 Okay, so the last of the Warner Mamelis lab group is Dr. Ryder. He comes from us by way of Pennsylvania and the Rochester School of Medicine. And we'll be presenting on a sulcus fixed lens that they've been testing to dabberize. Thanks. All right, can you hear me? All right, today I'm going to be talking about a new piggyback IOL that we did a study on in pseudophagic dabberize. And again, we have a research grant from MediContor, the maker of this IOL that was using the study lens. And so I'm first going to talk about why we use piggyback, otherwise known as supplementary IOLs, go into the history of piggyback lenses and then talk about the study that we did with the new MediContor lens. So a patient that already has a primary IOL, you can add a piggyback lens in to add multifocal or toric function to that primary IOL. A more common indication is to do with post-cataract surprises. As my fellow fellow John touched on, you can have some options for post-cataract surgery or fractal surprise. The easiest is glasses or contacts, but most patients want to be spectacle free. You can do PRK or Lasik. And that is more refractive fine tuning. You can use like 0.1, you can get within 0.1 or 0.2 diopters of your goal refraction. It's usually more expensive than out of pocket. Your other options are lens exchange or piggyback, which are usually covered under insurance. And you can get within about half a diopter of your goal of refraction with that. As far as lens exchange versus piggyback, lens exchange is a more technical surgery, depending on the study that you look at. You can have up to 50% zonular dehiscence, about 8% chance of capsular rupture back into the vitreous. Whereas with piggyback, it's a lot simpler of surgery. And the one state I could find that was head to head with piggyback versus lens exchange. Better outcomes are reported in piggyback implantation with 92% of eyes getting within that goal refraction and just 82% with lens exchange. So the first time piggyback was placed was in 1993 with a patient that needed a 46 diopter lens, which isn't available. So Dr. Gaten chose to put two lenses into the bag to achieve the 46 diopters. In that case, I'm Michael Famos. The patient actually had good vision like a year, a year and a half out. And this was done two lenses in the bag throughout the 90s. But a complication of having two IOLs in the bag is inter lenticular pacification. So it's pretty much the same phenomenon as PCO. You have the lens on the picture on the right, the equatorial capsule cells can grow posterior to the primary IOL to cause PCO. Or if you have two IOLs in the bag, they can be funneled between the two IOLs and cause hyperplasia between that and cause a pacification. In addition, the piggyback lens in the bag can push the primary IOL posterior and cause a hyperopic shift with that. And so in the early 2000s, instead of putting two IOLs in the bag, they started placing the piggyback into the sulcus. But the lenses they were putting into the sulcus were originally engineered to be in the bag and that caused the complication. So on the left you can see this is in Acrosoft. So this was designed to be in the bag. So it has very sharp optic edges to prevent PCO. It has a very textured sidewall and that's to prevent the positive dysphotopsies you can get at night when you have a bleak light coming in and reflecting off of the optic sidewall coming back on your retina. So what happens when you put a textured sidewall and a sharp optic edge into the sulcus, it can chafe up against the iris and cause deposition of IPE cells as you can see on the picture on your right, causing pigment dispersion syndrome and even worse that can lead to pigmentary dispersion glaucoma if that ends up in your canal flim. So how do we avoid the ILO which was when we had two lenses in the bag and how do we avoid pigmentary dispersion syndrome which is caused by the optic rubbing up against the iris. So between 2007 up to the present a couple of lenses have been put on the market specifically engineered for piggyback implantation into the sulcus. And they're designed with round optic edges and thin haptics to avoid that chafing that something like an Acrosoft lens would cause. So on the left you can see it's very sharp IOL optic edges and on the right that's a sulca flex lens, very soft and undulating edge. So if you had to choose one of those to rub up against your iris you'd want the rounder one obviously. And these piggyback sulcus IOLs also have posterior haptic angulation. So as you can see in the picture on the right it kind of vaults the optic posterior and that's again just to avoid any possible rubbing up against the iris. And they also have a, the piggyback lenses have a concave posterior surface as opposed to a convex-convex configuration which IOS usually have. So you can see on the right the red is outlining a piggyback lens which has that concave surface and that's just to increase the interlenticular lens distance to avoid the optic-optic rubbing. And in general piggyback lenses are larger than normal IOLs, around 14 millimeters in diameter, overall diameter with the haptics. Your sulcus is like 11 millimeters and the optic is 6.5 to 7 millimeters. To compare the sulcus flex is 13, which is on the bigger end of IOLs, and about 6 millimeter optic. So none of these are FDA-approved but at least on the European and worldwide market there are three piggyback lenses currently used, the Rayner, sulcus flex, the Aspira, and the first Q first add-on. So if you notice the first Q has this kind of square optic design which is theorized to prevent pupillary capture and that's our current study lens also has that design. So now I'm going to talk about the study that we did