text:
I have something super exciting to share with you.
Through the years lots of folks have asked me to make more videos, and that has been on my 10-mile long To Do list for looooong awhile.
Videos are such a wonderful way to say things that are hard to say in writing. There’s no doubt that they are important.
I’m happy to finally say I’ve gotten some of that process started!
I’ve got two DID videos to share with you today — videos created specifically for folks with Dissociative Identity Disorder. If you have been following the Discussing Dissociation Facebook Page, you may have seen these already.
However, I’m pretty sure that there will be other folks who haven’t yet seen them. Or maybe you’d like to have an easy way to find them that didn’t involve going to Facebook or YouTube. Regardless, these videos relate to THIS blog, and to THESE blog articles, so HERE is their home.
And we all need to be tucked in safe and comfortable at home, right?!
There’s something about putting words with images and music….. wow.
The impact of bringing that all together, even after you have already read those words over and over again …. it still packs an emotional punch that is so much more powerful.
Please watch these videos as many times as you need to. Let them remind you of your system, and what your system needs for healing. Even listening to the music by itself is calming, soothing, and healing. Beautiful.
So far, the response to these videos has been amazing, staggering… and absolutely overwhelming. I’m both humbled and honored to see that they connect so deeply, resonating with so many wounded souls. At the same time, it’s shattering to see the response, and it breaks my heart. I’m so sorry that there are so many dissociative trauma survivors hurting inside.
I truly hope you hold tightly to these videos for both comfort and healing. I want them to be a positive step in of your healing process.
And absolutely yes… I will be creating more videos.
I just received the email about these videos. Thanks Kathy. They are beautiful.

lowercased:
i have something super exciting to share with you.
through the years lots of folks have asked me to make more videos, and that has been on my 10-mile long to do list for looooong awhile.
videos are such a wonderful way to say things that are hard to say in writing. there’s no doubt that they are important.
i’m happy to finally say i’ve gotten some of that process started!
i’ve got two did videos to share with you today — videos created specifically for folks with dissociative identity disorder. if you have been following the discussing dissociation facebook page, you may have seen these already.
however, i’m pretty sure that there will be other folks who haven’t yet seen them. or maybe you’d like to have an easy way to find them that didn’t involve going to facebook or youtube. regardless, these videos relate to this blog, and to these blog articles, so here is their home.
and we all need to be tucked in safe and comfortable at home, right?!
there’s something about putting words with images and music….. wow.
the impact of bringing that all together, even after you have already read those words over and over again …. it still packs an emotional punch that is so much more powerful.
please watch these videos as many times as you need to. let them remind you of your system, and what your system needs for healing. even listening to the music by itself is calming, soothing, and healing. beautiful.
so far, the response to these videos has been amazing, staggering… and absolutely overwhelming. i’m both humbled and honored to see that they connect so deeply, resonating with so many wounded souls. at the same time, it’s shattering to see the response, and it breaks my heart. i’m so sorry that there are so many dissociative trauma survivors hurting inside.
i truly hope you hold tightly to these videos for both comfort and healing. i want them to be a positive step in of your healing process.
and absolutely yes… i will be creating more videos.
i just received the email about these videos. thanks kathy. they are beautiful.


text:
If you want to improve your diet, you may want to get into organic gardening. However, effort is required in order to effectively grow. This probably has you wondering where to start your own garden.
You need to consider beginning the plants into pots. Then, you can plant the seedlings into your garden. This increases the chance that your plants will survive to adulthood. This also helps tighten time between plantings. The seedlings are ready to go, once you remove the mature plants.
Make garden tools do double duty as handy makeshift rulers. You can convert any large handle tool, such as a hoe, shovel, or rake into a measuring tool. Just lay your tool down on the floor then lay a yardstick beside the handle. Then, with a permanent marker, you want to label distances. This modified ruler will serve you well as you begin working in your garden.
You do not need store-bought chemical treatments for plant mildew. Mix plain baking soda with a small bit of liquid soap and water. Spray this onto your plants about once per week or until it subsides. Baking soda treats the mildew effectively and gently and it won’t damage your plants.
Keep your plants thriving through the winter by bringing them inside. This is especially useful if you have a particular plant that you love or was expensive. Be careful not to damage the root system as you dig up the plant, and place it in a pot.
To get the best results, you must use the right soil. Fertilizer can enrich the soil to make it more viable. You can also make an artificial area using only one type of soil.
Do a soil analysis prior to planting. Have a soil analysis completed so you can know what you need to add to have soil which will fully support your garden. Many Cooperative Extension offices will provide this service, and it is well worth knowing exactly what the soil needs to avoid ruining a crop or two.
Plants need to take in CO2 to grow and thrive. If the level of CO2 is extremely high, your plants will grow much better. A greenhouse has the best levels available. A greenhouse will help maintain a high level of CO2 and cause the plants to grow faster.
In conclusion, creating and maintaining an organic garden requires hard work, effort and research. So you can see these results, you must keep working with them. Keeping the aforementioned tips in mind, you are well on your way to becoming successful with organic gardening.

lowercased:
if you want to improve your diet, you may want to get into organic gardening. however, effort is required in order to effectively grow. this probably has you wondering where to start your own garden.
you need to consider beginning the plants into pots. then, you can plant the seedlings into your garden. this increases the chance that your plants will survive to adulthood. this also helps tighten time between plantings. the seedlings are ready to go, once you remove the mature plants.
make garden tools do double duty as handy makeshift rulers. you can convert any large handle tool, such as a hoe, shovel, or rake into a measuring tool. just lay your tool down on the floor then lay a yardstick beside the handle. then, with a permanent marker, you want to label distances. this modified ruler will serve you well as you begin working in your garden.
you do not need store-bought chemical treatments for plant mildew. mix plain baking soda with a small bit of liquid soap and water. spray this onto your plants about once per week or until it subsides. baking soda treats the mildew effectively and gently and it won’t damage your plants.
keep your plants thriving through the winter by bringing them inside. this is especially useful if you have a particular plant that you love or was expensive. be careful not to damage the root system as you dig up the plant, and place it in a pot.
to get the best results, you must use the right soil. fertilizer can enrich the soil to make it more viable. you can also make an artificial area using only one type of soil.
do a soil analysis prior to planting. have a soil analysis completed so you can know what you need to add to have soil which will fully support your garden. many cooperative extension offices will provide this service, and it is well worth knowing exactly what the soil needs to avoid ruining a crop or two.
plants need to take in co2 to grow and thrive. if the level of co2 is extremely high, your plants will grow much better. a greenhouse has the best levels available. a greenhouse will help maintain a high level of co2 and cause the plants to grow faster.
in conclusion, creating and maintaining an organic garden requires hard work, effort and research. so you can see these results, you must keep working with them. keeping the aforementioned tips in mind, you are well on your way to becoming successful with organic gardening.


