 How do you follow a talk like that? I mean, you don't. So already I'm apologizing here and I haven't even put up my talk yet, but my talk's going to be nothing anywhere near exciting as that one was. Unfortunately, I was approached a week ago and they said, oh my gosh, I've got extra time at Grand Rounds because you give a quick talk. So this is that quick talk right now. And so on a topic that's of interest, but certainly not as interesting as the adjustable one, every year we do a survey on why IOL directs planning. And we do the survey with members of the ASCRS, but also the European Catering Society, the ESCRS, but other people outside the societies can submit questionnaires to us for this survey. And so at the end of the year, calendar year, we tabulate the findings. Unfortunately, our data isn't prepared yet for this last year. And so I'm going to have to do the one from two years ago, which is the most recent update that we've got. But trending looks about the same, so it's probably going to be very similar. And when we look at this survey, we started this through a grant from the ASCRS and the idea is that we wanted to know why IOLs are being expanded or why they're being exchanged. And so when we put together a questionnaire initially, we had a seven page questionnaire because we wanted all the data we could get. As you can imagine, nobody's going to fill that out. So we had this wonderful questionnaire, no one would fill it out. So we basically boiled it down to what are the pertinent questions that we can ask on one page. And so for those of you who are explaining an IOL, we're trying to get the word out to everybody, please fill out one of these forms. It takes 30 seconds while you're in the operating room. And I'd love to get more data. And whenever we present this talk, people will say, well, what about this or what about that? We have to get some data. And so this is kind of a compromise. And so this is really a one page form. And the idea is we want to look at the signs and symptoms that are causing IOL to be expanded or exchanged. We want to look at the visual acuity, the complications, any secondary interventions. And what we did is we divided it up into different designs. And so when we look at IOL designs, there are one piece plate type lenses. These are the old silicone plate type lenses. There are one piece with haptic. And these are the standard hydrophobic acrylic lenses that we have now. There are three piece lenses and multifocals can be any one of these, but we wanted to have a separate category for multifocals because they are truly different than some of the other lenses. And so we put a separate category there for multifocals and accommodating lenses. We also put a category there, but the amount of expanded accommodating lenses are really small at the moment. Now we also looked at different materials. And so when you look at different IOL materials, they can be associated with different complications. So we separated out the materials, silicone, hydrophobic acrylic, hydrophilic acrylic. And there's a weird columnar material. It's a collagen copolymer that's just in the star lenses. But it's different enough that we gave it its own separate category. Now, don't worry about this slide. This is just all of the different lenses that we had in our survey. So this just shows you that we had a representative total of pretty much all types and all materials of IOLs when we're looking at this. Now, it's important that you realize that we can't tell you from this survey which IOLs are the best and which IOLs cause the least complication. Because first of all, we don't know the numerator. We don't know how many IOLs are explanted. We only know how many are reported to us. Secondly, we don't know the denominator. We don't know how many IOLs of a particular kind are put in. That's just data we can't get a hold of. So from this survey, I can't tell you lens A is better than lens B. But what I can tell you is if you put in lens A, these are the complications that occur and these are the frequency that they occur. And so that's what we can really get out of this survey. We really can't tell you which lens is better. So when we break it down by different IOL types, when we look at the one-piece plate silicone material, the most common complication, as you can see in the purple there, is the de-centration dislocation. And this is going to be a common trend. Fortunately, we're seeing this as our leading complication is dislocation, de-centration. Now, other less frequently seen complications, we can even see calcification. And these are the lenses that are in eyes with asteroid hyalosis. And so you can get secondary calcification on the surface of a silicone IOL in an eye that's got asteroid hyalosis. And I don't know if people are really aware of that, but we're seeing that showing up in our surveys. When you look at three-piece silicone lenses, these three-piece lenses, once again, half of them are removed due to dislocation, de-centration. So a very common reason for the removal. When you're looking at the one-piece with haptic... Question, if you have a patient who has a silicone lens in with asteroid hyalosis and they need a yak, what do you do? You just yak and hope it doesn't calcify or... Yeah, you yak and keep your fingers crossed. The incidence of calcification, although