 All right. Well, it's eight o'clock. Time to get started with grand rounds. So I've got refractive grand rounds this morning. Thank you for joining us. So we've got three talks. First, one of our fellows, Cole Millican, is going to give a talk on updating on ICL's, indications in sizing, and then Brian Zog and I have some basic related talks. All right. Cole Millican, one of the cornea refractive surgery fellows for the people I haven't met in the audience. So the talk itself is not meant to be a comprehensive review of all data pertaining to ICL, but maybe to give those that aren't familiar with the technology kind of an overview of how to approach it in the clinic and maybe some of the senior residents that are going into end-tier segment surgery, how to approach it in their own office-based surgery. So quick history of the ICL. The ICL is a posterior chamber-facic IOL, which essentially means that it sits anterior to the lens capsule and posterior to the iris right in the ciliary sulcus. And the idea of a posterior chamber IOL is actually not new, maybe out of the scope of this discussion, but there are a couple prior iterations to posterior chamber IOLs and maybe some of the more senior surgeons. Remember these IOLs, one of them was the Chiron posterior chamber IOL, and then the PRL-facic refractive lens. And both of those have been since discontinued, one caused quite a bit of AC inflammation, and the other I think had a kind of a predisposition to slip into the vitreous cavity. So both of those are discontinued, and being as such, ICL right now is currently the only FDA approved posterior chamber-facic IOL on the market. And a lot of us think of this as a new technology, but it's really not. So it was actually released by STAR in 1993, and it gained its FDA approval in 2006. So it's got a couple newer iterations of it, the EVO and the EVO plus ICL. And as you see here pictured on the slide, this is the EVO ICL, and these little ports in the center and on the side facilitate the flow of aqueous. So it decreases the incidence of anterior subcapsular cataracts, and then with the allowing of aqueous through the port, it'll decrease the incidence of pupillary block, and surgeons no longer need to make a peripheral iridotomy with these type of lenses. In addition to spherical correction, there's a toric version available, and that can correct up to four diopters of sill in the spectacle plane. So classically, I think when we think of ICL, we think about using it for patients that may not be candidates for laser refractive surgery. And this is all patient dependent, could include patients within pochimetry, history of inflammatory disease or corneal ectasia that exclude them from having LASIK or PRK. So it's different for every patient and surgeon, but typically speaking to our cornea team, a lot of times we'll introduce the idea of an ICL around a minus six. That being said, the indications for treating myopia are a little bit broader than that. So the FDA approved indications treat a range of myopia from a minus three all the way to a minus 15. And then in addition to that, the goal of your treatment, if you have a minus 20 patient walk into your office and they're looking for a refractive option, could be to reduce the level of myopia in those patients. So if you have a minus 20 patient and you implant an ICL that corrects them up to a minus 15, then they may be a candidate for an additional laser refractive surgery on top of that. The age and the anterior chamber depth are interesting in the FDA indications. Currently it's FDA approved for patients that are 21 to 45 years old. Overseas, that's expanded a little bit. So it's approved for patients that are 21 to 60 years old. So if you were to put this type of lens in a 50 year old patient, you wouldn't necessarily be wrong to do so, just knowing that it would be an off label FDA indication. Additionally, anterior chamber depth, there is some flexibility in terms of how you approach this, but that should be a little bit of a harder deadline for you. So the FDA indications approve it to a three millimeter anterior chamber depth. Some surgeons that use this more frequently will treat patients up to a 2.7 or 2.8 millimeter anterior chamber depth, and those are indications that are being used in Europe. That being said, going anything below a 2.7 or 2.8 millimeter anterior chamber depth can introduce problems in terms of sizing, having a little bit higher than expected vault of the lens may cause iris chafing and endothelial cell loss. So that should be a little bit strict or cut off for you in approaching patients in a preoperative exam. And then additionally, you want to see a stable refractive history. Contraindications I'll review here include pregnancy, anybody that's got a closed anterior chamber angle, low endothelial cell count, and they kind of guide that by age requirements, but typically anything over about 2000 cells will keep you out of trouble. And then additionally in the United States, it's currently only being approved for myopic patients, but overseas they're using it to correct hyperopia as well. So your preoperative evaluation should include a manifest refraction, a cycloplegic refraction, a measurement of white to white, which sounds simple, but it actually isn't. There's kind of some discussion on how to approach the measurement of white to white in order to size your lens. Agonioscopy exam, so you can look at their angle endothelial cell count in a dial aged exam. Now, the sizing of the ICL is probably one of the most crucial components to making it a successful procedure. And when we talk about the vault, the ICL is vaulted over the natural fakic lens, but it's sitting below the iris. So the ideal size of this vault is somewhere between 250 and 750 microns. If you leave them with too little vault, it's going to hug the anterior capsule of the lens, and it's going to give you an anterior subcapsular cataract. If you create too much vault over that 750, you can imagine that it's going to be bowing into the iris, can cause iris chafing. And prior to the new iteration of the EVO ICL, you may have had some pupillary block glaucoma. So there's a sweet spot in between the two. And the way that we control the amount of vaults is by changing the size of the lens. So you can imagine it's kind of like contact lens problem on your OCAPs or boards. The larger the lens, the more that's going to bow anteriorly. The more vault that you're going to have, which may lead to trouble in terms of iris chafing or pupillary block. And then the opposite is true, too small of a lens, and it's going to hug that anterior capsule. So here's a good picture of a UBM, and you can see that lens vaulting over the anterior chamber, but just below the iris surface. So really important component of using the ICL is to accurately size it. And in order to accurately size the vault, it's very important to get an accurate white to white or sulcus to sulcus measurement for the patient, because the sizing of the lens depends on that measurement. Now the ICL doesn't necessarily come in custom sizes. So there's four preset sizes that include a 12.1, 12.6, 13.2, and 13.7 size lens. And there was a really nice study that was performed by Dr. Wong and his group, and he compared the different tools that we use to measure white to white, because, believe it or not, with all our biometers, there's lots