 So we'll go ahead and get started at 8 o'clock. Obviously, Dr. Crandall needs less of an introduction than myself, but we're very lucky to have Dr. Crandall with us. His list of accomplishments and awards is longer than we need to go over. I will just say from a resident perspective, I know that all the current residents and residents I've spoke to are so extraordinarily grateful for the opportunity to work with him. And I know that the current residents are very grateful for the faculty who let us go up and attend his course as well during January. So thank you so much for the faculty who supported us in going to that as well. Without further ado, Dr. Crandall. Well, today I thought I'd do it a little bit differently than we normally do, just for a couple of reasons. So you're very entitled to my bowl of set work. OK. I'm hoping for a, I was trying to get a very interesting patient complaint. We videoed it last week, but I wanted to teach. She wrote me a five page letter of introduction, which I think ran. That's always scary when you get a five page one. Well, Nick has seen the letter, but it's an interesting thing because she was 100% cured by the surgery that we did. And she was like 10 months of complete misery from positive dysphotopias. So today I'm going to present a couple of things about some of the new stuff that I think everybody here is pretty much aware of femtoseconds. But I'm going to present this in two sections. The first section is going to be so that Randy and everybody else can argue, which I think is valid. And I think it's a really important point because I think everybody is missing the boat on what femtosecond is ultimately going to be. And we'll see if we'll argue a little bit about that. So today is going to be more of a fun discussion type of grand rounds than a this is what we're doing type of grand round. So let's talk a little bit. So the first thing we'll do is we'll talk a little bit about femtosecond. And the next thing I'm going to do is talk to Liana as it comes in. And if she doesn't come, I still have the slides anyway. And I think you saw those slides, didn't you, Nick? OK, good. So let's talk a little bit about femtoseconds. Just so everybody knows, I do consult for Alcon. And because I'm talking about the Lens X, I do that. I also consult for AMO and also for B&L and also for DORC, which is a Dutch alfamic company in the refractive medium. Here's one huge controversy, of course. It's a $450,000 machine. Fortunately, you can use the wheel and deal and get it for around $200,000. And if you further wheel and deal, you can do studies for the company and reduce it. And if you further wheel and deal, you can buy lenses from them and end up paying almost nothing for the machine. There are lots of tricks to get the machine into your clinic if you're big enough to do it. But one thing you do have to understand is that reimbursement is a humongous issue. The Medicare does not care how you do a cataract. And that can include such things as intracap, extracap, FACO, PEMPTO, any way you want to do the cataract. They're going to give you X amount of dollars. And you're going to get your reimbursement. You're going to take home or your ASSIN is going to take home is based on that. And almost all carriers follow Medicare's guidelines. Randy and I started. The average fee for an intracap was $2,500. Yeah, that was in the late 70s. So it'd be about $6,000 now. And the ASSIN that your facility could charge about $950, as I recall, for the intraocular lens, which they bought for $500, which the company made for $1 back then. Is that correct? OK, so as things have gotten, all the changes have occurred. And also, the other thing that was interesting in that era, everybody was hospitalized. So you could actually bill also for your hospital visits. When we started, it was probably 10 days in the hospital. By the time we ended the career, it was five days in the hospital. The next year, it was two days, three days, one day, 20 minutes, whatever we do now. So there's been a humongous change. And all of that has kind of ratcheted down that the amount of money one can bill for the surgery. So it is really important to understand that when you introduce any new technology into your system, it can be incredibly expensive for the team. So we also need to look at what I think are some of the potentials at the front of second. Then we'll show a couple things. We'll talk about what's being talked about now, which is a little bit of BS. But also, there's some real potential value for the femto second in real cataracts, not just in. So if we look at the pros, there's no question. You can get there's incredible development. As everybody knows, one of the facilities I work at has had the femto for two years. We're in our sixth software upgrade in our third two years. And all the companies are rapidly approaching each other. One of the interesting issues is because all these machines are similar in nature to the femto second shoes for lasty type of shoes. Initially, we didn't even have specularly that would work in