we're seeing it, is still very, very small. But when we see it, the most common setting is someone who has asteroid hyalosis and is undergoing a yak laser capsulotomy. And that allows that calcium to diffuse forward and deposit on there. So it's something you just need to keep an eye on. But you're going to have to yak these. You can't just not yak them. And I'm certainly not going to explain an IOL to prevent a complication that may or may not occur in a small percentage of them. I'll just follow up on that, right, because in all papers we published on there, actually the ophthalmology thought there was a speciol and yak and it was calcification already. So if there is a way for you to really check if you see deposits and everything, if there is a chance that it is calcification, maybe you should consider and explain. Because in all the cases we have, the yaks think it's speciol and it was calcified already. Does detractive need prevent the calcification of the IOL that? Some retinal surgeons one time suggested, and then there was a discussion, okay, do we have to be a very thorough detractable? What's the worst, a very thorough detractable or explanation exchange? So I don't know if I can answer. Yeah, what Liliana was saying is basically a lot of surgeons are saying, oh, it's PCO and they yak it in. And then the PCO doesn't get better. It's because it's not PCO. It's actually deposited calcium on the posterior surface of the IOL. So you've got to be really careful when you look that what you're seeing is really in the capsule, not on the surface of the IOL. I think you talked about chelation agents. There's kind of plus years ago about that, cut prevent cataracts on IOL, calcification, does that ever go anywhere? Or is that something that you've ever... I haven't seen that because the difficulty is if you're going to put a chelation agent, it would have to go inside the eye behind the IOL. And what is that going to do to anything else inside the eye? I don't know the answer to that. Now, when you look at the one piece with haptic hyperphobia acrylic, these are the standard lens we use most commonly in the United States. Once again, you can see that dislocation, de-centration in the purple is the most common complication, but the second most common complication is incorrect lens power. And so that really is applicable to this adjustable lens technology that we're looking at. And you can see that incorrect lens power is the second most common complication requiring removal of the most common lens that we use in the United States. Now, when you're looking at three-piece hydrophobic acrylic lenses, you can see that, again, dislocation de-centration is more than 50%. What's interesting in these is there's a significant proportion of iridus-ug syndrome. And this is where I would love to have a more detailed questionnaire because why would you get iridus-ug with a three-piece lens in the bag? You wouldn't. But if that lens is in the sulcus, which I suspect some of these probably are, then you are at increased risk of uveitis, glaucoma, hyphaema, pigment dispersion, chronic hyphaema, recurrent hyphaemas, things like that. So I'm suspicious that this subgroup of patients is probably the ones that have this lens put in the sulcus rather than in the capsular bag. When you're looking at the hydrophilic acrylics, it's totally different. Hydrophilic acrylics are almost 90% due to calcification. And so hydrophilic acrylics, unfortunately, do calcify. We are still seeing some of the old memory lenses that were pulled off the market more than a decade ago that are calcifying and are being removed. And these are not like the silicone lenses where the calcium is deposited just on the posterior surface. These are actually within the substance of the lens itself. And so we're still seeing in these hydrogel lenses they are being removed due to calcification. So when we're looking at multifocal lenses, multifocal lenses are completely different and the multifocal lenses are being removed due to glare, visual aberrations, dysphotoxies. So a totally different reason for removal of multifocal lenses. And so when we do take out these lenses, it's visual symptoms that are causing them. And again, this speaks toward one of the advantages of having this adjustable technology in that if someone has a multifocal lens that's been applied there, you can actually unapply it. So the patient can try it. If they don't like it, you can reverse it, which would be very interesting. When we're looking at toric lenses, we wanted it to see if it's toric any different than the standard hydrophobic acrylic lenses. And what we found was that this location of de-centration is still most common. But again, incorrect lens power is second. So when you're putting in a toric lens, power and proper alignment of that lens are critical. Otherwise, the patient's going to have suboptimal vision. So what can we say about this? Dislocation, de-centration was by far the most common reason for IOL exploitation. And why is this? I don't think we can blame the IOL for this. And so there was an old cartoon character named Pogo 40 years ago who lived in a swamp and he's gazing his swamp and there's trash and junk all over. And his comment was, we've met the enemy and he is us. And so what it means is that the fault isn't in the IOL. The fault is