 I'm going to go over just a few of the new treatments in cornea and refractive surgery here. So the first thing that we've started doing at the Moran also is corneal cross-linking. And so I think Julie is going to talk a little bit more about this, but I'll just be brief on this one. So this uses UV light and photo sensitizer to strengthen chemical bonds in the cornea. And it was FDA approved this year for using keratoconus with the VEDRO system. And the approved treatment is an epithelium off treatment. So we stripped epithelium off and then applied riboflavin for 30 minutes and then do a UV application for 30 minutes for keratoconus. There are a few things that this has been done for quite a while outside of the US. And so some of the future applications that we may be doing are for a polluted marginal generation, for ectasia after refractive surgery, taryons. And after cross-linking, it's possible that we may be able to do refractive surgery, like PRK on keratoconus patients. And some people are doing this already even in the US. A couple other interesting treatments that are done outside of the US are PIXEL, which is a refractive procedure that uses these apertures. These apertures, like you can see over here, to selectively cross-link parts of the cornea as a primary refractive procedure. And then there's also LASIK extra, which has been done pretty extensively outside of the US, where after lifting the stromal flap or lifting the flap in LASIK surgery, that cross-linking is applied briefly to the stromal bed in order to provide better stability in patients that may be at risk for regression after refractive surgery. Before the ablation, yes, but after lifting of the flap. Yeah, actually, I think the people who are most cautious are actually, I mean, there are people doing LASIK, but most people are doing it. Yeah, yeah, you can have LASIK or PRK extra. There have been about 100,000 cases done outside of the US. So I move around. I want to send you guys to patients for point of cross-link treatment. What papers do you have? 12 to 50. OK, yeah, we started recently, but we have a list of people that were going to operate, too. You were in the FDA trial, or one of the trials for the rapid cross-linking. What was approved by the FDA is a 30-minute standard kind of resident protocol, which is what we have to do now. But we treated about, I think, four-year, 50 patients. And we treated as young as 12, and as old as, you know, infant 50s. But I don't think it works very well in all the people, but honestly, I mean, it doesn't work very well. Most LASIK, at least in our experience, but it works quite well. It's a good adjunctive treatment for young care of those patients who are discussing it. We don't want to still do this kind of thing. OK. What's the utility of cross-linking in an ulcer patient if you wanted to use the ultraviolet light to hopefully kill the bug and also strengthen the form of the test and all? Well, yeah. There are some case reports of this that were, there are a couple of case reports from Mexico. And I think there was one for Spain, also, where they showed afterward that they were able to eradicate even a canthamoeba from the cornea using cross-linking. But, you know, it hasn't really, we don't have any controlled studies of that yet. Is that approved? Not approved. No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no. You mean, especially for, you know, We have some results from the symphonies that have been done here from Dr. Crandall too. So I'll be quick on this one, also. but the symphony, the symphony TORC lens is a new lens that's available recently and it's different than the other AMO multi-focals. It's an extended range of vision IOL. Both TORC and non-TORC versions are available and it uses this diffractive echelette to provide an elongated focal area. So it basically has a larger defocus curve. You can see that in the graph down here. So it supposedly is providing quality vision for up to the intermediate range. And you would expect that patients would need to use reading glasses still with this lens, but down in the bottom right here, you can see the mono focal has a single focal point. Of course, multi-focal has two, and then this has the elongated focal point. And we can talk a little bit later about the results from the Moran so far with this lens. So another of the big drugs that is out now for corneas is Zidra, the fitagrass 5% ophthalmic solution. They have a not so modest advertising campaign, so probably a lot of people have heard about this. So it's the first drug in 13 years that's approved for dry eye, both for signs and symptoms of dry eye. It's a two time a day drop. And the mechanism, or at least in vitro mechanism is it binds LFA1 receptor on T cells and blocks the ICAM1 LFA1 binding. And in vitro studies, this prevented T cell adhesion in pro-inflammatory cytokine release. And there's a thought that the ICAM is upregulated in patients that have dry eye on their ocular surface. So they did, in the clinical trials for Zidra, they did four separate studies, both looking at the signs and looking at the symptoms. When they were looking at the symptoms, the results looked a little bit better with these studies when they compared the vehicle to the drug. And they showed improvement on this 100 point dryness score in all four studies over a period of several months. The, for the signs of dry eye, those results were pretty close together actually, I think for the drug compared to the vehicle, but there was improvement in the four studies. And the side effects are pretty similar with Zidra compared to rastasis, burning or insulation, side irritation, some decreased vision and eye redness. But probably the most prominent difference is that a lot of people have bad taste with this drug and it's not always a mild side effect either. And some patients are saying that this, even though the company says it lasts for 15 minutes, some patients say that it can last for hours that they have this bad taste in their mouth. But Dr. Lin and I have used it in a number of patients so far and we've noticed that some people that don't get any benefit from rastasis that they have said that this has been pretty helpful for them. And also it seems like it may be taking effect more quickly than the typical three to four months that it takes to get the full benefit from rastasis. But those are just kind of anecdotal evidence so far from what we've done. And then the last thing I wanted to talk about is topography-guided LASIK and PRK, which we've also started doing here with the Wavelight, Allegretto, eczema laser. So the topography-guided LASIK, T-CAT, was approved in 2013 and has become more widespread early this year. And then just a few weeks ago, topography-guided PRK was also approved with this laser. So the difference compared to Wavefront Optimized, the prior treatment was based primarily on refraction and treating the sphere and cylinder. And Alkan's kind of changed the way that they think about this recently, but they're saying that now the treatment, which is based on refraction and corneal topography, is more thinking about treating sphere and higher order aberrations because they say that the higher order aberrations affect the amount of cylinder that patients are taking in their refraction. And so in a number of patients, and I'll show an example in a minute here, they're, the amount of cylinder is quite different