 Can everyone hear me okay? I don't know if it's working. Good. Thank you. Give me a second to pull this up. So I'm grateful for Dr. Holt, warming you guys all up. We'll try to finish quickly here and on time. I just want to begin by thanking Dr. Warner and Dr. Mamelis and everyone I was able to work with on this project. I really appreciate everything, especially Dr. Warner, who's able to do for me and get me here today and for ground rounds presentation. So thank you very much, Dr. Lennon Warner. So start off, not very many of you know who I am. It was the oddball that was sitting in the front. Why does anyone sit in the front? So my name is Kevin Kirk. I'm from a very rural town, southeast Utah, Blanding, Utah. I grew up hunting, fishing, trapping, and those canyons and mountains all over that area. Who I am today, I have a family and I have a beautiful wife, two perfect children, and I'm a third year medical student here at the University of Utah. I came to medical school with the sole purpose of going into ophthalmology. If medical school wasn't how you became an ophthalmologist, I would have chose that other route to become there. And that was, I don't know how, five or six years ago I knew it was the perfect field, but I still feel that way. And after a lot of school, a lot of research, a lot of personal reflection, I still feel very strongly that way, more than ever. So a couple of pictures just of my family and situation. So this presentation is based on a summer research project. I did, between the years of my first and second year of medical school, I started out. When I first got here to medical school, I didn't know what to do. I was interested in ophthalmology very strongly. I was told to contact Brian Zog, and I did. And he set me up with Dr. Warner right off the get go. I mean, probably the first week of medical school. I'd only lived here for two weeks maybe. And she got me going right away with rabbit studies or whatever it may be, and I was able to meet a lot of other great physicians, Dr. Manless especially. And that summer we did this project. And it was a grant that's here at the University of Utah, a lot of first year and second year students do it. All the work was done in the Warner Manless Lab, and I appreciate all the help that they did. This presentation is built on this paper that was published in ophthalmology in 2012. It was, so, this is where we like to start. This is the nuts and bolts of the presentation. So we're going to focus on these two lenses. I felt like this is what I want to do when I'm pointing, but, you know, these two lenses. These are electron microscopes, electron microscopes, scanning electron microscopes, showing the design of these lenses. There's a very sharp square edge to these lenses. And this is what we're going to focus on. This is kind of the root of what's going on. Exactly, thank you. These are the Acrosoft, the Alcon Acrosoft single piece, and the three piece lens. So it's two different, two different lenses we're looking at kind of just in, not in comparison to each other, but just looking at individually in the pathology that comes with asymmetric fixation out of the bag. So the square edge, like I mentioned, is the focus of it. It's a great design when it's placed in the bag. The idea is that it's supposed to prevent posterior capsule pacification. The idea when it's out of the bag and what our study is about is it causes damage. It's kind of a sharp abrasive edge that can rub on structures of the eye. Here, this is nothing new. We know that the single piece Acrosoft lens is not intended for implantation outside of the capsule bag. These are the reasons why it's not planned for that. It has those rounds, those square edges, and on the optic and the haptic. Additionally, it's not the right size. There's kind of a bulky, large haptic. There's unpolished rough sidewalls. The haptic's very flat. It's not very big, so once it's out of the bag, it's a little too short. That can cause it to not fit perfectly in the ciliary sulcus, which then can lead to some de-centration. And then these are some of the complications that we see. The UVitis glaucoma hyphema syndrome. Similar complications were also found with the three-piece Acrosoft lens. We're not going to go into all of them. Whether they were put in in standard sulcus fixation, that means just by themselves or put in as a piggyback with another lens behind them. These are two papers that show some of these complications that I mentioned earlier. One thing I thought of mention here in this bottom paper, one thing they mention is kind of the versatility of the three-piece lens. How they saw it as kind of this very utility lens that if you rupture the posterior capsule, that it was a great lens to put in this. I don't want to say great lens. They said it was the lens that you could put in the ciliary sulcus. But they did mention all these complications that we're going to talk about. So this is kind of where the focus of our study goes, which has been shown by Dr. Mamalist and Dr. Warner in these other studies showing clinical evidence with these three cases of asymmetric implantation out of the bag of these Acrosophilinsis. You can see here kind of where a haptic has rubbed on the eye here and caused some obvious clinical damage that we can see clinically. So here is the purpose of this study in this paper. We're here to provide pathological evidence. We might all be quite as interested as Dr. Mamalist is in pathology, but I beg you to stay with me here and we'll just listen to it all here. The purpose was to document these things, to show the evidence with both histopathology and the clinical evidence that we get. So here's just a picture of two different single-piece IOLs. You can see the haptic that's not in the capsule or bag that's out of the bag. This side's out of the bag on this one. This one's not as evident the problems that are happening back here, where this is very evident. This is just some light shining on it and we're able to see a lot of the damage that's caused there. So this is what we're used to seeing clinically, but we're going to look at things that happens that we can't see with our naked eye. Here's the process that we went through. 