 All right, my clicker just turned over to eight o'clock, so I'm gonna go ahead and get started. I think we have a fair amount of material to cover today. Welcome to cornea theme, Grand Rounds update. I'm Mark Mifflin. We're gonna be, I'm gonna present a talk and then either Dr. Zager or Dr. Ibb will present next. We're not quite sure yet. And I'll be talking about limbal stem cell transplantation. Dr. Zager's gonna give us some updates in the area of our field. I think including talking about the new pylocarpey 9 drop for Presbyopia. Colin is gonna talk about some DMEC complications. So I'll get started. Maybe, no financial disclosures. Lymphal stem cell deficiency. I'm not gonna really go into that whole is not gonna go into all of the pathophysiology or kind of how to approach limbal stem cell deficiency except to say that it runs a spectrum. Most of us know what that is and it involves scarring and loss of normal cells on the ocular surface, which obviously interrupts the clarity of the eye and the ability to see and refract light. It can be, it can range from complete as in the lower left panel to other variations of partial which are shown in the other three panels. And as I mentioned, basically there are two components. So the most important is that we lose our corneal phenotype, squamous epithelial cells that are highly developed to be clear and very uniform and formerly good optical layers that refract the light regularly and support the tear film. But they also perform a barrier function which prevents the natural tendencies of the conjunctiva blood vessels and scar tissue to grow onto the cornea. The diagnosis is really a clinical one although impression cytology looking at, even biopsy looking at markers, cell markers and staining and confocal microscopy can also be used to help decide or prove different variants of limbal stem cell deficiency. I'm not gonna really talk about non-surgical management much but it is important in these patients to manage the acute causes which are generally injuries of a variety of sources or in the latter part of the slide prevent other conditions or comorbidities which allow limbal stem cell dysfunction to worsen and eventually cause loss of corneal clarity. Just quickly mention kind of temporary or partial limbal stem cell dysfunction is very common in contact lenswares and also due to medication toxicity. So always think about that. I've had countless countless patients in my career where I've just simply withdrawn medications, put them on maybe some preservative free steroid for a while withdrawn contacts and their stem cell dysfunction gets better. There's a lot of nomenclature associated with this topic. We don't need to go over all of this but I'll describe the different things as we go through them. It does become kind of word salad and the abbreviations are actually helpful in sorting it out. It's actually pretty simple. If you just sort it down to the tissue being transplanted and whether it's an allograft or allogeneic process or an autologous graft. The different variations of surgery can be performed either autologously in the case of the three that are listed there or if it's an allogeneic graft a more in block type of sclero corneal graft is performed in the form of keratolimbal allograft. People have also used living related donors in the case of the non-KLAL grafts and HLA matching is sometimes done. And I have some experience with that I'll mention later. The in block procedures as I mentioned above are keratolimbal allograft and then the CLAU stands for conjunctival limbo autograft which we'll be talking about in a couple of cases today. The other approach to this which is a little more modern and more simple is proliferating donor limbo stem cells. And when I say donor could be from the fellow eye or from a donor eye but and proliferating them on amniotic membrane and that can be done in situ and vivo and that's slat simple limbo epithelial transplantation or it can be done in a culture type setting and CLET stands for cultivated limbo epithelial transplant. So keratolimbal allograft is performed for complete limbo stem cell deficiency. The most common use for this is aniridia it actually has the best prognosis. I learned about this from Ed Holland and others but there are really large populations of aniridia patients including many that I've treated here in Utah who've done pretty well with this surgery over a long term. We also use it quite a bit for chemical injuries or burns and many times those are bilateral injuries. It's not used as much for unilateral conditions because some of the other techniques can be better. So this is just a little diagram I borrowed from Dr. Mosifar in a recent online publication that he did and this diagram just kind of shows the idea of keratolimbal allograft where in panel A it just kind of represents removing the scar tissue from the eye, taking actually two donor eyes that are relatively fresh and have good epithelium and the EyeBank actually prepares these with a skirt of conjunctiva left and then three hemi sections of the donor tissue are used to make a complete 360 degree barrier as shown in panel B and that provides not only the limbal stem cells but also this really strong barrier to re-conjunctivalization and vascularization. And this is actually a patient that I'll show a picture of later. This is a gentleman with aniridia. This surgery was from about 2000. That's why the video started to picture so bad. But back then it was long enough ago that we were getting whole donor eyes and whole globes and so this is just shows harvesting the keratolimbal graft and now we use cornea in situ corneal scleral rim so we'll show an example of that as well but the tissue is partially dissected with some cornea and very thin rim of sclera with overlying conjunctiva and of course the important limbal stem cells and then it's actually recessed and sutured a little bit posterior to cover the limbus and that's why you need three half circumferences to surround the eye because we're recessing it or moving it back. This is actually just a picture of the fellow eye of that same gentleman in aniridia patient after his second eye, limbal stem cell, keratolimbal allograft. So the challenge really with this surgery is it's technically not the