text:
...provides a superior education for students in K4 through 12th grade. The 50+ acre campus is located at 3931 White Horse Road in Greenville, SC, about 3 miles from Interstate 85. TCS has provided over 55 years of continued excellence in education to the Greenville/Pickens/Anderson area. We invite you to come and join our institution that provides a Christian alternative to a Christless education system.
A Bible-based philosophy and curriculum continue to direct our school into the next millennium. The goal of our school is to glorify God by meeting the intellectual, emotional, physical, and spiritual needs of the leaders of the twenty-first century. This philosophy is implemented by a faculty that is eminently qualified to ensure an excellent education. Whether a student is in K5 Phonics, Pre-Calculus, or Fine Arts, he will receive instruction that will show him how to live and how to make a living.
You can find out more detailed information about our mission, curriculum, tuition, dress code, extra-curricular activities, and other various information here.

lowercased:
...provides a superior education for students in k4 through 12th grade. the 50+ acre campus is located at 3931 white horse road in greenville, sc, about 3 miles from interstate 85. tcs has provided over 55 years of continued excellence in education to the greenville/pickens/anderson area. we invite you to come and join our institution that provides a christian alternative to a christless education system.
a bible-based philosophy and curriculum continue to direct our school into the next millennium. the goal of our school is to glorify god by meeting the intellectual, emotional, physical, and spiritual needs of the leaders of the twenty-first century. this philosophy is implemented by a faculty that is eminently qualified to ensure an excellent education. whether a student is in k5 phonics, pre-calculus, or fine arts, he will receive instruction that will show him how to live and how to make a living.
you can find out more detailed information about our mission, curriculum, tuition, dress code, extra-curricular activities, and other various information here.


text:
Homelessness is a business issue too - East Bay Leadership Council ?
Homelessness is often addressed as a human issue and rightly so. An estimated 7,000 people are struggling to find shelter and stability in San Francisco alone. But the growing homeless population is also taking a toll on many local businesses.
On August 15th, a group of Bay Area manufacturing leaders gathered in San Francisco to discuss trends and challenges in their field. It quickly became clear that the Bay Area housing crisis was to blame for a serious lack of qualified applicants for manufacturing positions. Too often, qualified candidates cannot afford the staggering cost of living in or transportation to the Bay Area on the salaries and benefits manufacturers are able to offer.
Miranda Jones of Galanter & Jones agreed and added to the conversation. She explained that not only is the housing crisis limiting qualified applicants, it is pushing residents out of their homes. And while Galanter & Jones is located in the heart of a burgeoning economy of makers on the central waterfront of San Francisco, their neighbors also include a growing number of homeless people. People have set up trailers where they live with loud animals, cook on the sidewalk, leave dog feces, do drugs, and create an enormous amount of trash. Multiple company vehicles have been broken into or damaged. One was even set on fire and nearly burned down the entire facility.
Jones estimates that over the four years her company has utilized the space, they have spent approximately $5,000 addressing these challenges. For many entrepreneurs like Jones who choose to keep their business local, this has become an all too common cost of operating in a region stricken by a housing crisis.
Ending homelessness will be complicated and must include collaboration between health care providers, social workers, housing advocates, business owners, and many more key stakeholders. But one thing is certain, homelessness and the impact it has on our communities will only get worse if we do not increase our region’s housing supply.

lowercased:
homelessness is a business issue too - east bay leadership council ?
homelessness is often addressed as a human issue and rightly so. an estimated 7,000 people are struggling to find shelter and stability in san francisco alone. but the growing homeless population is also taking a toll on many local businesses.
on august 15th, a group of bay area manufacturing leaders gathered in san francisco to discuss trends and challenges in their field. it quickly became clear that the bay area housing crisis was to blame for a serious lack of qualified applicants for manufacturing positions. too often, qualified candidates cannot afford the staggering cost of living in or transportation to the bay area on the salaries and benefits manufacturers are able to offer.
miranda jones of galanter & jones agreed and added to the conversation. she explained that not only is the housing crisis limiting qualified applicants, it is pushing residents out of their homes. and while galanter & jones is located in the heart of a burgeoning economy of makers on the central waterfront of san francisco, their neighbors also include a growing number of homeless people. people have set up trailers where they live with loud animals, cook on the sidewalk, leave dog feces, do drugs, and create an enormous amount of trash. multiple company vehicles have been broken into or damaged. one was even set on fire and nearly burned down the entire facility.
jones estimates that over the four years her company has utilized the space, they have spent approximately $5,000 addressing these challenges. for many entrepreneurs like jones who choose to keep their business local, this has become an all too common cost of operating in a region stricken by a housing crisis.
ending homelessness will be complicated and must include collaboration between health care providers, social workers, housing advocates, business owners, and many more key stakeholders. but one thing is certain, homelessness and the impact it has on our communities will only get worse if we do not increase our region’s housing supply.


text:
How do I conveniently change my car tires and engine oil?
For every mile, I have to stop and fill my volkswagen passat radiator with water.
What is a car brainbox?
Things to always have in your car.

