 That's our way on here Well, good morning if we could have everyone, please take a seat we'll go ahead and get started It's my great pleasure this morning to introduce our guest speaker dr. Mark. Michael son He is out here visiting really for today And so we're happy that he's able to stop by and give us a nice talk on Grand Rounds Dr. Michael son did he has undergraduate training at Tulane and then medical school and residency training And ophthalmology at University of Alabama Birmingham He then did a cornea fellowship at wills in Philadelphia, and he's been practicing in Alabama ever since So he is on faculty at University of Alabama Birmingham. He does cornea anterior segment But also has a large private practice in which he does cornea refractive surgery anterior segment surgery in general he's a very innovative surgeon both in refractive surgery and in Areas of cataract surgery has done multiple presentations at meetings such as the AO and the ASCRS meeting and we're happy to have him here He's going to talk to us a little bit about Accommodation in pseudo-fakie a very interesting topic and a very timely topic. So with that said I'll introduce dr. Michael son Truly a pleasure to be here is this is no different than giving Grand Rounds in Birmingham. Everybody sits in the back There's something about sitting in the back today, I want to talk to you about My concepts on pseudo-fakie accommodation and This is really a new paradigm shift in refractive surgery and how do we choose the best options and We really break this down into two basic categories And that's multifocal owls and accommodating owls But is this subject really that simple that you can break it down into just two types of lenses or is it really more complex and something that we sort of overlook is The concept of apparent accommodation in pseudo-fakie and that's what we're going to spend the next 45 minutes talking about Because it's the hidden factors In accommodation that we don't really pay attention to now. What is apparent accommodation in pseudo-fakie? This is the potential of a monofocal eye to have both functional near and distance vision Now that means that their static properties of the eye that are capable of increasing that the focus independent of the ciliary body So I have a question for you and you can this is an interactive talk So what does a 61 year old faking presbyopia and a 61 year old monofocal pseudo-fake have in common one 2020 J8 how many would you raise your hand and say that's possible. That's Okay, how about 2020 J1? No way. I Love it. How about either of the above? Anybody want to say either you say either How many of you seen apparent accommodation in pseudo-fakie in a month? Yeah, so you know this happens question is why does it happen? And that's what we're really going to explore today Now this is well documented in monofocal pseudo-fakes, but it's not a well-described phenomenon in fake it presbyopes So I'm going to tie these two together. What are they hidden factors that restore? Functional accommodation in pseudo-fakie Monofocal pseudo-fakie and we're going to explore the dynamics of monofocal pseudo-fakie up and apparent accommodation And can we truly decipher the code? To predict apparent accommodation now. Why is this important? This is important because When we put a lens in the eye and we get an accommodation effect Is this coming from the lens? Or is this coming from other factors that are sort of unknown? So let's do a brief literature review on the subject Most of the literature reports an incidence of pseudo-accommodation about four to nine percent And I'm going to go through some of the articles that I thought were important 1990 this report Shows that pseudo-fakie accommodation actually occurs in all types of lenses including a faking patients Which is rather surprising If you look at the mean reported accommodation It can be anywhere from one to three doctors If you look also in the literature and look at the factors that have been reported to affect Focus depth of focus and pseudo-accommodation. These are things that come up So you look at well, what is corneal multifocalium? You know corneal aberrations. It's really not a real well-defined subject This is the effect reported in 1992 Showing that the pupil size is inversely Related to depth of focus so anybody that has the If it's ever used a camera and you know that you increase your depth of field by Lowering the iris to a smaller diameter you basically in allow the the depth of focus to increase by decreasing blur circles and This is an example of How that happens You have a two millimeter pupil things are focused Pretty well, and then you go to a four millimeter pupil six millimeter pupil and by enlarging that pupil size You're increasing the blur circle and making things more blurred Now if you look at depth of field, which is the object Plane and the depth of focus, which is the image plane you can actually measure the interior and the posterior depth of field And by doing that you can actually determine how much depth of focus you have In fact the amplitude of legibility may even extend beyond the range of depth of focus This is an article that was published in 1984 Showing that the anterior depth of field is directly related to the depth of focus, but what was important about this article was this Correlation between the apparent accommodation and the anterior depth of field is greater than the correlation of the reciprocal of the Pupillary diameter Now what this means is Something else is going on There are other factors that are accounting for this improvement in depth of focus So what about a stigmatism? There are a couple of reports that show a stigmatism is associated with increased depth of