easiest surgery. Takes a little bit of time to do that manual dissection but mostly immunosuppression and this requires strong immunosuppression similar to what a patient would get for a kidney transplant. So it's not really the best option for all patients especially if they're younger or childbearing age, et cetera but it does actually work well and there's a high success rate in a lot. I won't go into this diagram. It'll be in the box presentation if anybody wants it. It actually works well for patients who are willing to go undergo systemic immunosuppression and sometimes that means even young patients if they have bilateral disease. This is actually that same eye. I didn't have a recent clinical photo but this is a recent topography of this gentleman 19 years out from his keratolimbal allograft and he's still seeing about 2,100 to 2,150 out of this eye. He's actually a gentleman who has pretty good oveas for aniridia. And his fellow eye also has had the surgery and he's maintained good clear corneal empathelium for well, his other eye is actually further out more than 20 years out. And he was back in the days when we used cyclosporin. He's a thioprinazone for immunosuppression. He was on that for about three years. He's been maintained on restasis twice a day and I think he's on fluoromethalin twice a day and has not rejected his grafts after all these years. Partial imbal stem cell deficiency might be more sectoral. If you can see in the top panel, there may be some areas especially on that left side laterally where there might be some actually functioning stem cells there are other areas where they look like they're pretty wiped out. Maybe three quarters of the limb vest looks pretty abnormal in this patient but sometimes when there's some population of healthy cells it's better to do some kind of a partial less aggressive surgery. The bottom panel just shows the chronic FB defect in the patient with cornea transplants times five or six and just poor surface just couldn't grow her up feeling. So for this surgery, we would consider doing if they had a healthy fellow eye, a conjunctival limb oligraft or even a this can be done from donor eyes as well, but generally doesn't work as well as carried a limb oligraft. I'm even stumbling over the letters. The conjunctival limb oligraft, which is taken from the fellow eye actually works really well and it does provide a partial barrier effect. So this is a really good surgery if you have some quadrants of vascularization that you want to kind of block and maybe the patient has some functioning stem cells and it particularly burns. This seems to be a good surgery. Many times the inferior limb vest is burned and there's some sparing superiorly. This is just shows some how we harvest the tissue from the fellow eye can be done under topical anesthesia or sometimes we do these patients under general makes it easier just to work on both eyes at the same setting, just to picture suturing that limb bull transplant in the position. And notice that we take a fair amount of conjunctiva with this because it is the patient's own conjunctiva. And if we were to recess the scarring, we can actually have that donor conjunctiva from the other eye kind of contribute to maybe making the fornix a little bigger or just decreasing scarring from sutures too close to our other graft, the limb bull part of the graft. This just shows healed tissue after the donation and a couple of weeks of healing, things are well. Fellow eye limb bull stem cell deficiency has been hygienically induced by this surgery. So one has to be careful not to harvest more than at the most six o'clock hours and pay attention to other pathology. But in my experience, I've never seen any problem with this even harvesting up to six donor clock hours in the fellow eye. This is, I'm gonna zoom through these because I don't wanna take too much time. But this is actually a patient who, one of those patients who had multiple, multiple transplants was monocular, had a living related donor from an adult child, limb bull stem cell transplant actually shown on the left there. That's actually where the conjunctival limb bull transplant is from the donor and really helped the patient. This is actually another example. Well, this just kind of shows that, how clear this cornea is, it's not perfect, but for sure corneal phenotype epithelium. Many of these patients with multiple, multiple repeat surgeries have failure of stem cells. And then actually another patient, this was his seventh transplant into his monocular eye. And he also had a living related donor transplant from his son who was a six out of six HLA match. And he did well with this graph for a few years until I can't remember. I think he got a central retinal artery occlusion or something and eventually went blind in his only remaining eye, but we were able to keep this eye seeing for years because of the stem cell transplant. And that just again shows the ocular surface of that same eye. SLAT is one of the kind of less invasive to the donor tissue procedures where we take a very small biopsy, a little bit smaller than what I just previously described, cut it up into pieces, put it on amniotic membrane, which is placed on the eye after removing the scar tissue. And then basically these little donor clumps proliferate in situ with the protection of a bandage contact lens. That's called SLAT. And again, amniotic membrane, we've been using amniotic membrane for these kinds of surgeries since about the late 90s. And interestingly, Biotissue, which is the company that we started with is still going strong and most of us still use this frozen amniotic membrane. It seems to be a little better than the dry stuff. This is a video, I'm not gonna show the whole thing, but it does show, I'm gonna go back here, shows the SLAT procedure, just a slightly different way of, sorry, it will play, I just need to let it play. A little bit different way of harvesting. There's more than one way to harvest the donor tissue. In this video, we're approaching it from the congenitival side. On the other video that I'll show in a minute, we're approaching it from the corneal side. This patient had a thermal injury actually and had had multiple rounds of amniotic membrane, prokera, et cetera. Seems like all these