Neda Nikpoor (00:08): Hi, Neda.

Neda Shamie (00:09): Hi, Neda.

Neda Nikpoor (00:10): I'm Neda. I'm here with Neda.

Neda Shamie (00:12): And I'm Neda. Welcome to Neda Squared.

(0:20) Hi, everyone. Welcome to another episode of Neda Squared. Neda and I are here with one of our dear friends and colleagues, Dr. Eva Kim. Eva and I have had a lot of opportunity to share ideas together, talk about patient care, traveled around the world, learning new surgical techniques. One of my most memorable trips with Eva was to Argentina where we went together to learn more about the ICL guru and such. Eva is just such an incredible resource of information and so passionate about what she does. And without further ado, welcome, Eva. Thank you for joining us. Tell us a little bit about where you are, what kind of practice you have, and a little bit of background. And let's dive into talking about keratoconus and everything exciting about keratoconus and also maybe what a lot of people don't often talk about, which is vision correction for keratoconic patients.

(01:21): So welcome, Eva.

Eva Kim (01:22): Thank you. I love seeing your beautiful faces and I'm grateful to have this opportunity to meet with you guys. I am based out of Denver, Colorado. I work with a group called Icon Eyecare. And to put it, I guess most succinctly, we focus on anterior segment mostly, although we have medical retina in our group as well, but no surgical retina. And we are a group of eight ophthalmologists and eight really, really amazing refractive optometrists and they partner with us really well. And I've been here for about 10 years focusing on cataract, refractive/cataract, and refractive surgery in general. I'm also a uveitis specialist and a cornea specialist.

Neda Shamie (02:19): Oh I didn’t know about the uveitis part, but I bet it comes in handy.

Eva Kim (02:21): Yes. It's been a passion of mine for ever since residency when I got to work with Dr. Steven Foster at the Massachusetts Eye and Ear Infirmary. And I just was one of those rare ophthalmologists that really didn't want to leave the body. And that was my way of not forgetting how to think of the body as a whole as an ophthalmologist. So I spent about the prior 12 years before Denver in Northern California in Palo Alto, San Francisco, where actually Dr. Neda Shamie and I met briefly. I think we were a few years apart, but I remember you were at UCSF and definitely already started looking up to you back then. And I was a comprehensive ophthalmologist for about 12 years focusing on cataract surgery and uveitis mostly. But interestingly, not a refractive surgeon, even though I was trained to do LASIK and PRK as a cornea fellow, I didn't really practice it until I got to Denver.

Neda Shamie (03:28): It's interesting. It's similar to me. The first 10 years of my career, I was trained, but I wasn't so focused on it. I was much more focused on cornea, anterior segment, ocular surface. So let's dive in. I mean, that's quite a background. I think we want to focus on keratoconus for this conversation. There's so much we could talk about with you. You have such breadth of expertise, but for this conversation, let's talk about keratoconus. And I know that you're very passionate about caring for keratoconic patients. It probably stems from also that same kind of wanting to take care of the whole of the patient and the whole of the medical care of the ocular health and keratoconus is definitely one of those conditions that some surgeons have real passion. And I think Neda and I feel the same. There's Epioxa that's now available or coming to a lot of our practices.

(04:22): So love to hear your thoughts on that, on stabilizing cornea, but probably even more kind of interesting a topic that a lot of people don't talk about, which is correcting vision for keratoconic patients. So, touch on Epioxa, what your thoughts are on that and then let's dive into how you correct vision for these keratoconic eyes that have been stabilized using collagen cross-linking.

Eva Kim (04:46): Yeah. So, we have yet to officially start Epioxa epithelium on cross-linking. However, our group has committed to multiple units. We probably perform about anywhere from five to 10 cross-linking procedures every week, kind of spread between myself and two other cornea specialists, but I would say that's the average. And so we're fairly busy as a group and probably of our four regions, all of our regions do perform cross-linking, but we might be the busiest. And I'm excited about Epioxa because anything that's going to make it easier for our patients, I'm all for it. And I am eager to hear from a colleague who is in my city who has already started Epioxa, frankly, how reimbursement is going for him. Not that that's the primary reason and any way that we do it, but I'm just curious about that part. And so, to be continued. I’m wondering if you guys have heard about how that's going for colleagues of yours and your cities, or is it too early to say?

