 Good morning everyone. Let's go ahead and get started. It's a few minutes after 8. We're going to start with Dr. Sean Kaluci. He's one of our path and research fellows and he attended medical school at Baylor. Good morning everybody. Can you hear me? I'd like to present some research that I was involved with during my last year as a medical student at Baylor and it's carried over into my time here at Moran. It's a multi-focal intraocular lens exchange. It's a case series of retrospective chart review. My mentors were doctors Doug Koch, Bose-Hammel and Mitch Weikert, a one-time cornea fellow here at Moran. I have no financial disclosures and Dr. Weikert has involvement with Alcon and AMO. So this was a chart review of 45 eyes of 32 patients who wanted their multi-focal lenses removed. All four types of lenses were involved. The Restore, Resume, Array and Technus lenses and they were removed between July 2005 and March of 2010 at Baylor. Multi-focal IOLs were first introduced in the 1980s and they went through various incarnations in the following two decades with the goal being to allow cataract patients to see at distance and at near at the same time without needing additional reading correction. They depend on the brain's inherent attitude for multi-focality and the different models of lenses have different refractive or refractive properties to put two images on the retina at the same time. So this is the Restore lens by Alcon. It's a hydrophobic acrylic one-piece with a near add of four diopters at the center. And there are concentric, appetized rings that surround it, appetized meaning a gradual tapering of the diffractive steps with the goal to create a blended transition from intermediate to distance vision at the periphery. In the middle is the Resume lens by AMO. It came out in 2005. The center has a near add of 3.5 diopters and there are five alternating rings of near and distance refractive power. It's a three-piece silicone lens and this is just a revision of the 1997 Array lens also by AMO. And then here on the right is the silicone three-piece Technus lens. It's the most recent and gained approval in the U.S. in 2009. It has a four diopter at the center and it had been available in Europe for several years prior. So there are many studies out there that conclude that multi-focal IOLs are advantageous for providing superior near vision without correction, without glasses when compared to monofocal IOLs. Many studies also say that you get increased spectacle independence with the multi-focal IOLs, comparable or increased patient satisfaction and they don't affect distance visual acuity either with correction or without correction. But adverse effects are also well established. Decreased quality of vision, glare, halos and dissatisfaction with multi-focal IOLs have been reported in many subsets of patients in many studies. And the decreased contrast sensitivity and the perception of optical phenomena results from the division of light energy between the distance and the near focal points. This has resulted in a trend that's been well documented by my bosses, doctors, mammals and warner, in their yearly surveys of the ASCRS surgeons. Every time a lens is taken out for any reason from an eye, a surgeon can fill out a survey and send it to our lab. In the first year of the survey dislocation was the number one reason for removing the foldable IOL. And this is still the number one reason but now glare and optical aberrations have supplanted the other reasons as the number two reason for taking out a foldable IOL. And there's been a concomitant increase in multi-focal IOL removal since that time. So with that in mind we wanted to look at a group of patients, 32 patients who wanted these multi-focal IOLs removed and gather the preoperative subjective and objective information, surgical information and postoperative information on these patients. Who were they, what were their complaints and how was their vision before and after IOL exchange. Information was gathered from the chart, visual acuity was converted to log mark to allow us to perform t-tests. Post-exchange visual acuity was taken at least six months after IOL exchange. In the patients that had additional treatments after IOL exchange we waited three months at least after their most recent treatment. Many patients were from out of town and phone calls were made to their primary ophthalmologist if they had left town immediately after IOL exchange. A survey was also mailed directly to the patients, 22 of the 32 patients responded and we wanted to find out what were their expectations for the multi-focal IOL, how the IOL fell short of their expectations, what kind of discussions and counseling that they had received from their private ophthalmologists who gave them the multi-focal, what kind of hobbies and occupations were adversely affected by the symptoms and their quality of vision before and after, and if there was a trend in their personality type, if more type A's or type B's wanted the multi-focals removed. Before IOL exchange the patients averaged 65 years old, they ranged from 47 to 78. There were 27 females outnumbering males, there were 5 males and the majority were restore lenses, 31 eyes, but there were also 7 array lenses, 4 resume lenses and 3 technus lenses. Of the 45 eyes that got multi-focals, 42 were a cataract extraction but 3 were actually refractive lens exchanges and these multi-focals have been put in by private ophthalmologists in Texas, Arkansas, Louisiana and one case in Mexico. 