patients come from Idaho. This guy was from Idaho. We were really able to completely clear the vascular panace from his eye. It was pretty deep and, but we were able to recess the congenitiva and try to smooth the tissue a little bit here with the diamond burr and I'll jump ahead here. So we put the amniotic membrane on there, in this case, suturing it in a position, also with fiber and glue underneath. That's the fiber and glue, the amniotic membranes in place. We take our donor tissue. This is a really good donor tissue here. You can see there's just a little tiny bit of sclera on it. So I'm 100% sure I've got those little, bold palisades in this. It's very thin. We divided them into 10 to 12 sections and then we place it on the surface and I'm gonna show another video of this. So I'll just quit this one. This surgery can be done with just a bandage contact lens or amniotic membrane over the slight donor tissues. In this case, we used two layers of amniotic membrane. This just shows the fellow's eye about a month or two after the surgery. You can kind of still see peripherally the little islands of donor tissue that have stayed in place. He actually, even though his cornea looks pretty hazy, he improved about five lines from 2400-ish to about 2060, 2070, 2080 with refraction and about 2080 to 2100 without refraction. He actually, we were thinking originally we were gonna do a cornea transplant on the side but he just decided it was good enough that he didn't wanna mess with it anymore. That just shows the surface. It's not a great picture but you can kind of see in the lower right. There's probably some congenitalization and then the more shiny, good looking cells centrally where the corneal phenotype epithelium is present. So the slat surgery, again, what kind of showed you the way that we do that and as an in vivo or in situ expansion and then this cultivated limbal epithelial transplantation is doing basically the same thing, taking a donor eye, cultivating the cells either in a slurry or more commonly on the amniotic membrane and then growing them in kind of a culture for maybe three weeks or so and then transplanting that sheet of the amniotic membrane and cells onto the eye. It's not widely practiced in this country as you can imagine. There'd be a lot of maybe expense and issues but certainly something that is promising for the future I think with bioengineered limbal stem cells, maybe kind of making truly compatible cells. This may be something that we'll be doing more of in the future. This video, Colin and I did this case in November and Colin put this together. We're gonna post it on core and it actually, when I was kind of looking through the literature, it may be, I'm not sure this has been described. It's the first time I've done it and I just thought it would be a good idea. We have a, also from Idaho, 45 year old gentleman who was working construction and got a cement burn to one eye. His other eye was pretty much completely uninvolved. So we decided to, we wanted to do a sled. He's young enough. He didn't wanna have systemic immunosuppression but when you see his eye, you'll know why I wanted to, I felt a little nervous about just a sled because he has such aggressive vascularization and conjugalization that I just felt like there was no chance that this would really work for him. So we combined it with the carotolimbal allograft. So there's our little donor graph from the LOI and we're gonna reserve that and just put in some saline on a little telphus sponge and then we're gonna move over to the other eye. This gentleman had two rounds of surgery with Doug Marks before I saw him and Doug was able to put some mucous membrane graphs and they're on the top of the near the lid spec and you can see a little bunched up area or one of the mucous membrane graphs. But one of the really important things with these cases is making sure that you manage the eyelids and other aspects of the anterior orbit as well as you can before you start putting these delicate cells on there and so we really appreciate our oculoplastics colleagues who debulk things and get things ready. And another thing is it's really important to let these things kind of burn out. And this guy is now, this is about maybe 18 months or so out from his original injury or longer actually but even waiting for the mucous membrane graph surgery as we waited three to six months at least. In this case, we're really lucky to be able to find this corneal plane. You're always a little nervous dissecting because you're not sure how thinned out the corneal was before it's cut over. But for this gentleman, we're just cautious in proceeding and we really find a pretty good plane there. I'll jump ahead here in the interest of time. So, and then we just like the other video, put some amniotic membrane on there and then we'll use our donor tissue. Oh, yeah, I forgot, this is the keratolimolilograph. So let me go back here a little bit. I'm gonna show with the, let's speed it up here. Just getting our donor eye from, so from an iBank eye, which is a healthy, younger, fresher tissue. You can see that the conjunctiva is left on this eye purposely by the iBank which we have to request this. We can make about a half thickness scleral corneal rim. And this one, we didn't really divide it in half, we just got more like a three-quarter and a quarter from, we only used one eye because we didn't really wanna completely have a limbless with foreign tissue cells. So this is the keratolimolilograph just being sutured on over the amniotic membrane which has been pre-placed. And interestingly, I'm not sure you can see it in the post-op for those, but the only place where the vascularization is really coming in is in those areas where we don't have that barrier keratolimolilograph. So now we have our little donor slat tissue. This part looks really similar to what I showed before, so I'm just gonna zoom through that. And then we did not use a second layer of amniotic membrane. We put a bandage content after our fibrin sealant and it's sped up and that little bit, but we kind of let this dry for a bit and then we place your bandage contents. And so that, that's that gentleman. He since moved to Nevada, we've only seen him a couple of times post-operatively, but just a few weeks