 So we're going to move ahead now to our resident presentations. Our first resident presenter is Julia Burd. She's one of our senior residents. She is going into pediatric ophthalmology. She's going to be doing a fellowship at Children's Hospital in Washington, D.C. next year. And she's going to talk to us about long-term outcomes in capsular fixation for pediatric ectopia lentis. Dr. Burd. Thank you. Thank you for the introduction. And as Dr. Hoffman said, I'm one of the chief residents. And I'm going to be talking kind of piggybacking on the talk that Dr. Ahmed gave last night at the UOS dinner and talking about a study that I did this year on long-term results on scleral fixation using a capsular tension device in pediatric patients with ectopia lentis. There are no financial disclosures related to this presentation. And I'm going to go through kind of an introduction, background, the methods, and then talk about our outcome measures and results, and then do a brief overview of my quality improvement project that I worked on this year with Dr. Han at the VA. So ectopia lentis describes dislocation of the natural crystalline lens. And this can happen for a variety of reasons. It can be idiopathic or associated with a systemic disorder. And when it is associated with a systemic disorder, that is most commonly due to Marfan syndrome. When you're seeing these patients and treating them, the kind of initial treatment or thing that you try to do is provide refractive correction, either with contact lenses or spectacles, and try to make sure their vision develops and is OK. However, it can be challenging, because as you imagine it, as the lens starts to dislocate more and there's changes, it can be hard to appropriately refract the patients. And you can have difficulty with enosmetropia and amblyopia as a result. So once it's decided that that's really the patient isn't getting an adequate vision with just refraction, the decision can be made to do surgery. And there are a variety of techniques that you can approach a patient who has capsular bag or zonular weakness or zonular loss. There's sulcus IOL fixation with a number of different methods, ACIOL placement, IR sutured IOLs can do a part as a plane of atrectomy and lensectomy. There's iris claw IOLs. But given the fact that this is a fairly rare disease and it's in a pediatric patient population, we have some data, but we don't have great data on long-term outcomes. And we don't have huge patient. We don't have large numbers in our studies. And there's still quite a lot of debate about even if scleral fixation is appropriate in these patients in the pediatric ophthalmology community. So for our study, our goal was to provide long-term follow-up data on the use of transcleral fixation of an IOL using a CTR device in the large cohort of pediatric patients with ectopia lentis. Quick review, I think we're all fairly familiar with this, but Capsular Tension Ring was first introduced in 1993 to use in zonulopathy with adults. And it was modified by Cione in 98. And you can see the addition of an islet that is positioned anterior to the anterior capsule. And that provides a spot where you can fixate the lens. And then it was modified by Dr. Ahmed into this segment that you can also use in conjunction with the Capsular Tension Ring to provide segmental support. Hopefully a video that just kind of demonstrates some of the key principles in doing the case. So this lens isn't, it's kind of mildly dislocated, but you can see the superior zonules there and kind of inferior dislocation of the lens. So while making the Capsular Rexis with eutratas, as you're going around, if there is significant weakness in zonular loss, you can use MST Capsular Tension Hooks or Makul Hooks that can provide counter traction as you're making the Capsular Rexis, which allows you to create a curvilinear Capsular Rexis. And now we see there was, so there's different ways to fixate the devices. The Dr. Crandall usually uses two sclerotomy sites at the point of maximal zonular weakness, two millimeters posterior to the limbis. And then you can see this, in this case, adiogortex is being used. It's threaded through the islet and it's going to be rotated into place and then fixated in front of the anterior capsule. And then once that is fixated, IOL can be inserted in the bag and that can either be a three-piece or one-piece IOL. Here's another video just demonstrating a more significant dislocation of the lens and still, again, using the same principles and the same techniques, it is possible to do a Capsular Rexis in this type of a patient. Again, using the MST Capsular Tension Hooks, you can create the counter traction you need to create this Capsular Rexis. And these lenses are usually quite soft, so they can be, the video is kind of messing up, but they can be aspirated either with a bi-manual aspiration or a handpiece. This quality is not the best, but we'll move on. So that's kind of the surgical technique that's used here for these patients. So we conducted a retrospective chart review searching for patients who had any sort of lens removal or IOL placement who were under 18 years old at the time of surgery, and surgery had to be done from 2006 to 2016. This was, and either at the Mariana Center or Primary Children's, this resulted in 599 patients. And our final analysis of patients included 37 patients and 67 eyes with a scleral fixated Capsular Tension Ring. Patients who had a topial endosecondary to trauma were excluded from this study. So initial analysis of our data demonstrated a mean age of 7.2 years. Our kind of predominant underlying etiology for ectopiolentus was Marfan syndrome. Not listed on this slide, but our mean post-operative follow-up was 35.3 months with a range of one week to 120 months. Surgery characteristics, this demonstrates there were various kind of combinations of