 Our next presenter is Jack Stringham, who is a fourth-year student here at the University of Utah. We may not all know that ophthalmology is Jack's second career choice. He initially wanted to be a professional skier. Not a downhill skier, but an aerial skier, like with fancy flips and things like that. Jack has successfully completed a double backflip and landed on his feet, both in a pool and on the snow. He's also unsuccessfully attempted many backflips in the pool and on the snow, and survived to be here today to present for us. So today, I'll be presenting on a summer research project of mine. Silicon IOL calcification in eyes with asteroid hyalosis. This was made possible by a grant to prevent research in an NIH training grant, and there's no kind of conflict of interest financially in this by the authors. So dystrophic calcification of IOLs requiring explanations typically associated with hydrophilic acrylic lenses. But back in 2004, 2005, the Mamless Warner Lab reported four cases of dystrophic calcification in silicon IOL lenses in eyes with asteroid hyalosis. Three of these lenses were silicone plates depicted there in the bottom left corner. One lens was a three-piece silicone lens. Two additional cases were later described in literature, and we now report 16 additional cases. So asteroid hyalosis is characterized by small, brilliant reflecting benign white-yellow opacities called asteroid bodies which float in a normal vitreous body. The origin of these asteroid bodies is unknown. It is predominantly unilateral. The prevalence is about 1% with no race or gender predisposition. It may be correlated with diabetes, and asteroid bodies are known to be composed of hydroxyaptide, which is made up of calcium and phosphate. So the pathological process and clinical course which led to the pacification of these lenses and their explanation when it follows. The posterior capsule is known to serve as a barrier to large non-electrolyte molecules or to negative electrolytes. And asteroid bodies are not charged and small, which then allowed these asteroid bodies over time to slowly diffuse through the posterior capsule and precipitate on the posterior optic surface, leading to whitish granular deposits which gradually appeared on the posterior optic surface. And so these patients return to their physicians with decreased visual acuity, typically about seven and a half years after implantation of the lenses, at which time many of the physicians use the YAG laser for dusting in the posterior capsuleotomy. But with the posterior capsuleotomy, that then directly exposed the posterior optic to these asteroid bodies, leading to rapid reaccumulation of these deposits and to explanation of these lenses, typically within a year and a half. These are the 16 new cases which we're reporting today. Of no, all these cases came from the U.S., except case number 12 came from Germany. In cases number 14 and 16 represent the most modern of silicone IOLs with square optic edges. So analysis of these X-planted IOLs, all of them underwent gross analysis and light microscopy. Selected lenses underwent alizarin red staining for calcium. Selected lenses also underwent scanning electron microscopy coupled with energy dispersive X-ray spectroscopy for elemental composition analysis. And we also looked at clinical data in relation to 111 hydrophilic-acrylic lenses explained it because of calcification for comparison to see if there's any correlation with asteroid halosis with those. The science behind it all, to be honest, I'm not so clear on. I know that it analyzes the components up. I think Dr. Warner, the expert here, will see one of those graphs which it produced here in just a minute. We also looked at 111 hydrophilic-acrylic lenses to see if they were associated with asteroid halosis. Results, we found that asteroid halosis was found in 13 of the 16 cases of calcification of these silicone lenses. There was no record of asteroid halosis in three of the cases, but I don't know that necessarily excludes asteroid halosis in these cases. It very well could have been present subclinically or not noticed. We did have one case in particular that there was no record of asteroid halosis. And later the physician, again, looked at the eye and did indeed see asteroid bodies. Deposits were only on the posterior optic surface of the silicone lens and were composed of calcium phosphate. It is significant that they were only found on the posterior optic surface. The hydrophilic-acrylic lenses, which were calcified, those deposits occurred both on the anterior surface, posterior optic surface, and a lot of it actually occurred within the lens itself. So our IOL analysis, all of them underwent microphotographs in which we saw this white amorphous granular material, which is consistent with calcium deposits. They are all located on the posterior optic, centrally located. And as you can see here, many lenses have these yak pits from the dust scene. You can see the calcium deposits here, the alizarin red staining. And here's a scanning electron microscopy, which revealed crested granular morphology. And here's the energy dispersive x-ray spectroscopy, which analyzes the elements present. So here's the graph, which it produced. And as we expected to see peaks with silicone, oxygen, and carbon, which is consistent with the lens material itself. We also had some salt deposit contaminants. And as you can see, peaks with calcium and phosphorus, which confirm the presence of hydroxyapatite, which is a known makeup of asteroid bodies. So these 16 lenses, which we're reporting to you today, represents eight different IOL designs with five different manufacturers made of five different silicone materials. We're able to determine the difference between these silicone materials using a refractive index, with different refractive indexes representing a different type of silicone material. As you can see, the names are highlighted and color-coded. Those in yellow have the same refractive index as those in white, representing different types of silicone. And it is significant that we see this in different types of silicone, because initially, all these dystopic calcifications occurred in the star plate silicone. And people originally believed that as they changed the silicone material that they no longer have problems with this dystopic calcification. But as a mammalist, Warner Lab later reported one case in a three-piece design. As you can see here, the refractive index of 1.46 differs from that of the star plate of 1.413. So this is significant, showed that it does indeed occur in different silicone materials. And this is also a particularly interesting case, and it happened with a patient with bilateral acerid halosis. And in the contralateral eye, they had a hydrophobic acrylic lens, which was not calcified. So our study now reports this phenomenon in additional silicone lenses. As I mentioned, even with the most modern silicone lenses with the square optic, which leads us to believe that this pacification in silicone lenses in eyes of acerid halosis is more widespread than initially thought and not just limited to that specific type of silicone material. So again, we did look at 111 cases of dystopic calcification of hydrophilic acrylic lenses looking for acerid halosis. And we did not find any note of acerid halosis in any of their records. So it appears that dystopic calcification secondary to acerid halosis is restricted to silicone lenses. So in conclusion, including this current series, there are currently 22 cases of calcification of silicone lenses that are this time published. And talking to Dr. Liliana Warner, she does report she's actually received more lenses since this has been published. Involving eight different designs manufactured from different silicone materials described in literature. The presence of acerid halosis was confirmed in 86% of these 22 cases. And this phenomenon does appear to be restricted to silicone lenses and it's unclear why the number of cases is relatively small, given the large number of silicone IOLs that I'm sure are out there in eyes of acerid halosis. Part of that might be due to the lack of recognition of the correlation not being reported. So that we may see an increase here in the future. But implementation of silicone lenses in the eyes of acerid halosis may be reconsidered in the future. And I'd just like to give a special thanks to Dr. Manlis and Dr. Warner who have been my mentors on this project and throughout medical school and have really made it possible for me to pursue a career in ophthalmology. Questions? Yeah, Jeff. No, so it was 12 of the 16 had, correct me if I'm wrong, Liliana, but the dusting was actually somewhat, did show some improvement here where the hydrophilic acrylic lenses, when they were calcified, didn't show any improvement. So, yeah, as the posterior capsule was removed, we then saw in those that were removed rapid re-accumulation within the next year, which led to their experimentation. You know, to be honest, that's, I'm unsure on that. Dr. Warner, do you have anything to add to that? Hydroxyaptide doesn't have any charge to it, it's completely neutral.