 My name is Shragan Daliwal, one of the cornea fellows here. And today I'll be just presenting a quick review on the new TORQ ICL. So just to start off with a little bit of background on what intraocular refractive surgery is. Previously, refractive surgery was essentially synonymous with corneal refractive surgery, but that obviously was limited by limitations in the cornea. Patients' thickness of their cornea, high refractive error, or corneal curvature kind of limited their options in this case. And a lot of people were not candidates for corneal refractive surgery. But advancements in intraocular refractive surgery, specifically FAKIC intraocular lens implantation, has allowed for a larger number of patients to have corrections in their refractive error. So there's many different kinds of FAKIC intraocular lenses. You can see that there's angle-supported lenses, iris-supported lenses. We'll specifically be talking about sulcus-supported lenses, so the Vizian ICLs, the Vizientoric ICL. The implantable columnar lens, the ICL, is essentially a FAKIC intraocular lens that's implanted between the iris and the lens, and it allows us to correct high refractive error without disrupting the eye's natural refractive state too much. And in that picture there, you can see a light beam showing the cornea, you can see the lens, and then you can see the implant there bolted over the lens. And many studies have been performed on the predictability, the stability, and the safety of these ICLs. They've been performed in worldwide for several years, but it was only in 2005 that the first Toric ICL was approved in the United States. And that too, it was only for myopia, up to 20 diopters of myopia. It was not recommended for patients who had more than 2.5 diopters of astigmatism. So patients with any moderate amount of astigmatism could not undergo ICL implantation. But in September of 2018, we recently had the Toric ICL FDA approved. This allowed for the treatment of both myopia and astigmatism. So once again, up to 20 diopters of myopia, but also allowed for correction of up to four diopters of astigmatism. And in that picture, you can see a Toric ICL that's been implanted. It looks quite a bit just like your average ICL, but you'll notice that there's two kind of diamond hatch marks that that yellow line goes through. And that signifies where the axis of alignment for this Toric ICL is. And we'll go over that a little bit more, a few slides on. The contraindications for implantation of this ICL are very much the same as the non-Toric ICL. You obviously want a patient who has an adequate anterior chamber depth. You want a patient who is open on gonio and has a minimum endothelial cell count. And of course you want to make sure they're refractively stable. So patients who are younger or pregnant or nursing are not great candidates here. So the Visian Toric ICL is the one that's been specifically FDA approved in the United States. Just to give you some stats on it, it's a single piece Toric ICL. It has an optical zone that varies in diameter from 4.65 to 5.5 millimeters. And it's available in half diopter increments of spherical and cylindrical power. So you can address a lot of different types of myopic stigmatism here. And that's just a picture of the Toric ICL there. You can get a better view of those alignment marks there, which you're going to use to kind of align with your 180 degree axis in your patient. So there was an FDA clinical trial that was performed on the Toric ICL. And this is some stats to kind of reassure us. They examined 210 eyes. And they noted that 97% of these eyes at one year post-op achieved the best corrected vision that was 2020. And nearly three quarters of patients, a little bit more, achieved a post-op uncorrected visual acuity that was better than their best corrected visual acuity pre-operatively. So that's pretty remarkable. Surgical implantation. I think this is the most important take-home point in this quick little update on Toric ICLs. You have to know that the implantation is very similar to non-Toric ICLs. Those little hash marks that are on the Toric indicate the degree, the axis of alignment. And typically you're going to align it just with the 180 degree axis of the patient. You might have a small adjustment that you need to make and the Visium Company states that it's not gonna be any more than 22 degrees. More typically it's going to be, just as we showed in this picture, about five degrees, if that. So it's not like a Toric intraocular lens where you're rotating it significantly to match the axis of the stigmatism in the patient. That has already been ground into the ICL. So another question is, people will say, how do I know where to align it? So when you order the Toric ICL, there's an online Toric ICL calculator that will print off calculations essentially, which will