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how do i conveniently change my car tires and engine oil?
for every mile, i have to stop and fill my volkswagen passat radiator with water.
what is a car brainbox?
things to always have in your car.


text:
Located in Wyoming, Montana and Idaho, Yellowstone was the first U.S. National Park and may be the crown jewel of them all. Its diverse landscapes, geothermal features, and wildlife populations offer many opportunities to capture special images of Nature. Yellowstone Lake near the middle of the park is centered over the Yellowstone caldera, which is the largest “supervolcano” on the North American Continent. The volcano is considered active, and while there are no current eruptions or lava flows, areas of Yellowstone Park experience constant hydrothermal events and thousands of small earthquakes each year.
Given the short time of our visit, most of my images were of the geyser pools and bubble pots surrounding Old Faithful. This intriguing area presented an abundance of fantastically colored, otherworldly shapes of a hostile, yet beautiful Nature that I could not resist.

lowercased:
located in wyoming, montana and idaho, yellowstone was the first u.s. national park and may be the crown jewel of them all. its diverse landscapes, geothermal features, and wildlife populations offer many opportunities to capture special images of nature. yellowstone lake near the middle of the park is centered over the yellowstone caldera, which is the largest “supervolcano” on the north american continent. the volcano is considered active, and while there are no current eruptions or lava flows, areas of yellowstone park experience constant hydrothermal events and thousands of small earthquakes each year.
given the short time of our visit, most of my images were of the geyser pools and bubble pots surrounding old faithful. this intriguing area presented an abundance of fantastically colored, otherworldly shapes of a hostile, yet beautiful nature that i could not resist.


text:
We have been talking to experienced fisherman about how to get ahead of these wily salmon and catch a few more of them. Fishermen are a bit of a shy bunch when it comes to sharing tips on how to land a few more salmon, I am not sure if this is because they don’t want competition on the river bank or the salmon are tricky but here are a couple of bits of advice to help you on your way. Ian Gordon Ian Gordon runs the Spey website which is the the complete information highway to salmon and sea trout fishing in Scotland and river spey in general. Ian is an instructor and has designed a specific range of Ian Gordon fishing rods and spey lines which help the salmon fisher get the best out of their salmon rod, reel and line combination.
I’m now a better caster, but I catch less fish! Why? Discipline! This is one of the lead articles on his website, I am sure that you also need a lot of persistence not to say a bit of patience as well. The question we asked Ian was – “How many more salmon will you catch by having the ability to throw a very long line?” And this was his reply – “This question is one I have been asked many times on the river bank and the answer, based on many years watching people of all abilities fish is always the same; none. Much more important, is thinking about the depth, and position of fish in the pool. In most salmon pools fish will be present between 2 and 20 yards from the bank. Reading the water, working out where fish are lying, then fishing the fly at the correct speed and depth is far more important than throwing a long line. Another golden rule, often forgotten in salmon fishing is - remember you are after a “wild” creature, remain quiet and use stealth!” John Henderson John Henderson is the Sales Manager at Hardy and Greys and has fished for many years, here is John’s fishing tip - “Never underestimate local knowledge, whether you are fishing on a river for salmon or a Stillwater for trout, the fishery manager or Ghillie/Boatman can give you valuable information on what is catching fish at that time. You could find out what lines, flies or even specific spots to fish, which could end up making your day even more special with a fish of a lifetime! Other avenues are local tackle shops in the area where you’re fishing, other anglers who have fished there before or checking on websites that target the rivers or lakes where you intend to go.” Jim Curry Jim Curry runs Halstead and Bolton, international sporting agents who are dedicated to providing the finest sporting experiences at home and abroad, he has given us this tip – “Often experimenting with your casting angles is the key to success when salmon fishing. It's very easy to fall into the trap of continually casting at 45 degrees and putting in the standard upstream mend. If it's not working try casting at different angles. A square cast across the current and a down stream mend will speed up the fly and often produce an aggressive take.” Jim has been passionately involved in the fly fishing industry for over twenty years and is an AAPGAI Master Casting Instructor and is a lead assessor for this world renowned qualification. He has a number of published articles and is a regular contributor for Trout and Salmon magazine as well as being a tackle consultant. We know salmon fishermen are a dedicated group and I am sure that they have lots of tips they can share so if you are a salmon fisherman why not email your salmon fishing tips to flyfishingtips@johnnorris.co.uk so we can then post them on the blog or, alternatively, let us have your thoughts on the tips we’ve posted. If you have any questions call us at John Norris of Penrith on 01768 864211 or email us sales@johnnorris.co.uk.

lowercased:
we have been talking to experienced fisherman about how to get ahead of these wily salmon and catch a few more of them. fishermen are a bit of a shy bunch when it comes to sharing tips on how to land a few more salmon, i am not sure if this is because they don’t want competition on the river bank or the salmon are tricky but here are a couple of bits of advice to help you on your way. ian gordon ian gordon runs the spey website which is the the complete information highway to salmon and sea trout fishing in scotland and river spey in general. ian is an instructor and has designed a specific range of ian gordon fishing rods and spey lines which help the salmon fisher get the best out of their salmon rod, reel and line combination.
i’m now a better caster, but i catch less fish! why? discipline! this is one of the lead articles on his website, i am sure that you also need a lot of persistence not to say a bit of patience as well. the question we asked ian was – “how many more salmon will you catch by having the ability to throw a very long line?” and this was his reply – “this question is one i have been asked many times on the river bank and the answer, based on many years watching people of all abilities fish is always the same; none. much more important, is thinking about the depth, and position of fish in the pool. in most salmon pools fish will be present between 2 and 20 yards from the bank. reading the water, working out where fish are lying, then fishing the fly at the correct speed and depth is far more important than throwing a long line. another golden rule, often forgotten in salmon fishing is - remember you are after a “wild” creature, remain quiet and use stealth!” john henderson john henderson is the sales manager at hardy and greys and has fished for many years, here is john’s fishing tip - “never underestimate local knowledge, whether you are fishing on a river for salmon or a stillwater for trout, the fishery manager or ghillie/boatman can give you valuable information on what is catching fish at that time. you could find out what lines, flies or even specific spots to fish, which could end up making your day even more special with a fish of a lifetime! other avenues are local tackle shops in the area where you’re fishing, other anglers who have fished there before or checking on websites that target the rivers or lakes where you intend to go.” jim curry jim curry runs halstead and bolton, international sporting agents who are dedicated to providing the finest sporting experiences at home and abroad, he has given us this tip – “often experimenting with your casting angles is the key to success when salmon fishing. it's very easy to fall into the trap of continually casting at 45 degrees and putting in the standard upstream mend. if it's not working try casting at different angles. a square cast across the current and a down stream mend will speed up the fly and often produce an aggressive take.” jim has been passionately involved in the fly fishing industry for over twenty years and is an aapgai master casting instructor and is a lead assessor for this world renowned qualification. he has a number of published articles and is a regular contributor for trout and salmon magazine as well as being a tackle consultant. we know salmon fishermen are a dedicated group and i am sure that they have lots of tips they can share so if you are a salmon fisherman why not email your salmon fishing tips to flyfishingtips@johnnorris.co.uk so we can then post them on the blog or, alternatively, let us have your thoughts on the tips we’ve posted. if you have any questions call us at john norris of penrith on 01768 864211 or email us sales@johnnorris.co.uk.


