed that it's over 63% of patients that had no preoperative pathology preventing, presenting for cataract surgery evaluations had tear breakup times less than five seconds and 77% of eyes had positive corneal staining. So it really is very prevalent. The Oscars cornea clinical committee developed an algorithm for identifying this. So they suggest doing a dry eye questionnaire in clinic and then maybe doing some point of care testing, look at the refractive measurements, topo, biometry, look for those inconsistencies like we talked about and then obviously a clinical exam. Another thing to think about is even if you decide to move forward with the procedure like a superficial carotectomy or other things that you really have to be cautious with placement of Toric IOLs even after this because of the recurrence rate. So, UBMD after phototherapeutic carotectomy has shown a 13% recurrence rate and Salismans after superficial carotectomy had a 22% recurrence after being followed up time in up 61 months in one study. So, going back to the patient, so there's a few options after this because he still has significant astigmatism still wasn't happy with his vision. So, obviously one option is rotating the Toric. So the astigmatismfix.com is the calculator that's very popular. It showed that even rotating the Toric back to the intended target would still leave 1.18 of kind of oblique astigmatism. So this wouldn't fully correct his astigmatism. So that's one option. Then we looked at, you know, considered IOL exchange. He would still, without flipping the axis would still have, you know, 0.45 or 0.43 doctors of residual cylinder in this case. And then the last option that we considered was corneal refractive surgery. And so this is ultimately the road that he went down. So, he underwent PRK in this eye and you can see here three months afterwards his monocular dyplopia symptoms and ghosting symptoms were resolved. He had uncorrected visual acuity of 2015 and you can see his refraction there. So just a little bit about refractive surgery after cataract surgery. So one literature review showed that laser vision correction is more effective in predictable outcomes than intraocular surgeries like IOL exchange and piggyback IOLs. And then obviously it has the benefits of avoiding the risk of intraocular surgery. And then another thing to consider is that pseudophagic patients tend to be older than the typical refractive patients that we have. So this can make treatments less predictable and less effective, not only because of tear film abnormalities but they also have corneal incisions from previous cataract surgery. So this can also affect the refractive outcome and if you're considering LASIK could affect the ability to make the LASIK flap. So that's just a brief review of things to consider. Yeah. It's like a really important learning point of why you should take off the nodule or the turigium. So she didn't really describe it, I don't know if there's a pointer up there, but the red line basically would simulate epithelial thickening peripherally because the epithelium wants to kind of ramp up to whatever the elevated area is. So if you did the cataract surgery and then said, oh, one second thought maybe we should take these nodules off or take that really bad turigium off, biopters of biopic shift. Because essentially you're taking off not only the nodule but all that peripheral elevation which essentially steepens the central cornea. So it's important to kind of figure out whether you're gonna train those things ahead of time to avoid those huge surprises. For residents, I mean, you need to understand these principles for optics and cocaps and things. This kind of how curvature changes with elevation and just kind of the effects of clinical things like this is it's just really, really helpful if you can just kind of get that in your brain of how that works, that's so helpful to understand a lot of questions that you'll see. Just an issue that I wanted to raise is that part of the problem is that we keep creating higher and higher expectations of what results are going to be. And so patients obviously are increasingly demanding and I think we could help ourselves by being a little more reasonable with patients. So one thing that I'm seeing more of is that patients are coming back and really we've hit it about as close as we can expect to but they're still very unhappy and it's a residual high order aberrations particularly after refractive surgery that's bothering them. It's something about the natural lens. I think there's a certain softening that the artificial, our intraocular lenses are allowing that to occur. And one key is that if it doesn't quite make sense and it doesn't really sound like a dysphotopsy, that's how they usually are getting treated, is to do a wave-friend analysis and then point to the point spread functions is that what blight looks to you? Is that what's bugging you? And if it looks like the point spread function, that's the higher order aberrations that are bothering them at that particular point. And unusual amounts of coma, often, they'll want to try to partially correct that as cylinders pick where cylinder doesn't, seems to move around a lot. And so in those of the issues that we could be dealing with and so you gotta let the patient know, you know, this is a little more complicated and you're 2015 and maybe this isn't such a big deal and you need a contact lens or something at this point. Good news is is that I know we've talked about in a long time but sometime in March, the first serious human trial of this refractive index shaping