So we've got Dr. Coder here with us today and he's from Germany and I remember how well everything is punctual So I'm gonna I'm gonna do what I remember waiting at a train. It was supposed to leave at 1714 00 and the conductor sitting there looking at his clock with his hand up like this true story Thomas And he goes around and he says okay. It is now 715 Formal introduction now starts So it's a pleasure to have Thomas. He's been a very long-term friend and A most unusual individual because he's clearly had his feet both in Europe as well as in the United States So Thomas has MD PhD in regards to everything you need in regards to Germany But rather than to be settled with that after doing his residency He decided that he wanted to experience the United States And so he went to Baylor and worked with Doug Pope and some of the most productive two years They've ever seen out of that group and he just came on like a storm involved in many many studies and other things and Had an incredible experience And so with that he went back into academic ophthalmology in Germany and a lot of you Don't know the German system, but there are very very few department chair positions that are open and It's just a handful of people that are allowed to get that opportunity to move on to be a chair Now it's not all over the same. There are many of them They're in the old previous East Germany and the previous East Germany the feeling is is that The opportunities aren't nearly as much as not there is important so he was a fortunate and Probably at the time about the only non-retinal person you almost had to be readily trained to be a chair still is the case And he was selected as the chair at Frankfurt has been working to build that program Clearly one of the main program because Frankfurt is the financial center of Germany and with brexit it could easily be the Financial center of all of Europe of what's ongoing and He's also very very innovative very research oriented all that he's done He's associate editor of the the journal cat and refractive surgery does an amazing job there Recently previous president of the German ophthalmology society. He's now president of triple IC Which brought him here. They had a meeting an aspen here just last week. So he was here for that Senior person and ESCRS is not an area that you can't see he's had important presence Now the reason why the work he does in Europe is so important is Europe has got a different system And they're able to see lenses and they're able to see unique technology and they're able to work with it in ways We can't do and we don't have access to this and he has clearly been an International leader in helping understand and do research on all this new technology And so it's an honor to have my good friend a professor Conan here with that and I now introducing we'll get started Tomas the floor is yours. Thank you Really, thank you. It's a pleasure to be here actually to be back here and yes We just talked with a Liana about it. It was actually 2011. I was here time Here my financial disclosures. I learned this all over the world. You have to a first second slide as financial disclosures We work with a lot of companies Of course, they are companies from Germany from Europe But also from the United States and the development goes all around the world Two words on my university yesterday. We drove to through Salt Lake and I Asked at the end of the day. I went to a little pub had one German beer there went to bed And I asked the driver how many students you have in Salt Lake and they said 30 35,000 is that the right number now Frankfurt is with 48,000 the third biggest university town in Germany You're involved going from Goethe 1749 to 1832 you see all what he has accomplished biologist polymath theoretical physicist and he gave this university the name so it's a more than hundred years old university This is the main building of the university and the story behind this is it was a headquarters where Hitler produced a lot of his stuff for actually fighting When the second World War was over This was the headquarter of the United States and in this in the mains in the main building Just when you enter this on the left side There's still a room called the Eisenhower room because Eisenhower actually came there and they made the division for Germany in four parts You remember maybe that now when the United States and the troops went back It was like you think the 80s in the 90s They basically donated the whole area to the Frankfurt town and then the town of Frankfurt was so clever not to Basically divide it because this is land. It's in the center of Frankfurt. We talked about it's very you know We are a small country compared to your country and and the the property is so expensive now I just told Randy yesterday if you have bought a building in Germany or an area for one million euros You're most likely can sell it now ten years ago. You sell it for two to three million because it's so crowded now the the Frankfurt city actually denoted this to the university and therefore we have one of the biggest Kampai in Europe now we are a little bit outside of that that is the main building on Universitätsklinikum. That's a German name. We have all the clinics there like you have here the big Kampai On internal medicine surgery and on the right side. This is the old building. It's it's a very traditional one. It's The the department of Tomergy has seen five chairs. I'm the fifth chair of this. Everybody is there for 20 years approximately. That's a story Okay, so my topic is today a topic. I really like and that is because there's so much going on in accommodation and in Presbyopia and We know that worldwide many many people are actually Well