of different ways to obtain this measurement. So he included in his study a measurement with the PenaCam, a measurement with the OrbScan IOL Master, and then he used these Castro Viejo forceps here. The study included 107 eyes, and it compared the white to white measurements using each of these different technologies. And what he found is that when you're using the IOL Master and the PenaCam, it predictably overestimated the size of the white to white and oversized the lens, and he found that OrbScan and the calipers were actually the most likely thing to accurately size a lens with the desired vault of 250 to 750 microns. So very similar to IOL selection, people have kind of taken this information and run with it, so you can get into the weeds as much as you want in terms of sizing and refractive outcomes of the lenses. There was a really nice study done by Dr. Moshefar, and he tried to summit the different nomograms that are being used to size the ICLs. So in that paper they reviewed over 18 different nomograms, and here's some of those listed to the left. And the difficult part about it was there wasn't necessarily a consensus as to this formula is better than this formula all of the time, but it's patient-dependent. So some of the formulas worked better for patients with certain size, white to white measurements, others worked better in other scenarios. I found a simple approach to looking at these is the one that is produced by the manufacturer, so the star nomogram, which is I know what we use here at the Moran. There are nomograms that require topography or biometry, so using your PenaCam or your IOL master, and then there are nomograms that require UBM, so you need an ultrasound in order to do it. Now the UBM is kind of an interesting component of it because you really have to trust the person that's taking your ultrasound. I know Dr. Zogg and I were looking at one yesterday, and there's kind of blurred lines in where you're going to measure that sulcus to sulcus measurement, so you have to get really, really accurate pictures of the sulcus, and you have to have somebody that you really trust taking those measurements. And then one of the newer developments are these nomograms that utilize machine learning, which is kind of a cool application at AI. I think that the majority of surgeons are using the star nomogram at this time, so I'll review that one. As I mentioned, it's created by the manufacturer, and its requirements are a white-to-white measurement, the ICL power, keratometry measurements, corneal thickness, and an ACD measurement. So there were a couple studies kind of in my literature review that showed when you're using the star nomogram, you need to be a little bit careful, especially for the larger size lenses. So if you're implanting one of the 13.7 size lenses, it was shown that the star nomogram can sometimes underestimate, and you'll get an oversized ICL, and you'll have more vault than you originally anticipated with that. So be really careful if you're borderline in between one of the larger size lenses, maybe the 13.2 or the 13.7 size lens, and one of the alternatives that they suggested was using this optimized white-to-white formula. So it uses all the same variables, but it's better for the patients that are at risk for a high postoperative vault. So if you're putting in a larger lens, you may benefit from having a patient run through this optimized white-to-white formula instead of using the star nomogram, and it's just an extra kind of word of caution on that. In general, when reviewing all the different nomograms, the formulas that were able to successfully use UBM and have somebody that was accurately taking those photos were more accurate in predicting postoperative vault than the ones that use biometry and topography. Overall, the two had very similar refractive results. And then one word that's worth mentioning, there was a study done in military patients where they actually showed that over time, the ICL, well, you'll have a decrease in vault. So over the course of a seven to eight-year postoperative period, those patients that had high initial vault generally flattened over time. So when discussing any refractive technology, I think it's important to go over outcomes. And the first off, we can review some of the FDA trial outcomes. And this was over a three-year follow-up period. And it separated them into different levels of myopia. So patients with a less than minus seven correction, 98% achieved greater than 20-20-year greater corrected vision. Patients with a minus seven to minus 10, 87% received 20-20-year greater vision. And then the people with the larger myopic corrections being the minus 10 plus, 84% of those had vision better than 20 over 40. So you can see that the more myopic you are, the higher risk that you come of not getting them to their desired refraction. Uncorrected vision, correct? Yeah. Thank you, Dr. Olson. And then there was an additional review that was performed. It was looking at active duty military members that received ICL technology. And this was reviewed over over 3,000 eyes and an 11-year retrospective review. And their measurement was rate of achieving desired refractive correction. So they found that 97% of those patients received their desired refractive correction at one year, 90% at eight years. And then they measured an adverse event rate at about 1.2, which is interesting because I think they ended up explaining about 4% of those IOLs, ICLs, I'm sorry. The adverse event rate, the most common thing that they noted was anterior subcapsular cataract or iris chafing. And in addition to that, the newer iteration of the ICL, the EVO has an even decreased incidence of the anterior subcapsular cataract with that central port that allows for aqueous flow. A question, Cole, about that military study. Did they include laser touch-ups in the achieving desired refractive correction by one or eight years, especially eight years? No. Just the ICL. Yeah, it was just the ICL. And then I think it's worth mentioning some of the upcoming technology in terms of the ICL. So this is a lens that's being implanted in Europe. It's called the EVO-VIVA. It's an aspheric EDOF-ICL. The indication ranges are 21 to 60-year-old. And it can be used for both fake and pseudo-fake patients. And the idea of it is to be a presbyopia correcting lens. I think their targeted demographic is early presbyopes that are 40 to 50 years old. So this is something that's coming down the line. Off the top of my head in the studies that are being published out of Europe, it seems that it gives you about 1.3 diopter range of vision, although the intention was to give you about two diopter range. But it's something that's interesting coming down the line. And here are my references. Questions? They're on Caranet, which is kind of a worldwide listserv of cornea specialists and anterior segment surgeons. There has been an uptick in discussion about using ICLs as a good piggyback lens. So it's designed for the sulcus. And so I've seen a lot of surgeons that have picked that up a little bit where they might need to do a refractive shift of some kind and don't want to do a corneal procedure. And so they'll throw in an ICL as a piggyback lens. I don't know that I've seen awesome stability studies as far as in pseudophagic patients, if it works well, but just something that I've seen kind of out there. Just kind