 Welcome to cornea grand rounds. We're gonna get started because dr. Lynn and others have to leave, but this is a quarterly thematic grand rounds and dr. Lynn's going to talk to us about raindrop inlay for Presbyopia correction All right, so this is just going to be a brief overview of this new device kind of going over what the raindrop corneal inlay is and I've Got a surgical video of my first case No financial disclosures. So what is raindrop? It's a corneal inlay for near vision. That was FDA approved last June It's placed in just the non-dominant eye under a thick lacy flat. That's created by the femtosecond laser You have to make sure that the central corneal thickness is at least 500 microns and just like with lacy You do not need at least 300 microns of a residual stromal bed below the flap The parameters it's approved for age 41 to 65 so presbyopia age You know before cataract It's a 2 millimeter diameter hydrogel inlay. That's 32 microns thick. So hydrogel is the same Material as contact lenses. So it's just a very very very thin Mini contact lens and the way it works is that actually if you see the profile here The anterior curvature is a little bit more steep than the posterior curvature And then actually when it's placed under a thick flap It induces increased corneal curvature on top and that increases the depth of focus. So the inlay itself actually has no refractive power Everything is just based off of changing the corneal curvature There is a loss of one line of distance vision and It is best used in patients who have a spherical equivalent of minus a half to plus one with less than or equal to three diapters Sorry three-quarters of a diapter of cylinder And the original FDA study they found that 92 percent of patients had uncorrected near Vision of 20 40 or better at two years. The most common Complication was central corneal haze in 16.6 percent. It resolved in 89 percent of patients after Steroid topical steroid use the x-plant rate was 3.7 percent from haze. So this is kind of bad and since the FDA study there's been some Measures to decrease the incidence of haze So haze prevention I mean one thing I guess that they figured out during the study was that you need a thick flap if you have a thin flap or a flap that Maybe it's the same thickness as what we typically do with LASIK which is like a hundred ten to 120 microns You're gonna have more haze so thicker flap deeper less haze Intraoperative application of mitomycin C is also highly recommended now. This is off-label from What was approved by the FDA? We really want to limit any sort of debris in the flap because unlike LASIK we can't do any Irrigation underneath the flap because the raindrop in lay is right there So the advocate latex free gloves, local free syringes, lint free sponges Just we don't want any chance of any debris getting underneath the flap and cause haze And post-operatively we actually treat very aggressively with topical steroids They they get started on a Durazol QID for a week And then they taper it down after a month and after the first month of Durazol Let's switch over to Lodomax for a total of two months and patient expectations. So It takes at least several weeks for the vision to settle So even though this is a LASIK like procedure or making a LASIK flap, it's almost like the Visual results with PRK. It just takes a while for the vision to settle down They're gonna start off with blur very blurred vision for distance and that'll settle in the end result Is that they may notice better near vision than their intermediate vision? They will be slightly blurred at distance in that eye because they do lose one line of distance vision But their vision with both eyes open should be unchanged Should be emphasized that the long steroid taper is essential And very important to keep the eye lubricated That is actually more dry eye reported with the raindrop than with regular LASIK because the flap is being cut deeper More corneal nerves are being severed So here's my first case a 57 year old male right eye dominant meaning left eye will be getting the raindrop He did have a mild nasal tritium to the limbis in the left eye Central corneal thickness was quite thick. So if you calculate 30% of that that's a 180 micron flap At the bottom and very fine print. We've got his refraction He is Plano in the right eye and minus a quarter plus a quarter in the left eye And I've got a little three minute video here. So this proceeds like with normal LASIK with the femtosecond laser creating a thick flap again 180 microns and I always put marks on the flap just so we can line things up afterwards and So far this is proceeding exactly like regular LASIK We use this little blunt disector to sever The small attachments that are made by the femtosecond laser So we free everything up And the difference here is that because it's so thick it wants to like flap back So I put it back it flaps up flaps back open it up flap suck Open it up again. And finally I get it to stay and then I put on the mitomycin So this is 0.02 percent and I actually put it on for 20 seconds and I put the flap back So I'm getting the mitomycin on the underside of the flap and on the stromal bed That comes off Flap comes back and then I actually rinse with 20 cc's of bss So lots of bss Then I put on down a shy at style sponge That's going to keep the tears from actually getting into the stromal bed because once the raindrop is down We want everything to be very dry we don't want tears getting in there and it's got a nice little platform that actually helps that flap stick and Stay open and we have to dry the center very very well with a lint-free mericel sponge And the raindrop is delivered through a little notch With a sinsky hook and I didn't realize at the time but the raindrop came out a little bit too dry And so it's kind of like if you imagine a dried contact lens It's gonna stick so it's sticking to my since key hook. I can't get it off. I'm trying to this is not a trimmer I'm actually trying to get off get that raindrop off and it's not coming off so I decided to get into second instrument and See if I can pull it off, but because it's stuck it actually ends up tearing so like a third of the raindrop tears off And I don't know if you can see it right there tearing off. That's okay. That's why we have backups So I get a new raindrop open and This one comes out perfectly and you can see it there. It's clear. It's thin. I center it just on the pupil And I let it dry for 90 seconds You can't I think I'm yeah, anyway, we'll talk about that so once 90 seconds pass Flat gets put back. I don't irrigate Dry everything dry the gutter the gutter is a little bigger than normal just because there's a foreign body now under the flap And it actually placed a bandage contact lens for the first day just to help with irritation from that gutter So as far as the orientation, there's not a way to tell I think it's okay if it ends up being upside down may not work quite as well But there's really no orientation marking, but it does come out right side up Okay, so post-op day one. This is actually normal very blurred vision at distance 21 25 He's J2 plus contact lens taken out. He's on antibiotic endura's all lots of artificial tears and post-op week one Better 20 70 J1 with both eyes open He's 2015 and J1 and he's tapering down his durazal continuing lots of artificial tears He's actually coming back for his month one appointment today. So I don't have that information yet, but I mean I'm he's very happy. He was already saying that he wasn't needing any Reading glasses even with the fine print. He's a lawyer. So he's doing a lot of reading and very very happy with the results so far So that's about it any questions They must have I don't have that detail. I know I've seen talks where they looked at Looked at it, but I don't know what the deposits of their being Yeah, so after expectation it always pays more