these older eyes. Patients with bogey, congenitiva, you couldn't dock. It was really difficult to do a lot of these. Huge, with the lens, would you get much less with the newer soft fit that they have, but also zero instrumentation. But docking still remains an issue. And the other question was of pressures. They're working on that pretty much now. Most of the dockings are under 35 millimeters. But in the original, Alcons was probably at the, I'd say, 40 range. And if you've docked somebody 40, 50 for any length of time, then it certainly could be an issue for somebody that has an endangered optic nerve. Can you let Paul in or no? Okay, he's not ready for primetime. Well, I was gonna still show the case anyway. So, I was hoping to show you her complaints, but I'll let Nick, he saw him, sorry. I'm not lying to you. So, the issue with the traditional, of course, would be incisions made with a blade. And incidentally, no ephemtosecond makes an incision that's as good as a diamond incision or as good as the one we make now, none of them. That won't be the case in the future, I hope. But now, frequently, I'll abort the, I'll do the LRIs, because I think they are real, but I often abort the regular incision. And you still need ultrasonic, not all the time, but certainly less than before. And then we won't talk about the limitations of traditional. We all know those. Any kind of, you have excess phakotermin, you can get burns, endothelial cell loss. The LRIs are really surgeon dependent. Some are tremendously good. Some are variable. And then, of course, the variable of the capyrexus. And we all know the importance of the capyrexes. It is incredibly important for the outcome of most of surgery. And certainly, if you're looking at a surgery, cataract surgery as a refractive piece, which is becoming more and more important than what we do, then we want to be able to do that. And if we look at this, some of the studies have been done, there's a lot of work that has to be done on the back end if you're really looking at it from a refractive standpoint. Now there's lots of issues with that right now because even though our formula are getting better and better, and since the regression formulas were getting better even with LASIK and all those things, nevertheless, there's still a fair amount of leeway that can occur in an individual patient. And if we can get rid of that, it would be helpful. The other big problem other than one company now, we still can't get lenses that are less than a half diopter. So you're always gonna have some swing with what you want it to be. And so here is what's being touted as the big thing for femtosecond. Increasing your precision, reducing your variability, and achieving expected outcome results. I'm not arguing with that. I'm gonna let Randy argue about that in just a minute. Because, but I wanna talk about that today. I'm gonna talk about the real things that we can do. This is some of the work that Bob and I have done looking at SIA, which is Surgery of the Perfumian Deuce to Stigmatism, doing one eye versus the other eye, looking at the types of incision, looking at the arcuate incisions. These are with OCTs. And the beauty of the machine is undoubtedly in two areas. Actually, I think three areas. One is the Rexus, two is the LRIs. And three is the ability to ultimately reduce the ultrasound power. Not getting rid of it, but possibly reduce it. But it also induces some other interesting problems. One of them is, is everybody here probably half, maybe half have seen a femtosecond? How many have actually seen it? Done. Okay. So this will be good for the neuro-automologists. And every, no, I'm supposed to, Vakoma guys might not have any. So at any rate, this is a classic Rexus. Now as everybody knows, I, we now measure, we put a, I put a marker on the cornea. I don't dilate the patient. I have the patient look at a red fixation light. So I know exactly where their optical center is. I put my 5.75 millimeter thing on. And I can do a pretty good Rexus. And I think I can approach this, but whether or not I can't get it that perfect, no matter how hard I try. There's no question. So we're looking at all these things. And I think, I'm gonna talk a little bit about the bottom two in a minute. So if we look at the reproducibility, this is, there's no question. I don't think there's any question about the reproducibility of the Rexus. Again, all these are, these, this is Bob did himself, or not Bob, Zaggy did in, remind me, is he, where is he, Armenia, Poland? Hungary, Budapest. He's in Budapest. And he probably has done more, I think probably more femto than almost anybody. He's had a machine probably for five years. So I think he has three machines. I think now that somebody that's approaching him is Burkhardt Dick in Germany. And Burkhardt has a, I think he has probably has three machines, but he usually uses the catalyst unit for most of his work. And we'll talk about why there's advantages of the different systems. So this is, this is the kind of stuff that, that the refractive guys are really looking