on 12 cadaver eyes which had primary IOLs already in place premortem. So this is our study lens, again it has that same kind of square design as the first Q, first add-on. It's a one-piece hydrophilic acrylic. It has the same large dimensions as the other 3D IOLs in the market and it has these four flexible loop haptics that configure into different sizes of sulci. So we did a Miyaki Apple technique which is cutting coronally the eye, placing some glass and gluing the eye to it. It just allows for easy video photography from the posterior view which we don't usually get to see in eyes. We did a pre-op OCT, then we removed the cornea and the inner iris leaving the peripheral iris to simulate pupillary dilation. We then inserted the add-on lens and did post-op OCT and anterior and posterior photographs. And we were looking to see if the IOL was centered, if there was any tilt in the IOL, as well as assess the inter lenticular space between the primary and piggyback IOL. And so don't get lost in this table, but this is just to show that we specifically chose eyes from our library of eyes that we have in our lab of different axial lengths with different primary IOL materials, representing acrylic, PUMMA, silicone, etc. and different amounts of some rings ring just to kind of replicate any possible clinical scenario that our study lens could find. So as you can see, different amounts of some rings ring and primary IOLs and these are the actual eyes we used. And so what did we find? So I'm comparing what we found in this study to what we did in a previous study three years ago with the sulcoflex analogous study. So in all 12 eyes the lens has never touched, there's always a positive inter lenticular distance between point 3 and point 1.2 with the metacontor compared with the sulcoflex, which also always had some kind of inter lenticular distance but was a little closer. Three years ago with the study of the sulcoflex, we found a correlation between the amount of some rings ring and the amount of inter lenticular distance. So the more some rings ring was present, the more it kind of vaulted that piggyback more anterior. We found a weak association up to moderate but that trend didn't continue this year with the metacontor with severe summer rings ring. So we didn't find that same association. Also with the sulcoflex study, we found that with thicker primary IOLs like silicone, there was a smaller inter lenticular distance just because it occupied more of that space. We did not find such an association this year with the metacontor. As far as tilt, we found four cases of tilt. One was due to an area of localized summer rings ring, which I'll talk about, and three cases due to zonular dehiscence. Subjectively, all 12 eyes had that piggyback lens well centered as per Miyake view and OCT. So I'm going to talk about the two cases of tilt that we found. So this is I number three had a localized couple of clock hours of inferior summer rings ring as you can see. And I kind of overlaid a ghost image of the study IOL, which in reality is anterior to all these structures. There's a posterior view of the eye. So those loop haptics would actually be anterior to the slayer processes and the summer rings ring. So when Dr. Manlis put this IOL in that inferior haptic was overlying the summer rings ring and with my animation here, it kind of vaulted the inferior haptic anteriorly causing some tilt on OCT. As you can see on the left, there's just less distance on the left between the two IOLs than on the right. So Dr. Manlis then rotated 90 degrees so that each of the loop haptics were kind of straddling that localized summer rings ring. As you can see on the left, that resolved the tilt. This is before and after on the left and right of the tilt before and after that rotation to straddle the summer rings ring. We also had some cases of zonular dehiscence causing cases of tilt as you can see here on OCT. The piggyback relative to the primary. Again, the piggyback is on the top and primary below that. This is an anterior view now of the eye. As you can see, these loop haptics should be anterior to, in other words, closer to the camera than the ciliary processes, but they slipped posterior to the ciliary process due to compromised zonules there. And in eye number eight, you can see on an anterior view that gap between the bag, which is visualized with the summer rings ring and the ciliary processes. There's about four clock hours, three clock hours of zonular dehiscence. And indeed, in that eye, we did find a tilt when we implanted the study IOL. And on anterior view, again, we found one of the haptics slipping posterior to the ciliary processes due to weak zonules. This is kind of hard to see. This is an posterior view, and you can see the outline of a loop haptic there. So some of the take-home points from the study just outlines the importance for the preoperative exam when you have a patient that you're going to plan a piggyback lens into. If you can identify any isolated areas of summer rings ring, then interoperatively, you can plan to straddle the tabs. If your lens has four tabs to straddle or if it has two, again, just to rotate 90 degrees to avoid any possible tilt. And although very difficult attempt to identify any zonular dehiscence preoperatively, so you don't misplace a tab posterior to the ciliary processes. But in general, this Metacontor study lens centers well. It fits into a variety of different sizes of eyes with different amounts of summer rings ring with different primary IOL types. It always has a positive interlinticular distance and has minimal tilt in the absence of zonular dehiscence and isolated summer rings ring, at least. Thank you, and I'll take any questions.