in patients and there are already algorithms here that will treat specifically after surgery, you know, coma, spherical aberration, cylinder all in the same treatment at the same time. And I think that's gonna be extremely powerful because it's something you do after surgery, your effective lens position is already known, you know, residually what the whole system is doing. We think about it, we've got a toric cornea with a toric lens, we've got two toric services with each other and now we have a residual which is almost like a third toric thing that we're trying to deal with. And so if we could deal with all of that in the intraocular lens based on the outcome and get after these higher order aberrations, we finally, I think, can really meet patient expectations of getting this really dead on. Just one more question. Presumably the toric was off so much because of the EVMD originally. And so with you or maybe Brian, you're gonna cover this comment on, you know, it's your algorithm ahead of the toric or EVMD patients. Tell me about that. Well, one of the things was. You've the mic, sorry to say it. I think one of the things I brought up was, you know, looking at is the EVMD central? Is it, you know, looking at the Myers on the topography? I think those are very important to tell if it's visually significant. And I think in this case that it won't be future to emphasize this monocular dyplopia after the best corrected prescription was put in there. So it wasn't just the toric being on that, just patient end quality issues. So that's why this is a particular thing we've done. It's basically to care of the monocular dyplopia with best direction, and then it was just a matter of the toric could have been in there for a long time. Rotating it wasn't gonna get rid of all of these things. I just think if I hadn't seen that topography, I don't know that the head of cataract surgery. No, I don't think putting a toric in was wrong. It just, you know, it's just a way to bring it up. I still think you're kind of, you're just trying to optimize their visual system whether you're gonna use a toric or a lens, right? After surgery glasses. I think if you can get it regular enough, I think it makes sense, but it is tricky. I think it's hard to kind of decide. I feel like I've created a lot of really loyal patients by essentially telling them, I think we need to delay your cataract surgery. I think you have a really funky cornea is kind of the term that I like to use. And they can kind of appreciate that their body's not healthy because they're older, even if they think they're healthy. And so they can kind of appreciate that their eye is not normal and we may not have perfect outcomes after cataract surgery, but if you take them through that, let's do a superficial care technique, see if we can smooth out your cornea as best we can. I feel like you create a little bit of an advocate for their outcomes too. So I think it's helpful. But in some of the milder cases, I bring it up because I think it's an important thing because you may have to cross that bridge later after surgery and deal with some of these issues. So it gets challenging. So, so Maddie and I decided to hammer this principal home a little bit unknowingly until last week and I decided not to change just to kind of keep it going. Because I think I have quite a few good clinical examples of it as well. So the first one was a 72 year old who came into clinic. His right eye vision had been slowly getting blurry over time, he was about 2050. It was just kind of constant blurry vision with a little bit of fluctuation to it, but we couldn't get him any better than 2050. He had exfoliation syndrome and a two plus NS cataract, no signs of glaucoma on exam. He had a little bit of ABMD that looked pretty mild to me clinically. I couldn't appreciate a whole lot going on. There was a little bit of negative stain there, which is an important principle to kind of take a step back, throw some more floor scene in there, let it kind of dry off a little bit and then kind of look at it again to see how the pattern looks. Tier breakup time is actually a pretty good. Sarah get to try to figure out how significant ABMD can be as well. So some things that you can kind of use on exam. He had a historic refraction where he was minus two plus two against the rule. And that's kind of what we got on our exam. We weren't seeing much of a myopic shift. I tried to give him more myopia to see if I could get his vision clear because his cataract didn't really look 2050 to me, but it was bad enough. But again, the cornea was kind of a questionable to me. So I sent him for scans for cataract surgery, told him I'd review those before surgery and kind of go from there. I tried to get topographies on any cataract eval in clinic before they're dilated, but that doesn't always happen. In his case, it did not happen. So this was his topography when it was done and he had that two diopters of against the rule of stigmatism. The numbers, which one did we decide is the laser? I actually, I look at this pattern up here always. I'm always looking at the Myers, but I like to look in this little central zone here and look at the stigmatism numbers. So it's 44.5 here, it's 43.6 here. So a little bit irregular. And then 40.9 here and 38.9 here. So pretty big differences in the stigmatism in those axes that are 180 degrees apart. And so irregular. I still think that he would have done pretty well with the torque had I put it in. Like it probably would have minimized some of his astigmatism. He probably would have done pretty well, but I still think he would