in our surgical techniques. And so this location of de-centration is where you have an incomplete capsulotomy. That implant is not completely in the capsular bag. And so that's really not an IOL specific complication. That's a complication of cataract surgery. Second most common complication is glare optical aberrations. And these were most commonly seen in the multifocal lenses that were removed. And so this is something inherent to the IOL itself because multifocal lenses are removed due to these glare, these dysphotopsies, and these visual symptoms. Now number three is still incorrect lens power. So no matter how good we are at doing our IOL measurements this is still a common complication. And especially now as this huge blip of baby boomers comes into the cataract age many baby boomers have had refractive surgery. So when you've had previous RK or previous LASIK that really makes the measurement of the IOL more problematic. And so I think this is not something that's going to go away. Our measurements are getting much better. Our calculations are getting better. But as Oliver said with Doug Koch one of the brightest, most careful surgeons I've ever met even he can't get optimal results using all the potential measurements we can do this is an issue we're still going to have to address again, why this technology that Liliana presented is so exciting. So there are increasing numbers in this survey every year of expanded multifocal IOLs and that doesn't mean that necessarily that multifocal IOLs are bad it means we're putting in more and more therefore we're seeing more complications that are requiring exploitation. And so I think that's going to be a trend that continues. Hydrogel lenses, plate haptic silicone lenses are being expanded less frequently. Does that mean that they are becoming better? No, it means we're just putting in less and less of them. So as we put in less over the years we're going to see less taken out. So that's why we're seeing that. Hinch plate silicone accommodating lenses are just beginning to appear on the survey so I think we're going to have to follow that in the next few years and see what these lenses are doing that are requiring exploitation. Now, because we've been doing this now for about 18 years, we wanted to say that what trends have been happening over time and unfortunately we've only got the three main groups of lenses that we've got all this data all the way back but when you're looking at three piece silicone lenses what you're seeing is that de-centration dislocation is still the most common reason for removing these and if anything it's not going down, it's going up which is interesting. When you look at three piece acrylic lenses exactly the same thing. This location, de-centration is still the most common reason and over the years, if anything that's even gone up a little bit. Incorrect lens power, glare optical aberrations is trending downward but it's still there. So that's important that we keep that in mind. And then lastly one plate silicone lenses by far and away most common complication is dislocation, de-centration but we're seeing less and less of these every year. So what can we conclude from this? How do we avoid complications? How do we keep from having to expand the lens in the first place? The first thing is good surgical technique is essential. You've got to have an intact capsule of rexus you've got to have an intact capsule or bag you have to have that IOL centered within the capsule or bag. If you can do that you'll eliminate some cause for complications. You've got to have accurate IOL measurements. If we can get a perfect way of measuring an IOL and maybe we need to look at better techniques of measuring an IOL maybe better aberrometry techniques other ways of doing that we can eliminate the third most common complication. Now in terms of dysphotopsies, in terms of visual aberrations we have to have proper patient selection. So you have to have the proper patient selection when you're putting in a multifocal IOL and you want to be very careful that you take care of other factors that they don't have any left over astigmatism they don't have severe dry eyes or surface disease and so as Sam Mascot says they don't have any of the opethies. You know they don't have keratopathy they don't have maculopathy so you don't have other things going on when you do these so think about those ahead of time and maybe you can decrease the potential complications. This is an ongoing survey so again I ask the fellows, the residents, the attendings when you do take out an IOL you know that patient, they're on the table it takes 30 seconds to fill this out so please send it down with us for those of you, I don't see anybody from the community here but yeah, all over anybody in the community this is available online at the ACRS website so please if you're going to take out an IOL fill out this form for us and every year we will put the data together we're going over that data right now for calendar year 2016 and we'll present it to ASCQS this year thank you, questions? I guess you're not able to say overall from year to year if IOL exploitation is increasing or decreasing, how to say? You know because we don't have a specific numerator all we know is the amount of form sent in to us so I'd love to answer that question again alright, thank you