Suffering from this problem and more will to come now This is a paper from the journal of cataract and refractive surgery and I put this together surgical correction for Presbyopia We have used and worldwide a lot of options on the corner But we know that the the the real the natural place is the lens and I would like to summarize in my talk Not the options there we worked on a little bit on eczema Profiles and presbyopia treated in the cornea But now at the moment the most the area is lens technology and there are a lot of lenses And I would love to go a little bit through this more vision in the United States is used Monofocal I were corrected for zero point seven five to minus one point two five In the US is even two diopters But but all this I think depends on the pre-operative evaluation Because you have to see if one eyes for distance the other one as for near if the patient tolerates this The success rate is between I would say 80% of patients This was an older paper with contact lenses one refractive surgery here from the United States in 2001 And there's a recent paper from Graham Barrett school I was invited to give a main name lecture in Australia last year and We talked with Graham about it is a big big friend of modern vision and here's a paper small group 26 patients I just go through this a little bit quicker. They achieved 92% achieve Yeager for or better Good stereopsis in their cases. No patient required in drug lens exchange or other refractive procedures and the outcome here was spectacle independence 88% Of course if you have this you don't have to struggle with any type of Optical disturbances with all the lenses which I will talk now in the next in the next 20 minutes but What is also true is that not everybody likes monovision if you can test it in refractive procedures You can do it but in calerex is pretty difficult if they have a dense calerex You cannot test for it and some of them losing stereopsis They cannot drive because it's too different not every human being can really use monovision for their advantage So the big area is the type of intraocular lenses and I put this here a monofocal lens in the upper part you see on the right side the Vision the system here how it was on the optical bench in the middle multifocal lenses with Several foci and then the extended depths of focus lenses you have them here as a symphony lens You will have an extended test and I would like to go particular to the two areas of multifocal and extended depths of focus because that's a very interesting Randy pointed this out. I was in the United States did a fellowship here in Baylor But when I was a medical student The German system runs like this you do five years of medical training and the last year the sixth year you actually do Practical year do four months of education and surgery four months in internal medicine and four months of a subject You can choice choose and I choose at this time Minneapolis because we had a connection at bond where I was doing the medical studies I went to Bill Raspel and he was a he was a researcher in the field of calerex My father dr. Father in Germany sent me to this as I'm trying to cook You know the guy who's suturing the iris Proceses and these things I was there for two weeks and then I decided well I cannot see four months in the lab just doing my practical year So I went to the department I went to the Grand Rounds and the the boss of this department This one was Dick Lindstrom and Dick Lindstrom took me on you know We worked there together that was my first experience and actually at this time was just 3m by 4 Interocular lens it was first this is in the 90s 90 90 in this region and then I had a lot of experience You see this here all all types of I was I would like to go through this multi focal lenses And I think the journey is here when I came back to Frankfurt We started on a real FDA trial on the restore lens in 2000 that was a three-piece diffractive Epidyes plus four diopter lens and then we get into a lot of iterations I mean we worked with other companies, but I just took this as an example So I'll come produce all these type of lenses from plus four to plus three two and a half Epidyes Lenses then with filters then touristy, but I can tell you from the point now We don't use bifurcule lenses anymore and the reason is we have other lens And you will have them I think pretty much soon and it's time that you will have that The other the other group is extended depths of focus. I came a little bit later to this So my talk is first of all I talk about the trifocles then I will talk about the eat-off lenses now The trifocal principle is here. You will have in the upper part. That's the Zeiss model Three four guy one for far one for near and in between an intermediate When I first saw the concept that that cannot work because the brain cannot understand this I implanted the first trifocal lenses actually in a physician. He came to me. He heard of this lens It was 2011 This was one of my only donation Randy I got from him I got a little donation for our department when I had encountered the two lenses. He's so happy It's now eight years. He just was recently at Follow-up with it and then there is a quadri focal principle, which most likely will the first one you will get here approval I come to this now the thing is here if you do an MDF curve This is a paper from Gattinelle. He is one of the owners of the patterns of the Trifocal lens you can see that at the intermediate you have this extra dip and When you think about it you say that the brain cannot really work with this But but the thing is actually it works and there are two things which I will point out is first of all If you do a deep focus curve, you