text:
What a wonderful jumble of color!!
Carla, thanks again for your comments and support. So glad you like this one!
Bunches of vibrant beauty, Lainie. Wonderful image.
Thank you, Ann ... your comment is greatly appreciated!
Lots of wonderful color. Great capture Lainie.
James, thanks very much ... nice to hear from you!
Judy, What a lovely comment ...thanks very much!
Byron, so glad you named these flowers as I had forgotten .... thank you!
What nice is the color!
Another great shot of color and composition...very nice!
Delightful shot, Lainie! Ranunculus such a gorgeous flower!
Elaine, you are so kind ...thank you.
Shana, Thanks for the feature in "For the love of color".
Bunches and bunches of flowers at a market in Provence.

lowercased:
what a wonderful jumble of color!!
carla, thanks again for your comments and support. so glad you like this one!
bunches of vibrant beauty, lainie. wonderful image.
thank you, ann ... your comment is greatly appreciated!
lots of wonderful color. great capture lainie.
james, thanks very much ... nice to hear from you!
judy, what a lovely comment ...thanks very much!
byron, so glad you named these flowers as i had forgotten .... thank you!
what nice is the color!
another great shot of color and composition...very nice!
delightful shot, lainie! ranunculus such a gorgeous flower!
elaine, you are so kind ...thank you.
shana, thanks for the feature in "for the love of color".
bunches and bunches of flowers at a market in provence.


text:
The Big River Dry Bag from Sea to Summit is meant to keep your gear dry and functioning on land or water. It is made from a strong and abrasion resistant nylon fabric with a TPU laminate and fully taped seams to seal out water. It has space saving low profile Hypalon® lash loops on the sides for secure stacking and a roll−resistant oval shape. Non−PVC and a great choice for rugged water sports like kayaking, canoeing and rafting. Suitable to keep contents dry in any wet situation where the bag is not submerged.
Customer Opinions "Big River Dry Bag 20L"

lowercased:
the big river dry bag from sea to summit is meant to keep your gear dry and functioning on land or water. it is made from a strong and abrasion resistant nylon fabric with a tpu laminate and fully taped seams to seal out water. it has space saving low profile hypalon® lash loops on the sides for secure stacking and a roll−resistant oval shape. non−pvc and a great choice for rugged water sports like kayaking, canoeing and rafting. suitable to keep contents dry in any wet situation where the bag is not submerged.
customer opinions "big river dry bag 20l"


text: We are sorry, there are currently no meetings listed in this Country. Please check back soon for any updates or changes. If you dont see your country listed here, click here.

lowercased: we are sorry, there are currently no meetings listed in this country. please check back soon for any updates or changes. if you dont see your country listed here, click here.


text: Fish Ponds Above Ground #2 - Pond Supplies Santa Rosa Pond Design Sonoma CountyCaesar was uploaded in July 21, 2018 at 2:21 pm. If you like to utilize this file as your desktop wallpaper, you should click the download link at the bottom or you may just right click on the image above and choose "Save Image As" to save the Fish Ponds Above Ground #2 - Pond Supplies Santa Rosa Pond Design Sonoma CountyCaesar or by pick the "Set Desktop Background As" options if your internet browser has that capability. If you could not bring the the most wonderful picture you are expecting for, you should go for "Search Column" at top right or browse different image wallpapers whatever you wish. This image has the image size is 575kB and the dimension of 800x600. Fish Ponds Above Ground #2 - Pond Supplies Santa Rosa Pond Design Sonoma CountyCaesar has been viewed by 32 users and it is an attachment from Fish Ponds Above Ground.

lowercased: fish ponds above ground #2 - pond supplies santa rosa pond design sonoma countycaesar was uploaded in july 21, 2018 at 2:21 pm. if you like to utilize this file as your desktop wallpaper, you should click the download link at the bottom or you may just right click on the image above and choose "save image as" to save the fish ponds above ground #2 - pond supplies santa rosa pond design sonoma countycaesar or by pick the "set desktop background as" options if your internet browser has that capability. if you could not bring the the most wonderful picture you are expecting for, you should go for "search column" at top right or browse different image wallpapers whatever you wish. this image has the image size is 575kb and the dimension of 800x600. fish ponds above ground #2 - pond supplies santa rosa pond design sonoma countycaesar has been viewed by 32 users and it is an attachment from fish ponds above ground.


text:
The judge’s actions were especially incongruous given his track record of incarcerating juvenile defendants, according to local media. A Houston Chronicle investigation in October revealed that Devlin and Judge John Phillips accounted for more than one-fifth of all children sent to Texas juvenile prisons last year, sending them “younger and for less-serious offenses than the county’s third juvenile court."
"I am baffled by why he did it," Harris County Chief Public Defender Alex Bunin told NBC News on Thursday. "It's definitely not good for the kids in that they are being released without any conditions."
The public defender also said he is sympathetic to the district attorney's concerns saying the judge’s move could “endanger the public," according to a statement by Harris County District Attorney Kim Ogg.
"Neither side is happy," Bunin said. "This is different in that it’s across the board. It's just never been done without any consideration of the effect of the release of the child and the community."
But Harris County Juvenile Courts Manager Cindy Milom contested any portrayals of a "mass release" of defendants. She said only seven of 13 juvenile defendants who faced the judge Wednesday were released.
Milom, who said the judge was on vacation and couldn't comment on decisions he made, is also pushing back on Bunin's claims expressing concern for the conditions under which the children were released.
"I really find that hard to believe because the public defender did not represent all the juveniles," Milom said.
The ACLU condemned the judge’s actions Wednesday calling it "improper" and saying it was "motivated by partisan interests" or the "result of his political loss." The organization has since called on the Texas Commission on Judicial Conduct to launch an investigation.
"Judge Devlin’s mass release of children today, without any apparent concern for the children's safety or for ensuring that they are released to their parents, proves his detachment from the needs of each child,” the ACLU said in a statement.
Oakes responded to a request for comment on Thursday evening saying, "I am out of town but from what I've heard I would not expect that from a professional."