field Nanavadi in 2006 published in the journal of cataract and refractive surgery that the incidence of pseudo accommodation was 9% In his criteria were 2040 and J4 And looking at these the Akrasov s a 60 a t Had a target refraction of minus a half These are the factors that he looked at and if we look at these This was an interesting piece of information out of his article 50% of the patients with pseudo accommodation were greater than 60 years of age so it Sort of throws a ciliary body out of a picture, but he did show a statistically significant association with the stigmatism So this begs the question How does the cornea influence pseudo accommodation? And I think probably one of the landmark articles was by Oshica published in 2002 and he compared two IOLs the Akrasov in the stores PMMA lens In his conclusion criteria were best corrected visual acuity of 2020 and he showed an average amplitude of accommodation of about two doctors plus or minus one and what he's found As he looked at the difference between the max and minimal corneal refractive powers between the vertical and horizontal Pupillary diameters and found a positive correlation with corneal multifocality So what he was looking at was the asymmetry of the power from the lower cornea and felt that this was relevant to accommodation And he found that the coma aberrations were important in his article He found that tree foil was the most commonly The highest had the highest correlation for the parent accommodation So let's look at tree foil for a minute. This is a trial low zernike polynomial from the third order of zernike in the Red area from the way front shows phase retardation and the blue area shows phase advancement And you get this sort of increased depth of focus But you do it at the expense of convolution of the image and this is what the convolution of tree foil looks like In his article he tried to show that the tree foil didn't really influence The point spread function that badly and that patients could tolerate the vision All right, so the other thing that he mentioned in his article was that spherical aberration had no influence on the effective sphere of pseudo accommodation So he didn't think there's any relationship a spherical aberration to pseudo accommodation all right, so let's take a pause for a minute and Look at the lenses that were used in all these studies. They were all spherical how else And in 2005 The a-spheric how else were introduced in the marketplace Now what they did was they introduced negative spherical aberration to the lens If you look at what negative spherical aberrations supposed to do if you look at a modulation transfer function of Amatropic lens with no aberrations You see that the defocus value of zero has the highest amount of contrast sensitivity But when you throw spherical aberration in what we're doing is we're lowering the contrasted Amatropia, but we're also increasing the depth of field slightly in the defocus values that extend beyond So in the essence the negative spherical aberration is increasing depth of focus Now how does it do this? It does it by manipulating what's called the caustic envelope of light and what this is is The projection and spread of the envelope of light from a curved surface from an ideal image point Let's explore negative spherical aberration for a minute We have the paraxial rays coming in and focusing at this point called the paraxial focus Marginal rays are focused behind at the marginal focus And this is the caustic of negative spherical aberration Now at this point This is called the best focus or the medial focus where the lowest rms values are present And you can actually see that in the caustic by the Concentration of light coming into that point And if we look at the way front of that point, it's right at the green area Which is the lowest rms value in spherical aberration You can see the diverging rays from the paraxial focus and the still converging rays from the marginal focus All right, let's put the retina in here and put the retina right here at this point The retina is at the paraxial focus the actual highest concentration of energy is coming in at this point but unfortunately we have the most diffuse amount of Light from this marginal rays causing the greatest amount of spherical aberration But if we move the retina to this point right here where there may be a minus a quarter or minus a half We're at the medial focus or the best focus and we have increased the depth of field Significantly, so this is how negative spherical aberration improves depth of field All right now let's take another break for a minute and let's look at the adaptive optics of accommodation in the natural eye This is the eye and an unaccommodated state And you can see the surface of the lens is relatively Straight and flat we all accommodate and the lens changes And so everybody contracts and this is Daniels relax if we look at the way front The defocus values from the retina are pushed into a way front this relatively flat for emetropic vision But when we accommodate The anterior surface of the lens changes and we're actually producing negative spherical aberration One of the most interesting studies was by Velopura Rota and Glazer from University of Houston where they did changes of zernike aberrations With increasing accommodation in rhesus monkeys and showed that negative spherical aberration and vertical coma were increased with stimulation of the Edger Westphal nucleus in fact the vertical coma In the negative spherical aberration were the only two aberrations that changed significantly When the red near Westphal nucleus was stimulated This is a video of the rhesus monkeys and you can actually see how the lens contracts How the changes