ago, we saw him for six weeks post-op. You can see how good the eye looks. I mean, it's completely epithelialized. That little spot there is just an area where the basal amniotic membrane has kind of melted the place, completely epithelialized. Pretty good view through. That's just another view. The amniotic membrane does stay kind of easy for a while, but with time now clear up. And then that's the donor eye, which heals very nicely. So I'm not gonna go much further here because I know these other guys have good stuff to talk about, but whenever I do something like this and I start to dig into what's known about it and then more so what's not known, it reminds me like hiking up in the Uintas. And this is a picture of our feet, myself and four of my adult children on the top of King's Peak. And when you get up into the Uintas, you realize how big the country is and you could never hike every peak up in the Uintas, even if you did it every day, every summer for your whole life. And sometimes I feel that way when you're trying to understand all the immunology and just all the little nuances of this kind of stuff. But I can tell you that it's been super helpful to me in my practice. And this limbo stem cell surgery actually does work. It requires TLC and very good compliance from your patients and you have to follow the immunosuppressed patients really carefully because you can't actually kill them with the medicine, but it certainly works well. And I really look forward to future advancements of this case, I think is something that might be interesting in that if one could provide a carotolimbal allograft as a barrier and then have better ways of transplanting these more simple epithelial proliferation, it may work better for diseases like OCP or Stevens-Johnson's and maybe we'll get to where we can really cultivate some conjunctiva and corneal cells and then just put like a K-Low on there as a barrier to keep all the scar tissue from going back onto cornea. So anyway, thanks for your attention. And it looks like Colin's on. So Dr. Zog said, Colin, he wanted you to go next. So I'll take home points, sorry, wasn't my last slide, but basically I just said what was on there. So I'll stop sharing my screen. Oh, Colin's already on, so thank you. Thanks, Dr. Mifflin, I'm sorry for cutting you off there. So I'm calling one of the cornea fellows and I'll be briefly going over DMEC complications. I have several videos of ours and photos as well as a case at the end. My talks divide into three categories. First up is intraoperative complications followed by early postoperative complications and finally late postoperative complications of DMEC surgery. So to begin with intraoperative complications, I would like to first briefly review DMEC surgery. Here's a diagram of a scrolled DMEC graph and below is a DMEC graph in the Jones tube. So in this day and age, DMECs are pre-prepared in the eye bank and given to us in a modified Jones tube to be injected into the eye, as you can see down here. This diagram, the endothelium is actually on the outside of the scroll and the dust mitts layer is on the inside. This is pertinent to the next few slides. When this is injected into the eye, we manipulate the eye so that the scroll unfolds like a taco and then we approximate it to the posterior cornea. So first potential complication of intraoperative DMEC surgery is ejection of the graft through the corneal wound. Here in the photo below, you can see the DMEC graph here being stuck and ejected, being partially ejected through the main corneal wound, even with the Jones tube in the wound. These graphs are very flimsy, they're flexible, and they will follow the pressure gradient. They can go through the main corneal wound, they can get stuck in the parenthesis wound, and you can see here the graph being stuck in the wound. And this is not ideal, the endothelium is getting damaged in this process. Another potential intraoperative complication of DMEC surgery is loss of staining of the graft. As you can see here, without staining, it's hard to see the graft even under microscope. And another extension of this is these graphs have either an F or S stamp to let the surgeon know the correct orientation of the graft in the eye, and the stamp itself can also lose staining potentially, and if that's the case, can make it very hard to know what the orientation of the graft is. Next, I have a video of one of a previous cell of surgery where the surgery is complicated by my hyphema or hemorrhage in the eye, unfortunately caused by the suturing of the main corneal wound. You can see there's some blood being leaked into the anterior chamber. A hemorrhage in the eye has several potential, makes the surgery a little bit more difficult because it's harder to see. Sometimes there's a lot of blood. It also, the blood can get in the interface between the graft and the cornea. So the graft may not be fully attached or increase the risk of postoperative detachment. In addition, blood in the eye increases risk of rejection or inflammation too. Here, they're trying to get the blood out, but it's not possible. So they decided to just to go ahead and open the graft and get it attached to the cornea. You can see that there is some blood in the interface here and you can also see the stamp here. So we got the graft attached and the gas bubble in and fortunately this patient did well to the hemorrhage resolved on its own and didn't have any detachments. And this next video of an interoperative complication with DMX surgery is one of my surgeries this year or as, yeah, this past year. And this is an illustration of, or injection of the DMX graft into the posterior chamber. So like I said earlier, these grafts will follow the pressure gradient. Here you can see I'm putting a little bit too much pressure on the eye. The eye needs to be more centered. And then this is the DMX graft in the Jones tube getting prepared to be injected into the eye. And you have to be very careful with this process applying only very light pressure. And you can see right there, the graft just gets injected right into the posterior chamber. It has a slow motion video. And so at this point, we're expecting to see where this graft is and it's actually behind the intraocular lens between the bag and the lens. So