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the judge’s actions were especially incongruous given his track record of incarcerating juvenile defendants, according to local media. a houston chronicle investigation in october revealed that devlin and judge john phillips accounted for more than one-fifth of all children sent to texas juvenile prisons last year, sending them “younger and for less-serious offenses than the county’s third juvenile court."
"i am baffled by why he did it," harris county chief public defender alex bunin told nbc news on thursday. "it's definitely not good for the kids in that they are being released without any conditions."
the public defender also said he is sympathetic to the district attorney's concerns saying the judge’s move could “endanger the public," according to a statement by harris county district attorney kim ogg.
"neither side is happy," bunin said. "this is different in that it’s across the board. it's just never been done without any consideration of the effect of the release of the child and the community."
but harris county juvenile courts manager cindy milom contested any portrayals of a "mass release" of defendants. she said only seven of 13 juvenile defendants who faced the judge wednesday were released.
milom, who said the judge was on vacation and couldn't comment on decisions he made, is also pushing back on bunin's claims expressing concern for the conditions under which the children were released.
"i really find that hard to believe because the public defender did not represent all the juveniles," milom said.
the aclu condemned the judge’s actions wednesday calling it "improper" and saying it was "motivated by partisan interests" or the "result of his political loss." the organization has since called on the texas commission on judicial conduct to launch an investigation.
"judge devlin’s mass release of children today, without any apparent concern for the children's safety or for ensuring that they are released to their parents, proves his detachment from the needs of each child,” the aclu said in a statement.
oakes responded to a request for comment on thursday evening saying, "i am out of town but from what i've heard i would not expect that from a professional."


text:
Instagram is making its face filters accessible when you go Live on its platform, and releases a new exclusive sunglasses filter.
Face filters used to be Snapchat’s thing. In fact, for most of us, they bring back memories of countless hours of fun checking out what our face looked like using each of the filters. Of course, Instagram now also has face filters. And now, the platform is making them also available during Live video.
If you ask me, face filters are even more fun when used during live videos. And on top of all its existing ones, Instagram is also introducing the new sunglasses filter, exclusively for Live video.
When your broadcast has ended, you can share a replay on your Stories, and it will include all the face filters you have used.

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instagram is making its face filters accessible when you go live on its platform, and releases a new exclusive sunglasses filter.
face filters used to be snapchat’s thing. in fact, for most of us, they bring back memories of countless hours of fun checking out what our face looked like using each of the filters. of course, instagram now also has face filters. and now, the platform is making them also available during live video.
if you ask me, face filters are even more fun when used during live videos. and on top of all its existing ones, instagram is also introducing the new sunglasses filter, exclusively for live video.
when your broadcast has ended, you can share a replay on your stories, and it will include all the face filters you have used.