have had problems because you're essentially gonna over correct astigmatism here and under correct it here in your algorithm. You're just gonna do it. And so they're not ever gonna be completely plano. So my astute biometer, it was Crystal, she looked at the patient under the slit lamp and said, hey, will you look at this guy again? I think it's more significant than you're thinking because you kind of put minimal, why don't you look at him again and get an opinion on it again now that you see the topography. And so I brought him back into clinic and I unfortunately did not get a picture of him, but you can look on here on the Myers. Like it's very central that he's got this irregularity there. And she tried tears. We actually did biometry a couple of times on him and just still couldn't get it to clear up. And so I brought him back into clinic and I just said to him, look, I think we've got to deal with your cornea first. And so let's do this superficial carotectomy. Let's remove the skin, let it heal back and kind of see where we're at with your cataract. Wait a few months, probably do cataract surgery on you. So I wanted to just show a few different pictures of what ABMB can look like. These are usually pretty obvious when it looks like this. You get these weird pockets of cysts kind of all over. A lot of these patients will have kind of recurrent erosions when they look like this. Some more subtle ones would look where it's just kind of irregular epithelium. Couple other ones here. This is what his topography looked like two months after superficial carotectomy. So I mean just a crazy change in his topography to the point where now he has no astigmatism. He still actually manifests that against the rule of astigmatism, which I thought was kind of interesting. But he corrected, he was 2040 uncorrected at week one, corrected to 2020 at two months, 2015 at four months. So we delayed his cataract surgery. So you had two plus NS. Like I thought his cataract was pretty significant, but once you get the cornea kind of cleared up, it actually cleared up really nicely. A year later, he came back. He was still correcting to about 2025, but complaining of a lot of glare. He actually glared up to 2100. His cataract had progressed a little bit over two years. So I did a fake go on him. This was just in January. And I put in a ZCBU-19, obviously without any touristy in it. And I had to do a CTR because he had really, really loose zonules. I exfoliation scares the crap out of me, even with our training. Because you just never know how loose the zonules are gonna be. And so I'm trying to get this guy's expectations, trying to hit him right on. I cleaned up his cornea and then I go into surgery and I'm like, his lens is gonna be tilted like because his zonules are so bad. So I was really nervous, but he ended up 2015 uncorrected. So he ended up doing super, super well after the cataract surgery. And I wanted to get into a little bit more of kind of hit the details of his case, just to kind of look a little bit more in-depth at the biometry and what maybe would have happened had I done surgery two years ago in this cataract. So if we look at, so this is in 2017. So this is his Lens Star measurements. And what Clutus ended to repeat the measurements was these little exclamation points saying that the Lens Star was not able to pick up good keratometry readings. Anytime you see that, you wanna repeat it because you've got a huge change in sort of the standard deviation of what it's trying to measure. So it's not getting good measurements. You're not gonna have a good outcome with that. It had that astigmatism at two and a half diopters against the rule, which you could argue matched again with his refraction, so you might feel okay about that. But if you don't have a topography, you may just move forward and do a tuoric lens. So I don't think we're the kind of center that does biometry without topography, but there's a lot of places around the country that do this. And we actually have a few places in the state that do it as well, that they don't use topography pre-op and they're just going off the K readings on the lens star, the IOL master. And I think it can get you in a lot of trouble like it would have in this case. So this is again, 2017, get a little crystal here that had my back. Average Ks here were 43.8 on the biometry. A ZC Boo had a kind of the standard lens would have predicted a 20 diopter lens. And then we go to two years later. So 2019, his Ks are a little steeper at 44. And so he actually backs off to a 19 diopter lens. I could have pushed it and maybe done an 18.5, but I'm a little bit of a chicken, especially in somebody with cornea issues. And so I went with a 19 diopter lens. So had I put in that 20 diopter lens, obviously I would have probably put in a tuoric to kind of correct his astigmatism. And then maybe you had to do a superficial care technique because he was still struggling. He would have ended up a little bit myopic. So I would have kind of overpowered his optic and under predicted what his cornea power was. So you can kind of see it's pretty straightforward as far as the math. If you look at just basic lens formulas, right? So the Ks increase by a diopter, it's about a 0.9 difference in theory on the IOL calculations, if you look at that basic formula. And so kind of backed it off one diopter on the lens. Okay, so another case. So this was a 70 year old that I saw for a second opinion after cataract surgery. He was about to go on a church mission to Germany in like three months. And he was really unhappy with his outcome. So he was 