somehow it got shot there. And you spend a lot of time manipulating the eye to try to get this graft out. During this whole process, as you know, the more manipulation of the graft, you can lead some more endothelial damage, which is not good. And you don't want to touch the graft with your cannula. It's DMX surgeries and no touch technique. So luckily we're eventually able to release this graft from this spot here. With careful manipulation. You can see the graft is coming out. And eventually we're able to get this graft into the anterior chamber, open it up, get a bubble in and get it attached. Fortunately for this patient and for us, the graft actually did very well. It stayed attached with no re-bubbling needed and it's working and the cornea is clear and the patient has pretty good vision. So yeah, those are several potential intraoperative complications with DMX surgery. I'll be moving on to early postoperative complications and I just have a few photos here. So this is shortly after surgery. So number one potential complication is graft detachment. So the number one cause of graft detachment after DMX surgery is that the graft was not fully attached during the primary surgery. Sometimes it's hard to tell but these grafts want to scroll inwards. And so you have to look carefully at the edges to make sure that the edges are completely flat to the cornea underneath the air bubble. If there's a little scroll at the edge of the graft, the scroll may continue to scroll in, as you can see in this photo and lead to detachment. You can see the scroll here on the edge. So this is a graft detachment here. On the second most common cause of graft detachment is poor support from the air or gas bubble in the eye. So we inject gas or air into the eye to keep the graft detached and we have the patient position face up. If there's poor positioning by the patient or if, for example, a gas leaks out through a leaky wound and there's not enough gas in the eye, this will increase the risk of a detachment after surgery. Here on the right hand side, you can see there's a clef in the middle of the graft. So there's an area here with fluid between the graft and the cornea. And so this is considered a detachment and both of these will need to be re-bubbled in the minor procedure room post-operatively. In this case, I will probably need a little bit more manipulation with the cannulus on the corneal surface to open up that graft again. Another potential complication shortly after surgery is pupillary block. So like I just mentioned, we put gas in the eye to keep the graft detached. And we put a lot of gas in the eye. To prevent pupillary block, we do an inferior per-surgical aerodotomy. And we do it inferiorly because gas floats. So we want the aerodotomy to be patent, not plugged by air. But if there's too much air as you can see in this diagram here, the air can block the aerodotomy and the pupil and lead to pupillary block. To relieve this, you let air out, you burp air out. So you can see post burping air, there's no pupillary block here. In this diagram, you can see that here too. You can see the PI is open. Well, of course, you don't want to burp too much air out because the air gas is there to support the graft. So you don't want to graft detachments. You have to be careful. And finally, a potential, and this is with all intracluse, there's potential for infection. This is a picture of a graft that never cleared. And so that makes sense. There's a plaque on the posterior capsule behind the lens. This patient got P. acne, and not the minus after DMEC surgery. And finally, moving on to late postoperative complications. So there's more time after the initial surgery. So number one is primary graft failure. So primary graft failure, it means that the graft never cleared and never really worked after surgery. You can see here, this is a picture of a swollen cornea, decimates folds in a DMEC graft, and here's a slip beam of that. And so this corner is swollen and never cleared after surgery. So number one cause of primary graft failure, or primary graft failure is caused because the endothelial cells are not working or not working well enough. And this can be caused by damage to the endothelium during surgery. If it was a complicated surgery or there was a lot of manipulation. So that's one cause of primary graft failure. Another cause is the donor graft may not be healthy. So maybe it was a poor donor, a low endocount or whatever reason. So these are two causes of primary graft failure and this I will need to be regrafted. Another late postoperative complication is allograph rejection. So these are pictures of KP on a DMEC graft. So as you know, I is an immune privilege system. And fortunately for corneal transplants, these patients don't need systemic immunosuppression, they just need topical immunosuppression with steroids. And the most common cause of allograph rejection is the not enough steroids. And this can be from poor compliance, poor follow-up. And luckily the treatment for this is just increasing the steroids. Unfortunately, if there's recurrent rejections or if there's a really bad rejection, this increases the risk of graft failure. And finally, my last, actually, no, not my last one, but this, another late postoperative complication is infectious keratitis. These patients in particular are at higher risk for this because they're on steroids, topical steroids for a very long time. So suppressed immune, ocular surface. And in addition, these patients usually have some for corneal pathology like bull's keratopathy. So they may have an epi-defect, it's a loss of barrier as well as sometimes we do a superficial carectomy during surgery. So these things increase the risk of infectious keratitis and that's why they need good follow-up to prevent this from happening. And finally, I have a case of another late postoperative complication. This is one of our patients. This is a 65-year-old who underwent DMAC for a fuchsia and idyllidisher fee. This was done by a fellow and the case was again complicated. It was interoperative complication. The graph was actually injected under the iris and it was stuck in the iris. Fortunately, it was able to be manipulated and repositioned into the anterior chamber and bubbled under the cornea. Shortly