text:
Refractive outcomes following cataract surgery in patients that have previously undergone laser refractive surgery have traditionally been underwhelming. This is related to several key issues including the preoperative assessment (keratometry) and intraocular lens power calculations. Peer-reviewed literature is overwhelmed by the influx of methodology to manipulate the corneal or intraocular lens (IOL) powers following refractive surgery. This would suggest that the optimal derivative formula has yet been introduced. This review discusses the problems facing surgeons approaching IOL calculations in these post-refractive laser patients, the existing formulae and programs to address these concerns. Prior published outcomes will be reviewed.
The unfortunate irony for post laser refractive surgery patients has been the difficulty in achieving consistent, accurate refractive outcomes following cataract removal and intraocular lens (IOL) implantation [1,2]. Subsequently, researchers have described various errors in IOL calculation and developed a variety of approaches to overcome the reported refractive surprises [3-5]. Although refractive results have improved significantly over time, it would appear an optimal solution remains elusive, indicated by the significant number of methods available to aid post refractive IOL calculations . The purpose of this review is to identify the issues relating to IOL power calculations and describe the available methods to improve the accuracy of post cataract surgery outcomes. Published results will be discussed to provide an overview of current outcomes.
There are three main sources of error in IOL calculation for patients who have previously undergone laser refractive surgery: the index of refraction error, the measurement of corneal radius error and the inherent errors within the IOL formulas . These are discussed in more detail below.
Most keratometers measure the central anterior surface of the cornea only. The production of an accurate corneal power value thereby is reliant on several assumptions; firstly that the corneal surface has uniform curvature and power; and secondly that the relationship between the anterior and posterior surfaces remains fixed. The use of the average keratometric index, routinely 1.3375, assumes that these models are adhered to. Ablative laser procedures inherently change the relationship between the anterior and posterior curvature of the cornea, immediately invalidating the above assumptions. Furthermore, the true index of refraction will vary dependent on the amount of laser ablation (and remaining tissue) further impeding the use of a basic or standardized keratometric index . In eyes that have undergone myopic ablative refractive procedures, the resulting keratometry readings obtained by standard keratometry or topography will appear erroneously high, subsequently leading to an underestimation of the final IOL power . Depending on the literature, this value is estimated to represent a difference of between 14% to 25% . The opposite will occur in patients that were previously hyperopic.
This error may be mediated by adjusting the corneal power values through the use of refraction-derived keratometry values or through the use of regression-based formulas [10,11]. Although current literature provides adequate outcomes, the results do remain variable suggesting further validation is still required [12-15]. Bypassing the keratometric index and calculating corneal power by using Gaussian optics formula or ray tracing, based on Snell’s law, may yet provide the optimal approach . Both approaches require the examiner to obtain valid measurements for anterior and posterior corneal curvatures.
A further functional error may occur in obtaining the actual keratometric measurement . Corneal curvature measurements not obtained from the corneal centre may be erroneous . This error has been referred to as the “radius error”. This may reflect both the incapability of some keratometry units (or corneal topographers) to measure the central corneal area and the inability of these devices to incorporate the change to an aspherical cornea produced by the surgery [17,18]. These errors have been ameliorated with the use of diagnostic technology such as ray tracing and with the evolution of lasers using larger effective optical zones. The radius error impacts all post refractive IOL patients, however the risk of significant invalid measurements is increased in patients with small or decentered laser ablations.
It has been suggested that the magnitude of error in IOL power calculations is much lower in previously hyperopic eyes than in post myopic eyes due to the relatively minimal corneal steepening in hyperopic laser in situ keratomileusis (LASIK) and a diminished reduction in the change of refraction index secondary to the corneal steepening [19,20].
Most third and fourth generation theoretical formulas share the same basic approach. This includes the primary equation to determine the effective lens position (ELP), based on parameters such as keratometry and axial length. Thereafter, this result is used in the original vergence formula to determine the suggested IOL power [21-23]. Identified by Aramberri, the use of the post laser keratometry values to determine the ELP is flawed . Essentially, anterior chamber depth should not change as a result of the laser surgery. Therefore, using the artificially lower keratometry values will lead to an underestimation of the ELP and resulting IOL power. The proposed “Double-K” procedure, using the preoperative keratometry for the ELP equation and the postoperative keratometry values in the IOL power calculation was derived to overcome this. Subsequently the “Double-K” technique figures in the majority of the calculations proposed [24,25]. This issue was similarly recognized by Holladay and is incorporated into his proprietary software available to surgeons (by checking the “previous RK” box on the IOL Consultant Program) . Of note, within the Holladay IOL Consultant Program, if the pre-laser keratometry values are unknown, a standard value is then used, which has been variably reported as 43.86 and 44.00 in the literature [4,26]. The true value remains under proprietary considerations.
The Haigis-L formula represents an alternative approach to bypass the inherent errors of post refractive subjects. The formula applies a correction curve to the existing measurement to derive the effective corneal power thereby bypassing both keratometer and radius errors . This value is then incorporated into the original Haigis formula for standard eyes. Significantly, the original formula does not use corneal radius as a predictor of IOL position thus further reducing the risk of the formula error.
To fully describe the historical outcomes of post refractive IOL power formulas, a PubMed database search was performed for relevant literature between 1998 to October 2014. The search included the following keywords; IOL power calculation, refractive surgery, keratometry, LASIK, photorefractive keratectomy (PRK) and radial keratotomy (RK). Two hundred and twenty four articles were retrieved and evaluated. Approximately 70 keratometry or IOL power formulas were found. These were separated into 4 separate sub-headings including history methods, change in manifest refraction, no prior data and others (Table 1). The majority of calculations included in the “Others” column include topography derived keratometry values. Some approaches may have differed minimally from other established formulas and may not have been included.
^Used in conjunction with other methods to derive IOL power.
*May be used without clinical history information.
°Incorporated into the American Society of Cataract & Refractive Surgeons Post Refractive Calculator.
#Available in the Hoffer-Savini LASIK IOL Power Tool.
Note: references not provided for IOL formulas based on topographic measurement variations.
A discussion of the main formulas and respective refractive outcomes follows.
Originally proposed independently by Eiferman and Holladay, the “clinical history method” represented the first method to overcome the intrinsic IOL calculation issues in post laser refractive surgery patients [27,28]. For many years, this method remained the so-called “gold standard” for comparison . The methodology remains relatively simple. The effective keratometry value is calculated by subtracting the change in refraction induced by the treatment from the preoperative mean corneal power. This method effectively bypasses the index of refraction error. The main disadvantage of the clinical history method and similar formulas is the reliance on preoperative keratometry and refractive data. The effectiveness of these methods may be reduced by the possibility of further errors including but not limited to: the use of inaccurate central corneal measurements, variation in measurement units before and after surgery and the potential impact of index myopia [7,9,30]. Practically, the follow-up required to obtain the data may be particularly cumbersome if the patient had their refractive surgery elsewhere or a number of years previously. In a large study, Wang et al. found that formulas requiring both the preoperative refraction and keratometry values performed poorly compared to other available methods. Results showed significant variability with high IOL prediction errors and relatively low percentages of outcomes within ± 0.5 D and ± 1.0 D . This has been mirrored in subsequent studies and these methods should no longer be used [31-33].
Several approaches aim to bypass the need for preoperative keratometry and represent valid alternatives.
A number of methods propose applying a correction, based on the change in refraction, to the postoperative keratometry value. This value is then appropriately inserted into the Double-K formula to provide the final IOL power [34,35]. The “Adjusted Effective Refractive Power (EffRP)” and “Adjusted Atlas 9000 (4 mm Zone)” methods are commonly used examples available through the American Society of Cataract and Refractive Surgeons (ASCRS) IOL Calculator. These methods rely on the availability of the particular topographical unit and require the examiner to directly assess the measurement to confirm the quality of the reading.