tell you where to align it and they will send you a Toric ICL that's specially made for your patient. And that's a little diagram there, which I assume is how it typically looks like. So just lastly, just to touch briefly on complications. The complications of a Toric ICL are very similar to the non-Toric ICL because implantation is very much the same. The only new thing is off-axis rotation, which would be something to consider. But that was very rarely reported in the FDA clinical trial. Only one patient underwent IOL repositioning. So it seems like it's not a major issue, but it's something to be aware of if you're offering this to your patients. So that's about it. It was just a quick little touch on this new Toric ICL. Any questions? So are we even planning some of these? Mark, are there some? I think Dr. Zogg's done the first one here. Ed, you did a great hit, like two and a half diapters of silk. I just have a comment. Most of us use intraocular cataract surgery, Toric IOLs. The ICL, just the way it fits, it is actually pretty stuck in that space. And so that's why we don't see the rotation of these. And you know, if it's sized appropriately, we've done some exchanges where, certainly there was kind of a pendulum swing. The original FDA data suggested a larger or higher vault to prevent cataracts. And then there was kind of this swing back and practice of putting in a smaller vault. And so we've done some exchanges on ICLs that are too small for the eye. And it's very interesting when you go in and just irrigate saline or anesthetic in there, it will move and it will shift. And so it's very, very important to not put in too small of an ICL. So it's just the same old bugaboo with this lens and sizing is everything. So vaulted enough that it doesn't touch the lens or cause a cataract, but vaulted where you get glaucoma, pigment dispersion issues, virus abnormalities. If you put in too vaulted of an ICL, you can actually get a kind of a pupillary pseudo dilation, which can be problematic. But what do we tell people to five-year incidents of cataract as these days? What's the latest? You know, Dr. Moschvarn, you might remember the U.S. meeting where I had a discussion with Dr. Sione. You know, in our practice, we've been putting an ICL since at low volume, but probably 5%, I would say. And most of those are not visually significant. 8% was the original, but I think it's gotten better than that. But a visually significant cataract is really, really rare with these. You'll see little touch marks where, I mean, sometimes it's just impossible to not touch the lens as the IOL unfolds, but it tends to be peripheral. Little anterior cortical cataract, which doesn't progress. And even in patients who get cataracts, they seem to progress very slowly. I mean, we've had numerous patients. They tend to be people over 40, which really it's not, quote, approved or recommended for over 40, but we put them in up to about 50, I would say, on average. So the older patients are the ones who tend to get the progressive cataracts. We do have to worry about, like, blood force trauma. Like, it's not really my first day at Moran here. I saw a patient who was, like, deployed to the Middle East, came back, had a blast injury, and had bilateral cataracts from his ICLs, just hitting his lens. But what do you have to build those cataracts in? Yeah, that's hard to do. It's harder to blame than ICL, if I don't know. Moran, what are the ICLs there? Have you guys had to rotate any of your TORC ICLs at all? I think, personally, the real question is, what's the vault that's too shallow? Because with the TORC, it can rotate. And I think you kind of have to be careful to get it above 300 or so. If it's 150, that's a really small vault. That's what puts it at risk for rotation. But, you know, I agree with the data that we really don't see it a lot of rotation, but I have seen it. Like, it definitely does happen. But I think sizing is the one issue that is probably the main issue right now with ICLs. It's just getting the right size, because essentially, we're guessing. You know, we think we can measure pretty well with ultrasound, but those measurements don't necessarily equate to what the vault will be. So nobody, you know, you hear so many different formulas, and that's because there's no single one formula that's the best. Does that make sense? Yeah, and Dr. Waite, for those of you don't know him, but in practicing in Utah County, but yeah, so the company would recommend at least a 500 micron vault, and they don't, you know, they'll see even a, you know, a one millimeter vault is okay. So certainly, the manufacturer is promoting a higher vault, partly for that reason. Because it was a vaulting, it means it's sitting where it's supposed to, and then it's likely to rotate. I think Dr. Mamal is that a comment? What he said. Okay. Yeah.