from what they have in their refraction that we're actually treating. So this is how the procedure works. There's a topolizer, which is a placidodisk topographer, basically. And we take a number of pictures on a single day for the treatment eye. And using these pictures, which it also has iris registration, so when you're applying the treatment, it stays on the correct axis. We create a composite image using at least four separate images of the cornea that are similar. And then that's sent to a planning software and it's quite a bit more complex process for planning the treatment compared to wait for an optimized. And then that's sent to the Axmer laser after the treatment is planned. So who might benefit from this treatment? So the definitely normalized with higher order aberrations, especially coma, can benefit from this. And it's approved for LASIC for up to eight diopters of myopia or up to nine diopters, which with three or less diopters of astigmatism. And you can't actually program more than this into the laser, it won't let you do the treatment. But it can be useful potentially for a regular astigmatism, eyes that have already had a refractive procedure or patients who had a previous de-centered ablation or small optical zones. And then like we talked about post-cross-linking, this is gonna likely be a good option. So here's an example of one of the treatments that we planned recently here. So you can see this patient has kind of asymmetric astigmatism and some changes superiorly here. Down in the left, this is the way front optimized ablation pattern. And with this treatment, we're treating a little bit of sphere and just a half diopter of cylinder. When we planned this with the topography guided treatment though, the amount of cylinder went up pretty dramatically from a half diopter to 1.75 diopters. And because this is inducing significant coma. And then the thought is because of that, the patient's manifestor fraction is different because of the higher aberrations. So these are some results from the FDA trials for topography guided LASIK. And so you can see the results are pretty impressive here, better than 90% of the year getting 2020 vision. And probably the most interesting thing about this is at one year, 30% of patients had an uncorrected visual acuity that was better than their pre-operative, best spectacle corrected visual acuity. And more than 10% even gained greater than two, well at least two lines more than that. So that's a pretty significant difference. It just got for more than one day. Yeah, we're actually gonna do a study for our fellow study for probably next year or two is gonna be a comparison of one eye that receives a way front optimized treatment and then the other eye, we're gonna do a topography guided treatment. And it's hopefully gonna be both for PRK and LASIK working on getting the final approval for that right now. Since everybody's these patients with dry eyes, you may want to expound a little about where you should use the fitting graphs for the site of the scoring, for the site of the scoring. Where do you introduce it? It's what, because a lot of patients are coming, as you say, with advertising in their hands, say, can I have a big Zidra, please? Well, so finding, a lot of this is financial, I think at this point, because they're doing a 30 day free trial for Zidra. We've been using it mostly in patients that have tried or stasis and didn't have good result from their stasis. I don't think that we've tried doing both in the same patient, but some people are doing that since they work by different mechanisms. I think sometimes people that can't perform, they can't perform for stasis, or at least doing a trial of the filth of grass, but the insurance coverage for this variant. It seems like it's generally fairly expensive, but we've had a couple of people who've said they paid almost nothing for a little filth of grass for their insurance. That may change at the beginning, but I think we have been doing it fairly early on for patients after artificial tears, and maybe we've been doing it for four blocks in some cases, but I don't think it depends on them. Yeah, so I guess the protocol that I use is for usually trying artificial tears, artificial oil furs, fail that, try to stasis, then do plugs, later on maybe consider Zidra. Zidra though is, I think it's gonna be, it is gonna be financially driven because it'll depend on their insurance, and the other thing about Zidra is that for most insurances that aren't covering it very well, it's still very expensive, and the stasis is still very expensive. And the thing about stasis is that there's a lot of drops in each little vial that each unit dose is actually good for multiple doses, like about three doses of restases. So one month supply of restases can last at three months, or maybe even more. So that really kind of cuts down on the cost, but the makers of Zidra were very savvy, so they cut down the number of drops in each vial. There's literally only maybe two and a half drops in each vial, so you cannot reuse it. What that means is that the one month supply of Zidra is gonna be a one month supply of Zidra. So again, if you have someone who maybe has the same, if their insurance has the same price for both restases and Zidra, in reality, and in kind of practical usage, the restases is gonna be a third of the price of Zidra. So Zidra is provided, reserved to free single-body deliveries by understanding? It is, yeah, just like restases is. Right, it is reserved for free, so all these parts of the company say, it's reserved for free in single vial, it is single use to free vial, so that's what the expense comes in. In my clinic, we keep an average cost of the drugs that I respect. People are asking, how much do these cost for me? It's, we should know, do we know what a month supply of Zidra costs? It's really very good. Again, it's from a zero to like $500 a month. So that means for the residents, if you're practicing medicine today, you don't know the cost of the drug you prescribe in, do not prescribe it, because there's an antibiotic that I can prescribe for a simple infection that'll cost you $500 with insurance, and an equally effective one that'll cost you $4. I think it's not in my job to really know these things. If you ever come to my clinic, in the cupboard where the technician sits, open it, and there are costs of all the top of the drops, the steroid drops, anti-bacterial drops, a few more or less, perhaps it's there. And I'll urge you to carry that to your pocket. I think that should be the pretty 16th where we position these days. So I think it's not zero to $500. We need a better idea for our pharmacy, for what we say. Yeah, but the problem is that the insurance companies are so variable that that really is the price, zero to $500, I mean, depending on the insurance. So there's absolutely no way, and I'm not gonna sit there and look up their insurance and look up what the price of the Zidra is. Unfortunately, it's kind of, the onus is now in the patient to look into it themselves. I'm not even sure that you can. Yeah, it's still possible. And the number of insurance companies, when you get some that are, you know, common, then we can kind of figure it out. I think a lot of the insurances are still figuring out how they're gonna cover this drug. It's only a couple of months. Sometimes the patients are the first one to try to get near enough.