2040 with best corrected vision. On dilate exam, he did have an epiretinal membrane on that right eye, but I just couldn't get him seeing any better. The epiretinal membrane looks pretty significant, but not awful, but horrible visual quality, just tons of glare, dryness, irritation. And he had not subtle ABMD. I mean, this was like easily the worst case of ABMD I've ever seen. And so I talked to him a little bit about the reasoning why he went ahead with the cataract surgery. And he said, well, I just kind of ran out of time. I really needed that cataract out because it was getting a lot worse. And I just didn't have time to do both. And because he's about to leave on this church mission. So this is what his ERM looks like. So he definitely has an elevation of the phobia with some irregularity on the surface there. He's got a little bit of disruption of the layers of the retina. But this is what his cornea looks like. Again, I think this is really hard to image even with our awesome imagers here, but you can kind of see just the irregularity and kind of the whitening that's going on in this cornea. He's got all these little crypts and valleys and cysts and it's just really irregular. All that subtle stuff going through the center of the cornea too. Yeah, it's just, it's everywhere. That's that fibrosis stuff. And if you don't look carefully, you can miss that. And that could really have a big impact on that irregularity. Yeah, and so you kinda, anytime I see a cataract, I'm like, okay, we're gonna take this cataract out. I'm like, all right, we've decided we're gonna take it out. I always back up and I just look at the cornea. I look at the endothelium. I look at the corneal surface. I lift their upper lid, looking for Salzman's nodules. I just try really, really hard to make sure that I have the capability of getting a good outcome for them by examining their cornea. And then I just go straight to their macula too and just really look at their macula really closely. So it's kind of a mental approach that I have to it. As soon as I mentally decided that cataract's bad enough, I back out and go back in deep and just kinda really examine the visual axis. So his left eye actually looks okay, but there are a little bit more subtle, but still pretty significant ABMD. You can kinda see some of these little crips here and then down here as well. And the central area does have some that are coming into that visual axis too. The left eye was still correcting to about 2025 at the time that I saw him. This was I think back in 2017 as well. I really liked the retro illumination photos they did down in photography because it kinda picks up some of the irregularities on the surface and there's a few here as well. The photo looks better in the imaging system than it does on the projector, but. So a really hard discussion because he was leaving in two months. And the superficial keratectomy can really change refractive area as we've seen on these previous examples. And so I was like, well, we can do this, but it's really gonna change things. And I'm not gonna have time to get you some glasses before you go. And so you're really gonna be struggling until we can update glasses. They have good people there in Germany. You'll be fine to be able to get some glasses there. And I even said to him, you could even have this surgery in Germany. I could kinda help connect you with somebody so that they could take you through it. And at the time my OR was really booked even though I like to do these in the OR because they're just a lot more comfortable even though it's a really quick case. But he kinda pushed me and he's like, can you just do it in the office? I was like, okay, fine. It's not gonna be comfortable. I cannot keep you comfortable with this. I'm worried about that one. Yeah, as much as I've got tetrachane and lidocaine gel, I cannot keep you comfortable. So it's gonna hurt. And after surgery, it's gonna hurt really bad because I don't have any IV medication to kinda take the edge off. So we did it in the minor room. And it came off really easy. It actually was not very challenging. I did very exact same technique I would do in the OR which I essentially just remove the skin usually with Wex cells. It'll actually come off pretty easy with that. And then if it doesn't, I use a little grease hopper blade to kinda clean up and smooth off the entire epithelium. I usually leave about a one millimeter skirt on the edge so that we're not getting into limbo stem cells at all. And then I use a diamond burr, just really low frequency just to kinda gently polish across the entire cornea. If you kinda sit on that diamond burr in one location, you'll remove tissue. And so you don't wanna do that. You're just trying to create little micro scars. So really, really light, just kinda pressure across the entire cornea. And usually there's kinda this weird little flaky substance that will kinda come off even though it looks normal. And you're just trying to get a really smooth bowman's layer. And then I put a contact lens on and usually leave that on for a couple of weeks to kinda help the epithelium heal. So his ABMD was awful and I did not have a pre-op topography to show you. But his post-op topography was, it was still not great. Like he still had a lot of irregularity. This was only a month after and again he was about to leave. But if you look at these central numbers, it's 44 this way and 43 this way. So he still has quite a bit of central astigmatism and really a lot of irregularity on his mire still. But doing reasonable. He's seeing a little bit better. I could correct him at