can see that the normal deep focus curve Which goes like this every human being has for distance and near and in between he can focus Accommodate the second thing is if you have three four guy then Everybody interferes with each other so the distance with the intermediate the intermediate was a near and the patient cannot really tell what They cannot they can just not say they have three four and I know it so very well because my mom has a trifocal lens in her eyes And I'm talking with her all the time This is the iteration if people from the United States I'm sorry to say this I give this talk very often, but see these are the options we have and they are more to come They are even a seven six and the seven trifocal technology was different intermediate Steps and you see I don't want to go to all of them. I have personal experience This is my one of my first lens start in 2011 was a trifocal lens It's a plate haptic design hydrophilic lens from Zeiss and Zeiss is a German company But it's very strong. Of course in the United States developing. You all know the IOL master the technology We use here variant system for actually placing this man most likely exclusively use this now This is a paper in AJO are published and They were very interested in the paper and this was first of all On this side the outcome shows that if you look at the pre op was pretty much some of them in the myopic rage Hyporopic rage 54 eyes We looked at this afterwards. I have to go to this a little bit further that still patients have halos They have symptoms, but let me talk to this a little bit later if you see you the day focus curve That's actually what makes these lenses so special the patients can really see in distance Near but also intermediate and therefore they like it so much 12% Occasionally near near correction everything else was without glasses for intermediate for distance and then If I go back one slide I the the the questionnaire optical quality Was pretty good in the range of seven to eight on a scale up to ten But patients overall very happy otherwise we would not have come into the opportunity to implant a lot of them Since this I have not Explanted a trifle lens 2011. That's a long time of my own and I will show you how many we have done This is a paper. I did was one of my fellows. We looked also for high myopia We compared it to a group of normal eyes to high biopia and the overall thing it also works in high myopia I cannot go into detail of this papers This is also published in the Journal of Chalerectal Factor Surgery now 3rd of July 2015 has the pleasure to be the first surgeon in the world to implanted the panoptics from Alcon This is the lens here. You can see it. It's a blue filter IOL trifocal technology quadri-focal technology and Sure to say we also put our first data together We published again in the American Journal of Ophthalmology The principle is here that you have a quadri-focal lens and the first book in the first focus actually Transfer to the distance image it and makes it a trifocal lens as well lenses on the right side These are three months follow-up. We were pretty much on target for ametropia. You have to get these lenses on ametropia Here is the thing and again the day focus curve You can see this and the only thing what people see is the halos This is what I tell everybody you will have halos in the beginning, but they Decrease they decrease over time and I have not seen really a patient who really after three to six months Actually cannot it when this lens comes to the market And I think I put here's a comparison of the pen focal trifocal All the public this year this year in journal calerectal infractive or last year and the main difference is just if you look at the Focus curve at 60 centimeters 60 to 50 the pen optics does a little bit better And I think that the computer, you know the the area is usually 60 centimeters rather than 80 centimeters That's that's the main difference beside the materials in this Now this I submitted this article. Yes I think two days or seven days ago to ophthalmology because it's the biggest study prospective multi-center international single arm non-randomized study 167 eyes of the pen optics lens the outcome is here basically that we have to demonstrate the same I have to rush a little bit to this no serious adverse events, but again very good at near intermediate and distance And the acres of provided good visual acuity of at least 2025 and Here's the focus curve from this study very very much the same what we found so I'm I think you will have this I don't know when it will happen, but most likely end of this year beginning of next year something 20 what I've heard is 2020 2020 each second of third quarter So so middle of next year and I can tell you this will change Multifocal technology in the United States because you will see that it will be better than wrist or or the Technist multi-focus lens because these are all bifocal lenses. I Come at the at the end a little bit about what what what a little bit my pearls are Rainer has Produced here something now. Everybody fights a little bit. How should the optical zone size be we just where the the Espen meeting triple I see there's new company from East Europe. They do a little even smaller optical zone So we have to figure this out. What is really the best technology? See here's a new trifocal With different step additions intermediate 1.5 1.75 1.66 2.1 so they're playing around with these intermediate foci and this is just beta is showing that the Also one point of the trifocal lenses. It uses the light better than the bifocal lenses here Is this 92 effective light transmission? That's better than in the bifocal, which is like 84 85 percent Okay, and