post-operatively, there was a cleft that was re-bubbled in clinic and the graph remained attached. But the cornea never cleared. So this is an example of an interoperative complication and an early post-operative complication with the re-bubbling and then the graph never cleared. So primary graph failure. And for a year, it seemed like we weren't sure if the graph was gonna clear or not but gave the graph a lot of time, a lot of steroids and it actually never fully cleared. So the decision was made after discussion with the patient to do a DSEC on the same eye and this was done about a year later. And the DSEC went fine. The cornea cleared. Unfortunately, the best corrective visual acuity of this patient was 2,400. And we expect the vision best corrected after DSEC to be a lot better, like 2,030 or closer to that. So further workup was done and an OCT MAC was done and unfortunately it showed a significant system of macular edema and this was not previously known. And so this was treated with topical steroids and NSAIDs. It didn't need any injections. And after a resolution, the best corrective visual acuity improved to 2,070. But this is unfortunate because there's been some permanent damage from the edema. And this case just illustrates why we, let me get back to check. So we did not know, we assumed that the poor vision was from the swollen cornea throughout this whole time. And retina was not fully evaluated. So it just illustrates the importance of doing, thinking about the whole eye, doing a full workup, making sure that it's not just the cornea that's causing the poor vision. So and CME is a late postoperative application. Yeah, that's, and then presentation. Does anyone have any questions? Well, thanks Colin. I see macular edema, not terribly uncommon after EK, after endothelial caretoplasty. So definitely when a cornea is cleared and a refraction is not giving us the expected outcome that we want or hope for, then I think evaluating the full eye is a good idea. And sometimes you can end up with macular edema. Sometimes you can actually get optic neuropathies from elevated pressure after that air fill. So there's a few different sort of causes for loss of vision after endothelial caretoplasty, but this is definitely one that's treatable. So we've been watched for that early. Can I just chime in really quick? I would just add that, and I just said in chat, but not just postoperatively, but preoperatively we really need to think about all the causes of visual loss just yesterday. Kyle and I saw a patient referred for endothelial transplantation and that patient is had poor vision and both eyes, but one was significantly worse. And long story short, we found a submacular hemorrhage and the patient has a high myopic and probably has some myopic degeneration with some choroidal neovascularization. So just remember to be thorough preoperatively as well. Okay, so I'm gonna go through a couple of corny and refractive updates with you. I don't have any financial interests to disclose. We're gonna go through a couple of different things. One is the new Vuity Drop that was recently approved by the FDA for Presbyopia Treatment. And then we're gonna discuss the Technus eyehands intracure lens that was released on the market earlier, I guess late last year. First of all, the Vuity Drop, it is essentially a pylocarping drop in a different percent than we're used to using. It's at 1.25%. It is essentially FDA approved for one drop daily in both eyes to enhance near vision and presbyopic patients. Typically lasts about six hours. It's a cholinergic muscarinic agonist. So it's gonna act on the ciliary muscle to kind of give you a little bit of a myopic shift and then it'll shrink the pupil a little bit to give a pinhole effect as well. So those are the two mechanisms of actions that were used to try to give this enhanced near vision. There were a couple of studies that were done about 750 subjects that were studied over about 30 days. These are patients between 40 and 55. About 30% of patients had three lines of near vision gained without losing more than one line of distance vision. So the trade-off to kind of causing that myopic shift and the pinhole effect might be a loss of distance vision in some patients. So about 30% seemed to fall in that ideal category where they had a pretty significant increase in near vision with their distance vision still held good. There are some side effects this medication. It does have the BAK preservative in it with it only being given once a day. It's a fairly uncommon to get too much effect from the preservative, but they have warning labels on the medication about night driving. So I advise these patients to use it only in the morning for daytime use only. So you don't have too much of that myopic pupil to cause problems at night. And then there is a retinal detachment risk is as well known with higher percentage as a pile of carbene used in the past for glaucoma treatment that hasn't been hashed out with this lower percentage yet. A lot of patients describe a little bit of a headache with this and then also redness of their eye that is transient. It's not covered by insurance. It's about $80 as a cash pay. When you prescribe this, the pharmacy will try to do a prior off on it. And so I essentially write in my prescription, do not prior off cash only so you don't have delays in the prescription of it. We do have some samples of this floating around. The reps have been giving samples to try. I have a couple of technicians that have used it with good success. They noted a little bit of the headache felt like their distance vision was good and had that enhanced reading. So I've only been using it for about a month on my patients and have prescribed it to a few and haven't heard back yet on their results. So the jury's still out a little bit but we're getting some early results back. Questions about viewity from anybody? Okay. All right. So the technus lens, technus came out with a new lens called the eyehands. It's labeled as the DI-Boo. Dr. Olson, let's see. I had a question. I don't know where my controls went to unmute you. All right, there I am. So it's interesting. You know, I watched a viewity and what's happened. I mean, pylocarping 1% has been around forever. I go back in the days when that's