of walked down memory lane. I actually put a patent in and tried to work with Star to put together a lens that would correct both for dysphotopsia as well as refractive precision and had a design and actually had a patent issued in Australia. And we're still fighting the U.S. patent. And I just had so much going on, let it drop, but that all was submitted and put in place in like 2007. So this is not a new idea. So I had to laugh when I saw that all of a sudden I would be curious to see and I wouldn't surprise me that this also would help with dysphotopsia. So this could be an easy fix for those with bad dysphotopsia with the ICL. One thing I'm surprised that the white to white still has existed because our own Liliana Werner did a study, a seminal study, you know, a long time ago. She's not, I don't think Liliana is here, right, or Nick. So this would be probably 15, 16 years ago in which looking at avarice, you know, in fresco d'avarice inflated normal pressure showing that there was not a really good correlation with white to white with the actual sulcus diameter side to side with, there was big variation. So it, UBM should be, but it is true. That's an art form as well. But I'm amazed that white to white has survived. Dr. Wong, I think in his group, their final recommendation on that paper was to take a caliper measurement. If you're only using white to white was to take a penicam and a caliper measurement and then kind of have the two or take an average of the two just to make sure you're not oversizing it. Kind of kind of kind of a bunch of fudge factors at this point. Hey, it's Nick Mamelos. Am I, am I on now? Am I allowed to speak? You're on. Yes. The study that Liliana did, it was very interesting because she was comparing the UBM measurements, looking at the actual ciliary sulcus as opposed to the white to white. And what we found in that study is, is that the white to white was really inaccurate. And I think the inaccuracies come first of all in defining where the white to white is. And if you look at that, there can be a fudge of, you know, millimeter on each side that can make that inaccurate. And the second thing is that it's not directly related to the measurement that you see in the ciliary sulcus. And so I'm surprised that they're still, you know, advocating some white to white measurements. It's really better. And you have to have an accurate UBM. I mean, it has to be lined up. It has to be perpendicular. But the UBM measurements were much more accurate than were the white to white. When you're looking at the actual diameter of the ciliary sulcus. Thank you. I actually have a question. Dr. Wait, I know that you're doing quite a bit of ICL implantation. When do you approach it with patients in terms of having a discussion if there may not be a candidate for laser refractive surgery? Or if they may be a candidate for both how do you kind of broach that conversation with them? Well, first off, great presentation. Nice work, Cole. Okay, in regards to a patient coming in for refractive surgery, your job as a refractive surgeon is to first do what's the safest thing. So usually if a patient comes in and I'm reviewing everything with them, I'll usually give one recommendation. Here's what we're going to do in your case. So for example, patient comes in in their minus 10, you know, that we got one option, I'm not going to do Lasik in that case because I know I'll have actually more a safer result with better vision post-op using an ICL as opposed to Lasik. Those that are kind of on the border line, let's say they are a minus five and a half or minus six or something like that, they could go either way. Most of the time I'm leaning towards Lasik, but there are certain cases where for example, let's say they have inferior steepening or there's some question about their cornea, then I'll lean towards not using carotid refractive surgery and using an ICL instead. In regards to sizing, I'm glad you guys brought up about the white to white because that's really what people have been using for years, but you'll always have outliers. That's just the way it goes. If you use white to white, you will have outliers. And that's because the sulcus doesn't, doesn't match the white to white. So for the most part, you'll actually do pretty good. And the EVO is very forgiving in regards to bolt anywhere from, you know, say 200 to up to a millimeter, you're doing fine in most eyes. If so long as they have a deep anterior chamber. But if you can refine that, you know, you're obviously going to want to do that. So using a UVM or, you know, high frequency ultrasound, whether it's the ARC scan is another method that people are using, you're going to get it more accurate, but you're still going to have outliers just because the ciliary body is so variable in the size and the way, in the architecture of it. I was just, you're with Carrie Salmon, I was just down with him in Argentina in November visiting the Zaldobar Institute. And they're talking about using AI with not just measurements taken from the ultrasound, but videos taken from the ultrasound, where they can look at the architecture of the anterior chamber and start to make more accurate guesses, if you will, as far as the proper sizing of the ICL. And from their measurements, they've shown that they've been able to be within about 300 microns in pretty much every, every case, which is great. I mean, 300 is a big, that's a big number for the eyeball, but still that's much more accurate than we've been getting with, with white to white, for sure. So great job. All right. So yeah, great, great talk, Cole. I'm going to switch gears and kind of talk about a case presentation, a case that I had recently. That was a LASIK case, hopefully, can advance here. Okay. So this was just normal, normal patient, 33 years old, interested in LASIK. He wears glasses. He had tried contact lenses in the past, but he had a lot of trouble inserting and removing them. So he really never, never wore them. There's his refraction, kind of moderate myopia, some stigmatism gets to 2015, stable refraction in his glasses, normal exam, normal topography, normal PENICAM. He wants to proceed with LASIK. And I agree that that would be a good choice for him. So before I go into the exact things about what happened with this case, just wanted to review for all the non-refractive surgeons out there about what LASIK is. So LASIK starts off with a flap that's made in the cornea, typically used using a femtosecond laser. That flap is lifted, and then a different laser, an eczema laser reshapes the cornea to correct the refractive error, and then the flap is put back. And so that's basically it. And the way the femtosecond laser for making that flap works is there's a suction ring on that left picture that goes around the limbus and adds suction to the eye. And then the laser is actually attached to this aplanation cone. And the cone at the bottom of it fits into the suction ring and aplanates the cornea. And there's a vacuum that's used to really get a good dock. So that's what's going on with the actual flap creation. The femtosecond laser creates these very short pulses that are 10 to the minus 15th of a second, or femtosecond. And each little pulse creates a cavitation bubble that releases carbon dioxide and water. And that reaction photodisrupts the tissue and creates a resection plane. So again, so each pulse forms