Neda Nikpoor (06:03): Yeah, I'll speak for Hawaii. Several of us have already ordered and/or received our units, but we haven't actually gotten any payers to cover anything yet. But I think Glaukos has done a really good job of getting ahead of it. Their head of medical affairs, she's been meeting with all the insurance companies and I think they've been doing a really good job of trying to explain the logic to both doctors and payers and even at the level of explaining it to our staff and to referring doctors. I think there's always sticker shock when the price is 20 times what it was with epi-off when we're talking about a drug. But I think it is controversial and people have mixed opinions about it, but I think it makes sense that their logic is that they really are trying to find all the patients that have gone without treatment and they're really tackling it from every front.

(06:58): They're creating a handheld topographer that's going to make it easier for pediatricians, optometrists, everybody who can't necessarily invest in an actual topographer, tomographer, just trying to find patients do peer-to-peer education, do direct to consumer education, doing all of the things like having a patient access program. I think they've been really thoughtful in how they're approaching it. So I'm hoping that all the legwork they've done on the front end is also going to make it easier for patients to get coverage. But so I'm interested to hear, it sounds like you've been doing cross-linking for a long time, just like I have. And the percentage of patients who have keratoconus who can afford a vision correction procedure is limited, but having done so many cross-thinking over the years, I'm sure you have experience where, okay, now let's say a patient's stabilized, at what point do you consider them stable?

(07:48): Is it a year? Is it two years? And then what's your preferred way of treating their vision? I know what my preference is, but I'm curious to hear what you think as the expert.

Eva Kim (07:56): Yes. I've been cross-linking for I would say almost the entire 20 years of my practice, definitely more volume in the last 10 years. I think part of that is that yes, I definitely see keratoconics, young men, late teens, early twenties who have keratoconus. But my practice before I joined was a LASIK only provider and had been in existence for, I think it's now been over 20 years. And so over time have a huge volume of patients who had LASIK 25 years ago plus and unfortunately we have seen over time patients with ectasia status post LASIK that was probably just slightly more aggressive than what we would recommend these days. My practice has about a 25 year history of high volume LASIK. When I joined 10 years ago as medical director, I kind of transformed it into anterior segment surgery. And so, we do many more things than corneal refractive, but really over time have large volume of patients who have had LASIK.

(09:17): And because LASIK was potentially just a little bit more aggressive treatments 20, 25 years ago, there's a subset of patients with ectasia. So, I'm working with keratoconus patients, I'm working with patients with post-corneal refractive surgery ectasia. And so these patients are getting crosslinked and this population a little bit different than the keratoconus patients are interested in regaining their ability to see without glasses and contacts once their corneas are stable. And I think that's probably where I came up with the feeling that we stabilize keratoconic or ectatic corneas with cross-linking and then we think-

Neda Shamie (10:04): And then now what?

Eva Kim (10:05): Yeah. We have providers that we're celebrating, right? We're like, "Congratulations. Six months later, your cornea looks stable. It actually might even look a little bit better and there's a little flattening there." Or we're kind of looking at our patients ecstatic and then a year later things are looking even better because there's stability that's proven. And then the patient's kind of looking at you like, "Well, what are we going to do next? How are you going to fix my vision now?" And I think this is a valid question because perhaps that's a feeling unimportant to us as ophthalmologists. Technically we're thinking, "Oh, it's okay. We'll get you into a scleral and perhaps we can do these glasses or whatever solution in the past might have been.” But I think it's only fair to be able to think of ways that we could offer our patients some more independence from their glasses. It's probably not going to be total independence and I never promise that, but an ability to have some vision so that the patient doesn't feel like if they have issues with their contacts or glasses that they're completely blind.

(11:20): And I personally have never been in that situation, but I could only empathize with my patients.