in the periphery actually produced that negative spherical aberration as the center of the lens Reflex changes and you can also see that on the Hartman-Shack aberrometry So in the human eye That's exactly what happens is we accommodate and we end up producing negative spherical aberration So if we look at the adaptive optics of accommodation, we have negative spherical aberration and vertical coma Equaling accommodation alright Let's look at the pseudo let's look at the adaptive optics of pseudo accommodation This was an interesting article that came out by Patricia Pears and Fernandez in 2004 Talking about adaptive optics simulations of intraocular lenses with the modified spherical aberration And what they determined was that a spherical owls outperform spherical owls They improved at the focus up to one diopter They improved best focus and this was really interesting at different values of defocus So the modulation transfer function is Not degraded by these lenses. It's actually improved So now the question is Do a spherical owls? That have negative spherical aberration Improved depth of field and depth of focus in pseudophakia We looked at the alkyne lens the SN60WF and I looked at 50 eyes and this is what we found 60% of these patients had uncorrected near vision of 20 30 or better And this is from several years ago that we looked at this and David Chan was in Birmingham giving a talk to the residents and at the research day and I asked David I said have you seen an association between Improved depth of focus is coronal asphoricity and he said no And didn't think anything about it in two weeks later He called me up and he said tell me what you're talking about and I said well We've been looking at this and we've been finding this incredible association of improved Visual performance. He said well, I want you to write a chapter about this I said sure because I didn't know what I was doing at the time But I ended up writing this chapter, which is really the start of the Work that I'm going to present to you today Give you the background of where this came from actually had the opportunity to Visit with an astrophysicist from NASA Who's working on the next project with the Hubble telescope? You don't call it the Hubble anymore. I spent about five or six hours with them trying to understand Adaptive optics of what's going on. How can you put a monofocal lens in an eye? That's designed for one point focus of vision at distance and end up getting 2020 J1 vision out of these patients totally unexpected and when you think of the implications of this if you put a crystalline's in the eye That's supposed to get accommodation and you get 2020 J1 and I put an acrosoft or a monofocal a spherical lens get the same thing What's the difference in the two patients? Why is this happening? so let's talk about interactions of corneal higher-order aberrations and a spherical IOLs and The first talk we gave as an asterisk in 2008 And this is the data we presented and You can see that there's a high percentage of patients that have an incredible Functional near vision within a monofocal lens So what we wanted to do based on the Oshika article is look at the way fronts of the zernikee polynomials and Compare them in eyes that accommodated and eyes that didn't accommodate with monofocal lenses Now what we did we did not look at the total eye aberrations. We looked at corneal aberrations and we did that by the topographer and this is the printout that you get on the Humphrey topographer and we found this to be our Goal standard for what we used and this is what we found initial study showed that The more the patient was able to pseudo accommodate the greater amount of vertical commas present in the cornea So that was an interesting correlation, but unfortunately it was only a correlation. It was not clinically or it was not statistically significant So we went back to the data and reanalyzed it now. Let me show you what I'm talking about This is the right eye of a patient who is 2020 J1 In his vertical coma is 0.357 This is his left eye He's 2020 J6 His vertical coma is 0.016. So in this particular patient There's a 22.3 times more vertical coma in his right eye Then there isn't his left eye and the right eye is J1 in 2020 and the left eye is J6 in 2020 So this is the association that we're making so with that one of our residents last year undertook a project and we presented this at the AO and he actually was honored with one of the Awards for one of the best posters at the Academy and I'm going to show you the results of the study We did a retrospective review of these patients That had these a aspheric lenses and we categorized the patients on whether they could see J4 or better or J5 or worse And all of them had to have a refractive error plus or minus a half An uncorrected visual cutie at one month of at least 20 30 or better And we did the corneal way fronts and all of the way front data was attained using the six millimeter optical zone What's interesting? Well, I'll get back to the pupil in a minute We looked at absolute values for individual third and fourth order terms And we looked at the root mean square of paired terms meaning tree foil All the tree foil terms and we and this is what dr Myer found is is a new term That's never been described in the literature and he called it the distance between paired terms Now what this basically is I'm going to go into this just a minute is we looked at the difference between vertical and horizontal coma So the value between the differences and this is going to be an interesting phenomenon And we looked at the mean values for the way fronts We compared them among the groups Using a statistical mixed statistical model now this basically shows