this little microscopic bubble. And this photodisruption occurs just at that little point, and the surrounding tissue is unaffected. So if you can imagine you've got these overlapping little pulses going across the cornea, you've got these overlapping bubbles that then connect in these separation planes. So I almost imagine like a postage stamp in 3D, where you've got these little overlapping pulses. So you just have to break these little mini connections between all the bubbles. So this is what a normal Lasik flap should look like. I'll just play this video here. And this is real time. This is only very lightly edited. Nothing sped up. So putting in the lid speculum, we get things focused, we put in a little more topical anesthetic. There's that suction ring going around the limbus. And we get good suction. And once you achieve good suction, then we bring the aplenation cone. Again, it's attached to the laser and that gets docked into the ring. So that docking is happening now. You see that surface aplenating the cornea. All those bubbles on the side are just kind of the vacuum building. And then once we have a good dock, the laser says things are good. We start the laser. And you see the flap being created. And all those little white bubbles are gas. And the gas gets vented out through that hinge, which is at six o'clock, which is really kind of superior for the patient. And so there's not much gas built up there. And that's the entire laser flap creation. Let's see. Let's get over to the next patient. So this is my patient. It's gonna be kind of a longer video. I'll speed through it. But he's very squeezy. He's got a really tight, help people fissure. And he's squeezing. And so imagine, I mean, you guys all doing surgery, you put in the lid speculum and it's like, oh, gosh, this is not gonna be, this is not gonna go well. And the guy's really nice. I mean, he realizes that he's not cooperating. And he's really, really trying. And he's just apologizing the whole time. And we're trying to get him to relax. And we can't see his cornea. But there it is. Yeah, oh, major. So I decide like, well, he's got a tight fissure. And sometimes, even with the lid speculum opened all the way, there's not enough space for the, for the, for the suction ring. So sometimes I actually will take out the speculum, which is what I decided to do in this case, just because the speculum can kind of get in the way of the actual suction ring. But then we still have the same issues of him squeezing. So we get, again, this is right eye. So first eye, we're getting the ring in very carefully. He's trying really hard. And getting some decent suction there. And we get the aplenation cone down very slowly and gently. So it looks, it looks decently centered, not the best, but it's within the realm of what I'm happy with. And we'll start, I'll start the laser and you'll notice he's got a little rotatory motion because he's still squeezing a little bit. So there's a little rotation going on. But the flap otherwise is looking good. And that's it. So then, then we go to the other eye. And the other eye is really is, is worse. Just imagine like it's an even tighter squeeze. So there's like, at least five attempts of, of trying to dock. And I'm just going to speed things along because it's a lot of the same attempts here. So let's go without here. So I get to a point after like the fifth attempt of, of docking. And, and things aren't great. He's got some congenitiva creeping in on the side. There's a lot of opaque white, we call it OBL or opaque bubble layer kind of coming off along the limbis kind of right where that flap edge is. Not exactly sure what's going on there. So, so that's the flap. So I wanted to ask maybe refractive surgeons, what would you do, what would you do at this point? I would abort LASIK on this eye. Okay. You already made the flap, but I would abort the second part of it. All right. So if a patient's struggling this much, I think it's helpful to give them something like a ballium and, and you kind of have to talk them through the process as well. Oftentimes it's like, okay, just relax, open both eyes and look straight ahead. Because what he's doing right now, like with the, with the first eye, if it was his right eye, he's squeezing his left eye closed as hard as he possibly can and you're trying to get it in there. He has to open up both eyes and look straight ahead. Yeah, we, we tried talking. He's, he's trying and, you know, this is just what we have. Ballium can be helpful, right? Yeah. I saw this exact same scenario watching, I was, for one of the ESCRS meetings, I went to go visit a friend, Francesco Carones, who's in Milan. And in Italy, there's no cash pay in their healthcare system. So ophthalmologists who want to make extra money will do LASIK because there's extra money involved. So this was a retina surgeon who was doing LASIK on the side. And so, you know, when you dabble in refractive surgery, it just makes it really difficult because you don't have quite that skill set. So exactly the same scenario, exactly the same thing happened. If the conch comes over the side cut, you don't get a side cut. And so as he tried to lift, lift the flap, he got half of it up and the rest he just couldn't get up and he was just, he was just lost. As I'm saying, they're watching him like, you need to let this, you got to get this patient to relax, but I didn't speak Italian. Anyways, so fortunately he was able to get Francesco to come down and help me and kind of lift this flap, but had to get out some accrescent blade to cut that edge, to kind of create a side cut. But anyways, let's go back to this case. If the patient's not relaxed, you've got to get them in a position where they're feeling relaxed to really get a good femtosecond creation, flap creation. Yeah, agreed. All right. So one vote for aborting LASIK in this eye. Would anyone venture anything else? I mean, if you can go back to just before you did the, you've stepped on the pedal. Let's go forward a little bit. So what, what I noticed, sometimes you get something called pseudo suction where the laser thinks you have suction, but you don't. Yeah, he's got kind of some foggy. If you look at that red mark up at like 12 o'clock, look at it move. Yeah. You see it turning there. Right. So the laser thinks you have suction. And so it's saying you're green, good to go, make the flap. But look at that movie. Oh yeah. No, I knew, I knew this was actually, I kind of knew at this point I was going to abort because this was actually the best doc I could ever do on this eye. And I was like, I'm just going to go for it. And I, I can abort and come back and do PRK another day. Because I know I'm not going to, I'm, I'm not going to swap because it's just going to, you're just asking for trouble or going to have, I'm going to, I would have this half flap, you know, having to cut a side cut who knows what kind of stromal bed I would have had. So, so I boarded in the left eye. So I had a conversation. I told him like, you know, we got it, I think we got a good flap in the right eye, going to proceed with lasik in the right eye, but I can't do it in the left eye. We're going to have to come back another day and do PRK. And he was, he was amenable to that. So I'm just showing kind of the rest of the case with his right eye. I mean, it goes, it goes fine. It lifted and oh yeah, this is the eye that was rotating