then even a little bit further which you will have not so so quickly But I show you this it's this add-on technology. It's very interesting because he has a pseudo-faking patient and He came to our department to me and asked for for Presbyopia correcting I was or basically for Spectacle independence and what we have to our availability is now an add-on technology is a second I well You put the trifocal lens on top of a monofocal lens and can make every monofocal system trifocal And I do this here and you can see the trifocality as a add-on lenses has no power Basically a trifocal lens you can even take a plus one or minus one or a little bit of astigmatism So you can correct any refractive error residual refractive error and put this lens in also this has to be worked out But the principle I think is very interesting is that in the solcus. It's a solcus lens You put it in or that's the rainer lens is a solcus lens, but there's a first cue We have two other already three other companies who provides this add-on technology. This is one of the rainer lens published In this year source from Amon, so also it's starting to be not not much Publications at the moment. So my pulse for trifocal lenses is basically I use them when I have really healthy eye So no pathology on the cornea because if you have I think that's true for any multifocal lens If you have irregularities on the cornea or let's say fuchs distro free That's not a good case Macular pathology is not a good case and the patient should have a high demand on vision in all distances and requests Perspective independence if a patient comes that doesn't want to have spectacle in pens I think you just give him a monofocal and say he takes glasses, but I can tell you Over the years now over the last I would say ten years the request from people becomes every day more and more More people come and say we have heard you doing this and successful and you come and so that's very good There are contraindications cornea diseases as I said, you know severe glaucoma retinal diseases That's they have other problems with other words. You give them better monofocal lens now the extended depth of focus I'm ready. We just put together paper with the Norman Clature paper of Extended depths of focus and the interesting thing is there are four types and not everybody knows this. It's a small aperture You can see the IC8. There is a bioanalogic of the Lumina There is a diffractive and the non diffractive at the moment You only have to affect if I was and basically they say J and J say this is not a multifocal lens It's it's a diffractive lens and in the future We know already that at the ESRS or maybe at the beginning of next year Big company icon comes with a non diffractive and that will be also a game game changer I believe because the benefits of these lenses are excellent distance vision improved near intermediate Function we call it functional near vision and I show you this why it is an optical quality in front of depend really on the lens design If you have a non diffractive system, I expect I have not implanted one of them But as they will be less optical disturbances So here's the IC8. This is also an interesting concept because what it you know the camera implant I think that's the ocular focus is approved in the United States, but they have put the same thing into the eye Well, so you fold the eye world you bring it in the in the capsular bag and now we have this principle of small aperture Book a dick has published here paper on this and they also found very good at summarizes Small aperture with some kind of my opus a little bit of mono vision, but also happy patient now It's a beast. It's a little 3.5 millimeter incision So I'm not using it currently for my repressed your patient, but I'm using it at this type When I have a patient for example RK or let's say a patient with Cataconus or highly aberrated cornea. This is fantastic because it blocks all the aberrations and you still have a depth of focus So that's that's a really good advantage for those patients Lumina Accommodate if I were they call it you see this here publication Also an AGO. We have no experience with this. It's a from the Netherlands but we have experience with actually the Mini well, it's a it's a technology from Italy therefore It's so interesting because many company many countries also come with this This is the lens my uncle has an SI because he wanted this extended depth of focus also very happy And we have published on the symphony. I don't have to show you this is a normal case here I think you have seen this all this is a foldable lens Hydrophilic material and I put it here into the folder the outcome is published in a British journal. It's called the eye We published the visual performance and you can see the day focus curve And you see the outcome and with hundred percent patients were spectacular in the pens for distance and intermediate and 71 for near so 30% still needs something and I come to this in a minute The Zeiss Technology they have taken this idea of the trifle lens put it on on that next technology and put Depth the extended depth of focus is called the Lara lens in Europe And we just have published or we just basically put this together and on our way to publish this For for this type of lens So indications for this are basically those patients in my opinion who cannot get a trifle lens And these are patients who maybe Want to have less for optical phenomena But so really not true if I compare a symphony to a pan optics pretty much the same of optical phenomena I think that that the companies here fool us and I usually like to see my own data than I can tell you what's what's really true Optical phenomena compared to