Neda Shamie (11:26): Yeah. So, walk us through– in my mind, I think of three categories of keratoconic patients who now have been stabilized with collagen cross-linking. One has residual refractive error but low. They may have some astigmatism, some myopia, but they're mild to mild-moderate keratoconic. And they may be too low for ICL, but they're correctable and they're interested in having spectacle independence or contact lens independence. Then there's the higher correction, the higher myope with the higher astigmatism, but still correctable well enough that they don't absolutely need scleral lenses. And then the more advanced keratoconic who has highly irregular cornea, who cannot be corrected, who doesn't have really central regular mires, and how do you correct those? So let's start with the mild one. Let's start with the minus two with two diopters of astigmatism and you were able to stabilize their cornea and now it's actually flattened and they're correctable to 20/25 plus two.

(12:39): How do you manage that patient?

Eva Kim (12:41): Yes. So I feel like we see a lot more of these patients and that's a good thing, right? Because there's earlier detection by our colleagues in the community and earlier detection by our own internal optometrists. This is the time that we need to be catching keratoconus. And so that stabilization is the win. And so, since this patient type is correctable with contacts, even soft contacts and/or glasses, that's usually going to be my— I'm going to encourage our patients to continue to use glasses and contacts and to not necessarily go into the surgical realm if they can help it. These are our younger patients. Interestingly, Mark Lobenoff has a really fantastic protocol and he will do kind of a simultaneous PRK to either debulk the cone or not necessarily to fully correct, but just to debulk that cone with immediate simultaneous cross-linking right afterward. And he's been working on a cross-linking similar to Epioxa where it's very, very quick.

(14:02): He says that he with this high oxygen concentration will be able to perform cross-linking, I think, in about 10 minutes with his C2 device that I think he's getting FDA approved currently. So he says ideally it's nice to do the PRK first, the cross-linking immediately after on the same day, but just due to some coverage issues, he will sometimes just split it by 24 hours. And he's finding that when he thinks he's just trying to debulk a cone, he's surprised that sometimes these patients will end up with 20/20 uncorrected vision. I personally am not doing that, but if I had a patient like this who was extremely motivated to do something, I might recommend that my patient go and see him at this time. How about you guys?

Neda Shamie (14:53): Yeah, my main concern is what you alluded to, which is a lot of these cross-linked corneas continue to flatten over time. And so I was really intrigued by his protocol, but I do wonder physiologically if long-term. I mean, the data will speak for itself of course, but if anything, I think I'd be more prone to doing the cross-linking, giving it a year to stabilize the cornea, have definitive data for stabilization before I consider PRK potentially on these lower corrections. But yeah, I mean, I’d almost much rather have low powered— I can't wait to have low-powered ICLs because I would love to leave that cornea untouched in these patients because you just don't know.

Neda Nikpoor (15:40): I totally feel the same way. It's interesting at ASCRS, recently this year, 2026, I got to moderate a session on, it was one of the debates between Bill Trattler and Dr. Kanellopoulos on topo-guided PRK and cross-linking and Kanellopoulos was pro combined and Trattler was pro sequential and obviously they both are very well respected and very academic-minded, but I personally fell into the camp of, I believe, Bill, that he's shown continued flattening in some of these patients over many, many, many years. And he shared one of his own patients who he did, I don't even think it was combined. I think it might've been sequential, but he basically waited a year, patient stabilized, he did PRK, then the patient continued to flatten and ended up like a plus four or something. And so they can really continue flattening over time. So Ned, I'm with you where I would much, much rather treat at the level of the lens with an ICL that is reversible than reshaping a cornea that is probably going to keep reshaping.

(16:46): Now, some people are more responsive to cross-linking than others and so maybe we'll see less aggressive flattening in some of these mild corneas and maybe that'll be the case with epi-on where it's not such a dramatic continued flattening over so many years, but we really just don't know. And going and then removing tissue in a cornea that's been cross-linked is also not my favorite thing to do.

Neda Shamie (17:09): There may be ways to have predictive factors using advanced diagnostics where you can anticipate how much flattening a cornea would have. But I don't feel—and Eva, I'd love your thoughts—I don't know if we have those indicators yet at this point to be able to make those predictions to adjust our nomograms for PRK and such on these eyes.