that the two groups had no differences between the refractive eras And their ability to see a distance. They were very well matched statistically This is what's interesting. We looked at the root mean square of the individual terms. Here's the one that pops up coma 0.002 p-value nothing else just the coma this is sort of What the monkey study showed vertical coma? And here it is again now if we look at the absolute values of of individual terms two things pop out one again the vertical coma being a p-value of 0.005 And the other thing is spherical aberration Which really was a contra distinction between the oscica article where he found No spherical aberration to be relevant to pseudo accommodation And in our study we found that the lower amount of positive spherical aberration in the eye Is statistically significantly associated with pseudo accommodation Now this is important because As I said negative spherical aberration is enhancing to the visual system Positive spherical aberration is very degrading to this to the visual system and and the reason when you think about it the peri Axial focus is slightly myopic to the retina when you're at the best focus But in positive spherical aberration if you're at best focus Things are all hyperopic to the eye everything is behind focusing behind the retina unlike negative spherical aberration so anytime you have Increased amount of positive asphoricity of the of the system. You're actually degrading the optics of that system So this is in line with that thought that the lower amount of positive spherical aberration The greater the ability of the eye to have Improved up the focus All right. Well, let's look at coma You have the same thing going on where the green area is the Is the way front at its lowest point Uh, the blue area There is uh phase advancement Which means that light is actually speeding faster Then the light coming from the green area and it focuses in front of the eye And then you have this phase retardation of this little Red area that's that's pumped out that phase is retarded And it focuses behind the eye and we get this depth of focus And actually the coma value doesn't degrade the image as much as as the Tree foil does So that's the now here is where we get into the interesting thing Because there's vertical and horizontal coma. These are harmonics. They're all symmetric. These are symmetrical Terms in the zernike polynomial And we have the vertical and horizontal coma and what this looks like is this this is the Vertical coma on the right and the horizontal coma on the left And the only difference is the whether it's the harmonic of the cosine or the sign of the angle that that That that orientation of that particular Coma value is located Now let's go back to the patient that we had the right eye left eye seeing 2020 j1 And 2020 j2 and if we look at the distance between paired terms And compare them between the two We find that this is the value we get And what we found was that this distance between paired terms Was the most statistically significant factor associated with pseudo accommodation of a p value of 0.0007 So we were pretty excited about this So in conclusion what we found in this particular study was that pseudo accommodation Is associated with higher corneal vertical coma and eyes with aspheric IOLs And pseudo accommodation is associated with higher values for terms that combine vertical and horizontal coma Such as the rms of the paired term And it is most significantly associated with higher values for terms that generate the distance between vertical and horizontal coma So what we have here is really an aberration of the harmonics Of vertical and horizontal coma and it is this distinction of the differences that tend to create Sudo accommodation, but it also does it in conjunction with lower amounts of positive spherical aberration in the cornea Now if we look at the total system here, we have vertical coma and decreased amounts of positive a sphericity Then we add that some negative spherical aberration in the lens And we end up with enhanced apparent accommodation and improved depth of focus and amplitude of legibility So let's go back to this diagram negative spherical aberration in the IOL And vertical coma in the cornea is equal to pseudo accommodation This is the same wavefront dynamics that we saw in accommodation And if we look at the point spread function of coma and negative spherical aberration and sort of combine them There's your bifocal in the cornea right there. You can actually see it and what's really interesting is if you compare that to the Wavefront from the monkey studies. They look exactly the same All right. Now. Let's go back to the faking Uh presbio the 61 year old faking presbio This is a patient that I saw in the office Who was 2020 and j1 61 years of age? Recycled pleased her and she was still 2020 j1 So I said wow, that's pretty impressive. Let's get a wavefront on this patient So we did And our coma values were out of sight. By the way, this is a non ectatic eye No care to conus or anything weird going on The vertical coma point four and point five this is probably the highest vertical coma I've ever seen In a virgin cornea that is not pathologic And this patient never wears glasses for distance and never wears glasses for near So the question is how much vertical coma aberrations Can the eye tolerate without image degradation? Anybody have an answer? All right. Well, let's let's explore that for a minute. This is an rk patient And we ended up putting a torac lens in this patient This is the videocarotography of the patient showing the Distorted values of the topography And this is the ortho non orthogonal K values that the general machine generated the severe