hardware used, either with a Capsular Tension Ring and a Capsular Tension Segment. Any combination, these are the modified, the CO2 modified Capsular Tension Ring. But the most common was just a single modified Capsular Tension Ring. The most common suture type used was Gore-Tex. In 2006, when we first started reviewing the cases, that was kind of when the shift was taking place from using proline to using Gore-Tex. I will say that the 9-0 nylon would be very abnormal. It was noted in the OP report, but it would be abnormal that that would have been used, but it was included. So our outcome measures were best corrected post-operative visual acuity, refractive outcome, and presence of any complication. So when we analyzed the best post-operative vision, there was a statistical significance of improved vision when all eyes were analyzed, and when either eye of a patient was randomized to the analysis. We also specifically looked at the visual acuity improvement that was 2050 or better, and did find statistical significance at each follow-up time period that we evaluated at two months, one year, three years, five years, and 10 years. For refractive outcomes, we can see that preoperatively the majority of patients were myopic, as we would expect, and they were targeted towards hyperopia, post-operatively, but did have a trend towards amitropization over time, as we see with a standard IOL placement. We evaluated the presence of any complication, and of note, we did not find any cases of retinal detachment or glaucoma other than this uveitis glaucoma hythema syndrome. We found four cases of IOL dislocations, and those occurred at post-up month three, post-up month eight, post-up year three, and post-up year seven. Post-ear capsular opacification occurred in 35 eyes, which was 52% of the patients, and we had found one case of UGG syndrome, and that was at post-up year seven. We did not find statistical significance in complication by stuture type. Interestingly, the PCO formation was more common with adogortex, which approached statistical significance, but did not actually, and when we did analyze the PCO formation in the adogortex group, we did not find an age difference to account for that difference in PCO formation. The posterior capsular opacication was the most common complication. As I mentioned, it occurred in 52% of the eyes. Out of those patients, nine eyes did have to go undergo another surgical procedure with paris plaintivitrectomy and membranectomy. 25 eyes were able to undergo an in-office adcapsulotomy. This rate of PCO formation is very similar to previous rates reported in the literature using this technique. Regarding the IOL dislocations, as I mentioned, we saw four spontaneous IOL dislocations that was 6% of our eyes. This is lower than previous reported rates in scleral fixated cases, and this kind of does reflect the changing times where we're using adogortex, whereas the previous reports with IOL dislocations were really mostly using 10-O proline. So in summary, this is the largest pediatric cohort to date reporting long-term outcomes of transleral IOL fixation using a CTR device. Our study did demonstrate that there is improved vision and long-term IOL stability using transleral fixation in the capsular tension device and IOL placement in the bag. Overall, there was pretty minimal long-term complications. Most common was PCO, and many of the patients who developed PCO were able to get an in-office adcapsulotomy. And of course, as is the case with any retrospective review, it is not the most robust data that we can have. So looking more in a prospective nature in the future would be great. And a few other things to kind of note about the study, the surgeon for all these cases is Dr. Crandall, who is obviously very skilled and amazing at doing these. And so one critique is that maybe the surgeon skills is why there were such great results. But I think kind of as Dr. Ahmed mentioned last night, a lot of these are skills that we can have and apply them to these complex cases and really with some training and practice, get good at them. And then quickly to touch on our quality improvement project. Dr. Han and I found a problem at the VA and this has been going on for a while where it's actually quite difficult to get cornea cultures. The lab didn't have the various culture plates that we need. And the patients who come in with cornea cultures were kind of far enough between that each time they came in, we kind of reinvented the wheel for each one. But one day during a really busy clinic after four hours of trying to figure this out, we decided this is probably something that would be beneficial to help residents in patient care. And so we wanted to both streamline though how we would get the cornea cultures and make sure there's a process in place and also create a process that the veterans could obtain fortified antibiotics. So for the cornea cultures, the VA microbiology lab is gonna process and stock e-swams. And so e-swams are kind of a fairly new thing but we've been using them more and more. There was a study out in the American Journal of Ophthalmology in 2015 that they did review 81Is and found quite similar culture results using the e-swams rather than using the multi-plate process. So it seems like a reasonable kind of alternative and at least we can get the culture results we need. And then the fortified antibiotics is kind of a work in progress. The big problem, the VA has said that they will reimburse the vets for getting these drops. We feel like these could be a big upfront cost to vets and after hours in the middle of the night, it's maybe hard for them to pay upfront which is a pretty big roadblock. The VA says there's kind of a VA choice pharmacy version of that program that maybe, well it's supposed to be rolled out but it's unclear when that will happen. One pharmacist didn't