Masket and Masket recognized the difficulty in obtaining accurate postoperative corneal measurements and effectively bypassed these potential errors by creating a formula based on the change in laser correction . The authors determined that the chief corrective factor in post-refractive patients was the amount of pre-ablative myopia. Subsequently, a value based on a simple regression formula deriving the change in manifest refraction, was added to the standard IOL calculation. Other authors have undertaken similar approaches with basic variations of the regression formulas [37-41]. Walter et al. described an even simpler approach: by assuming the patient never had myopic laser surgery and replacing the standard IOL target with the pre-laser amount of myopia . Although the authors reported excellent results, the initial study has been criticized by the use of a small sample size to derive the formula.
The risk of index myopia related errors remains considerable for methods based on the change in manifest refraction.
Common to all previous formulas is the requirement for preoperative keratometry and/or refraction data. This is often unavailable to surgeons and alternative approaches therefore remain necessary. Formulas based on postoperative information serve either to re-measure or recalculate the current keratometry values prior to entry into existing IOL calculations.
The over-refraction of a hard contact lens has been described previously [30,43]. This effectively re-measures the corneal curvature rather than providing a recalculated value. This approach has been limited by technical and time constraints. Difficulty in achieving an adequate refraction in patients with poor visual acuity further reduces the effectiveness of this method.
Shammas et al. previously described a simple equation modifying post-laser keratometry values to determine the corrected corneal power to be used in IOL calculation formulas . Other researchers have taken similar approaches. The Maloney and Koch-Maloney methods convert the post-laser keratometry values from corneal topography to the exact power present at the anterior corneal surface and then add an average negative power value for the posterior corneal surface . These latter formulas have been based on values obtained by the Atlas topography (Zeiss, Germany) and thereby remain of limited value to practices without this unit.
As described earlier, the Haigis-L formula bypasses the various errors through the use of a correction formula then applied to the standard Haigis formula. The relative availability of the Haigis-L formula across several platforms including both instrument and web-based programs, has led to the formula rapidly becoming a focus of many comparative studies albeit with varying results [46,47].
Mackool et al. suggested an alternative approach . The cataract is first removed and the patient is required to wait for an hour before an aphakic refraction is undertaken. An algorithm is then applied to the refraction to determine the true IOL power to be inserted. Ianchulev and Leccisotti also described “on the table” approaches with reasonable postoperative outcomes [49,50]. Sheppard, however, compared all three intraoperative aphakic formulae with mixed results . The author suggested that intrinsic differences within the formulae determine the most appropriate use in patients, that is, both the Leccisotti and Ianchulev formulae appear to provide better results for posterior IOL positions and the Mackool algorithm more appropriate for anterior chamber IOLs. Intraoperative reforming of the anterior chamber either with balanced salt solution or visco-surgical devices and variable refractive indexes remain significant obstacles for these methods achieving consistent postoperative outcomes [49-51]. More recently, the use of intraoperative wavefront aberrometry has been described to further refine outcomes . Results using the WaveTec Intraoperative Wavefront aberrometer were compared with several established formulae in post refractive patients. The WaveTec readings were more accurate than predictive formulae, most often predicting to within ± 0.5D of emmetropia. Tellingly however in this study, no method was able to achieve this accuracy more than 50% of the time, which highlights the relative inaccuracy of the post refractive formulae. Ianchulev and co-authors recently described more optimistic results with intraoperative aberrometry. They detailed results achieved with the Optiwave Refractive Analysis (ORA) System wavefront aberrometer that appeared to surpass those with comparative preoperative methods of IOL calculation .
The principles of ray tracing suggest that using this method for IOL calculations may provide more accurate, reproducible results compared to existing alternate keratometric methods. Ray tracing technology is currently available in many topographical systems although results may be enhanced with the addition of external computational programs such as Okulix (Oculix, Dortmund, Germany). Savini et al. indicate that ray-tracing avoids the systemic issues involved with post refractive cases . Calculating the refracted ray at both anterior and posterior surface avoids the use of the average, fictitious corneal refractive index. The ability of the ray tracing software to be performed over any corneal diameter minimizes potential instrument and thereby radius error. Finally, formula errors are avoided as the IOL position may be calculated without respect to the single anterior curvature value . Hoffmann et al. suggested that although the prediction accuracy of ray tracing remains only comparable to third-generation formulae, the accuracy in abnormal eyes, those with long or short axial length and those with prior refractive surgery is improved . The results obtained by Savinni and co-authors in recent papers further highlights the potential of using values based on ray tracing principles [12,17,53].
Although a number of formulae may now provide improved refractive outcomes in post laser refractive surgery patients, it remains a difficult and time-consuming action to derive the IOL powers using multiple formulae. This task however, has been made significantly easier with the advent of several available web- or app-based programs.
Developed with the support of the ASCRS, the ASCRS Post Refractive Calculator (www.iolcalc.org) remains an efficient method for obtaining multiple IOL formulae. The program utilizes several referenced formulas and provides an average of all available methods. Recognizing the increasing reliance on non-historical methods, the website recently introduced a further value representing the average of all non-historical methods. The formulae from the ASCRS website have been used in several studies and appear to provide consistent, reliable outcomes [24,25,29,52].
The Hoffer-Savini LASIK IOL Power Tool represents a similar approach, albeit through the use of a downloadable spreadsheet (available from www.iolpowerclub.org/post-surgical-iol-calc). The user enters the available keratometry and biometric values from which the spreadsheet provides the recalculated corneal power values to use in subsequent IOL formulae. The spreadsheet also calculates the IOL power directly through several available formulae. Although the IOL Power Tool replicates some of the formulae in use with the ASCRS web tool, the use of alternative formulae may provide further information for the surgeon.
Several other websites or applications remain available albeit without the range of the aforementioned sites. The Asia Pacific Association of Cataract and Refractive Surgeons (www.apacrs.org) provides the Barrett True-K formula for post-refractive IOL patients. The McCarthy Post Refractive IOL Calculator (www.mccarthyeye.com/post-refractive-iol-calculator) provides several relevant formulae based on the outcomes of the authors’ prior study of 173 post-LASIK eyes . Several applications are available for use with existing iOS or Android devices. These include the Eye Pro application, which utilizes the BESSt post refractive IOL formula and the PAK post refractive IOL formula. [Note: the BESSt formula requires the input of keratometry values obtained by the Pentacam topography unit (Oculus Pentacam, Germany) [55-57]].
Within the UK National Health Service, figures of within ± 0.50 D for 55% and within ± 1.00 D for 85% have been used to provide a standard for refractive outcomes following cataract surgery in normal eyes . While this gauge underestimates the visual outcomes now expected, it supplies a benchmark standard that has been used in previous studies [29,32,39]. Table 2 delineates comparative results from past papers evaluating a variety of formulas in post laser vision correction cataract procedures.
The range for values occurring within ± 0.50 D and ± 1.00 D remains highly variable. The lowest percentage is reported by Canto et al.  at 39% and 60% respectively, for their small series detailing the use of an intraoperative wavefront aberrometer. This would suggest that recording the simple intraoperative value does not take into account the impact of all surgical variables. Conversely, Masket and Masket reported 93.3% and 100% of patients within ± 0.50 D and ± 1.00 D respectively of the intended correction . Both Geggel and Hu similarly reported 100% of their patients within ± 1.00 D following surgeries in their respective cohorts [59,60]. Although Masket and Masket’s original paper was based on a relatively small sample size, which may have biased the final outcome, importantly the success of the formula has replicated with consistently good outcomes in further studies [31,32,61].
A criticism of most post-refractive IOL formulae remains the relatively low numbers used to derive the accompanying outcomes. The range amongst the listed publications remains significant from a minimum of 10 patients to a maximum of 246 (median of 27 patients) [46,59]. The availability of formulae and relative number of post refractive patients proceeding to surgery would suggest that further audits might provide additional important information to assist surgeons in choosing the most appropriate formulae. Similarly, it might provide a platform for a revised methodology.
The optimal correction of post-refractive IOL patients represents an ongoing concern for surgeons. The use of available programs and existing formulas serves to improve upon prior results however literature suggests that consistent outcomes similar to those obtained in virgin eyes currently remains out of reach. The continued audit of post-refractive IOL outcomes, the development of corneal imaging technology, and improved intraoperative wavefront aberrometry may provide the best opportunity for surgeons in the short to medium term.
All authors participated in the design of the review and helped. All authors read and approved the final manuscript.
Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS): http://www.apacrs.org.
Hill W, Wang L, Koch DD. IOL power calculation in eyes that have undergone LASIK/PRK/RK. http://iolcalc.org.