a little bit. And so I was worried there might be some extra adhesions in the flap bed. And so it was a little bit stickier than normal, but it was, it was fine. The flap was a little bit sticky, but it lifted just fine. The bed actually surprisingly looked really good. So we proceed with the eczema laser treatment. And so, so everything went fine, flap got put back and, and that I went fine. So I'll, I'll kind of stop this and move forward here. So post update one, his right eye is 2020 plus two is flap was intact. And I plan for PRK in a couple of months just to let things heal at that flap. And, and because I never lifted that flap, I don't really have any qualms about doing PRK on top, just because it's going to be still the cornea, the flap isn't going to move at all with PRK on top. So I did PRK earlier this month without issues at post update five in that eye he was 23 year already. So he hasn't come back for a post up month one visit yet. But yeah, I just wanted to kind of show kind of a quick little case about what to do with, with flasic flaps and you can always change plans and there's always going to be complicated patients and he's, he's doing fine. All's well then as well. Can I ask a question, Dr Lynn? Yeah. How long did you wait between doing and not lifting that Lasik flap and then doing the PRK treatment? So two months, two months. I probably could have gone maybe one month, but just, just to be safe. I decided wait to. And then if it's like a patient with a larger myopic correction, like maybe a minus five that maybe you're worried about doing a PRK and treating through the flap, are you still able to do a PRK treatment or would you think about doing something else? I probably would have thought about something doing something else because then yeah, you're right. I would have lasered kind of through the thickness of the flap, which is not ideal. So I may have talked about ICL, but luckily he didn't have that big of a treatment. So it was just fine. So in the middle of you creating that flap, you saw that edge kind of become a problem kind of in the beginning, right, which we could now see in retrospect. I wonder, is it better to have stopped in the middle because you can take your foot off the pedal or do you finish it out so that you have a little bit more uniformity, even if you know you're going to abort after that case, which I mean, I think I would have done the latter and like what you did. But if I had seen that, you know, become a problem in the middle of the treatment, I might have been tempted to take my foot off the pedal. Yeah, honestly, if because I didn't never lifted the flap, I don't think it would have mattered if I had stopped like before I completed the flap, I probably wouldn't have stopped like right in the middle. Like I wouldn't have wanted to stop it right in the visual axis just in case there was any issues there. But let's say I stopped in like, you know, the first third of the flap creation, I think it would have been just fine too. Yeah, that is something to kind of understand with LASIK is that once you've docked and you've told the laser I'm going to make the flap, you then have full control over that flap progression and it takes about 15 seconds or so, 12 to 15 seconds, and you're holding a foot pedal down. So if you let off the foot pedal, it'll stop or if the laser ever detects that there's a suction loss, it will stop. And so I've actually had one LASIK flap where it made the entire LASIK flap, everybody, everything looked completely normal as I was going. And then the last two seconds, it just felt like it lost suction. And so it aborted just as it made the side cut. So I didn't, I had a flap with no side cut. And so we actually went back and made a second flap with no energy on the flap cut, we just made that super low so it can actually cut. And then it made the side cut at the end. So it's kind of a cool case that I had earlier. But yeah, you have full control over that foot pedal as you're going through it. Okay, it does have me up here. All right, I am nowhere near the photographer that Nick Mamelis is, but I've really enjoyed over the years of Dr. Mamelis sharing his photography with us as he has traveled the world. And every time we have a pathology lecture, I learned something about awesome cities around the world. So these are pictures of my tour of Utah using the dreaded icon pass that I joined this year. If you can't beat them, you have to join them. So this was up above snowboard last Friday. So how many financial disclosures? So I'm going to review, I've been trying to start this project where I'm trying to understand our Lasik and PRK refractive outcomes a little bit better, and trying to actually tabulate some of those things. So this is just kind of some very early preliminary data on that. So I'm working with Steve Christensen to try to understand a little bit better. And then we'll discuss some of the complications and I'm trying to tabulate that a little bit more, like how many complications do we actually have with Lasik and PRK. And then if we have time, we're going to review some of our current screening things. So this is essentially data from about 2015 on. And this is around 11,000 eyes between myself. I was still a fellow, so I don't have very many numbers in the early years. And then Dr. Lin and Dr. Mifflin as our refractive surgeons. This is looking at just uncorrected vision testing at distance. This is extremely raw data that just we just barely got just a few days ago, kind of pulling information out of Epic. So there could be some selection biases here, like we have some patients who at one year they're not doing their follow up for Lasik or PRK because they're doing awesome. You might have some patients who hate you as a surgeon, and so they've left following you and are off somewhere else. So you could have some selection biases here in different in various ways. But this is just the actual raw data showing our Lasik and PRK outcomes and by kind of months as you kind of look at this. So the top line is 2015 and better. And the very top one there and then 2020 is that second line. And so you have one week, one month, three months, six months and one year data. Those are typical time points that we're seeing these patients over the course of a year. And so those are kind of the actual outcomes. If you look at actual published literature out there, you hit it about 90% of patients. They're uncorrected, just complete uncorrected distance visual acutes. 