make a note that Marlene most recently noted in the talk that in her in her experience, um, she has she always starts with suppressants following implantation of an Ahmed Shin, and she claimed that this has in her experience, never result in a hypertensive phase. The second point is for Dr Omar and Dr Ramesh that Ramesh you mentioned that the iris, if it's attached to the graft, there is a risk that that graph will fail later on. So it's going to end up removing the Irish. I think there's an indication, perhaps, uh, to do a combined, uh, corneal transplant with I o l and Iris prosthesis. In those cases, your comments, uh, you know, it's This is a pretty neat technology that's out there. And I think the past experience, especially coming into Brazil and some of their countries, has been disastrous. Uh, with you know, the way they try to implant this and the cause of syndrome and quantity, compositions, etcetera. Uh, so I was I was thinking the same thing, whether long term, uh, studies are going to justify this kind of an implant other than, uh, those with with an earlier and stuff like that right now, in terms of your cornea transplants were diaries. Is that remember the rim that is left behind the whole stream. It's always okay. So they don't have problems for for which I have to address but placing an artificial iris and take on the risk of an artificial itis. So I don't believe it is indicated. But one interesting thing. Uh um a that you showed is this, um why, If you're going to put this in the p k p i with all this irregular astigmatism, something that Aymara gruel shown in a catatonic I is to make a small pupil tiny training pupil to overcome the refractor weather. So I was wondering, as you were implanting this, my mind was thinking maybe if you make this pupil so tiny that the patient will have a pinhole effect and that may benefit without even the contact lens on top of it, which is always a problem, you know, the results are great, except these patients don't see well, it's just I mean, more than 50 60% of patients we end up having this problem. So with P k p. And so I I do believe that a lot more research needs to be done in the way the technology is being used. But, uh, your experience, I'm a thank you Dr L. A. So, uh, as far as the pinhole people who placed the that was described by Dr Dr Aggarwal, I've seen the videos. And, uh, to be honest, I don't, uh so for for the patient that I just, uh, showed the video for I tried. Like when I did his original PTP about a year ago with with the track to me and to capture cataract extraction. The lens was prolapsed in the A C and I tried to repair the iris, even open sky. I didn't even, like, try to do it through a person thesis wound, but I was completely over the Irish and like it was very fibrosis. I couldn't get it like to come down. And my plan originally for that patient, When when I did his surgery last year was to do that Capello plasticky and to do like an Irish future. I well, after I do the propeller plastic. But the Irish was just, like, completely stuck. I didn't I was not able to move it going back to your question about the pinhole people of plastic. I'm I haven't done any cases of that before, but to be honest, I think there would be a great limitation of visual field after you do that. I know. Yeah, you would have just like a very like, uh, like, you would neutralize all the effects of, like, the stigmatism, everything. And you would have just, like, a small beam of light go to the phobia. But But what about the visual field of those patients? I I don't know. Uh, any of the videos that I've seen for Dr Aggarwal? I've never seen him talk about that. Uh, he mentioned that the results are good, but I don't know if that's, uh, like, the other side of the picture. I would say, you know, we as glaucoma, uh, medical doctors. We especially trained in Boston. We had long experience with tiny pinpoint peoples that have been reduced by pilot Karpin, 4% pilot carpeting and, uh, possibly night, and used to be the mainstay of, uh, the practice in Macedonia for a number of years. And they seem to be doing pretty okay. I mean, I remember, a lot of these patients used to be pretty. All right. Now, when you do a vision field tests on those patients, obviously the peripheral rim is constricted. But you're whatever you swapping here for me. And if I'm gonna get 2030 uncorrected vision, straight ahead voices completely blurred vision with the big pupil. I would like to take the 2030 straight ahead vision with the restricted vision field any day compared with the con. Competitions are wearing this contact lens losing the contact lens and the surface issues, et cetera. You know, if I want to be the patient, that's what I would think. I have not done any myself. I was just thinking, When you're putting it out artificial implant in that situation, why not do it? Because it's a releasable thing. You know, you can always open it up. Later on, I got to call questions here in the chat from Dr. Everyone is for Dr Ahmed. If you can, uh, answer briefly. Uh, is there a risk of, uh, sort of fake Ebola scare topic with the artificial iris? Absolutely. Yeah, of course. Uh, like, uh, so in in if, like, directly damaging the cornea during the surgery. That's that's one thing. But on the long run, I think that the virus was approved. Uh, two years ago, it's been tried in the FDA study for a longer time, but, uh, on the long term, uh, I think the results of the study, uh, did not show, uh, like, uh, progressive loss of the NBC ourselves. But I'm what I'm What I mentioned before is is like, if there is some damage of the cornea during the insertion, uh, then that that would be expected. Of course. Uh, JJ Grey talk. Is there a difference in the rate of retinal detachment or secondary Iowa calls whether you take an interior versus a posterior approach. Um, from the data that I gathered? No. Um, but the case that I presented briefly the case report that I showed from my fellowship, my first. A curious case. It was a case that a patient had a dislocated, uh, one piece. I Oh, well, we expanded it and we put in an acrylic lens, and two weeks later, he had an r