661 eyes, they're all cadaverized that have been collected from iBanks nationwide. Dr. Mamalist, Dr. Warner especially has this giant, I mean 550 plus are just up in their lab up there. Just tons of information is there. So 256 were the Acrosoft lens. Only 18 we found with asymmetric fixation. We compared these wherever possible to the eye of the other side of the cadaver. Oftentimes it was an in-the-bag fixation compared to an out-of-the-bag fixation which we made for a nice control, a nice comparison. The process goes like this is where they have this machine up there, this ultrasound machine that takes nice pictures. We put the whole eye in there, take some pictures and gives us these beautiful pictures that look something like this. And you can see on these pictures it's even easy to see here. These are two eyes from the study. You can see the tilt of the IOL. This is the IOL here. You can see the decentration how it's not fit perfectly over that pupil. Additional eyes were donated or acquired from another group, a group that did an MRI research. These gave us again some really pretty pictures that they had done but we were able to again see that decentration, that tilt and kind of document those pictures accordingly just with those photographs. This right here, Brian Zog might be familiar with this. He did a ton of this research. This started off with Dr. Zog years ago and many people have contributed to this. Basically, we'd take the eye. If you look and this be the eye, if this be up by the cornea at the front of the eye, we'd cut it in half, put the eye, look from the posterior side with the microscope just like this. We'd look posterior through it and we'd give it a grade based on these kind of parameters. Things we looked at were like the capsular, the capsular rexus coverage, ACO, anterior capsular repasification. If it's fixated in the bag or not, peripheral PCO, central PCO, and then the summering's ring. We did a grade for how dense it was and if it was in all four quadrants. We didn't do this just for the 18 eyes that I did in my study. We did this for all 600 plus eyes. This is years and years of effort that's been put in and appreciate everybody's effort that put any time in here. So, which provided this giant Excel file. I was scared every time I opened this thing. It was like, I changed it, I opened it. I was like, oh, this is years of work. I didn't want to screw anything up, lose anything. It had me on my toes every time. But all it is, it's just a rich, very thick tons of information for Dr. Liliana Warner and Dr. Malmuss to work with and they have this for all 600 eyes and it's a great reference. So we went through this after doing, after going through all the rest of the cadaverizing grading them and picked out all the asymmetric Acrosulf lenses and put them into this study. And so here you see here, six of the lenses that were in my study. These top three were all single piece and these bottom three are three pieces. Some things to mention and notice here, all 600 eyes had these pictures taken and they're beautiful pictures that bring a lot of color to the paper but they also show a lot of things. You can see some of the pathology which we mentioned just grossly. But one thing I want to bring some attention to here in the three piece, there's this area right here. Now this is part of our finding. I just want to show it that not all of the pathology we found could we attribute to the asymmetric fixation. Some of it looks to be like due to complicated surgery, whether that's like a fake O-tip or something, something possibly caused that outside of the IOL. But otherwise you can really see that most of the pathology followed the side that the haptic was not in the bag, which is kind of good in our situation for that's what we're looking for. We expanded two of these IOLs before we did any histopathology cutting and anything and just looked under the light microscope atom. You can see the pigment on them. This is on the haptic of a single piece. You can see it right here on the square edge. It had rubbed off that pigment and again in this haptic. These were the two haptics that were out of the bag in the ciliary sulcus there. This is a busy slide. It's got a lot on it. But I kind of want you just to draw your attention to this far right, this far side over here. What I want you to notice for de-centration tilt pigment, Irish Transillumination defect, you're seeing mostly moderate, severe problems. That's for the asymmetric or the out-of-the-bag fixated lenses. Of note as well, the top ones are the single piece and the bottom ones are the three piece. And one thing that's very interesting that we found later is for most of the single