flattening inferiorly And here you see the wavefront on the right side And this is the lens in the eye Matched really well now. This is the coma values in this patient 2.8 rms This is the highest coma values we've seen and represents anywhere from 15 to 100 times more vertical coma than on a presbyopic aspheric pseudophagy By the way that patient's vision As you can see it was 20 25 and j2 And the patient was thrilled because she before she had this torac lens She had very very poor vision and she's now about three years post op And enjoys the same vision. In fact, I think her near vision's even improved to j1 All right. Now, what are the implications of corneal wave fronts on multifocal IOLs? Any questions so far before we go on You want to just be interactive? Let's make it interactive. Yes Okay, if if you look at the study what the the rms value basically Squares the number And then you you and you add your other terms you square each of the terms And then you take the square root of the mean So the the the negative values drop out Also, if we look at the absolute values of the terms The the negative or positive value drops out the problem we had in the very first study We had is that we didn't drop those values out even though we saw the the correlation We didn't find the climate the statistical significance But when you actually do it where you're doing absolute values and rms values The the the position where there's negative positive doesn't mean anything question Exactly Well, we're gonna get in that in just a minute That's that's that's that's that's also and I don't is alan krandall. There you go. Okay. I'm gonna if I got some time We'll talk about the synchrony a little bit too. Okay, so everybody with me so far. Yeah question Is not good I understand that and I don't think with the level of negative spherical aberration We have in the lenses today. It makes that much difference The fact is that you've reduced the positive asphoricity of the lens It's my feeling That we could put double the amount of negative asphoricity in the lenses and end up getting Tremendous amounts of Depth of focus in these lenses without degrading the optical system now That's sort of contrary to a lot of thought about negative asphoricity degrading the optical system But that article from patricia pierce in 2004 Really highlights the fact that negative asphoricity enhances the optics of the visual system Now this is interesting also because I got interested in wayfront dynamics of the eye in refractive surgery when we had The custom oblations we use the laid-ar system and we did a lot of work And and it was our thought that the eye needed to have you know, we didn't really know nobody really knew You want to lower the aberrations in the eye? And and most of the patients who had myopic lasik Their symptoms were created by increasing the positive asphoricity of the cornea. They end up getting huge amounts of positive Ab Positive aberrations So fourth order terms so My thinking has really changed a lot. I think that there are aberrations that are very beneficial to the eye and the question is You know, which ones and it appears to me from the correlation from all these studies That negative asphoricity and vertical coma Or the distance between terms of vertical coma really make the difference of how well a patient is going to see for Functional near and distance vision. Okay. Let's let's talk about the multifocal lens and then we'll go to the crystal lens All right, what are the impacts of corneal higher aberrations on multifocal lenses? Well, as you know, multifocal lenses have these concentric step zones and and they create these repetitive phase jumps to allow Interference to constructively allow the eye to focus at more than one point Now the problem is that these junctions also distort the wave fronts with increasing light scattering And they may lead to significant reduction in optical quality In fact, they there's a possible that over 25 of pages may notice some degree of Dysphatopsias and the tolerance to these lenses is very variable Um, you get this 2020 eye that they don't see And they go to see 10 ophthalmologists in their 2020 they kick them out of the office and the patients are crazy But these patients can't see because they have this huge amount of wavefront aberrations coming from these lenses And really to date the cause of these dysphatopsias is not really identified And there's no published reports correlating Wavefront analysis to visual dysphatopsias Or the risk in advance prior to surgery whether they would tolerate these lenses So we wanted to go back and identify The wavefront properties of patients who were very significantly dysphatopsic and determine if the aberrations were correlated And determine if we could create a marker to preoperatively screen For visual dysfunctional eyes with planned multifocal interocular lens implantation Because it would make sense, you know, you think oh, I got all this vertical coma Got it. We just need to put a monofocal lens in your eye and you're going to do great In fact, some of these patients really outperform These these multifocal and accommodating lenses with just a monofocal lens if you can choose them correctly So we did a retrospective review Of patients who underwent an IOL exchange for severe visual visual dysfunction And compared them compared them to patients who had successful tolerance to multifocal IOLs So our first group was our control. These are we did 55 eyes 38 patients And these are the lenses that were distributed among this group the The first and second generation of the restore and the three-piece restore, which was the first generation This is the group two They were either patients who underwent IOL