one of our major ways of treating glaucoma. And it was well-known, you know, back in those days that 1% pylocarping, I mean, people would try it and say, you know, it allows me to read and go fairly well. But by and large, most people who tried it for a while found the headache and the hyperemia, you know, not worth what they were getting. So I'm just curious, you know, with time, what's magical about this, that it's gonna be much different than what's been around forever. And frankly, you know, bottle pylocarping 1% because it's been around forever and generic is available was incredibly cheap. So it's gonna be interesting to see they're charging way more for something that really is just a formulation of pylocarping. I know they've got things they're saying to, but as I read it, it's pretty minimal. So this is an example of something that has been put in a study and now is being charged probably 80 times what it should be, you know, even though this is something that had been around for a long period of time and generally over time, most people found the side effects not very good. So let's follow this chapter and see, but do know that this is a deja vu all over again. Yeah, a lot of those same concerns were brought up in the chat and I do think, you know, the jury's out, just kind of have to wait and see what happens with it. Okay, so this new I-Hant Sintrachter lens, it's in a pre-loaded delivery system. It's the D-I-Boo that we have on consignment here at the Moran. It's also available in the Toric lens model. It's essentially FDA approved as a monofocal lens. It has this higher order polynomial aspheric surface is what they sort of describe it as as a biconvex design. What you get out of that is you get a slight gradual central steepening of the lens. So you're almost gonna get a little a depth of field with that. They did frost the haptics to help minimize rotation after implantation, to help with the Toric rotation problems that have been seen in the past. The ZCU model also has frosted haptics which is kind of the regular previous Technus Toric lens. It comes in a plus five to plus 34 and half after steps similar to the other lens consignments that we have. What we see with this lens is that it has a broad and de-focused curve. It gets kind of a bigger bump at about minus one. Some patients can see a trickle if I clear out to minus two. What that would give you is essentially a little bit of an enhanced intermediate. It also maybe gives you a little broader landing zone as well. So these patients tend to see better distance even if their refractive error is a little higher than the previous monofocal ZCU lens. So that's kind of nice for some patients. A lot of patients if you target like minus a half they seem to have a pretty good depth and still have good distance vision in their eye. I'm still targeting Plano in these and not overselling it. I'm essentially telling patients that you might have some benefit to your up close vision but this is still just a distance lens is how I sell it to patients essentially or give it to them since it's not extra cost to the patient. As far as clinical outcomes we're starting to see some studies come out. So there's one that came out in JCRS that compared the eye-hance lens to the actual symphony lens which is made by the same company it's an EDOF lens. What they found is it actually gave pretty similar distance intermediate vision and have less dysphotopsias in the eye-hance patients compared to the symphony lens. So there's maybe some benefit there to having a lens that you're having to charge the patient for but they're still getting some depth to it. Another study that came out that just compared the standard ZCU versus the DIBU the ICBU sort of nomenclature is if you don't have it in the preloaded system but it's that same lens. They had some similar distance visual acuity outcomes and their intermediate vision was a little bit better in the eye-hance model. Similar dysphotopsies between the two groups and again better sort of ability at intermediate tasks in the ICB group. Here's the defocus curve that kind of shows that sort of second elevation about minus one with the eye-hance lens compared to the standard ZCU lens which flattens out a little bit beyond minus 0.5. The interesting thing about this lens in the preloaded form, I haven't used any preloaded lenses before I never used the PCBU which was the regular ZCU lens in the preloaded form. And so there's some different sort of ideas of how to do this correctly. It was essentially the instruction that we received was you inject a little bit of BSS into the injector and then you push the plunger down as you see in this bottom left photo and it'll engage the little cross hairs on there that you can then start to turn the lens and that will just fold the lens by itself. So the two different ways that this is done is one is just if you plunge it and then just do one turn to engage the rotating mechanism or if you plunge it and then rotate it all the way in to essentially load the lens all the way down the injector. So you have either a partial load which is just a one turn or you have a full load where the technician essentially loads the lens to the end of the injector similar to how all of our lenses are placed in the eye. And I'll kind of talk about some of the nuances of some issues that we see with that. So if the tech does a single turn I'd term that as a partial load. What that leads to because there's only BSS injected into the tip of the injector it's only filled with BSS rather than OBD. You get a reflux of intraocular fluid or OBD coming from inside the eye into the injector and you'll then get a drop in pressure intraocularly while you're injecting that lens. The haptics tend to stick less when that happens so you see haptics stick on the optic or haptics stick together and that happens less if you have the single turn which means that the lens isn't folded for very long. If you have the multi-turn or the full load where the lens is essentially put all the way down to the end of the injector it definitely creates a more stable injection so you don't have as much reflux of fluid and drop in pressure, you still can but you'll definitely see more sticky haptics as these are unfolding in the eye. So let's look at