90% of patients usually hit 2020 or better with kind of primary Lasik and PRK. And that's about where we're hitting on both of these surgeries. So looking at that a little bit closer. So this is kind of the data that is published a lot of the time is where patients at at one year. And so we are hitting it about 62% at one year 2015 and then another 30% or 2020 or better. So you just kind of tabulate that up. So 91% of eyes at one year with Lasik are seeing 2020 or better and about 99% or 2030 or better. And then with PRK slightly higher, but pretty similar 92% or 2020 of the year and about 98% with PRK or 2030 of the year and almost 100% or 20, 40 or better at a year. And again, Dr. Olson brought this up, but one of the key things to understand with a Lasik patient is what is their actual pre-op best corrected vision? Because you may have a patient that has like some mild amblyopia and they're only 2025 or 2030 at their best corrected vision before they have surgery. And so that could, that could skew some of these numbers. And then another thing that people look at is also like, what's their best corrected vision? If they're not 2020, you know, can they correct a 2020? And I don't quite have that data yet for our data set. So what happens in Lasik? So what are some of the issues that we come up with? So this is just kind of pulling in some data just to show published literature out there some of the complication rates. There's over and under correction. That essentially means that you had surgery and you're not seeing 2020, you're not seeing 2025, you're not happy, you want to have a correction done. And so the enhancement rates that are kind of shown out in the published literature are somewhere around 5% to 10%. Last time I was able to pull our exact data, we were somewhere around 3% enhancement rate. Infection is somewhere around one to two, one in 2000 cases. This is specifically with Lasik. There's a very broad range for that. You may have some published data that's like one in a thousand and some that's like one in 15,000. So quite a range there. Flab dislocations with Lasik is published at around one to two percent of those. And then you may have this inflammatory action called Diplomelo keratitis, dry eye, glare and halos, epithelial ingrow, thectasia. Those are kind of the things that we openly discuss with patients as we're consenting them for these surgeries. And there's there's kind of variation in how often those things are occurring depending a lot on your climate and where you live. So my personal numbers with Lasik over this time period I've done about a little over 500 eyes. I'm not aware of any infections that I've had with it. I do see flap dislocations. I had a patient that really bumped my numbers up because she decided to dislocate both flaps about an hour after surgery. So my, what's that? I'll show you a picture of what she was doing in just a second. So my flap dislocation rate is 1.2%. I have one case of DLK that was pretty severe in one eye on a bilateral Lasik patient that eventually recovered to 2015 vision, but she was about 2050 for a couple of weeks with really bad inflammation. I did not lift her flap. I just treated her with topical steroids and it got better. I don't see as much glare in halos as a long-term complication. There's a unique complication with glare in halos with Lasik where you get what's called rainbow glare where when a patient looks at a light they actually see a rainbow spectrum. And that usually what we were finding happens is if you get an interface chatter event during the creation of that Lasik flap creation. And Amy's Lasik flap had like just a couple tiny little chatter lines that you saw. They're a little bit hard to see on some of the mapping, but that's something that's not as common anymore with the ablation profiles. And then dry eye, there's a ton of published studies out there. There's some published studies that show like 0% dry eye after Lasik. There was a military study that had one case of dry eye after Lasik in their study. You do not have dry eye. Yeah. So there's interesting, all the way up to 10%. I usually tell patients we're in a drier climate, so you're more likely to have that issue. But honestly, it's not a major problem after Lasik in my practice. I'm not aware of any ectasia cases with my Lasik. With PRK complications, pretty similar ideas about the different things that can happen. I tell patients if you want Lasik, you're signing up for all the flap complications. And if you're signing up for PRK, we get rid of all those flap complications. Those are kind of the main sort of decision points that patients are making here. Obviously, other things are very similar. One thing that's unique to PRK is haze formation. And then infections a little bit higher risk with PRK as well. For me, I have had one PRK infection, which is a really devastating case for me, which puts me at 0.007% in 1300 eyes. I see probably around three per year. I haven't tabulated this very well. I have not had to treat any patient to clear their haze. It just gets better on its own, meaning I haven't had to laser anybody. And dry eyes still do see it. Probably my biggest thing that I don't love about PRK is that patients complain about kind of a recurrent erosion syndrome. They're like, I'm doing fine throughout the day, but I still wake up a couple times a week with pain. It feels like something's tearing my cornea. So they're essentially having these minor recurrent erosions. And then I tell patients that glare inhalers are less common with PRK. The ablation profiles are the exact same, but you lose that LASIK flap interface as a potential cause of glare inhalers. Okay, so this is the patient of mine that had bilateral flap dislocations. And when I went to pull her video, I was like, I wonder how good this is going to be. I'm just going to show it. I don't know how good this is going to go. I don't remember anything detailed about problems making her flaps or anything. But as I went back and reviewed this, she was like the perfect patient, like zero squeezing, just open her eyes super wide, had no problems docking, really good aplination. And her LASIK flaps were about as smooth as they get. So no chatter, no OBL. So chatter is kind of the linear lines that you'll see. OBL is if you see like this big burst of white kind of down at the hinge area, but her LASIK flap just super smooth and made really well. And the same was true for her other eye. So we did her right eye first and then her left eye, and both LASIK flaps went really well. We currently use the Alcon suite of the laser. And it's been the only laser that I've actually used. So we've had it for, I think about 13 years, 12 years. I can't remember now. I wish Mark was here. I can't remember when we got it. We got it here at this building. And then when we opened mid-valley, we moved over there. So this one actually does have a little bit of OBL. So that's kind of that whitening that you're seeing a little bit more dense at the bottom. That's essentially as gas is trying to escape through that venting incision. It doesn't escape fast enough. And so it stays in the flap interface. And sometimes it'll make a more sticky flap. But that went really well. And then this is her flap. So you kind of mark the flap before you lift it so that you know where to put it back and essentially get her flap lifted up. So you kind of initiate a little at the side cut. You kind of initiate down to the bed of flap. And then you come across with this lacy spatula to lift it. And just a really nice consistent flap on this case. And then a lot of this was just approved to myself that I did get her flap in the right place at the end of surgery. And so you kind of irrigate the flap. You float it as we call it. So you're kind of putting a bed of fluid under there to rinse any debris out. And then we kind of milk the flap down into position with a really wet wax cell. And I think eventually you can see those marks come into view where they're just perfectly lined up again. We use that prednisolone to kind of initiate anti-inflammatory treatment. But also it kind of helps you see the gutter as we call it. Let me pause that for just a second. So if you look at the actual side cut all the way around, we're kind of looking to see if it