Eva Kim (17:33): Yeah. I was just actually going to ask you the same. I figure it’s always safe to wait as long as possible if someone's going to be really proving stability before doing any kind of vision correction for my patients. It almost might feel like torture. I give them this light at the end of the tunnel. There is something we could potentially do besides glasses and contacts, but I'm really going to want to see at least a year, if not more of stability. I'm not like, let's wait three to six months. I mean, no way do I feel comfortable with that even with lens-based. Although I have to say, if we kind of move into the higher myope category where ICL is possible, I do just love the reversibility aspect. So if we cross-link and we're lucky enough to have an amazing result where the patient is spectacle free, let's say, and having better vision than we expected, even with an irregular astigmatism, if over time flattening occurs that is more than we expected, if refractively the patient goes off target, I think that's wonderful that we could then replace the ICL if that's appropriate.

(18:53): Or if the patient is older, move into refractive lens exchange possibilities, which we can speak about in a little bit. But just absolutely ICL is one of my favorite surgeries for our keratoconics because a lot of them are young, they still have great accommodation. And I will always tell my patients—really, really stress—and I don't deliver the moon. I don't ever promise perfection. I will use phrases like, "We're going to reduce or debulk your prescription so that if you didn't have your glasses or contacts, you could still navigate and be safe." And I under promise and time and time again, it's incredible, you guys, just the over-delivery that occurs where you're thinking, okay, you have irregular astigmatism that's at five or six diopters and you're using your maximum Toric ICL and you don't even know exactly where the axis is with some of these patients, but you do your best.

(20:04): And then it's amazing, right? You'll see some of these patients at 20/20, 20/30, 20/25 and they'll kind of be in tears and say, "I don't want contacts or glasses. I see the best I've ever seen in my life." So it's not going to be every patient, but I think just explaining how this is going to be a partial solution and if it feels like a full solution to your patient, they're going to be delighted.

Neda Shamie (20:31): Would you agree that if a patient is reliable on sclerals or hard contact lenses, that's harder to—obviously in those patients, I hesitate recommending the ICL because it doesn't replace the need for sclerals and RGPs. And it's hard I think to fit. I've been told by our optometrist that it's hard to fit over a Toric ICL. Now debulking the myopia and then maybe having them stay in an RGP that doesn't have minus 16 and minus five rather just have it be minus one minus five, that may be an easier fit. I don't know, what are your thoughts? Everyone says I have to be in my RGP. I don't love my vision with glasses. In fact, I don't like my vision with glasses at all and RGPs or sclerals are the only way I can get about. And then you look at their topography and they're pretty irregular and that central mires, essentially the central three millimeters is not bow tied, would you still consider a Toric ICL?

Neda Nikpoor (21:39): Yeah. I mean, I love this question because I think it really depends on what is the delta between what they have and what you can achieve. And so why the low myope conversation, I love that we're kind of on the same page that maybe we tell that person, maybe just live in your glasses or contacts if you can, because what we can achieve might not be a big enough difference. Where like you said, somebody who's high myope, maybe getting them 20/25, 20/30 is super life changing. Now with somebody who's in RGPs or sclerals, maybe they like RGPs or sclerals because it gives them 20/20 sharp vision, but they're totally debilitated without them. And if we can get them say 20/40, then they can wear sclerals for whatever else that it is that they need that like higher level really sharp vision for.

(22:28): So, I'll usually spectacle, see what their spectacle best corrected is. And I've had patients who I have to go through this whole RGP holiday to try to get them to be final fit measurement for EVO. And I've done EVOs on those patients and they've done well with realistic expectations. Now if I have somebody who's, like I have a patient right now who I'm gearing up for CTAC, she had cross-linking in both eyes, one eye, she's like barely like a- 1 or anything like that, like sees great. Her other eye, she's like a minus 13 and came in as an EVO consult, but her spectacle best corrected is like 20/60. And I told her, I was like, "I don't know if you're really going to notice much benefit by taking this eye to 20/60 when your other eye is so good. What if we did CTAC first, try to regularize your cornea, get some improvement in your spectacle best corrected, then we can come back and do an EVO later." So that's kind of how I think about those.

