 Next we have Jed Assam from the University of South Dakota. The title of his talk is Hydrogel, Interoff your Lens Calcification Pathology, a Hard Case. Alright, well good morning everybody. I have the privilege of presenting a presentation with Developmental Systems by Dr. Manlis as well as Dr. Werner this morning and it will be discussing some of the case highlighting the pathology of Hydrophilic Acrylic Lens Calcification and hopefully help to provide you a validation for considering this uncommon but important pathology when evaluating case pseudophakic patients with decreased visual acuity. So as an overview, some of the items that we're going to be talking about today with this presentation include the case of Calcification itself as well as some of the benefits and drawbacks of utilizing Hydrophilic Acrylic Lenses, some of the history of Hydrophilic Acrylic Lens Calcification as well as mechanisms and risk factors and finally trying to tie in a clinical relevance case example. Alright, so in providing our case we have a 72 year old female that presented to the clinic who was left-eyed dominant. The chief complaint was blurry vision. The patient indicated a past history for the blurry vision of gradual diminishing vision over the course of two years which had become more noticeable over the course of the last six months. The past medical history, past surgical history was significant for a prior cataract extraction bilaterally with a full-stream interocular lens placement of a three-piece Hydrophilic Acrylic known as the memory lens. The patient also had a significant history for yacapsilotomy of the right eye. There was no significant history for any context lens wear or prior refractive surgery. Objective findings in the patient follow-up mirroring the patient's exam included a normal finding on external exam. Silt lamp examination was pertinent for bilateral pinguicula as well as identification of a right eye calcification, severely calcified interocular lens, and a finding of posterior viltrial detachment in the left eye. The fundal examination was normal in the left eye with normal retinal findings and the right eye was unappreciable due to the presence of a highly calcified interocular lens. Baseline testing did reveal a depreciated visual acuity in the right eye to 2400 and in the left eye it was normal at 2020. There was a slightly elevated pressure noted in the left eye at 21 and then the normal, within normal limits for the left eye. The image provided demonstrates a great example of a dilated exam showing an optic surface with good presence of calcification on the lens demonstrated by the red highlight. This would have been a good example of what would have been clinically identified in our case. As an assessment, the patient was found to have a calcified interocular lens of the right eye. The decision was made for surgical interocular lens exchange with the placement of an anterior chamber lens the L122 by Bosch and Lohm. The reason for selection of an anterior chamber lens in this particular case was due to the fact of the need to remove the capacitor bag due to loss of integrity from prior capsulotomy as well as noted patient intolerance of continued procedure for the placement of a posterior sutural ILL. Patient follow-up demonstrated on day one a expected decrease in visual acuity in this case to hand motion. However, as we continue to follow the patient case throughout the course of the week we do notice that there was a gradual increase in visual acuity increasing to 2200 in the right eye on the third day and then by one week to 2060. Throughout the course of follow-up the interocular pressure was noted to remain stable for this particular patient. Pathological findings from the extracted interocular lens demonstrated a diffused deposition both on the anterior and posterior surfaces of the lens with granular deposits which was also positive with an elizirin red stain which is significant for demonstrating the presence of calcium within the deposit. The images above show on the left an example of the diffuse calcification that was observed in our particular interocular lens. You can see the dense course deposits and then if we look at the image on the right you can see a comparison of the stained half of the lens demonstrating good uptake in the granules to demonstrate the presence of calcium contrasted with the lower segment which is unstained in this particular case. So, having gone through a case of interocular lens calcification with hydrophilic acrylic what are some of the benefits and drawbacks to the use of this particular lens type? The benefits have included noted high uveleal biocompatibility which translates to a lower inflammation in the post-operative period. Additionally, the flexible nature of this particular lens type allows it to be highly foldable which is very ideal for use in small incision or x-surgery. Some of the drawbacks to the lens use include a relatively poor capsular biocompatibility which translates to an increased risk for the development of things such as posterior capsular opacity with epithelial capsule migration. Additionally, interocular lens calcification as was discussed in our particular case is also a concern for this particular lens type. As well, there is a high YA grade that has been associated with this particular lens due to not only the poor capsular compatibility but also to the misinterpretation of findings on clinical exam in which case a patient might have a calcified interocular lens whereas the clinician might very well jump immediately to the assumption that they have a posterior capsular opacity and pursue on a YAG procedure. So, the background history, brief history on hydrophilic acrylic lens calcification. Overall for purposes of lens exchange for hydrophilic acrylics the sequela of opacification is the most common reason for needing to do an lens exchange in this particular type. Opacification causes calcification does represent the most common source for opacification in hydrophilic acrylic lenses. Another cause would include staining from a capsular