17 patients with bilateral multi-focals got the same implant in both eyes and one patient received a restore lens in one eye, 2.5 years after a monofocal in the other eye. According to the survey, 41% of patients decided they wanted a multi-focal because they expected perfect, spectacle free vision at distance and near. Another 36% wanted acceptable spectacle free vision at distance and near, while the remaining 23% of patients would have been okay with using spectacles on a certain occasion. A majority of patients felt that their physician did not discuss with them the possibility that there would be blurring fuzziness as Dr. Manlis calls it, Vaseline vision with the multi-focal lens, but at least more than half did feel that they were warned of glare and halos. Patients were subsequently referred to Baylor for IOL exchange at an average of 10 months after they had received a multi-focal, but one patient came as soon as one month after and one patient waited as long as 60 months after. Of note, about a third of the patients presented within fewer than 12 months. There were no systemic diseases that could affect the lens, the lens capsular cortical visual processing, but 10 patients did have remarkable ocular histories that could affect visual acuity with or without a multi-focal, including glaucoma, fuchs dystrophy, AMD and vitro macular traction. 15 patients attempted treatments to try to improve their visual acuity after they had had the multi-focal. Patients with PCO got YAC capsulatomies, three patients got corneal transplants, two patients had Lasik, there was one laser iridoplasty for glaucoma, and there was medical management for blepharitis and punctae epitheliopathy. Chief complaints from the chart, the most common chief complaints by far were poor visual acuity, blurriness, fuzziness, and optical phenomena like glare and halos. There was quite a bit of overlap, many patients complained to both, and complaints were homogenous among the different subsets of patients, whether or not they had ocular history, PCO, YAG, or donesis. All four types of multi-focal IOL elicited complaints of poor visual acuity, and all four types elicited complaints of glare and halos. A majority of patients felt that they experienced significant blurring at distance, intermediate, and or near, and in the survey we defined the word significant as impairment of most or all activities. And another 72% of patients felt that they experienced significant impairment due to halos and glare around lights. It was essentially a three-way tie for the most compelling reason for these patients wanting their multi-focal lenses removed. A poor distance vision, poor near vision, and glare halos. And in a follow-up question, six patients noted that night driving was specifically impaired as a result of the glare and halos around lights. Many hobbies patients felt were infected by the poor quality and vision. The most common was reading, but also sewing and computer work came up, as well as painting, photography, golf, hunting, fishing, cooking, gardening, and tweezing eyebrows. One patient noted in particular that the glare from the metal tweezers made it very difficult for her to tweeze her eyebrows. 57% of patients called themselves Type A, or very detail-oriented, and another 24% called themselves somewhere in between, while only 19% said that they were not compulsive about details. I thought the occupations were also very telling. These patients consistently tended to be well-educated, skilled, and specialized. There were two real estate agents, a symphony musician, a jeweler, an interior designer, a business developer, photographer, funeral planner, salesperson, housewife, and 11 retirees, including a secretary and artist, a business owner, gift shop owner, electrical engineer, economics professor, teacher, insurance manager, airline pilot, and salesperson. Uncorrected distance visual acuity before IOL exchange with their multi-focal was extremely variable. It averaged around 2040 across the IOL types, but the orange bars represent standard deviation, and so it approached 2070 in the restore lens at times, and even 2100 in the resume lens. Best corrected visual acuity was a better and a little bit less variable. It was averaged around 2030, and of note, 17Is were correctable to 2020 with the multi-focal IOL, but these patients all mentioned Glaren Halos and their chief complaint for wanting IOL removed. Uncorrected near acuity before IOL exchange was extremely variable. It averaged around 2040 or J3, and there was a wide distribution of uncorrected near acuities from J1 plus all the way up to J10. Best corrected was much better with the multi-focal IOL. Patients could be corrected generally to J1 or 2025. This is the surgery itself to take out the multi-focal. This is a patient with an intact capsular bag. The haptics of a restore lens are being loosened from their fixations in the capsular bag. Then the lens is bisected and removed with forceps from a 3mm wound, and then an injectable foldable monofocal hydrophobic acrylic is put in the capsular bag and centered suturless. 31 eyes had intact capsular bags and could receive their monofocal replacement in the bag, but when the bag had been yagged, surgery was more complicated. Ten eyes needed the sulcus, three eyes needed the anterior chamber, and one eye had their replacement lens sutured to the iris. A variety of anterior and posterior chamber models were used. Four eyes needed additional intraoperative procedures, including limb blur relaxing incisions for stigmatism, capsular tension rings, anterior vitrectomy, and posterior, pars plan vitrectomy for some vitreous prolapse. After IOL exchange, additional treatments were needed, including yag for PCO. At times it was left over PCO from the previous IOL, or it was new PCO, PRK, and more relaxing incisions for stigmatism. One patient had a pressure spike post-op, was treated with alpha-gan, and that resolved. No patients had CME post-op, and one patient had a retinal detachment, 16 months post-op that required a pars plan vitrectomy. She had axial length of 24.68, which was bigger in terms of the patients in our study, but it wasn't huge. Uncorrected visual acuity, we added the red bars to represent after IOL exchange. There was somewhat improvement, but it was still extremely variable in all lenses. Best corrected was more consistently improved across the lenses, particularly in their restore and their resume groups. Of note, though, three eyes did lose at least one snail in line of best corrected visual acuity, but the other 42 either remained the same or improved. Best corrected near acuity also consistently improved, particularly in the restore group. And this is a busy slide, but I just wanted to point out the P values, that uncorrected distance acuity did not improve with statistical significance after IOL exchange, but best corrected distance and best corrected near did. The subset of patients with donices before IOL exchange almost reached statistical significant improvement, but five of seven eyes did achieve at least one snail in line of improvement. According to the survey, an overwhelming majority of patients were pleased with IOL exchange. They felt that their symptoms improved. 