exchange or they were very dissatisfied but did not want to undergo surgery We had 45 eyes And this is the distribution of the lenses that we we expanded Usually the average time from Implantation to the removal of the lens was 22 months And we did the same thing with the topographer And we look at the numerical values of third and fourth order zernike polynomials And and compared them between the two groups And this is the formula for the root mean square where you're taking the Individual term squaring them Getting the mean And then taking the square root. So the sign drops out of the equation whether it's plus or minus doesn't mean anything We also looked at the absolute values of these terms And this is what we looked at And um If we look at the mean value of the z3s each individual z3s We found that there was absolutely no statistical difference between the two groups none whatsoever If we looked at the z4s there was really no nothing going on here either Until we get to this last one, which is horizontal quatrafoil And it was the only one that had a clinically significant value And that was sort of an odd zernike to pop up in our study. We didn't quite understand that so we kept looking at the data And we looked at the combined z3s, you know, all of the z3s together And we did find some clinical significance to looking at that If we looked at the z4s combined z4s, we also find a clinical significance But when we combine the z3 and the z4 and got the rms value for the global amount of the groups of z3 and z4s We did find that there is a clinical significance so What this means is that unlike pseudo accommodation where a particular term Is important in pseudo accommodation In the multifocal lens, it's the global Wavefronts that are impacting where there are patients going to tolerate that lens or not And this is what we found if that value was lower than 0.18 The patients had good tolerance to a multifocal lens But if it exceeded 0.23, they fell into the intolerant category All right, we're going to try to wrap it up here Let's talk about the crystalline a little bit Uh, these are the factors that are probably related to uh, well Whether the the variables for now or does the lens move anterior to posterior Increasing the power is always obviously you know if the lens moves and there's a higher power lens You're going to get more effect And we've already talked about increasing negative spherical aberration Or the induction now, this is another concept of whether these lenses should have induced vertical coma in the lenses or not You know it's a you know you with the light adjustable lens you put a little vertical coma in the eye and boom And you've got a little asphiristic You've got a natural accommodating multifocal lens think about that one All right, well if you look at the theoretical combination with a 1.5 millimeter movement of the lens In a 20-doctor lens your only your theoretical amount of accommodation is going to be about 1.25 doctors This is the crystal lens And theoretically this lens is supposed to move in the ap direction to get that That uh, a combination And this is a high frequency ultrasound Of the lens and I guess you can maybe see that there's a little bit of movement in the in the lens with a combination But what happens when you get something like this? And here's a high frequency ultrasound showing that there's no movement in that lens and look how full the four cells So we've had a series and here you see a high frequency ultrasound Wait a minute That movie's not firing up, but anyway there it goes and you can see that lens does not move at all There's just a lot of cortex epithelial cells elginic pearls whatever in there So this is a another little study that we did work We actually have improved the accommodation of these lenses and i'm just going to show this one case This patient presented to me three years post op crystal lens. They wanted me to do a yag on this patient I took a look at him. I said, you know, I don't think i'm going to yag this patient I think i'm going to do something different and this is what we did And we have a series of about six patients where we went in and did a bi-manual irrigation aspiration of the of the lens epithelial cells In the uh, fornix of the capsule bag And then we did something else That was sort of different. We didn't do this on the first two or three cases Which we did get some improvement in accommodation But i'll show you something. I don't think you've ever seen before So this is the mst bi-manual instruments going in just cleaning and these cells come out pretty readily This is three years post op And this is what this is about a 45 minute case this edit is down to about two minutes But this fibrotic band of material was peeled off the posterior capsule without rupturing the capsule used a blunt sinsky hook Basically to get a surgical plane going And it was persistence because a lot of us would say it's not going to come off It's stuck on there. It's very hard to get off But once I got the surgical plane going it's actually peeled off But it took a lot of time. This was probably about a 30 or 40 minute dissection But what was amazing Was that when we got through with this case The capsule was just as elastic as it was As if you're just operating on the patient that day and this is three years later And this is what the patient looked like post-operatively And this patient actually gained about a doctor of accommodation after we did this procedure So it's kind of changed my approach on these crystal lenses to just automatically start yagging them I don't know if we get paid for a procedure like this or not But we've had about six or seven of these cases where we've gone in And the patients love