monofocal lenses is not really true That's as patients say that Spectic independence for fine intermediate maybe for for intermediate a little bit better than for the with a trifle lens So if somebody really wants just a computer and not really reading then you could argue to go with this lens But I think they said reading glasses Here's a comparison. I was just a couple weeks ago in Italy and from Florence Department Rita Mancucci published this article. They compared the symphony the pan optics and the trifocal Acrylisa and they found that the trifocal have better near visually cute And I can agree on this and they found that either felt better contrast sensitivity I'm pretty critical. I think that this is pretty much the same, but okay, that's published here And you see the photopic Contrast sensitivity data Finally on on this type of they I would like to bring one one type of lens It's called the segmental refractive multifocal eye wells. You can see in the lower part It looks like a bifocal glass. You have an addition Of plus three diopters. Roberto Saliva talked about it. It's we call this the plus three But there's also version of plus 1.5 and it's called the comfort lens And he talked at the Espen meeting that he basically no monofocal lens anymore He has 100 of premium lenses because he gives This lens was a plus 1.5 in every patient because they have no optical phenomena because it's just two parts of the lens no diffraction no Refraction is basically these lenses and we publish also in a jo again this with very good outcome Even better than with the symphony High patient satisfaction 72 with respect to independence The downside of this material is a hydrophilic material There was a big crisis in great britain because they had to explain a lot of these lenses and most likely they come to you That's classification most likely yana has seen a lot of them But I think they have solved this issue. They've solved it over the now and the process is better This is an interesting slide and we also put this was just accepted for publication Again always this difficult curve and you can see in the upper part. It's in Basically, it's the pen optics. It's a acralisa. It's a symphony and it's a segmental and you see in dark blue is a symphony And that demonstrates what happens You need most likely reading glasses if you have a symphony kind of idolph lens You can maybe work a little bit with mono vision But also not so easy But usually the patients require this and we have to tell tell that in the in the beginning It's always better This may be interesting for you. These are 3193 slides as of july My own cases always femto over the time from 2012 to 19 it summarizes the lenses and If I put this together it's 35 monofocal lens and 65 percent Presbyopia correcting ios in this group now it it goes from basically monofocal spheric Toric lens and then it goes to the symphony it goes to lara lisa and panoptic Lisa we have the longest therefore we have the most implication Panoptics we have at the moment just four hundred eight and you also see that there's also a bar with toric So I can tell you if I put hundred lenses of pan optics One third will be toric Because we have to correct a stigmatism. I come to this now It's very difficult to choose these lenses from all this not every patient fits everybody So we do quite a selection and big of talking with all the patients. Maybe we can do this in the discussion couple pearls Preoperative evaluation is very important tomography and ethereal cell can't make if I'm don't do at these lenses when I have not seen this outcome No with OCT endothelial Measurement tomography because you have to exclude irregular stigmatism dry eye is a real big problem Then the post-operative refraction has to be amatropic If you don't have if you cannot achieve amatropia Then you have to do refractive surgery and many surgeons in germany basically do calorects and we talked about it an Intervitory ejection that's all they do and they have no access to eczema surgery And then the patients aren't happy because if a patient is minus one or plus one You have to do something later after three months six months Centration is important therefore. I think that we go in in the direction of more computerized surgery We don't want this tilt of lenses because of smaller caps or larger capserexes So the computerized medicine I think will help us and very important is information. I always tell In comparison to the bifurcate you have intermediate is very good But you still will have optical phenomena if you don't have this then most likely I haven't implanted that lens in your eye And they will decrease over time And we don't explant these lenses and we let the brain work into it But you have to good a good selection criteria couple other purrs Optimization of the surface is important. So any patients draw eye we have to do this I put this together. There's a big scheme here as published also In journal calorect effective 2017 pre-operative optimization of the ocular surface disease before calorects The second thing is and I'm sure you do all this you you have to work on the eye world formula We have basically abandoned srk to all the old formula. I mean that's a third generation There's a very interesting series if you're interested in the journal calorect effective surgery Four editorials on this topic last year. That coke was one of these adi ablyafia Graham Barrett, I think and we looked at the panoptics data We published this also nine for modern formulas and we found that the barrett universe of the hill Rbf the Olsen from danmark and the two t2 formula are the best for us to get ametropia as well So we're working with the new formulas third thing is astigmatic