pieces, they had their posterior capsule intact where most of the three pieces had their posterior capsule ruptured whereas the ag procedure, something like this. So what brought that to our attention, what helped us with this study is it showing that the three piece often had complicated surgery, showed a lot of complications during surgery. This is the control eyes. We didn't have as many control eyes because not every single eye had a contralateral comparison. But as you see here, again, bringing over to this side, you see mostly mild or no de-centration tilt, Irish defect. So just grossly, it was very obvious that in the bag fixation was a lot better than out-of-the-bag or asymmetric fixation. And you can see the posterior capsule, most of those were intact. And here is one of the previous slides, but also a lot of the bread and butter of the paper in this presentation. This is the histopathology that we were able to look at with a special thing to Dr. Mamelis and his expertise that makes this possible. We sit down and talked about these things. And you can see some of the pathology here. I'll try to point some out where possible. You see the trabecular mesh work. You see a lot of pigment in it that is accumulating, you know, possibly from that rubbing of that square edge, leaving the pigment in the trabecular mesh work. You see breaks in the pigment. You see this thinning or this pigment that's on which looks to be the capsule bag. This is something we found in the three, for some of the three-piece eyes, we were seeing that where the haptic was eroding into the sulcus, you can see here where the haptic is actually there. That's the little round three-piece haptic sitting there. So a lot of great pathology shown here. One of the things that was of great, of perfect interest for the study was more pathology was seen on the side that the haptic was out of the bag and then on the side that is in the bag. We just, you know, was able to mark those by when we cut them and looked at them and seeing what side was what, but it showed a lot more damage on the side that was out, so kind of verifying what we were hoping to find. The majority of the three-piece lenses though showed complicated surgeries rather than just the general pathology we saw in a lot of the single pieces. So I want you to get too excited because every time I saw Dr. Holt change slides, I was like, oh, my turn is my turn. This is not quite the end, two more slides. So hang with me, but for the first paper, we were, what we were able to show was pathological correlation for the single-piece. It matched the review, the literature that was reviewed. We found a lot of the similar problems and so we were able to say that with the single-piece hydropobic acrylic IOLs. But for the three-piece, we weren't able to say that as much. We were able to say that they were not maybe completely due to the asymmetric fixation. It might have been partly due to the complicated surgeries. So this was the conclusion of that first paper I did, that first summer. Like I said, two more slides. So hold on, there's one. Another study that was done in the MAMLIS Warner Lab was this follow-up study. And this is a great picture. I think this is such a great study too. So this is comparing now the three-piece square edge to a three-piece round anterior edge. And I think this is the scanning electron microscope shows this great. So the idea is it's not as sharp, not as abrasive of a surface there. This paper was also submitted to ophthalmology. It's currently in print for 2013. Let's see. Here is our conclusions of that study. All the methods, all the similar gross things were pretty much the same, which makes something very interesting. Anytime you had an asymmetric fixation, we saw a lot of the similar gross findings, whether that be decentration tilt, iris defects, or whatever it is. Whether it was the round anterior edge or the square edge, they all had similar findings in that regard. But when we dug a little deeper, compared the histopathology and everything else, the conclusion was that the square anterior and posterior edge, the one that was originally in my study, showed greater pathology with more pigment in the trabecular meshwork. This indicates that there was probably more trauma going on to that posterior edge of the iris, leading to more pigment being dispersed throughout the eye. So our results in our final conclusion of that paper was that three-piece round edges were more suitable for the sulcus fixated, which kind of makes sense. But this, again, is just documenting and showing those things that we all know. Of note in this study as well, whether it was the round edge or the square edge, any haptic that was out of the bag, that site showed more pathology again, just like the first paper, which I think is a very interesting finding. Which we all know, and I'll probably, I don't know, I shouldn't say we all know, because I don't know if I include myself, but you guys all know that due to these surgeries, in the bag fixation is always a lot better. We were able to show and document these pathological findings of the three-piece and single-piece when they were placed asymmetrically or out of the bag. So with that, that concludes a series of the sulcus fixated IOLs of the Acrosoft. Appreciate everyone waiting and listening for a minute. Strong teeth, I don't know, they're not bent or anything, but this is what we do at home, my house. Is there any questions? Dr. Horner.