d. And this is a patient, though that had previous two or three rd surgeries. before getting to us. So we place the Creoles all developed on R D and knowing that there's this issue with the calcifications, Uh, that has always been, um, uh, thought that is due to the gas intraocular gas. We placed oil in the eye, still developed calcification of the lens, and so I guess it's totally possible. But that's why I mentioned that if there's if you think there's maybe a risk for an R D in the future or need for victory to me that, you know you have to really think before putting inaccurate is because of the risk of calcification. Because if it cal certifies, the only way to resolve it is really to remove the lens. And it's not a good situation. Doctor says he wants to know if you have a preference for secondary lens placement, one method or another. Can I make a comment on this? You know, over the years, I've tried almost all of the techniques that you've described, uh, to me. Simplicity is the key to a successful patient outcome, and I phoned Iris future lenses or the best way to go around, you know, pseudo exfoliation with the capsule with three single piece in the bag. They're floating around with three para synthesis. I'm able to secure it in a bag. Half take to the iris. Perfectly fine patients. I mean, remember a lot of our patients in glaucoma, their old people, and that works in our favor. They're not going to go jogging, which now having having said that here in Florida and finding these 80 year olds do all kinds of things that 40 year olds doing the rest of the world. But having said that, the future lenses to the islands has in my hands the least number of complications and equally good success rate in terms of their vision. And that's my go to technique for all kinds of these implants. So I don't Doctor Ella, thank you for being here Number one, and but I don't disagree with you. I mean, I think I restructured IOS are great, and if I if I had time, I wanted 2% actually two videos of Irish calls, but I I think it was more more relevant to present the newer techniques, but I think that if you can get away with just rescuing and I oh Well, that may be, as you mentioned, the simplest solution. So if you have a three piece, I'll well, in a patient with good IRS tissue? No, maybe no. History of pigment dispersion of glaucoma. Um, you know that maybe the way to go right? Even in kids, sometimes that may be the way to go. Now, um, you know, uh, we you know, we have to you know, I think it's it's individualized individualizing cases is probably the best situation, but, um, to answer Jasmine's question, um, if I can rescue and oil, I would do it. If I have to exchange or plays a new lens, then I would probably go with a four point fixation with the materials and Gortex future. That would be my my first go to go to lens before the centralist, um, lenses. Just because there's more data on the accruals lenses as more data comes back from the Yamani land says the future less lenses that I think will have a different discussion. But driven by evidence, the Acuras probably has more data backing that lens. Um, John, uh, go ahead, don't remem Yeah, I was I was going to comment on JJ's uh, like, uh, what he mentioned about the I did some secondary IOS. I did the accuracy when I was in fellowship. The thing with that is that it's, uh, a little bit with the gore Tex I don't do, uh, truckers, of course, like for that attract to me like you do. And you mentioned that all the cases for secondary oils need to be done by retina. For that attracted me, uh, which would take some of that away from the anterior segment surgeons. But But anyway, I would, uh, like I've done like the I told you, the Aquarius. And, uh, with that, like with the cortex, there is a lot of like structures, like a lot of spaghetti on the surface of the, uh, the technique that I used currently is the honorable technique, which is the glued iol doing like to scare flaps, talking the hectic in the interest interest lateral tunnels and then use, uh, to see glue to to like to to seal the haptics. I've been trying to do some Yamani cases, but every time like something happens that especially with the sea to Lucia the lens, it's not available. So So I've been, uh, one thing you mentioned that you can do the Yemeni with them in 60. But my understanding is that especially that I'm not again not doing it with the truckers. I'm trying to do it with the tsk needles that the hectic of the M N 60 would not fit in the in the, uh, tsk needle. That's why I've been I haven't done any Armani cases yet, but I'm really eager to try. Yeah, I'm happy to do that, too. Uh, as you wrap things up here, I just wanted to thank everyone for our guest speaker, Dr Ayala, for coming out virtually again. Some spectacular talks. I'd like to thank all the for this. Uh, thank you for being here. This I'll turn over to doctor last for some closing comments. Thank you, everyone. Thank you again for all the great talks and we hold off our first virtual weapon. Or I think it offers other opportunities for extending our knowledge really to the world here. And so this was Thank you for all the attendees for staying for the entire symposium. I want again. Mention if you can complete your evaluations. Um, and it's on your handout to let links to that and also to claim your CMI that's also present. And, uh, and I just Maybe, Doug, if you have any other comments, that would be great. Thank you, John. I just want to congratulate again. Everybody on wonderful talks, wonderfully organized. Ramesh, thank you for for joining us. Um, you had a first class airline ticket, Uh, and you're commuting parking today. We're excited or easy. Uh, so, you know, again, thank you all to our attendees, You know, thank you so much for sharing us sharing your time with us today. I hope that you found it to be educational and easy to access. Uh, we're planning on continuing this format in this series, and so I hope that you'll join us in the future. Uh, and so I'll keep my remarks short, given that it's lunchtime. John. Thank you all for you. Thanks. Safe
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