their vision this way Now let me see if Ah, Alan All right, I'm going to show this and then we'll quit Alan sent me this information a couple of years ago I'd really like to get both eyes on this patient But but you had and I thank you for saying this to me you sent me the wayfronts based on the The visex aborometer And and these are the wayfronts. This is the unaccommodated state in the right eye So this is the right eye. You see the refraction up there And this is the left eye Now if you'll see what's going on here and look at the wayfronts look what's changing The coma between the accommodated and unaccommodated state So I don't know which eye was the eye that was the problematic eye But this also this is a total eye aberration. This is not corny elaborations But what we're seeing here is that the improvement in accommodation Is related to the coma that this patient gets on their wayfronts So In closing I would say there's a lot about pseudo accommodation. We don't understand This opens up sort of a picture of Of adaptive optics of accommodation. Nobody has studied this We just assume you you put a multifocal lens in you put a crystalline's in But the problem is corneas are not the same for individuals And as we can see as we explore this more and more the cornea is probably playing a very significant role In the ability of the eye to pseudo accommodate And it's and I think the onset of aspheric IOLs has really Unleashed this because the coma and the negative spherical aberration are the two components Of a combination that we're now seeing that are effective for focusing in improving Depth of field and depth of focus In uh, monofocal suit effects So with that i'm going to stop and open up to questions nick This from fenzel We're doing that right now as you speak. Uh, we're that's going to be hopefully be ready for a may presentation At our annual research day. In fact roi meyer Is actually doing that study for us right now So we're looking at all of our crystalline's patients And we're going to compare the accommodators and non accommodators and see if the corneal dynamics are playing a role mark Well, we have not been taking total eye aberrations on these patients So the answer to your question is no, we've not looked at what we've been looking at Specifically is what's going on in the cornea? And what's going on in the lens? Um To my knowledge, I haven't seen any Um of these patients. They're only about we only looked at 50 patients here I'm not aware that any of them they have decentered optics But obviously that's going to affect the system and people talk about To put an aspheric lens in the eye And the center is just going to throw the optics off and that would certainly make sense um And then the question is how much negative asphericity can you put in the lens that the eye will tolerate? And and that's going to be hard to find out because I don't think companies are just going to say, okay Let's just throw in an extra two tenths of a micron of negative asphericity That's going to be hard to do that could take 20 years to unfold in this country for longer um But uh We have we have not studied the differences between total eye aberrations and the focal local aberrations on the cornea to see Distinctions and the other thing that we want to look at is we want to compare The next step we want to do Is look at is does this information transfer from one piece of equipment to the other for example the pentakam Now gives us wave fronts, but when we look at the pentakam wave fronts And the top auger wave fronts on the on the um Humphrey The values are not the same it's giving us different values So one of the studies we want to do now is go back and take these same patients and run them through the pentakam And see what statistical models develop from that So this is a whole I mean this is like an opening a door of a whole new era that You know We don't completely understand one of the most interesting things is when I met with this this astrophysicist Yeah, yeah, I had a friend that came in for lasik surgery and he was at work for nascent I just started talking to him. He said oh, I've got the perfect guy for you to talk to This guy came to my office and we sat down for six hours talking about this and he started He was actually a graduate student of zernikey And it was fascinating to hear his take, you know, I said, how does an eye has a monofocal lensea at distance and near And I started showing him some stuff. He says this all makes perfect sense So it sort of validated our thought processes of what we were doing Dr. Imbadi Well, I'm not the statistician Uh, dr. Jerry McGuire is and I don't know enough about statistics to tell you about it But he's our he's our at uab. He's our statistician and you know, we can You know, he can take this day into whatever he wants to with it But if you've got a specific suggestion, I'm glad to take it to him Mm-hmm I think they make perfect sense because point one, you know, the average amount of Aspiracy in a human cornea is what what's the answer? Residents what's the average amount Of positive aspiracy in a human cornea Anybody know the answer Yes, you're not a resident About point two seven. So if that patient has point one They actually have less positive sphere Less positive spherical aberration than the average human eye Which means that their optical systems are supercharged. That makes perfect sense Well, I'm sure you could do an rk or something to create some vertical coma We've had we actually did a study where we looked at all of our rk patients We presented this about two or three years ago Where we put torque lenses in them and they do phenomenal and they have huge amounts of vertical coma You know, you like 2025 j1 2025 