correction if you believe that a Trifocal lens will work with 1.5 astigmatism You will see that the patient is unhappy. So either you have a toric version Or you have to do eczema surgery afterwards or limbo relaxing or something But you have to and this is a nice paper from hiyashi who shows that not only the distance visual acuity goes down When you have astigmatism post also the near visual everything goes down when you have increased amounts of astigmatism So the astigmatism should be below 0.5 Okay, this can rotation of the eye worlds interesting study from Japan from titsura also a good friend of mine. He shows that basically These lenses rotate and and the best time to re-rotate lenses are most likely between 7 and 14 days In the beginning we made that mistake a toric lens Three diopters first day of axis because we dilated the pupil We tried to rotate the lens next day after the first rotation same thing because the lens rotates in the same direction again That's not very good. And so we do this re rotation seven days and a little trick what I do now is since Maybe a year after surgery when I have toric lenses I let these patients really lie down for An hour that don't have to move We close the pupil with myotics so that the lens barely gets into place and let them In comparison to all the monofocal lenses The activities should be down in the first two three days because if they do too much of movement We also know that this trick was the lying down the the highest rotation Occurs in the first hour after surgery It's not the next day. It's the first hour after surgery And then I talked about this effect of manual capsauretis. You want good concentration And I want to skip this only eyes with a severely malformed capsauretis had a highly or slightly deformed Descented eye well and if you have the systems that the trifocal systems Decentred it's not good because they do not perform very well Now finally This is not european style. It's I think it comes from the u.s. But a little bit on this This is the holy grail. We want to look at the accommodative eye words in the future I think that's that's the way where we all want to go in the next and many companies have worked on this I go so this is the one cu from The company in germany accommodative it's a big high 15 years ago 2003 they published this But they showed some accommodation. No accommodation I think happened you and the united states have the bausch and long blends everybody thinks an accommodative eye were We in europe we used it for maybe one or two years and we abandoned it because it just was not working our hands Now it has this discussion. I have europeans call it the lens that only works in the united states That's something like you know, but but you know, there's the accommodation here And this has not really worked and then there were tetra flags I've just put this by comfort lens also haven't worked and the pilot study of focus shift principle in one design haven't worked The synchrony. I think this was a product from j and j or elegant Big beast also big implant, but also was not very successful. So New lens is a new technology But basically what we found and that is a paper from 2011 that so far we have no really accommodative iol Not everybody who reads will accommodate because many of them work this pseudo accommodation and sometimes of astigmatism So and we also have no good studies lack of good study design perspective ring mass Now I think there are two interesting implants which come up. This is power vision I think this is a company which was acquired at least in a shared and by alkan I have no information about this. I've never seen this lens First through shape changing fluid driven So there's a fluid around this lens and it changes the the lens itself And then I work with also with a company called uine. It's a This two-part system. I think I can better show this here It's an interesting concept where basically the kapsu rexes is done um The lens the the outer lens is implanted into the eye I think you have done this studies here as well And then the second lens is put into the kapsu into this lens into the first lens And then you can see as some accumulative process Because we know that the earlier body works. We know that the the zonials still work even after surgery But the problem is that we don't have lenses now. This is an interesting from some Implants they have done. I think in in central america And you can see in blue the the curve now you were familiar with the de focus curve You see in blue the lens gen called the lens gen. It's better than the symphony much better in near distance visual acuity And also there are three points which are intriguing in this first of all It seems that this lens keep very much the effective lens plane the position That means not much of deviation in post-op refraction The second thing is no not much rotation. This is a one month or 33 months Just example And then what is very interesting is this goes over enhanced calirate pristine capsules the capsule Most likely maintains very clear even after 50 months because the whole capsule bag is filled So that's just you know interesting data And i'm really looking forward to this and also these lenses will most likely will have an Opportunity have this base lens and then you can put anything what you want You can put even the trifocal technology or you can put a toric lens anything if it would accommodate Then it's good But it's I think that the second line of this lens technology is actually you have this and other companies also have this So I would like to summarize. I hope I was not too long the presbyal correcting I was my take home message mono vision 80 percent work 80 percent satisfied