 All right guys, we'll get started So we're gonna kind of change up the schedule a little bit. So first up is gonna be Brent Kramer So he's a fourth year medical student from Iowa. I'm gonna be talking about residual sickness at stigmatism after Twerk IOL So I'll let him get going Hello everybody. So as we said, I'm a medical student here for a month rotation at the Moran. I'm from the University of Iowa The research I am presenting today on residual stigmatism after Twerk IOL Was done with Dr. Burdell and Dr. Harton. I'm also going to present a little research I did at the Iowa City VA with Dr. Oding as well and a quick tangent I stopped in at Vance-Hompson vision. I'm supposed to say hello to everybody from Russell Swan So I have no personal financial disclosures So as I said, I'm going to present Some research I did with the astigmatism fix website and then also some research I did at the Iowa City VA So at the time of cataract surgery patients with stigmatism, corneal stigmatism can get a Twerk IOL in pursuit of spectacle independence however, sometimes they're left unsatisfied with some refractory residual stigmatism and This website created by Dr. Burdell and Harton Was created and launched in 2012 and it helps surgeons manage these patient patients and what the user does is enters the The current or the postoperative refraction as well as the Twerk that as you can see here at the bottom and then when you hit calculate and gives you this little print out and it tells you the Expected residual refractive astigmatism if you were to rotate to the ideal location And then you can see here how far you have to rotate and then at the bottom It's just a little diagram of the potential residual stigmatism if the IOL is rotated to any axis within the eye So to break it down just a quick background and refractive astigmatism residual refractive astigmatism Two potential causes are either wrong power So the power in the actual ferricity or wrong location and the wrong location itself can be broken down into two subcategories of Wrong intended axis so that means you want to put the IOL at 20 degrees potentially is that 20 degrees, but the actual ideal axis is 30 degrees This is caused by can be caused by a lot of things, but mainly just Measurement calculation errors Unaccounted for surgically induces stigmatism or unaccounted for post your coronal stigmatism Also, or the other category is misalignment and with misalignment That's mainly rotation or potentially put the IOL on the wrong location to begin with So I looked at the data from a stigmatism fix I took the entries from mid 2012 and did my data are all through the end of last year 2015 there are about 36,000 entries and Long story short after a lot of filtering we got down to 12,812 entries that were Likely representative of actual patients. So this is our final data set we worked with So of these 12,000 8,229 have the intended orientation and the IOL type because those prompts weren't required on the initial version of the website and so looking at those 70% of those IOLs were found to be misaligned by 5% so that remembers kind of the IOL likely post operative IOL rotation Surprisingly actually 76% so more were found to have an ideal axis shift of greater than five degrees. So remember that's the Potential like measurement air calculation air SIA post your corneal stigmatism. So I think this is a first big take home point when you're dealing with residual stigmatism in a patient and you're thinking about rotating Center So when you're working with residual stigmatism and you're thinking about rotating an IOL It's wise to use Toric back calculators such as the stigmatism fix because potentially let's say you have an IOL that you wanted to place at 20 degrees You have a patient with blurry vision At one month out you dilate them and you find that IOL 80 degrees You think well, I'll just rotate back to 20 and that'll take care of the problem But 20 degrees might not be the ideal location Due to just post operative changes or earlier measurement error. So I think that's a big take home point as well So next So back here with that 5600 that were found to be misaligned We looked at those specifically and we stratified them according to the manufacturer and you'll see that after soften technus are the the big players in the market which is was expected and What we did is we compared those to the estimated usage of these Toric IOLs in the US From a market scope survey And we found that the the technist Toric IOL is a little bit over represented in the misalignment or post operative rotation category and so the odds ratio for that was two and a half so About two and a half times more likely to rotate in the eye from an external validation We then looked at an internal validation So what we did was we took those same numbers and then we compared the total number of entries So there's an 8200 number again and once again, we found the technist IOLs were a little bit more Likely to rotate than the Acrosoft and a similar odds ratio there So two different mechanisms of internal and external validation Showed that the technist IOL was a little bit more likely to rotate Than the Acrosoft IOL and the true line and stars didn't really have enough power to to consider them in the calculations So moving on can reorientation help these are just some Some numbers so initially all play are all comeers to the website had a bout of residual stigmatism of 1.8 and by rotating the IOLs to their ideal location you can Reduce that reduce over adapter of a stigmatism. That's about a 54% reduction overall and About 40% of the the entries into the website could be Minimized or residual stigmatism could be minimized to below half a diopter so finally I'll get to the research I did at the Iowa City VA and I looked at all the IOLs that were implanted for about a 13 month span from February 2015 To March of this year and we implanted 634 IOLs 98 of them were torques. It's about a 15 and a half percent rate and For during this time, we were using the Acrosoft or a guy. I'll calculator 41 of those 98 patients had with the rule stigmatism and 26 of those patients had a manual or fraction at their one-month follow-up So looking at those 26 21 or 80 percent of them with pre With the rule of stigmatism flips to against the rules of stigmatism about with using the Acrosoft or a guy I'll calculator And then when we retro or when I retrospectively entered the data into the Barrett Barrett Torch IOL calculator 18 of those 21 Where it was recommended that a lower IOL power was used So just a quick background on the Barrett Torch IOL calculator one of the biggest differences between that and the Acrosoft and other Calculators is that it considers posterior corneal stigmatism So this finding actually supports coax findings But there's about a mean posterior corneal stigmatism of negative three diopters in the steep axis and about 90 almost 90 percent of eyes so Just to kind of phrase it one more way if you don't consider posterior corneal stigmatism this small study supports Basically, we already know that you will over correct with the rule stigmatism and potentially flip the axis to against the rule So just a quick conclusion the big take-home points from the studies that I talked about today was using a Torch back calculators important with residual stigmatism The Technus IOL which is an AMO lens is found to be a little bit more unstable potentially unstable than the Acrosoft lens Reorientation can significantly help and Then finally from the Iowa City VA study we found that not considering posterior corneal stigmatism Can potentially to overcorrection of with the rule stigmatism? Thanks any questions That was really nice talk. One thing I've been wondering about is when we actually know what the posterior corneal stigmatism is, we have a Pesticam I don't know if you know you can answer this question or someone else can in the audience But is there a calculator that takes into account our Pesticam measurement of the posterior corneal Stigmatism in that patient instead of just using like a normal gram like the Merrick does or is that in development somewhere? I Personally don't know of a calculator where you can enter the posterior corneal measurements in There's a few devices like the Pentecam the Galilei that can Measure the posterior corneal stigmatism. It's I don't believe it's a direct measurement. It's kind of an algorithm of its own But yeah to answer your question more directly. I don't think that there is anything Any calculators anybody else know of a calculator? I? Think the two big things is that the Barrett's and then also the Baylor normal gram Just to not date the Acrosol calculators change now Okay So when you go online to plug in Awesome, so I just want to make sure everybody heard that the Acrosol calculator does you can include the pull or it does Awesome, thanks guys