that point to 2030. So he leaves for a couple of years, comes back and this is his topography two years later. So it's smoothed out pretty good. He still has a little bit of irregularity in that center but it's kinda calmed down. He's now correctable to 2025 with that epiretinal membrane and a lot happier with the quality of vision that he has. But now he wants his other eye done because his cataract's gotten worse. And this is his topography on his left eye. So a lot of times you'll get a topography like this and you're like, oh, he just, this patient just has dry eye. Have him use drops and come back and we'll kind of deal with it later. But if you look again at the mires and just how irregular they are and we already know he has ABMD, we've seen it clinically. And so I told him, let's do a superficial care tech to me on this side. Do it the right way, kind of get it cleaned up, let it heal and then we'll come back and do the cataract surgery. So I had him wait three months after superficial care tech to me before we started to think about cataract surgery. And what I essentially do is I just repeat topographies in clinic. So one month I'll get a topography, at two months I'll get one. And then if that's looking pretty stable we'll kind of start planning surgery and then start getting biometry. And you may have to repeat biometry a few times because they're still gonna be dry and have to deal with those issues. But so he's still irregular but not as bad. So he's 44-ish in this direction. He's 43 and he's got a 42 over here. So a little bit of irregular astigmatism. My technician with a little bit of inexperience compared to Crystal said, I think you're a good candidate for a toric lens. So kind of plants that in his mind. Let's put a toric in to kind of correct this astigmatism. So I had to kind of smash those thoughts down. He only had a diopter with the rule. Centrally you could argue that maybe in one direction he has like two or three diopters but it's still just not gonna work very well. So I actually elected to do just like a little LRI just to kind of try to minimize the astigmatism down to at least a half diopter if I could. So I just did a superior LRI on him and then did the FACO. And he ended up doing really well again. I think he was 20-20 uncorrected is right I didn't correct it to 20-25. So I think if you approach this the right way you can have good outcomes. I have other cases I'll show you one where this didn't work and you can't, I can't get the patient to see well because we kind of waited too long on his pathology and I just can't get a clear cornea with him. And so when you think about superficial care tech to me I think it's better to just do it like to Jeff's point. Like if you have enough irregularity there on topography and you're seeing it clinically on exam then I would go for it. If you get a topography and it looks pretty smooth I think you're probably okay just to go ahead with the cataract surgery. Just I tell the patients you have a funky cornea it can affect your outcomes and we'll just have to see and deal with it after if we need to. So those are the three main reasons that I'm doing superficial care tech to me for EVMD for Salismans and then for recurrent erosions. Maddy already kind of showed you Salismans but that's a pretty classic Salismans nodule I saw one like this at the VA a couple of years ago and it was causing about seven diopters of astigmatism and she couldn't get a contact lens to fit. We did a really straightforward surgery got our astigmatism down to about a half diopter and then she was in soft context doing well. So these are pretty easy to remove. A lot of doctors are removing these in clinic. I usually again I take them to the OR just for comfort a little better controlled environment. Okay so another kind of entity that we deal a lot with so you can see here on the nasal cornea a large area of flattening on topography and subsequent steepening in the opposite axis. If you look at the Myers up here you can see that distortion of the Myers kind of coming across. I apologize I don't have a topography and a picture that matched so you'll have to kind of hallucinate a little bit because this one would be a lot worse but it's a teridium obviously. So these can be obviously really significant and sometimes it's hard to tell clinically how much it's gonna change the shape of the cornea when you're thinking about cataract surgery especially if they're only a millimeter or two on the cornea and so I think a topography is essential to kind of evaluate these. I usually am telling any patient that comes in with a teridium I tell them they can have it off. I just say if you want this off we can take it off. I don't care if it's irritated I don't care if it's causing blurry vision. I don't wanna deal with this when you disappear for two or three years and it's a lot worse and now we have scarring we have induced astigmatism and so I just tell them if you're ready let's get it off because I think our recurrence rates have gone down and our surgery is successful enough cosmetically and for recurrence rates that I think it's a safe surgery. So another patient came in this is the guy I was telling you about that I can't get him to correct. He had four plus brunessant cataracts and didn't want surgery. He was 2050 and he had a pretty large teridium which is you can kind of see it here but it was kind of a weird teridium in the sense that it was more of kind of a flat not really elevated and really broad but it was right at the edge of the pupil margin and causing a lot of astigmatism a lot of flattening in that