at is the ability to optimize lens constant. You've got Warren Hill who's working on these things and they're really trying to ratchet it down so you can get very, very controlled air distributions on our machines. And we're comparing them to what we do manually, doing right eye and left eye. And what it turns out to be is that a good surgeon gets pretty damn good results. And it may be a hair better in terms of the refractive predictability because of the potential for better ELP prediction, effective lens position. And with that I'm gonna stop for a second let Randy argue about why that may be BS at this point. Most of what we're seeing I think in the literature and on the floor is a little BS, but I wanna let Randy comment about that. So well, the argument is that if from that you have better prediction of effective lens position. So you understand that as we do our formula and we try to figure out what our results are, one area that is a good guess, where that lens actually is set. Through the back, it's so well, we essentially use the normal ground to try to guess but there's still part of the reason why it will have no matter what you do a certain number of patients, even a half a doctor. So the hypothesis have been that you can make a perfect half set of records. So the one who's done the most work on that is actually Bob Sione. This is the one that he can look at the most. And more and more people have taken that as a given. So what I can say is, and really the one that should talk about it, because I think you were there for the talk, is a very good group out of Vienna, which does good work. And then the Viennese group do excellent work to all of them, all of them who's done it. They said, okay, let's just test that hypothesis. And they're famous for doing that. They took a series of patients with a manual pass of arresters and they took all different kinds of variations to see if what they were quite on or not would predict the effect of non-sufficiency. And the answer they came to, they did not. And it's the first person who really looked at that in a very aggressive fashion. And so now you've got two different schools who've fought out there, but this has kind of thrown a bit of an afternoon, which I thought was almost a train going forward. So the answer will be, we're gonna get better prediction in the associate and faculty sector. And I think the answer's up in the air. I'm not sure if we're talking about it wrong. No, I agree, but I don't. That to me, from what I've reviewed and seen them, that was very provocative study, going through new literature, and knowing that group is gonna be very, very rigorous. Yeah, it was there. Yeah, it was there. Yeah, no. It was in the medical box after you did that. Correct. And if you look at the numbers that come out of most of the studies in the US, and I think that's one of my points is evaluating the literature. You have to look at numbers and you also really have to look at that first slide that I gave you. That is, do I have a bias because I'm a, not necessarily me, but whoever it is has a bias for whatever they're talking about. So I had, that would, Nick would maybe comment a little bit on that because it's really critical when you, as you guys evaluate the literature on that, I mean, talk a little bit about bias in the literature. But sometimes it's difficult to tell whether there's bias in them or not. And I don't think there's bias in it that they're presenting false data. Bias in that you're taking these very small difference and touting it as a very big difference. And that's what I'm seeing a lot of literature here saying that, oh yes, this is much more accurate as it's a little bit more accurate. Yeah, and that's the point I wanted to bring out. And then if we look at variability, again, look at the, if you look at the two graphs, again, smaller numbers, these are numbers we had last year, 0.25 diopters, we don't have a lens that makes, well, we do have one, I think they have soft tech HD, it has quarter diopters, but that's also an interesting lens too. One of the cases I am gonna show a little bit of is a patient with that. So if we look at the predictability of the lens of ELP in the study that we did, it was small variability, but again, it depends on how you present the data. I mean, you look at the slides, I sure as hell can't read that slide. I don't know about you guys, but I mean, somebody can look at it and tell you exactly what it means, I mean, I know what it means because we wrote it. But if I look at that, if I look at that in a paper, I ain't gonna spend two hours looking at that little data and try to figure it out. So that's sort of my point in talking about it. Now this is real. I don't think there's any question about this part of it. There is a significant or can be a small in the soft die to a large reduction in the CDE and everybody, for those that don't know, what they're talking about there is the cumulative delivered energy. Each machine measures it differently. And that's always a problem when you try to compare different