14% were displeased with IOL exchange, but the majority were pleased, or extremely pleased. So in conclusion, I think patients with and without ocular comorbidities who receive multifocal IOLs with cataract surgery may complain of poor visual acuity or optical phenomena such as halos and glare. And these complaints may not resolve with the adcapsilotomy treatment of ocular comorbidities, including invasive treatments like coronal transplants, or refractive fine-tuning like Lasik or spectacles. When the complaints are intrinsic to the multifocal IOL, surgical lens exchange is the only definitive treatment, although it is a relast resort, and it's helpful to not rush to yag the patient because then that would make the IOL exchange that much more complicated. It's a technically challenging procedure. It may require intraoperative, betreptomy, or follow-up treatments. In this particular group of patients, uncorrected near acuity and distant acuity were both very variable with the multifocal IOLs. Distant acuity did not approve significantly after IOL exchange, but best corrected acuities did improve after IOL exchange. Most patients were alleviated of their complaints. So I think the bottom line is that not all patients will be satisfied with the multifocal IOL. Half of our studies had very high expectations of perfect spectacle-free vision at both distance and near. And while it's true that in some studies as many as 84% of patients have achieved spectacle independence, it's probably better as Dr. Mifflin says to undersell and maybe offer a discussion that reflects some studies that say only a third of the patients will achieve complete spectacle independence. So with that in mind, I think our study adds to the 2040 literature that say that 2040 uncorrected distance vision is a common and expectable outcome with the multifocal IOL. 65% of the eyes in our study saw 2040 at distance, while only 25% saw 2025 or better. So putting my English major to use, if I were counseling patients, I would tell them that a multifocal IOL provides the ability to manage the majority of one's daily and social activities with more spectacle-free function than the multifocal IOL. And the ability to enjoy a combination of uncorrected distance and near acuities in the area of 2020. I would also watch out for patients with an occupation that require optimal contrast sensitivity, like the jeweler in our study or the symphony musician or the artist, any former myope that's accustomed to perfect near vision before Presbyopia or a self-described perfectionist who has high standards. For some patients 2040 could be just fine without glasses they could get by with a near vision of J3, but for other patients this isn't good enough and they would need glasses anyway. And if they need glasses with the multifocal then that kind of depletes the purpose of getting the multifocal, and then all of a sudden they're left with the intrinsic trade-offs, the glitter and the halos, the poor contrast sensitivity, and they could be left wishing that they had their vision before they'd receive the multifocal, particularly if this was a clear lens exchange or an early cataract. So finally I would like to just offer suggestion if I were seeing patients in a cataract clinic one day, if a certain patient walked into my office what would I give them? This is my opinion and not necessarily the opinion of the other authors in this study. So this is the lady from the Devil Wears Prada. She's a fashion designer. She's keep reading the newspaper, the fine print, keeping up with the current events in the magazine, fashion articles. She does the designs, the materials, the fabrics, details, details, details. So I would consider her a less ideal multifocal candidate. This is a realtor. She's driving patients to properties at night. She's checking her blackberry, checking her email, typing up property listings, typing up contracts for the properties. A lot of computer work. I would call her a less ideal multifocal IOL candidate. This is a fitness trainer. Let's say 8 a.m. she wakes up and she goes swimming, then she teaches a 10 a.m. step class, then she gets lunch at the cafe, then a 2 p.m. step class, then a 3 p.m. Pilates class and a 4 p.m. personal training session, then goes home, has dinner with the kids. There's nothing about her lifestyle that requires perfect immaculate vision at all times. So she could be a more ideal multifocal candidate. This is an extreme example that's loosely based on somebody that I know personally, my friend's dad, who absolutely loves his restore lens. He's retired. He's at a guitar store on a Wednesday afternoon. There are really only two shirts you can wear to convey that you're laid back. A Hawaiian shirt and a leopard print shirt, and he's actually wearing both at the same time. So he might be a more ideal multifocal candidate as well. These are my references. Thank you all very much. Dr. Mamelis. And I think, I don't know this for sure, but at the private ophthalmologists, they may have been yagged with as little as 1 plus PCO, while the patients had very severe symptoms. You know, they felt blinded by the oncoming lights and the glare and the halos. And if that was attributed to 1 plus PCO, it's probably important to weigh the physical findings with the severity of the complaint. Dr. Ambadi. That's based on the patients in our study that tended to see 2040 without correction. That's correct. That's correct. We don't know the mean of everybody. I did. Okay. Ten of the 45 had comorbidities like those. And those tended to have worse vision with the multifocal. Ten months on average, but it ranged from one month to 60 months. Dr. Mamelis. I agree. Thank you. Thank you. That was an excellent talk. It's obviously a very important topic.