area and so I kind of talked him into doing the teridium surgery told him let's get rid of those. I know you're not ready for cataract surgery but let's at least get rid of those and see how you do. He felt like he was functioning fine wasn't really complaining much other than a little bit of dry eye irritation. So I thought let's kill two birds let's get rid of as much astigmatism as we can and get this cataract or sorry the teridium off to help with irritation. His left eye kind of similar just sort of this flat not very elevated teridium but a lot of distortion on the topography and it was coming very central as you can see on here it was getting really into the center really distorted mires and if you look again at these central numbers I mean just crazy amounts of induced astigmatism 25 versus 45, 40 versus 39 I mean just really causing a lot of distortion that central vision. So I took the one off his right eye and it made it more regular but it's still that it had been so longstanding that it caused that flattening on the cornea and just didn't it didn't really relax. So I made him wait quite a while we actually waited about six months just to see if this would stabilize and improve and it just never did. And so if you look here it's a lot more regular he's 28, 29, 31 kind of in this direction so he's closer to where it would work. I elected to not do a TORC lens in this case because it's just too irregular a lot of people would argue well let's minimize it but I think you're gonna deal with all the aberrations that you're talking about where if you can't get a perfect match it's gonna cause a lot of issues and so we did a standard lens and I still I just can't get him better with glasses he's about 20, 30 after taking out his four plus brinescent cataract no macular issues I just can't get his cornea to see well. And so I think if you approach these and you just tell them like you have a really irregular cornea kind of change their expectations in some of these cases I think you could have a better conversation with them after surgery to kind of help them understand what's going on and luckily he wasn't complaining about a four plus brinescent cataract he thinks he sees fantastic he loves his new vision with better color even though I just I'm frustrated because I can't get him seeing better and it's his cornea and he doesn't wanna do contacts which I think would help him see better. So that's kind of a difficult case as far as some of the teridium. So again, I just tell patients if you want that off let's get it off before we have to deal with kind of this issue once you get to cataract surgery age. Okay, so any questions or comments about those? I know it's kind of a I'm just saying reasonable expectations is just incredible on the impact it has. Yeah, and the simple line that I think one of the interesting things about consenting patients is I think if you just plant that thought in their mind even if they don't they can't like repeat it to you if you mentioned to them, hey, do you remember that I told you after cataract surgery you might need some glasses to fine tune your vision we're kind of at that point, they remember that. And I tell every patient like same with complications sometimes complication occurs we're gonna have to do another surgery to fix it. And then I tell them we're at that situation now where we got to do another surgery to kind of go back and fix it. Just planting that I think is really helpful. That's a good idea. I don't have a lot of experience with PAM either. What about like potential acuity with that? Does that help with epiuretome membranes? I haven't really any, I don't think I see a retina special. Oh, there's one. Dr. Valkenberg, any idea? The overall accuracy of the latest information I've seen is fair. I mean, I've been told. Where it's particularly helpful is where the PAM does really, really well that the retina is not so involved. If it doesn't do so well. It's harder to judge it. And then it's much harder to know for sure whether that's just the patient having a hard time and not seeing it, other issues. But if you get a really good result with PAM that's pretty encouraging that the retinal vision is not as impactful. That's a good, I don't use that method very often. I send them to Dr. Petty to do it, or Dr. Meyer. But, fix Petty, not Jeff. I think we've smashed that, but. Okay, so I'm gonna shift gears a little bit and just give you a quick smattering of kind of what's new in cornea. Just so you have an idea of some things that are changing a little bit. The first one is kind of a simple study that Dr. Linn and I are involved in. Multiple myeloma is a really awful cancer. It's a bone marrow cancer where you get excess plasma cells. And typically it's kind of just a low grade cancer that you can survive. I think survival rates at kind of initial treat, or a diagnosis is about seven to 10 years. But as soon as it kind of starts to cause a lot of issues your survival rate drops off dramatically. And they're kind of running out of treatments. And so you have this refractory type where they failed two or three different treatments and now they're essentially, they have less than one year to survive. And so they came out with a new, it's kind of this humanized antibody that is giving amazing survival rates for these patients. And so we're involved in a study at Huntsman for this, that the medication is actually just finished the initial phase two trial. And so it's probably gonna start coming out more and you'll probably see patients with this. So it's called Blatimab, Maffidotin. And what we've essentially