machines. Each company has their own way of telling you how much energy you just used. You can ultimately go back to, you can go back as far as the beginning programs, but they, and you can get it the same thing on every machine, but it's not easy to do if you're just punching the buttons in the oar. That's simple. Yeah. Absolutely. And I did a bunch of things. When you take a, you know, we had a pretty four plus thing just breaks apart into small pieces. I think this one, but the next step from that is going to be harder. Is that difference in seeing you make a difference in out there? Correct. That's the hardest. I think right now that this is, this is one thing we can say yes. And the other, the question is with good, with good discolastics, with good techniques, being at the plane of the iris rather than up in the thing, is any of this going to truly make a difference? Don't know, but this part is real. And then the other part, let me just, for those that haven't seen, I'll just do a quick, just show you what it looks like. This is an eye that's been docked. This is with an older, the older software. It's gonna take about 12 to 14 seconds to do the rexis, which is now down to five to six seconds in this machine. This is docking, measuring the thickness of the corny up there, or the capsule rexis up there. That's the capsule. And I'm gonna stop this for just a second because this is critical. If you look at that, the gates on the right side, didn't stop it, let's try that. If you look at the gates on the right side, one of the things that's different when you do a femtosecond is you are, you're aiming the laser 300 microns above the capsule, 300 microns into the capsule. So if your docking is not perfect, in other words, if you have a little tilt in your dock and some of the machines have a good way of doing that, some of them a less better way, some of them are active when looking at the OCT, but the docking is critical because if you are, if the eye is tilted at all, you can either totally miss the rexis on one side and you're cutting the hell out of it on the other side. And if it's not docked correctly, it'll cut anything it eats on the way, which can be the iris. And this is sort of critical. The other part that you don't realize when you start doing these is you're cutting off all of the handles for your INA. So what used to be the simplest part of the procedure, irrigation aspiration becomes much more tedious and often you have to go to buy manual, it takes a lot, that's a new training phase. Did you find that case, Randy? So if we look at this, this is the machines not doing the capsule rexis and you can see the capsule being formed right up here. Okay, the capsule rexis is being done and after the capsule rexis, you're gonna see a divide pattern. This is an older pattern now. They all have cubes, they all have different ways of doing that. So that's breaking up the cataract and then we'll take the patient to the OR and complete the case after it's done the LRIs and I'll let that run through. This is again, last year's stuff, it's about five times quicker now. In this case, we're 300, the gates are now 200 in the machine. So again, so does everybody understand what the machine's doing now? The machine is breaking up the corneal incision. Now it's the corneal incision, there's the second hand incision, which I still think is better with the diamond and then here's the case, we just open those, you pull out the rexis, which in this case, we were about 98% perfect, and now it's pretty close to 100% perfect in terms of being able to produce it. This is some of the new software, you'll see it's a much quicker procedure. This was six months ago, so this is one, or four months ago, so this is one iteration behind, but now it's down to, takes about a minute and a half to two minutes to do the entire procedure. So there isn't really slowing down too much in the OR, but and by the way, you can change the position of that rexis, which I think is critical for what I wanna discuss a little bit now. So that's the new software, and this is- So the sound needs to be able to take our own. I understand when it's making its corneal incision, some people are saying they're too corneal. Correct, that's correct. Yeah, and that's true with all of them. The reason is, again, one of the issues is this area, because if your patient has any panacea, any blood vessels in the surface of the cornea, it can't cut through those, so it aborts it or it cuts partially. So a lot of times I'll just abort those, and if anybody has a teridium, forget it, pretty much, it's even docking with a teridium, it's kinda hard, so we can usually do people with pinguecula, but that's not even, sometimes that's not given with the soft fits, you can now do that, or with the liquid interface, you can now do that. But now, this is what I wanna talk about, I'm gonna show a couple cases, because I think this, the real, for me, the value of the femtosecond is not gonna be in refractive, because I'll let Randy and the cornea guys take care of those guys, it's gonna be in