such as hydro, the tetraline blue. Additionally, for calcification there is calcification that occurs by primary causes as well as secondary causes, primary specifically referring to lens calcification occurring as a result of defect on the lens surface itself, secondary occurring as a result of calcification due to environmental factors which we will go over in the following slide. Some other historical models of interest that would be valuable to be aware of that have undergone calcification previously include the hydroview by volition at home, the aquasense as well as the SC60B OUV for medical development in our particular case we did have a memory lens calcification. So, for the pathophysiology of hydrophilic acrylic lens calcification it is noted to be a multifactorial event. Of the known factors that have been considered for causes of calcification the chief cause of primary calcification in a hydrophilic acrylic lens has been noted to be the increased surface ionization energy potential caused by exposure of a hydrophilic acrylic lens surface to the physiological pH of the aqueous humor which predisposes to the precipitation of calcium from the aqueous humor. Secondary causes which include the environmental factors that we discussed include conditions that can increase the calcium level within the aqueous humor. This includes things such as metabolic and ocular conditions, inclusive of diabetes with associated diabetic retinopathy as well as renal disease failure as well as parathyroid abnormalities. Other items include surgical procedures which increase the inflammation and also disrupt the blood aqueous barrier as well as surgical adjuvants which include things such as silicone oil air gas as well as tissue plasmidogen activator used to decrease fibrosis of interocular lenses. So, in having discussed some of the history as well as mechanisms and risk factors associated with hydrophilic acrylic interocular lens calcification, what I'm hoping to present to you in this slide is to provide a valuation for why considering this uncommon but important pathology is critical in the differential diagnosis for decreased visual acuity and suofacic patients. In the image on the left, we see an interocular lens calcification which was demonstrated earlier in our case contrasted with a posterior capsular opacity case on the left or your right. From these two images, the close similarity can be easily identified how this could be on a rapid clinical examination misinterpreted in a case of interocular lens calcification as a posterior capsule opacity which would then predispose the patient to undergoing a unnecessary capsularity which predisposes the patient to not only increase financial burden as well as the risk of undergoing the procedure but also increases the risk associated with the eventual lens exchange that will be necessary to resolve the problem of interocular lens calcification. With that, I'd like to briefly review some of the items that we've gone over throughout this presentation. We've done a case review of calcified interocular lens. We've undergone some of the benefits and drawbacks to the use of hydrophilic acrylic interocular lenses. Some of the history of the calcification of hydrophilic acrylics mechanisms as well as risk factors and then also provided a clinical correlation to consider. With that, I would like to make acknowledgements to the following individuals for their assistance in the development of this presentation case. These are some of my resources and with that, I would like to take any questions. A nicely done talk on the calcification of these implants. Because these were so rarely used, especially in this area, we just don't see these often. I think it's critical that people have a high index of suspicion and the one point that we like everybody to take away from this talk is if you see someone where you look at and there's a opacity, use the OSPCL and then just jump in to do the ad. Look closely. It just takes a little bit of a longer look because the calcification is definitely different. When you look at these, these implants are calcified both on the anterior and the posterior surface. It's not in the lens capsule itself. And then people will just jump in immediately into the aggliseur capsule. Once you do that, the degree of difficulty in explaining these lenses goes way up. And your risk of a vitreous coming forward, risk of not being able to put an implant back in the capsule van goes way up. So take an extra few seconds and when you see some PCO that just doesn't work, maybe that should like something up that says look closer and see if it's really PCO or if it's the implant itself because we just don't see these very often anymore here. I mean this was taken off the market, you know, almost 20 years ago. So we just don't see these very often. But if you see some funny PCO look carefully at it. Make sure you're dealing with PCO rather than moving the capsule by that amount. Thank you for that. This is the slide. So just to complement what you said, those four major designs that you mentioned can give you almost no see that in the world because many of those things are useful and could be analyzed in any of them. But just follow the attention of what you are seeing now a lot in the laboratory. So if you have even in this country a patient with a hydrogeo or hydrocephal in the eye, and then this patient requires a procedure such as in the back of this sack, or a chemical injection of air, or also a tractomy, auto breath and surgery, to see if on the oil or gas or something. This is what we assume in terms of costification. So then these laces cause a fine to be very or not for access area and they require explanation. And this problem is not being related to one particular design. It's being related to any kind of hydrofever. And some papers like coming up showing that the risk that you have a patient hydrofever in the laces, and that patient under the sack or the macrosurgery procedure the risk is 10% to costification which is actually fine. Thank you Dr. Wernan. Any other questions at this time?