But I think that there are some problems with this not everybody can tolerate not everybody is spectacle independence You still need reading glasses most of the time So there is a big, you know height now on trifocal lenses And trifocal lenses work if you really have good situation in terms of medical medical Situations like good cornea good retina Basically a healthy eye the eat of lenses we use most of time if patients want to have more Good or better computer distance because I think they're a little bit better And we also use them in irregular corneas We use them post-lasik because they are more forgiving in terms of the refractive outcome And that's therefore this is a good choice as long as we don't have good formulas to give us a trifocal lenses I think trifocal lens post refractor 30 works But not in a minus 8 or minus 10 diopter because the cornea is highly aberrated on a plus 4 Hyperropic patients they only work I think in my opinion in the lower amounts of refractive procedure Maybe hyperopia plus 2 and then myopia up to minus 5 or something But more research needs to be done and then a very exciting field I think is acclimative eye well currently we have really nothing also in europe available But there are new ios to come and of course human beings and researchers work there for a long time We don't know where it will end up, but this is the holy grail because these lenses will have no optical system No optical phenomena and would most likely be the lenses of choice if they would work Thank you So a great lecture and it's amazing that you can have that experience Obviously our big problem is a lot of those smaller companies in europe Will never come to the united states because they're unwilling to spend the amount of money It takes the difficult of getting through fda, which is a whole nother story. Yeah, so here's the tough one I'm gonna ask you a really tough question. You have access to lots of technology Everything else in place knowing about it and having all these patients And I know you're doing about 2,000 surgeries a year. So that's he's a very he's not just talking about it He's a very very busy surgeon Which of the new technology lenses if you needed cataract surgery would you put in your own eye today? Well, this is a question I would Get very often. I know Randy that my cataract surgery comes up in between I would say approximately 20 years and the reason is my both parents have the same they have cataract surgery when we're 75 both, right?  Well, so I have to I don't have to make this But if I would have to make it today Well, then it would be a really tough one and I um I would be still a little bit afraid. I have to say an optical phenomena really would be afraid I hear that the the patients who really want to be Spectacle independence as the the type of patients which really love this is I would say very active people. They go for golfing. They they they still work on the computer They read a little bit. They do everything. There's this perfect lens of trifocal lens I would say if really somebody wants to be spectacular independence The best lens is a trifocal lens. You can argue do panoptics or you do a zias This is a little bit also your preference because the plate haptic design one is three place design But the results are pretty similar pretty similar and both work very well patients are very very happy I have never seen so many happy multi focal patients And since we have the trifocal lens it's really totally game changer. You will see that when it comes here The eat-off lens is at the moment I Personally I would only most likely go with this when we have the non-defractive ones So I wait for next year because archon comes with a new platform like this minival is a good other opportunity And then for the highly aberrated eyes, I think that the ich is a very good opportunity You know because it blocks this light So it would be three categories and most likely I would go for the first one because my eye is highly visual functional. I have 1.6 visual acuity 2015 even now so It's a bit difficult for me, but I know one of our colleagues from Italy right a Mateo Piavella Oh, sure how the trifocal lens does work on the surgery microscope every day He loves it He was just at the meeting and I can remember when he had the lens it was also eight years ago Perfectly doing surgery with it. So it's not a contra indication. Hiroko from from Japan tells me she's expanded eye wells in multi focal area as well in Japan and She has a lot of you know physicians dentists Engineers and and it works also with them. So the the big fear I think is over now You just have to know how to handle the complications and the complications reserve refractive dry eye You don't dislocate What I what I have to say is you have to work on the surgical technique I mean this is much more different. So for the residents you have a capsule rupture In a second eye after trifocal lens. That's a real problem Because the first eye has a trifocal lens the second eye you cannot put this lens and there is no of these lenses currently in the Sarkis we don't have a Sarkis lens available We also talk with the companies there, but it's not very profitable field for them because they Meltzer surgeons only use one out of a thousand So you have to get this lens into the capsule of agony becomes even more difficult if it's a toric version Because a toric version you cannot rotate you have to put it at a special place So then refractive surgery comes into play. You can do corneal surgery. We have great Outcomes now with a with a trans prk with the lasik procedures there isn't smile So we have three options all very good in terms of the outcomes at this moment Um, so that's important