the top cases. It's gonna be in pseudo-exfoliation, it's gonna be in loose zonules, and this is a case, I'll just show you the, let's get to the action, the fact is we've just said, the beauty of it is you can be centered, direct this and put it anywhere you want it. So what I'm gonna love it is when we can actually take it in the OR with my kids, with, so you see it's being centered, you see the tilts a little bit interesting there. Okay, so there's the, there's this, this is a congenital Marfan syndrome, it's not, the patient's about 12 years old, or 14 years old I think, so, you can see, that's the problem with- You wanna capture the rectus in that? It's hard, yeah. It's just like night and day. So what I do, what I normally do when I'm doing a rectus like that, now is I do a bimanual. So I start in a mineral, I hold the lens so it can't move, I make a puncture with my right hand, I start the rectus, I put in hooks, then I do a little bit more, put in hooks, do a little bit more, rotate the lens down, and I, you know, I can do them, but this would save me the most critical step in doing that. So, and then the other time, I think it's a value, is in, the management of these cases. So here's a case from two years ago, and everybody's had this, you open it up, and you have an Argentinian flag, blue, white, blue, that's where that term comes from. So, what we can do with those is the rectus. I don't care if you're doing anything else, you get a rectus perfect and a white cataract, that most of those quite frankly, are relatively a piece of cake once you get the rectus done. And so you can do it, bingo, you're done, you can go to the OR, in the case. Yeah, boom. But I can do it now in five seconds, four to five seconds, so it, you know, you're gonna get a little pressure, but it does complete, I've done about 15 of them now, so it just makes, makes the thing easier. So I'm gonna escape out of that, and I wanna show one other situation I'm gonna bring up, because we're also, by the way, we're getting into a new generation of Faco machines now. All three, all actually four companies including Dutch Optomic are coming out with different things, and I want, so I wanna just show two quick videos. So let's look at this one. Okay, so this is a case I did. So I've done the, this guy was sent down to have a ice stand done with his, surgeon up in Idaho started the case and realized that he couldn't do, he was gonna do a Faco and ice stand, and the lens was fairly mobile as in zero zonules, zero. So he decided he couldn't do it, he sent him down. So we ended up doing real glaucoma surgery rather than MIGs, because MIGs will get you three, four points which may be very important, I'm not arguing about that, we'll talk about that sometime. But this is a beautiful case, so I did the, you see here I've made no incisions, I've done nothing else, I didn't do any, I didn't do any breaking up of the cataract because in the other eye when I did it, the lens moved, it's shaped. So I didn't know where, I had to abort that because it could have popped through the capsule, I didn't know what the capsule was gonna do. So this is the case, so I just might be interested to see where I think there's some value in the femtosecond. Now watch the lens as I go across here. And you'll see that the first part I'm gonna have a little trouble because it's fairly shallow. And watch the lens go back and do its correct position. So there are zero zonules in this guy's eye too. So I'm just pulling off the, making sure I still, in a case like this I still assume that there are attachments and I'm able to remove the rest of the cataract or the rexus. And so now all I have to do is, the regular cataract is in this case. It would have been very, well, it was loose all the way around. So, and it was not, it was a fairly hard cataract as well. So all I end up doing here, so this shows the value of the femto. This is the new sovereign unit. So I was gonna bring, I'm not sovereign, excuse me, centurion. So each of the companies are now coming out with their next generation. We've had the same technology for 11 years now. And so what all they're doing now is they're working on their pump systems, they're working on their more predictability and on reducing their, their things. So you see here, I put MST hooks in, but I, you can, one of the things about the, nice things about this and I want everybody to look at one thing. Look up in the right side. Everybody freaks when they first see this. Says intraocular pressure of 60. That's a hell of a lot of pressure, isn't it? Does anybody know what the bottle height of 105 is? About 80. So all of us think we were, so when your bottle height goes from zero to 80, well, that's why a lot of times you'll see a chamber of deep end. You'll see, you'll get some high fluid move. If there's loose on you'll go behind or you get fluid misdirection syndromes. So a lot of times when I'm doing a difficult case, I drop the bottle of 40 and then raise it up after I get in so they don't get that. And then I reduce it as I'm coming out so we don't