and these patients if you get the power, right? Which is really the trick in these rk patients and you get the alignment, right? And I've got a whole talk on how we align these lenses these torque lenses up It's real simple. You ever y'all use a miloni caratometer We'll just hold and you can see The reflections a qualitative and you just put the lens in the short axis It's very easy to do and these patients do great if you get the power right Sometimes getting the power right is a little tricky these patients Now what's amazing about the rk patients is they come in with eight and nine doctors of corneal stigmatism and at the time The power of the of the lens was only a t5 We were making good visual optical systems without matching one to one Of the astigmatism And I don't know how that's to do with the lens being at the nodal point and out But you put in a lens that corrects two and a half doctors of stigmatism and the patient has 10 doctors of corneal stigmatism and they get 2025 eye And we started I I'm a little bit uncomfortable with these really high torque lenses in these rk patients because The optics of the astigmatism lens is really tricky If you put too much in it flips the axis in the opposite meridian So the assumption that you want to go one to one on these patients. I don't think is an understood science I don't know what your feelings are about that I I think the best way to induce vertical coma is have you guys do it in the light adjustable lens I mean if you tell me you can do it. That's what I'd like to see That's what I want to do. Well, thank you very much. I've really enjoyed coming back a salt lake What's the meaning I'm just hanging out Absolutely I know what he asked you about See he's coming in today. I think they should have left to get you a fox on me. Okay He's a Dwarf. Okay, who he had Very Okay, I did a big bubble DALK on his right eye And he uh great. His other eye I did a big bubble DALK And I had one suture in my full fifth with the dwarf. I mean a decimated attachment I think we're like an air bubble So maybe a couple of days. Well, I ended up a couple of days later putting on a suture. I mean take out the suture Eventually, you see all okay, but he uh He unfortunately didn't stand back And we ended up getting a zavalli of people and also A Keteran from the air bubble And so uh With all sutures So do you do do you have a pedicam and a topo one in the pre-operative room? I before you took the lens in I just had a topo. Okay. I didn't get a pain in the cam. I didn't really look at much And he's now complaining. Absolutely overwhelming double. Yeah, that's the problem with double problems What what what what power See that's the problem with these maximum I don't think you want to match this The cylinder one more. I think I think you gotta be very cautious. The other thing is you've got a big pupil But I think you might want to change that Because once you do the pupil you won't be able to get to the lens. I might reduce the Well, I would have to What I would want to look at is is what is this current refraction? This we had a patient like this that had an overpowered torque lens And what happens is let's say the astigmatism is here And the patient actually originally came to do with the axis of the lens off And they get this refraction where the astigmatism is coming from this direction So when I actually land the lens off all of a sudden the astigmatism is now Opposite so now we know that the lens is overpowered to the eye because it's flipped the axis 90 degree So if the lens is perfectly lined up, you know where your astigmatism is and then you can subtract the difference and determine What color lens the astigmatism and what amount of collision If it's Is the astigmatism lined up or is it no different? Different You can take the you can manipulate these lenses One of the things that we do is we get photographs slit lamp photographs of the torque lens We put it into a powerpoint presentation and we take a picture of the topography and we overlay the torque lens To see if the axis of the touristy of the lens matches the axis of the astigmatism on the top And if it's off a little bit, you might just need to rotate that lens So you got to have objective evidence to know Where that lens is, but if you dilate them take a slit lamp picture Well, but if you take a take a just take a What I mean is just take a retro elimination of the lens where you get the pre dot and then superimpose it into powerpoint over a And reduce it the transparency to 50 percent overlay it onto a in fact, um Let me show you what I do You're not taking up all my time Let me just see if I have it in this This is what I'm talking about So here's the lens Here's the axis of astigmatism and so we can actually see if the lens is correct So we take this picture overlay the topography and then we we then you can draw this line on powerpoint And then you can actually verify that that lens is in And if it's off a little bit Sometimes that double vision goes away even five or ten degrees off. You might want to go back and try to manipulate It's one thought but I would get that pupil down. I would do a circle on the pupil once you're Completely happy with the lens Okay, I'm gonna come up and just Okay I'll be up there a little bit. Absolutely And in fact, I had an eye tracer and I got rid of it. I wish I'd never gotten rid of it We're just simply this is just data But uh, it's it's it's pretty consistent and it's sort of the we're now actually You know, it's it's a money loser for us. I want to do a restore. I make a lot more money But now I'm actually Can't see it myself in the front because I know we can we can predict through the camera and it's very effective Well, you know You