stains that area white just a little bit. It's just that pred orte kind of pooling in the side cut. And that's one of the indications to understand is this symmetrically laying back down. And so that looked really good. And so we did her other eye. I think we'll just skip the other eye because it was the same. No issues there. So this was what her flap looked like. I don't ever take pictures of my own refractive patients. It's kind of like this weird thing where we have to charge them, but then we don't. It's like it's hard to get pictures of them, but I wish I would have had pictures of her because she had about a four millimeter gutter in the bottom of her cornea. So that meant that her LASIK flap pushed up four millimeters and it was all wrinkled. Just kind of sitting about halfway through. And I see patients about an hour to two hours after LASIK because that's when their flaps dislocate. It tends to be in those first couple of hours. And so I went to get her from the waiting room and I'm like, how are things going? And I'm looking at her and I'm like, both your freaking flaps are dislocated. Like I don't even need a slit lamp to see this. Yeah. I was like, oh my gosh. And she's like, yeah, they hurt. It feels like something's in both eyes. I'm still pretty blurry. And it's like, sometimes it's hard because it's pretty painful to have LASIK. The first couple of hours is pretty light sensitive. And so I said, well, so tell me what's been going on. And she's like, well, I don't really know. My friend's been helping me put my drops in. And I'm like, so how has she been putting your drops in? And she's like, she has been grabbing my upper lid and just pulling it up. And so her friend essentially just dislocated both flaps. And so she was about 2100. And so I just said your flaps are out of place. We just need to get it back in position. And kind of varies how I do this. Sometimes I'll do this at the slit lamp. I'll just re-clean them, just get betadine washing them, make sure they're nice and get that betadine all rinsed out. So there's no betadine in the flap because you can get DLK if that happens. I think in her case, I actually took her to the minor room. We were still at the laser center. So I just took her in there because I was like, both eyes was going to be a little bit tricky. And so I just did a full complete reprep and refloated them. And I just saw her, she actually moved to Seattle about six months after surgery. And I saw her this like two weeks ago and she was 2015 flaps looked really pristine. So if you can get to these early, they're not good. Yeah. Yep. We talked about that. You definitely are going to have really good outcomes that earlier you treat these. So I had a patient that had kind of a similar thing happen. I actually saw her at about a five hour post-op. And she was looking fine. Had a really good vision. Flaps were in position. And then her flap dislocated at some point in the next week. And when we saw her, she had kind of that similar idea where there was some horizontal striae. And I had to relift her flap, but it wouldn't flatten out. So I had to de-epithelialize it, flatten it out. And she's done fine with that, but a little more aggressive. Katherine Who and Mark Mifflin have their hands up. Yeah. Who do you want to go first? Dr. Mifflin. Hi. Hi. Can you guys hear me? Yes. Sorry, I'm not there. I'm home recovering from shoulder repair. But I wanted to comment great presentations, good comments. And just on the dry eye thing, I think that Katherine may be chiming in on that too. But I think that Austin and I wrote a letter to the editor and I think it was Corny or JCRS. I can't remember. But one thing, we have a prospective dry eye study going between LASIK and PRK right now. And I think what we find is that the symptoms tend to be worse in PRK and the findings tend to be worse in LASIK. So there's an element of hypoesthesia verified by esthesiometry readings and corneal staining. In terms of actual effects on the patient's quality of life, they both tend to be very low, even in our very harsh conditions here environmentally in the Salt Lake Valley and the surrounding areas. And so generally, outcomes are good in, quote, controlled dry eye patients in either group. And I think that's where the military study is a very interesting one because they didn't really look at findings. They just looked at symptoms. And if you can't feel your dry eye, then it's not there unless it gets really severe. Just to comment on our laser, we've had our EX500 laser. I can't remember for sure when Mid Valley opened. I think it was 2013. So we got it just a few months before we opened Mid Valley. Before that, we had the EX400, or not, it wasn't called EX, but we had the Allegretto 400. And then we had a 200 before that. And then we had the Vizix laser before that. So that's kind of our history. I think that's all I had to say. Thanks. Thanks, Mark. Hope you're doing well. All right, Catherine. Yeah, I was going to say, can you guys hear me? Yes. We're connecting from AUTO. But yeah, in the order of who do you unmute first, definitely Dr. Mifflin first. But yeah, I was going to mention our dry eye study. And we're looking at corneal asezometry as well as staining and also questionnaires for symptoms. That's the fellow study. And one thing I was going to ask you, Brian, is how did you keep track of this data? Because as a new attending surgeon, I've been just manually tracking my outcomes through like red cap, because you can do that as a faculty member, set up your own database. And that's been relatively easy. But just wanted to kind of know in terms of both cataract and refractive, I've been tracking my own outcomes, sorry, outcomes, but wondering if you have a better idea. I know that other practices will have like veracity, other built-in systems, but wanted to get your perspective on that. Then also the most shocking thing that I learned from the ScranRounds is that you have the icon pass now. That was the thing that I was very surprised by. I know it's sad. Can't beat him. You got to join him. So as far as data goes, I have learned this last year that there are data miners that work for the university that are kind of there for you to kind of request this information. And they can get stuff really quickly, especially with kind of how Epic is set up. And so Steve Christensen is who I've been working with. And we'll add you to this data set. I don't think you're in it yet because you're just getting started. But I can show you how to get access to it and stuff. I'm going to add a quick point. I think we got our new iterations of our lasers in 2016 because we had a big flood at Mid-Valley that ruined our half a million dollar lasers. And so we had them replaced within three weeks. So we were down from the laser. I think it was during your fellowship, no? Yeah. It was a little disappointing time. 2016. It's worked out. It's worked out. There was a flood in the pipes in the ceiling. So we got a new laser. It was great. But it was the same one. So I am typically seeing patients at the slit lamp, like I said, right after surgery. So I checked their eyes right after we've left the laser suite just to make sure everything looks okay there. I had one patient that as I was taking the lid speculum out, I was like, did her flap just dislocate? And it actually did. Because she kind of just squoze at the right time. And