get the sudden surge. But don't kid yourselves. That pressure is pretty high. Randy, you did studies on that. So that's when you have your steady pressure you're not doing in the set. Right. You've got a couple of things going on. Obviously our wounds leak a bit. The advantage of these newer systems that are coming in play, this will be the next round since you're... Yeah, yeah, so I already had it and I know that AMO is coming out with... Pressure? Yeah. You're gonna have to see if you do that in association with some, you know, in-stage glaucoma because I think you've got high pressures before as it was leaking around you. Okay. So we're gonna be beginning the evaluations of these new machines, yeah. It's based on what setting you have. No, no, no, no, no. It measures the pressure with sensors. It's in the chamber. Yeah. Oh, well it's on the machine, on the handpiece of the machine. It's actually measuring the line. Yeah. And so what it does is... Right. Line pressure pressure. Yeah. And so what it does, it doesn't have a bottle anymore. It doesn't have a bottle. The bottle is inside a casing similar to what the retina machines are. Pressure. It's pressurized. It's changing. Now I just wanna quickly talk about, people had this for a long time. Yeah. Yeah. Essentially this is the retinal unit all together with the infinity. Yeah. That is the actual pressure in the eye. Exactly. We've always had, when we do our surgeries, you know, if you walk in the OR, Judith, you'll see, you've seen the bottle hanging down, right? That, what we've controlled is bottle height. So if you look at all the other videos, you'll see something that says 105, 110. If you're Dick McCool, 150 up that by head, if you see different machines that gives you the bottle height, and then we know from studies that have been done in laboratories, I think Randy did one of the early studies, that correlates to a pressure of about, if it's 100, it's about a pressure of 90 in the eye. So if you're just infusing the eye for whatever reason, that's a big pressure. And it may be why some people with optic nerves that are very tentative have issues. For example, if somebody has had a non-eschemic aortic problem in one eye, then I do everything in the other eye to protect the patient against that. So I do a low flow, really slow system. Because they are at risk for the second eye having the same thing. And I think this may be a reason. You've got high fluctuations, 90 to zero, that kind of thing. And the other thing that everybody does, I assume they know, but maybe don't know, is that that bottle height is from the certain level of the machine. So a tall guy who's sitting up here, his bottle height or hers is lower than Darcy's or Leah's. Because they're down here, and so their bottle height, the machine says 90, there it's 90, for somebody else it's up here. So Brad and I have a different bottle height. We assume the same height. There are different pressure in the eye. So there's all these variables that we never talk about. Although I bitch and moan about them, but I don't get much. Okay. So the next thing I want to talk about is positive dysphotopsia. So I have in the last, and I thought this was appropriate time. So in the last week, which I hope doesn't continue, I've done seven IOL exchanges. Three for positive dysphotopsia, four for negative. And I'm gonna show you one of the positives now. Just a quick one. I won't, okay. That is a patient three and a half years out of surgery. Three and a half years out of surgery, who is complaining of mild positive dysphotopsia. She couldn't see very much. And I don't know if you can tell right now, but this is a restore, I think it was a restore. So she paid $6,000 to have this lens put in. And we'll just go to the, so all I did was bring it out, but I did want to show a little bit of the bringing out part. If I can get to that, that might be the second part. Sorry about that, you guys. I wanted to show that, but, because getting these lenses out of the bag is not the easiest thing in the world to do. So I think this is it. And I just want to show one thing. Yeah, this is her. So one of the things you have, if the surgeon's done a good job, and this surgeon has because they use the Pempto-Second Laser. So getting into those is not the easiest thing. One thing I love is using a viscocanolostomy cannula because that cannula is a 32 gauge. I can get underneath it very easily. So we have those upstairs and it's much, much easier to get into these. In this case, what I'm going to use is a, the other thing that's nice is the blunt retro-bulbar needle because it's blunt and you can get into it. I'll just show you that part. And then I'm going to show you. So that's that. So we finally get in and what you have to do is you have to hydrate a sect, or viscota sect, excuse me, all the way around. Now the trick with any of these lenses is not this part. This is all easy. What you have to know is you have to see, you see this, let me move this out of the way. If you look at this right here, that's, that is so socked in with the