to to know this and you have to listen to your patients We if they are not really happy we bring them in all the time we listen to them We don't say that we we understand you we know that is they have so you told this to you But let's wait before and then very often after two months after three months of patient Really suffers even for the trifle cleanse then all of a sudden he says well, I don't understand this But since yesterday everything is much better and that is not new adaptation and it's just happens I also we do cannot really I cannot explain it, but the realistic thing that that's what happens Yes So It's a prolate a little bit prolate surface here They have changed the surface technology and they give you a little of depth of focus induction, but it's more Uh It's a monofocal lens with a little bit more intermediate It's not really as either of lens, but it enhances a little bit not seeing at one But you can see a little bit further So it comes again taking from the monofocal lenses away, but it's definitely has a change of the We looked at these lenses in the lab and if you see this lens a monofocal lens same type the technus versus the eyehands You can see that they have little bump on it. So it's an optical process on the on the on the center of the of the anterior surface So it just started in europe as well, you know, it's maybe half a year that we have it And people that the question is is it a premium eye? Well, we Everything what is in this area? We have we have the same situation like in the united states. We can upcharge. So patients get the basic basic thing from the company from the from the insurance company caloric surgery and And monofocal lens swear at monofocal lens not even a swear Everything else is an upcharge a swear. I got not much but a little bit and then femto is upcharge and everything goes in this direction and then they can choose and I think Looking through Europe at least this is the best system you can have because for example My colleagues in austria Where where we go very often, but they the the only option they have either You take the cost as as as the university or they as as the hospital You just give it for free But then your margin is crazy all the patient has to pay the whole procedure itself himself Which I did four years five years ago when I used this lenses everybody had to pay because I had no other chance Now since we have this upcharge or this Yeah, that's really good and and many companies I was in in in poland one of my colleagues gave a lecture there in katowice university and What happens with them is because the the the the government does not allow this upcharge All the patients are now going to check republic to get their surgery done because they nobody in poland is allowed to do it So all the patients are Crazy is crazy one more question. Yeah How do you approach functionally monocular patients amblyopia? Maybe someone has a kind of trachearum in one eye, but they're really they really want a multifocal in their health Okay, so monocular trifocality works And we very often i'm i'm i'm not putting trifocal lenses between below An expected visual acuity of 2025 2030 That's not a good because the light splitting is too much And I would not go for a try for an e-dof lens below below 2040 Below this amount I always would go for monofocal lens, but if you have a amblyopic eye, which 2080 or 20 in this range you give them a monofocal lens and you can easily do a trifocal lens in the other eye Surgically technique have to be good and i'm not afraid of taking out a lens if it's if it's necessary With these lenses nowadays, you know, if you do it early and i well exchange always the risk of you know Infection everything but with all respect we can do this now And we just can explain the lens if the patient would and I always you know The same thing is don't perform. Yeah caps a lot to me many physicians do this early Because they think that this is the holy grail for making it better No, just make sure that you do a good technique keep the lens in place wait three months Maybe five months and before you do the egg Take the lens out if the patient is not happy if the patient was happy in the beginning very happy And three months later had an opacification and then you can yak him because that's that's the other story around it But you said explanation for you with these new lenses is It's rare, but you know in this passion when you're not so sure at the moment also I'm also telling the patient is not the end of the world if you really don't like it We still can go take the same type of lens. I have the same lens I just give you an a-squaric lens. We have the preloaded clarion at this point, you know We just take it out. Everything is It's already preset just take it out put the new lens should not be a problem But one eyed patients or you know, it's always it's difficult to say but I would say that But I would we do this we do it now with with great success and Good morning Yeah Yeah well I No, I think that was a trifle with all these with this fixed systems the trifle glens the eduflensis The the advantage will be always The optical system you put it in and it could work for 40 years because you know it always can work Whereas with all the acrobatics where it's the problem is the function Do we really at the end will achieve this? But you know and that that the companies are behind it and the development goes in this direction And I think everybody wants to be you know wants to have these type of lenses So it's an interesting field and maybe we as I'm sure one day we will have the answer. It's just a question of Months years decades. I don't know Any other questions Thomas is absolutely pleasure to have