so we just repositioned that really quickly. And then I'll usually see them within four hours and then a week later. So when we're doing, I wanted to go into just really quick just a few minutes of how we screen refractive patients. So as you're seeing a patient or talking to friends about it, you know, what are we looking for? So lifestyle considerations come up a lot in deciding, you know, is this something that's useful for you or if you just wear contacts and glasses? Obviously their correction level, how much of their cornea we're leaving behind is the residual stromal bed. We're looking at actual changes in the shape of the cornea. And then age and stability of refraction comes into play. And then just underlying ocular and systemic pathologies. There's a random and risk calculator. I don't physically like put patients through this. But it's something that we all use as refractive surgeons to kind of understand how risky this patient is. So if they collect four points in this calculator, they're high risk. Four points is if you have an abnormal topography. And also if you have a residual stromal bed less than 240, which not, I don't think there's very many surgeons that are going that low. And this is kind of older data. Like we're not really doing laser refractive surgery on somebody that's greater than minus 14. But that would give you a lot of points. And then it just kind of goes down from there. So three points is if you have inferior steepening a skew pattern on topography, if your residual stromal beds like somewhere around 250 younger ages get high risk factors because you don't know what their cornea is going to do over time, the chemistry readings less than 500 specifically less than 480 in this case. And then two points, it just kind of ticks up a little bit. So the older you get, the less points you collect, the thicker you get, the less points you collect, the lower your refractive error, the less points you get. And so this is kind of where a lot of us live is that we're not going to put people down below 300 on a residual stromal bed. We're typically waiting for patients to age a little bit before we're doing surgery, and we're not going above a minus 10, typically with a laser refractive surgery. Zero points. This is telling you, okay, this patient's a pretty decent candidate for refractive surgery. They have a stigmatism, but it looks symmetric. Their residual stromal beds above 300, their age is over 30. Their pychymotry is above 510 that treatments less than minus eight. So that's typically a good candidate. Some of the numbers that we use to figure this all out, if you have a percent tissue altered that's greater than 40%, it puts you at high risk. We measure this essentially by looking at their pychymotry, looking at how many diapters we're going to correct and use this formula to try to predict that. You can also plug it in the laser and the laser will tell you what it's actually going to remove with the treatment. And then there's some things about corneal flattening that if you flatten the cornea too much, it degrades their quality of vision. And so those are kind of the main things that we use for it. I had a bunch of cases I was going to take you through, but we're going to skip over that because we are out of time. But it's something I just literally pulled up like last Monday's clinic and just pulled up every refractive surgery screening that I saw that day and threw them in this presentation. It's something that we deal with every single day of like, how do I figure out what this patient is able to have and what do they want and lifestyle choices. And it's just kind of a discussion of hear your options. I'm going to consent you for all these different options and we take them through what like Dr. Wait said that we feel is the best and safest surgery for them. So refractive surgery is a lot of fun. I'm hoping to keep tabulating kind of our systems outcomes and data and complication rates. So thank you. Appreciate Amy for putting this together. Any questions? Yeah, Dr. Wait. Okay. I think to answer Catherine's question too, how do you track this? When you're doing LASIK and PRK, you want to be using a nomogram that can help you put the best numbers into the laser that will give you the most accurate results. I use IBRA, but also surgery vision has another one as well. Do you guys use that? Wellington. Okay. So Wellington's a paper nomogram. And the nice thing about this is it's kind of like using AI to figure out, okay, these are the results I've had. How do I tailor down the best results? And so it can be helpful, but then also you can go back and track your numbers. You have them all put into the system. So you can look at every single patient from the beginning to the end kind of a thing. I agree in regards to PRK, definitely RCE symptoms are one of those problems here in Utah specifically. They wake up with pain in the mornings. But I'm curious if you guys have noticed a difference in between your enhancement rates with LASIK versus PRK. I couldn't quite hold the data this time, but when I looked at in the past, they are slightly higher with PRK. Okay. Same here. My enhancement rate is higher with PRK than it is with LASIK. And I have to assume that the reason why is because the epithelium itself has a certain amount of refractive air built into it that we can't really take into account with our current technology, our current diagnostic equipment. And so we're making certain assumptions and then we assume it's going to heal how it's supposed to, and then it doesn't, and then you end up having to do an enhancement. And so my preference is if the corny is normal, I'd much rather do LASIK because I know that'll be, I have a lower enhancement rate, it'll be a quicker recovery, right? And then, oh, the last thing. Okay. In regards to flap dislocations, I don't know if this has necessarily statistically made a difference for me. I went to go to Dan Ryanstand's course in London a few years ago, which is phenomenal. He's a good teacher. At the end of the case, what he'll do is he'll put him up at the slant like you're doing, you're checking them. And then you use a Miracell sponge and you kind of, you massage out any fluid top to bottom to the sides out of the flap and you'll see actual fluid coming out of the flap. So you're laying that flap a little bit more securely to the cornea and you'll see that that gutter that's around the edge will actually disappear. You'll bring the edges to each other to touch. Since starting to do that, it's been amazing just seeing the flaps afterwards, how they heal with minimal gutter, very low dislocation rate. But I think, of course, if you're mashing on the cornea, you're going to dislocate any flap, regardless of how you put it down. But then again, even on, I know you're seeing them a few hours, then you'll see them a week later. I think completely appropriate. I usually will see them at the one they post up. You can still, there's still some motion in the flap. So if there were a little Microstria, you could actually use a Miracell to kind of push it out and get those to the edges. But that, massaging the flap after the case, I think, is the last step of LASIK, the surgical technique. And I think it's worthwhile to do that. For me, I think it's made a big difference and make sure the flaps are perfect before they even walk out the door. I'm done. Thank you.