lens and it isn't, that isn't the problem. It's where I'm shooting right now because what happens in these, the haptic goes out and there's a little ball out there. And that little ball is incredibly hard to get. I don't, it is a pain. But that, you know what? I got to tell you, the sock tech I did last week was harder to get out than this. That was the lady I was going to present today. I'm going to present her some other time because she was, she's the one with the. It was, I couldn't, it was the hardest of the six lenses. They wouldn't come out. So let me just. So we need the, that's always been an argument. Oh, I, well I use, I use viscote to protect the cornea and then I use it cohesive because I think they're easier to, to get them around. To get, but I stepped out the capsule. So in this case, I think I'm using viscote or disco vis. And I don't, I'm going to let Nick talk about this. I'm just going to, I'm going to, we don't need to watch the rest of this. I'll show this. Anybody is available to get that out. But one of the things is, do that pull to the center of the, of the, everybody wants to get their lens out by pulling this way. What you have to do is you have to use two instruments and you counterclockwise so that it pops out of its thing. And I've got a set of videos of those. Anybody wants to see those. We don't have enough time this morning. But I want Nick to talk about this. Because this is, this is this lady and this is the lens. No, I was hoping she was here. She did, she did these pictures. Yeah. Absolutely give her credit. And, but I mean, these are some significant scratches on the surface. You can imagine what that's going to do to the optics of multiple, multiple implants. Yeah. And so you think these are fold scratches? No, no, they can't be reddened. I think that, I think they gouged it when they did it. There's no, it was on the anterior surface. Not the, this is the anterior surface. Yeah. I don't know, maybe when they were losed across it. And there you can see the, the multifocal aspect of it. But look, I mean, look at the, the number of scratches that are on this one. Look at this next one. Yes, it could be. Yeah, it could be the injector. It could be how they, what instrument they grabbed it with, that happens all the time. So I'm going to ask, they were centering it. I think they were centering it. It's pretty straight. Okay. They're, they're slightly posterior to the injector. Yeah, so you look, if you look at, even on, look at this. So that's, I think there's, this is the haptic of this IOL. Okay. So now I'm going to ask the residents, you're in the OR day one and you see that because it was there. That didn't, that didn't happen the day afterwards. And the surgeon told him it came from the company that way. Oh yeah. Oh, I've got even, I've got even nice photographs for, we're doing a nice report on this for JCRS. But, so my question is, what do you do? You take it out. Absolutely. You don't pretend that you can't see those scratches. And that's exactly what they did. And three years later, they said it was perfect. They said it was perfect. Yes. Oh yeah. Yeah, she was, Yeah, so those, that is, this is true positive dysphotopsia. And that, the other case I was going to show is more interesting because of the complaints of the lady. She's my lady and I'll tell you a little story about her. She was, she came from, was referred down from Oregon. Rich Hoffman referred her because he didn't want to do the case. Turns out that she's a PhD in biostatistics. So I got a five page thing about how her outlight, she was an outlier and she told me what statistics she used to prove that this shouldn't have happened to her. But the point was, it was near, so yeah, she was, she was, she was a two tail test, 17 different. No, no, she wasn't multi, no, she wasn't a multifocal, believe it or not. She was just a, and I wanted, this is what I wanted to do here. It was a pure positive dysphotopsia that people told her she was crazy. It was the soft tech HD lens. And she went to nine different people before she was told to either come to you, me, or mask it. And I'll bet you in the recovery room she was in tears. She was crying, she was so happy. Yeah, she was cured. I just got a letter from her yesterday and I want to show you what she, I'm sorry to take up so much time but I think this is critical. Well, yeah, she's, here's a lady that's been, you know, 19, literally nine, they are actually good. That, I get that every Tuesday, by the way, if anybody's interested, that was yesterday, I know. Maybe I can't show it to you. But she had, she had drawn 20 pictures of what she sees. And they were classic positive dysphotopsia. So Randy, just talk a little quick minute about the difference between the two and why they, everybody thought she was a crank because it was perfect surgery. Couldn't pull it out. There could be very layers that come off things. One of the more interesting ones is the back scatter pattern. So take the back lens, front of the lens, and then it goes back and it goes in the reverse direction