(23:22): But if it's, let's say both of her eyes were that way and they were both 20/60 best corrected, but her uncorrected is like count fingers, then I show her and I say, "Hey, would this be a meaningful improvement to you? " And if it is, then absolutely I would do EVOs with the understanding exactly like you say, Eva, that we're telling this patient the goal is not perfect vision. The goal is not even driving vision sometimes with them. It's just functional independence where you can walk around your house. I remember my first ICL back in the Visian days on a keratoconus patient was a guy who was like, "I just want to be able to see my kids' faces without putting my scleral lenses in. " And he ended up 20/25 binocular uncorrected. So we far exceeded what I thought was even possible because the lens is just amazing and sitting closer to the nodal point, like the collamer material, all the things that we know that make the EVO so good, he had a very low expectation and a result that was way better than what I would've hoped for somebody like that.

(24:19): But with that kind of goal of like, "I just want to see my kids." And I have pretty good optometrists in the community who are comfortable fitting bitoric lenses. So, I think it depends on who you have in the community who's willing to do that.

Neda Shamie (24:33): So, you wouldn't hesitate doing toric as long as the optometrist, you communicate with our optometrist?

Neda Nikpoor (24:38): Exactly.

Neda Shamie (24:40): So, moving on to the last category, which is the, I think you already mentioned the CTAC, the highly irregular, but no central scarring but very irregular cornea. Obviously, the central scarred eye with high drops and such, those are patients that it's scleral RGPs or DALK, DALK or PKP depending on the surgeon who's taking care of them or if it's high drops or not. But for those who don't have central scarring, but highly, highly irregular cornea, how do we manage those patients?

Eva Kim (25:13): I think the way I think about it is there's definitely like the age of the patient matters when I'm trying to figure out what's best for them. So, if they're on the younger side pre-presbyopic, I think really hard and hesitate to do refractive lens exchange just like we do with a typical patient. I don't want to remove my patient's ability for accommodation if I can help it, but I'll go with the easier group. Let's say it's a presbyopic patient 50 or above as an example, then refractive lens exchange can be incredibly helpful for these patients who are even with pretty irregular highly myopic corneas. So, I like using the light adjustable lens for some of these patients. I've used Apthera for some of these patients if it was the near eye. I just did Apthera actually in a patient who, again, not a keratoconic but has ectasia, thankfully not from our group.

(26:27): He had it done in Florida 20 some years ago and had, he's measuring, although many of our diagnostic imaging devices are having trouble imaging him, but the closest we can get is that he has 25 diopters of irregular astigmatism. I sent this to the CA group for advice because he had a horrible cataract, you guys, and I was like, "What lens do I put in? " And he cannot tolerate sclerals. He just leaves it uncorrected and it's basically a blind eye, but wanting to help him in the end, I decided to use to try Apthera. Because I noticed he squinted everything he was doing, he was squinting and he saw better through pinhole, even though his cataract was so bad that it was really difficult to assess that. He doesn't test incredibly well, you guys. He's about 20/80 uncorrected, which I think is pretty-

Neda Shamie (27:23): That's still amazing.

Eva Kim (27:24): Yeah. But he was bawling. He said he thought this was a blind eye for the rest of his life and he just said that he feels like he can use the eye now. And so that's, I think in very special situations and Apthera can, an IC-8 can be a great lens to use even for refractive lens exchange, but LAL is a pretty typical lens that I go to because of that adjustability. I'm curious, Neda, what kind of patients do you sort of rule out or rule in for LAL when you have a keratoconus patient? What guides you in deciding what's a good LAL candidate versus not?

Neda Nikpoor (28:08): That's so funny. I was just going to ask you the same thing. Great minds think like. You know, it's interesting, I've had really good success also with LAL and I've put in so few Aptheras because my LAL patients, I feel do really well, even in highly irregular RKIs. So, Vance taught me that if the patient historically saw well and didn't need a hard lens, let's say if you don't have history, if their cataract is mild or moderate enough that you could assess that in your office of is there a dramatic improvement with a hard contact lens over refraction or not? If you don't think you're going to need a hard lens, just go with LAL and try LAL. And so that's been the approach that I've taken unless it's some highly irregular eye that requires a hard lens, then I do an Apthera because then it's a non-toric and they can wear a hard lens over it.