tell me that in dire situations the pharmacy has a credit card and could pay for them which I think is probably not a feasible long-term solution but for now they did give us specific names of three people who can at least expedite the reimbursement process and do it instead of having the patients have to kind of go through the bureaucracy and they say they can do it in seven days and we're still working on that other part because ideally we wouldn't have the patients have to pay upfront but at least we have a process in place and a place to start working in the future. So for this study I would like, I don't think Dr. Ohner, Dr. Young are here but Dr. Crandall for his mentorship and being able to see these cases and help with them that are amazing. And I can take any questions or comments. So Julie, just a couple, number one. I mean, when they've got a coating of ulcer they need those drops now. I'm wondering if we couldn't work out a relationship with the VA and our pharmacy who will make it, will front it with the understanding it's gonna be paid and if you need me to help put the cloud to see that that happens because sometimes that's what it takes. That would be a favor. That's sitting there and they cough up money to get the drops and it just may not happen. So I mean, that's just, I think that we should do that. We should talk, yeah, because it seems like an easy fix but getting the fat in places. Yeah, well anyway, if you need me, I'll work with you. Thank you, okay, that sounds great. The other one, just to point out that you talked about the refractive power issue which is huge in regards to all of these intraocular lungs is, Young and the patient are bigger than the problem and this new technology that Nick and Liliana are working with and that we just had a complete review and a lot of presentations of refractive index shaping can go in at least now for a technist's lungs and we're now comfortable and we'll be able to get up to five diopters per treatment and we can do as many as five treatments. So you potentially can move a lens 20 to 25 diopters and the company is very interested in assisting in doing that with kids. So I think it's something we want to talk to you about. Yeah, yeah. We need to get in as soon as possible. This is, you know, the FDA's going to opine on this here a little later in January or in June but if they treat this as a 510P process which is hopefully the case because there's no inflammation, there's no loomable. This is clearly just a very minor procedure on the lens. We could have refractive precision for these kids, you know, over their lifetime. It's something, well, that's a good solution. And I think then that really makes the technique so robust if you have a stable, capsular bag and a stable lens and you can treat that lens. But the procedure itself is so minimal that you, you know, even the Yag get that little bit of a reperfulsion or anything and there doesn't appear there's enough energy of any movement. It's, in comparison to a typical Yag, it's like a hundred to a thousandth of the number so that is really exciting stuff. So as an aside, Julia presented this information at APOS in Nashville this year. It was well received, represented Moran well. Got lots of good comments and Dr. Crand was asked to make a couple of comments about the study as well. Well, there are a couple of things. One of the questions I often get is, is it worth doing all that gymnastics to save the bag? And I believe the answer and we're getting some experimental results at Washington University in St. Louis where their red group backs it up because the standard procedure done mostly is a lensectomy, vitrectomy, and then suturing in a large IOL. And we have zero detachments and we have zero secondary glaucomas. And so even if you don't put a lens in the bag, it's worth saving the bag. I has leaves that space. Yeah, your original detachments are eye-locking. The majority of Mar-fans? Yeah, they're way, way more than that. There are early days, Alan and I, when we do an intra-cap with the vitrectomy, they all detach, all the Mar-fans basically. We almost thought it was anymore doing because they don't have a doubt about it. I mean, I was at Academy and the pediatric subspecialty day Mar-fans came up and someone went up and said, no, you can't operate, they'll detach. Which is now just really not true. I mean, even looking at the others, there's four other studies, reviews on this procedure, there aren't retinal, there's one retinal detachments out of four in, you know, 30 years, 60 years. Yeah, I think, just quick comment. I think great, great comments. And I agree with what you said. I still warn patients about retinal detachments. They have an underlying risk, even without surgery. So just for consent purposes, they have a higher risk anyways. I think, as Randy said, the refractive correction is always a challenge. In the other issue, you had a fair number that required to remember anectomies and refractomies. I will often, under the age of eight, typically do a posterior rexist and do a posterior out the buttonhole of the eye well. I know it's a bit lucky you have CTR on the bag, and can you do a posterior rexist? I've been amazed at how often we can do it successfully. And I think by doing that, we reduce, so that's a secondary intervention. Now you're doing a retractomy, right? Now we're talking about the risk. The old studies have shown, once you touch vitreous in Mar-fans, the risk goes up to 40% of RDS. Once you touch vitreous, if you don't touch vitreous, the risk is much lower. So if I can avoid it by doing a posterior buttonhole with the eye well for the younger patients, I think it's a good, I think I'll add to that as far as just conceptual thought as far as taking it to those patients who are early on. It's a good point. Thank you so much, everyone. Thank you. Thank you. Thank you.