the chat here real quick. Let's see. Yeah, Mark brings up that maybe targeting minus a half which I have found I've occasionally done that in kind of a non-dominant eye and I think it gives a little bit better of close vision and still doesn't seem to compromise the distance. I have less 2015 patients with the eye-hence lens compared to the ZC-Boo. The symphony study I know, I kind of agree with you. I'd like to see more data on that, maybe more patients because it was a pretty small study. Okay, so I'm gonna show you some videos. I did some recordings of my surgeries yesterday to kind of give you an idea of the different loads that happen and sort of their effect. So this first one is where the technician just did a one-turn load and you'll see right at the beginning of when I engage this lens, you'll see a big reflex of fluid from the eye. See that air bubble and everything that kind of came back. So the eye softens, so it's way less pressure inside the eye. So your bag is gonna be have more wrinkles and potential for tears. So you have to be really cautious about inserting this. I always insert kind of right toward the iris as I'm going into the eye, keep my hand pretty low on the injector and then I sort of drop that lens right up the last second. You can see the haphix just unfold freely here so they're not stuck down to the optic, okay? So let's show another one, kind of the same thing here. So another short load. This one happened kind of early. So you'll see like a little bit of heme come into the injector as I put play. And so again, the eye is really soft. So you have to be really cautious with injecting the lens without that OBD fill in the injector. Again, on this one, the haphix are not stuck to the optic so it kind of it unfolds pretty quickly. This one, my keratome I found out was dull on the tip and so I had a really bad wound. It wasn't, I like to tickle my wound to enlarge it just slightly. I hate doing wound assist but I had to do that on this one and you'll kind of see the result of that. You could see the heme come up into this lens even though it was a full load. The lens was actually put all the way down into the injector and there was also some OBD that came out the side, poor incision. Let me show that again. You can see that OBD coming out there. So again, a softer injection could be a lot more cautious about it. You'll also, I don't know if I kept this one running because the haphix stick. So you can see both the haphix were stuck on the optic. They're not coming off very easily. So it takes a lot more manipulation in a soft eye to get these haphix off. I hate how I got that one a little bit off too far off to the side as I was being a little forceful there. What I find with this is you have to get the pressure back toward essentially where that haphix inserts into the optic to try to get it to come off easier. I've got a couple of other videos that show that a little bit better. So here's another full load. No reflex of any OBD. So the injection is a lot more stable. But what you'll see is the haptics definitely stick. It's usually not the distal haptic that sticks. It's usually the proximal one but the lens is a lot slower to unfold. I'll kind of show in this one what I do when this proximal haptic doesn't come off very quickly. What I essentially do is I rotate that haptic so that it's distal. And then you'll see kind of, if you put the force of your instrument essentially back towards where that haptic is inserting, it comes off easy. So that's a really common thing that I see with it. These are all just cases from yesterday that I did to kind of show all the differences. So no reflex there, nice stable injection. And then again, this is the feared haptic hand holding that can be really tricky to get undone. I usually will try to pull up on the lens and use the anterior capsule to see if it'll give me enough pressure. If it doesn't right away, I give up. And this takes two instruments to get it unhooked. What I essentially do is I'll hold down with my irrigation aspiration handpiece and then I'll lift up with the second instrument. And that usually unhooks it pretty quick. Let's see, I think this one, this one actually had a full load but still had a little bit of reflex. So I'll kind of show this. And I think the reason this happens is if you lose, it's really subtle there, but if you lose your BSS in the tip of that injector, you'll get a little bit of reflex. And that happens if the instrument, if the actual handpiece and everything is held down, the water will just fall out of it. So you kind of have to have the technician keep this level or point it up a little bit. Again, that long load or the longer folding in the injector will have essentially a stick to your haptic. And so I again, rotate it around and then I just push it towards its sort of origin point and that actually comes off. All right, so we'll go into the chat here. So I don't underfill the eye. I fill the eye completely with OBV, but what happens is you lose some of that OBV. It comes out of the eye back into the injector because there's space for it there without any OBV in the actual injector. And so you end up losing some of the OBV put in the eye as it comes into the injector. You can get this with lenses that aren't preloaded. So this is actually some reflux that happens pretty intensely with a panoptics lens. So that had OBV in the injector that probably did not have enough fill. For the most part with those preloaded ones, you get a pretty stable injection as well. That is the end of my presentation. I think so far, I've been pleasantly surprised with the eye hands. I think I have a lot of patients who actually don't feel like they need readers for a lot of activities. So their lifestyle, I think is a little bit better. And so it's kind of nice to be able to offer that lens without them having to pay more, but it actually gives them a little bit of information. So yeah, so I think that that's what I essentially do now is in the chat, you essentially, if you do that full load and push the lens all the way to the end of the tip, you won't get as much reflux. And so I think that that's kind of the best way to deal with that. So far, pretty happy with that lens. Any other questions? It's like we hit the nine o'clock hour.