(28:59): But I've had, I would say the worst cornea that I did with an LAL was a patient who we couldn't get Ks on anything and he just really wanted the best. And I told him I was like, "Okay, well this is the best and hopefully we're going to be plus or minus two to three diopters of where we're going because that's what we can adjust and we'll see where you end up. And if I have to do an exchange, I'll do an exchange." And he actually ended up great and very difficult to refract, but we ultimately got him to the point that he was like 20/60 uncorrected and he wasn't bawling and happy like your 20/80 patient because I think maybe he expected a little more, even though we were pretty upfront about we're going to do what we're going to do.

(29:43): And it's really hard to know if you're going to get great vision from this, but 20/60 was functional for him and then he could just supplement with hard lenses over it.

(29:56): I think in my mind I'll exclude someone from LAL if I think they're going to be worse than 20/50, 20/60, because I think it's hard to ... Or maybe 20/40 sometimes if I'm really being strict and I think they're a good candidate for something else. If it's more of a retina pathology patient, then I'll say maybe 20/40 best potential is where I kind of cut that off because I think it's really hard to refract patients beyond that. But if it's a cornea reason why I want to do an LAL, then I'm willing to push that a little bit higher because I think it's worth it. Whereas let's say somebody has bad ... Not AMD because I wouldn't, but like a bad ERM or something like that. Okay. Well, if I think their ERM is going to make them worse than 20/50, then I'm probably going to be more reliable at hitting a target with keratometry from biometry than I am refraction with an LAL adjustment process.

(30:44): So that's kind of how I think about that. I'm curious, you asked the question, where do you guys draw your line of how do you think about that?

Eva Kim (30:51): Well, something that comes up just from a practical level is that a lot of our keratoconics are highly myopic. Their refraction is highly ... So, they might not be necessarily axial myopes. They're average axial length or maybe a little more, but then their Ks create that high myopia. And so, the LAL is really great because it does go down to negative two diopter power. And so, there are just not a lot of lenses available for us to use in refractive lens exchange. So, it just happens to be that we have this low or negative diopter lens at our fingertips and then we can adjust it. So, when you think about it, it's kind of a wonderful solution to be offering to our patients. I feel really lucky that we have that available to us. I don't use Apthera as my mainstay. I used it as an example because this patient, like you were saying, had just a cornea that was incredibly difficult to refract and definitely needed a scleral lens, but he could not tolerate them at all.

(31:59): And I did feel like if I put an LAL in his eye, it would not deliver anything that he was hoping for.

Neda Shamie (32:07): If I can share a challenge with the Apthera that this is, I learned through experience. Some of these patients have corneal scarring or highly, highly steep central corneas. And with the Apthera, if there's any PCO, it can get in the way of the vision, of course. Doing YAG through a scarred cornea is very challenging and almost not impossible because you can have the patient fixate differently so you can get around the scar. But with the Apthera, you really don't want to hit the disc, and you can't go in the center. It's important to anticipate how it's going to be to have to YAG around that disc. The same is true for the very steep corneas, because even if you use a gonial lens, that steep cornea will cause creases centrally and it'll get in the way of the YAG. So, I was a lot more excited about the Apthera until I implanted in a few eyes that were very challenging to do YAGs.

(33:15): And I actually had to exchange one, I had to do vitrectomy because she also had floaters to also remove the posterior capsule or at least central posterior capsule to help open up the view because she did love the Apthera, but then when the PCO came in, it was very challenging to YAG. It was nearly impossible to YAG it. And then the other one, I had to exchange a lens because we could just not get through the scarring. So that's something to keep in mind. But I agree with you, the LAL is a great, great option for a lot of these patients with, again, the full understanding that if they have high astigmatism, corneal astigmatism, it's going to take, especially in these highly irregular corneas, we usually wait longer before we start adjusting and we spread out the adjustments at least two weeks. And so, it ends up spanning over like four or five months before we're finalized.