as the constant brain doesn't correct for it. So every light they see, there is an oscillation going in the opposite direction of their mind. So they can see the lights are a velocity signal. It's a sub-freshold, and most of us won't see it. But those who see it often will accentuate it just by worrying about it. They're separating on it. That's right, isn't it? Well, you get better, you can drive them literally crazy by having them suicide, if they're associated with that. Negative dysphotopsia, and there's several others. Another common one, I think the end of the one right there, is also negative has to do with a shadow or a loss of vision. And there's a big debate about it. You have to be causing that, and you've got two big names that are fighting each other in regards to whether or not it has any negative. The shadow, the brain or sort of the darkness and the area can be extremely disturbing, thresholds, but for those who see it, and that persists. The patients, should you God take them seriously? I always ask them to give it six months because it's a panic statement. I don't see it. If they get to literally patients. Everybody see it? There it is. There it is. Okay, sorry. So here's her pictures that she drew and brought, this was part of what she brought to every doctor. That's one of them. That's one set of pictures. She's sending me six more. Yes, they do. She was sent to neurology. They often get confused when they're having more. So that's the... The difference is that it's consistent with the light pattern once they've got it. So Randy, look at that. I know their head there. Look at that right one. I mean, she literally was, when she came into the room, she had the, she had visors on. And so I can write her letter. I'll just show you the letter she sent to me just so you can see. So given, yeah. Wow, you wouldn't get it. You wouldn't, yeah. It breaks my heart to think of patients living with dysphotopsia. So take your patients, listen to your patients. You can learn a lot from them. Some of them are a little bit odd, but certainly if she keeps coming back or anybody does and says, look, this is a problem. Take it for real. And also, so positive dysphotopsia is a real phenomenon. Just wanted to think about that. Krista, are you here? So Krista has really one of the seminal papers that just came out last spring. Looking at a super normal cohort at least two years out from surgery. And the amazing thing is, is that these are patients who have no, no other disease. The fact is, it's tending. So we're ignoring it. And patients like this get shunned. Well, she gets shunned because she's a PhD in biostatistics. So nobody did want to operate on that. But she was, she was ecstatic. And she's, remains ecstatic. And here? Yeah. I just expanded the lens and put in a, don't put in an a-spheric lens, basically. So I put in a, I put in a AQ-5010 silicone, which unfortunately they've taken away from us. So we have to order them especially. So we need to, we need to deal with that a little bit. So that's, you know, any, any, any lens. Yeah. Yeah. So in a case like this, you wouldn't don't extend. The other thing is, don't think if you, if they have a positive dysphotopsia from an alkan lens or an AMO lens, explain it for the opposite. That doesn't work either. It's, because the issue is, is the, is the optics of those lenses, the a-spheric lenses. Maybe sometime we could have somebody from your lab explain the differences. I mean, everybody sort of knows what those are, but do they really? Well, someone has to explain them to me first. Okay. Mm-hmm. Mm-hmm. Yeah. Yeah. Second. I haven't seen a lens grow a haptic yet. Okay. dry eyes and we're looking for people with significant dry eyes, you know, so please be an elevator at all over, call Barbara Hart at, you know, from studying that, let her know we should do all the questions on the phone because our IRB here, if you slow this down about a little more time. We have a lot of dry eyes. We have a lot of dry eyes. We've got dry eyes. The pan is like a blood-derived product that's genetically made. It's not got actual human blood product in it, but, you know, a lot of people are thinking serum and spinning it down and using it for drought is the same idea. But it's a genetically engineered serum product. It's got some growth factors and other things in it. Inflammatory work is pretty impressive. So we have two more questions. If it's in the center, you have to get rid of it. But if you see that, the first thing you do is you either take the common McPherson that they use to grab it and look for defect and get the plunger. We had one last week. We had a splint for that reason, and the plunger had a nick in it. So, you know, when they're in a rush in the OR, sometimes they don't clean it well. So they'll have viscoelastic that's on it that can sometimes scratch it, and then the plungers can become damaged. Last question. Okay. So kind of a weird grand rounds, but I thought it'd be kind of fun to discuss these things. All right. Are you kidding me? We got thousands. They lost.