found in this study is about 70% of patients develop keratopathy. And about half of our patients, we had to delay treatment or stop treatment because of how bad it got. We didn't ever have anybody break down into like ulcers or infections, but like three, four plus Pek, confluent kind of stuff and really rapid tear breakup times. And so you can get kind of all these different grades of how bad it can get. But a lot of our patients in Utah ended up grade two or three. And so we were having to deal with a lot of really bad dry eye. So that's something that you might come across with multiple myeloma patients. Sequa is a new dry eye cyclosporin medication. It's a little higher percentage compared to Rostasis. And they think the vehicle actually is making a lot of difference as far as the dry eye treatment too, not just the cyclosporin. They've got some novel vehicle to try to get better penetration of the drug. So it's a calcium or an inhibitor. They did a study about 1,000 patients. 22% of the patients had pain with installation and kind of redness, periocular redness. The post FDA kind of studies, at least just not really studies actually, it's more just experience from on care in it is that patients are actually tolerating it pretty well. I have not personally prescribed this. Dr. Lynn has a few patients on it. It's still relatively new. At three months in the study, about 16% of patients had a 10 millimeter increase in tumor scores. So that's a dramatic increase in tear production. But the vehicle actually had an 8% increase. So the vehicle actually has without cyclosporin and that actually seems to have some effect too on dry eye. So it's a little bit tricky to prescribe as far as cost as these always are. And so there's kind of three ways that they recommend doing it. If you just e-prescribe it to this RX Crossroads in Kentucky, there's a specific pharmacy in Kentucky that does it. Or if you fax, you can download this form on their website if you fax that into the number. That's kind of the best way to get coverage for it. And so the cost right now for a one month supply through this pharmacy is $90 and for a three month supply, it's $180. So you'd wanna give a three month supply of it. And it's kind of similar to Restasis where if patients kind of recap their vials, a three month supply is actually lasting six to nine months. So it actually can be pretty cheap for patients if you go through this pharmacy. So that's CEQA. And then we're doing- I've had comparison with- Haven't had one yet. Haven't seen anything yet. Just general, what are they saying out on this? They feel it's a more comfortable drop. It's a, I mean, I'm saying the hype. The hype is probably it's a more comfortable drop and the onset is a little faster. And I know there's no good solid comparison, but- Yeah, that seems to be the sentiment out there. But it's always hard to know if it's the hype of the patients enjoying a new medication. And they often hesitate to study because often when they do, they find out that it's better. So the hype's better than the truth. Yeah, and you do have some other options for Cyclosporin 2. Restasis has become just hit and miss on coverage. And so I use imprimis Rx quite a bit. It's $50 a month or $150 for a three month supply and they mail it to the patient. So imprimis pharmacies compounding a Cyclosporin and it's a little bit higher. I think it's a 0.1%. And I use it mostly for like stem cell deficiency year or other ocular surface problems, not just dry eye. Amniotic membrane drop. So this is kind of something that we're very interested in kind of learning more about is how to amniotic membrane drops help with ocular surface healing and dry eyes and ocular surface disease. So there's two studies that are sort of one in the works and one that's ongoing. We're studying amniotic membrane drops in GVHD ocular disease. And so we're bringing patients in and essentially just doing a one month treatment. It's a fellow eye study. So one eye gets vehicle, one eye gets amniotic membrane drops. And then we're looking at tear breakup time at one month, three months, six months. So they're just on one month of treatment and then we're seeing the results. It's kind of a little bit of a safety study and efficacy study at the same time. And then we have a new fellow refractive PRK study as well. Looking at amniotic membrane drops, I don't think we've lifted yet but we're getting closer to starting this. And so it's gonna be a fellow eye study as well. It's a safety study. And so we're looking at amniotic membrane drops in one eye compared to the other and looking at epithelial healing. And then there's a little bit, there's kind of some surrogate outcome measures that we're looking at too, but again, it's mostly just a safety study at this point. So those are kind of what we're doing on amniotic membrane drops. There's a couple of new changes to sort of run of the mill medication. So Patanol and Patadase now have been approved as an over the counter dispension for patients with allergies. It's not quite available yet but the FDA has approved that. So we're getting closer to having that available. Acyclovir ointment which is a huge addition to our armamentarium for treating herpes eye disease was approved by the FDA and then they had some manufacturing issues and so that's on hold but that should be available at some point soon. So I can stop sending my patients to Canada to get their acyclovir ointment because it works really well in kind of some of the chronic HSV or VZV cases. Is it 904 or 853? Dang it. I'm looking at the wrong clock. Let's get out of here.