(34:09): And so, these patients are walking around with four diopters or three diopters of astigmatism and then the LAL only adjusts two diopters of astigmatism. And then also if you miss the target, both the sphere as well as having to treat astigmatism, you don't have as much macromers to do both. And so, I go through these conversations with patients, especially if they want this and monovision, I'm like, well, we can't do it all. So, it's important for patients to understand that the LAL for those patients, the time commitment and cost, I really lay down the expectations. And make sure that they understand their LAL experience is not going to be the same as a virgin eye or even a post LASIK eye LAL that has the chance of reaching 20/20 vision uncorrected, but it is a great tool.

Eva Kim (35:05): I love working with our keratoconic patients or our patients with ectasia because they've already been through this serious medical procedure cross-linking that takes a lot of patience and dedication, alignment, understanding from the patient that what we're about to do is going to stabilize the cornea but not improve vision in any way. And so, I think over time our patients, they start to really understand that part. And so not every one of our patients, but I feel like a good number of patients tend to understand the state of their cornea and that we are doing our best to help them gain vision that is less spectacle dependent. And so there just seems to be much more appreciation. I learned from Rob Weinstock how to stack toric LAL, and I have patients who they have let's say six diopters as an example of irregular astigmatism somewhere around there where you know your LAL is not going to be able to hit that.

(36:16): It's just not going to be able to get all of that. So, using a high toric and then putting the toric lens in first and then stacking in the same bag simultaneously the LAL right in there. I think some people will put it sulcus and do optic capture. I like putting both into the bag and have found that really, really great results. I have a few patients walking around. I really push them towards bilateral distance. I'm just like, I really just don't want to talk about monovision. Let's try to get your distances bilaterally excellent as possible so that you're wearing some kind of magnification for up close, but let's get your distance. And because I insist on that, I really feel like patients just say, "I will do whatever you say," because they understand that putting two lenses in the bag is just not for everybody and that we're doing something very special for them.

(37:19): So, have you guys tried stacking, and have you found some success with it? What do you guys think? It's been really exciting.

Neda Nikpoor (37:25): I haven't yet, but I'm excited to try. Yeah.

Eva Kim (37:28): Yeah.

Neda Shamie (37:30): I haven't with LAL, but yeah, most definitely I think it's a really great way—

Eva Kim (37:36): To put the LAL second. Yeah, second so that you can treat the LAL as opposed to putting it first because then you won't be able to do the full treatment.

Neda Nikpoor (37:47): Well, Eva, you're amazing. You're always thinking outside the box and doing amazing things for your patients and teaching us so much. So, thanks for taking time to go through this with us and teach us a little bit about how you approach keratoconus and so much more. I think this was really good. We got a lot of specific pearls that hopefully people can take away. One of the things that we ask every guest who's on with us is if you weren't an ophthalmologist, what would you be?

Eva Kim (38:13): Oh, great. Probably something in the realm of fashion.

Neda Nikpoor (38:19): I was going to guess that.

Eva Kim (38:22): Yeah, if I'm not feeling good, which luckily doesn't happen very often, but I'll be dressed to the nines. There's just something about fashion that makes me happy and can cheer me up. And I'm definitely someone who loves the classics with a little bit of a flair put on top of it, but I love to help friends with outfits for special occasions. I've never been someone who buys a dress for an occasion. I will just be around out and about, and I will see something for instance and be like, "That is amazing and I'm sure there will be an occasion where I can wear it.” I'll kind of do it in an opposite fashion.

Neda Nikpoor (39:07): I hope we're the same size and then we can share clothes because you always look so fabulous. Although I don't think I could pull off your clothes because you look so great all the time.

Neda Shamie (39:16): It's good to know that you will do fashion consultation. So, I'll be calling you on that. A little keratoconus, a little fashion.

Eva Kim (39:23): Yes. Yes. Oh, this is no charge, guys, definitely for you guys.

Neda Nikpoor (39:28): I love it. Thank you. Oh, this has been so much fun. Thank you, Eva. Thanks, Neda. Thanks everyone.