lowercased:
refractive outcomes following cataract surgery in patients that have previously undergone laser refractive surgery have traditionally been underwhelming. this is related to several key issues including the preoperative assessment (keratometry) and intraocular lens power calculations. peer-reviewed literature is overwhelmed by the influx of methodology to manipulate the corneal or intraocular lens (iol) powers following refractive surgery. this would suggest that the optimal derivative formula has yet been introduced. this review discusses the problems facing surgeons approaching iol calculations in these post-refractive laser patients, the existing formulae and programs to address these concerns. prior published outcomes will be reviewed.
the unfortunate irony for post laser refractive surgery patients has been the difficulty in achieving consistent, accurate refractive outcomes following cataract removal and intraocular lens (iol) implantation [1,2]. subsequently, researchers have described various errors in iol calculation and developed a variety of approaches to overcome the reported refractive surprises [3-5]. although refractive results have improved significantly over time, it would appear an optimal solution remains elusive, indicated by the significant number of methods available to aid post refractive iol calculations . the purpose of this review is to identify the issues relating to iol power calculations and describe the available methods to improve the accuracy of post cataract surgery outcomes. published results will be discussed to provide an overview of current outcomes.
there are three main sources of error in iol calculation for patients who have previously undergone laser refractive surgery: the index of refraction error, the measurement of corneal radius error and the inherent errors within the iol formulas . these are discussed in more detail below.
most keratometers measure the central anterior surface of the cornea only. the production of an accurate corneal power value thereby is reliant on several assumptions; firstly that the corneal surface has uniform curvature and power; and secondly that the relationship between the anterior and posterior surfaces remains fixed. the use of the average keratometric index, routinely 1.3375, assumes that these models are adhered to. ablative laser procedures inherently change the relationship between the anterior and posterior curvature of the cornea, immediately invalidating the above assumptions. furthermore, the true index of refraction will vary dependent on the amount of laser ablation (and remaining tissue) further impeding the use of a basic or standardized keratometric index . in eyes that have undergone myopic ablative refractive procedures, the resulting keratometry readings obtained by standard keratometry or topography will appear erroneously high, subsequently leading to an underestimation of the final iol power . depending on the literature, this value is estimated to represent a difference of between 14% to 25% . the opposite will occur in patients that were previously hyperopic.
this error may be mediated by adjusting the corneal power values through the use of refraction-derived keratometry values or through the use of regression-based formulas [10,11]. although current literature provides adequate outcomes, the results do remain variable suggesting further validation is still required [12-15]. bypassing the keratometric index and calculating corneal power by using gaussian optics formula or ray tracing, based on snell’s law, may yet provide the optimal approach . both approaches require the examiner to obtain valid measurements for anterior and posterior corneal curvatures.
a further functional error may occur in obtaining the actual keratometric measurement . corneal curvature measurements not obtained from the corneal centre may be erroneous . this error has been referred to as the “radius error”. this may reflect both the incapability of some keratometry units (or corneal topographers) to measure the central corneal area and the inability of these devices to incorporate the change to an aspherical cornea produced by the surgery [17,18]. these errors have been ameliorated with the use of diagnostic technology such as ray tracing and with the evolution of lasers using larger effective optical zones. the radius error impacts all post refractive iol patients, however the risk of significant invalid measurements is increased in patients with small or decentered laser ablations.
it has been suggested that the magnitude of error in iol power calculations is much lower in previously hyperopic eyes than in post myopic eyes due to the relatively minimal corneal steepening in hyperopic laser in situ keratomileusis (lasik) and a diminished reduction in the change of refraction index secondary to the corneal steepening [19,20].
most third and fourth generation theoretical formulas share the same basic approach. this includes the primary equation to determine the effective lens position (elp), based on parameters such as keratometry and axial length. thereafter, this result is used in the original vergence formula to determine the suggested iol power [21-23]. identified by aramberri, the use of the post laser keratometry values to determine the elp is flawed . essentially, anterior chamber depth should not change as a result of the laser surgery. therefore, using the artificially lower keratometry values will lead to an underestimation of the elp and resulting iol power. the proposed “double-k” procedure, using the preoperative keratometry for the elp equation and the postoperative keratometry values in the iol power calculation was derived to overcome this. subsequently the “double-k” technique figures in the majority of the calculations proposed [24,25]. this issue was similarly recognized by holladay and is incorporated into his proprietary software available to surgeons (by checking the “previous rk” box on the iol consultant program) . of note, within the holladay iol consultant program, if the pre-laser keratometry values are unknown, a standard value is then used, which has been variably reported as 43.86 and 44.00 in the literature [4,26]. the true value remains under proprietary considerations.
the haigis-l formula represents an alternative approach to bypass the inherent errors of post refractive subjects. the formula applies a correction curve to the existing measurement to derive the effective corneal power thereby bypassing both keratometer and radius errors . this value is then incorporated into the original haigis formula for standard eyes. significantly, the original formula does not use corneal radius as a predictor of iol position thus further reducing the risk of the formula error.
to fully describe the historical outcomes of post refractive iol power formulas, a pubmed database search was performed for relevant literature between 1998 to october 2014. the search included the following keywords; iol power calculation, refractive surgery, keratometry, lasik, photorefractive keratectomy (prk) and radial keratotomy (rk). two hundred and twenty four articles were retrieved and evaluated. approximately 70 keratometry or iol power formulas were found. these were separated into 4 separate sub-headings including history methods, change in manifest refraction, no prior data and others (table 1). the majority of calculations included in the “others” column include topography derived keratometry values. some approaches may have differed minimally from other established formulas and may not have been included.
^used in conjunction with other methods to derive iol power.
*may be used without clinical history information.
°incorporated into the american society of cataract & refractive surgeons post refractive calculator.
#available in the hoffer-savini lasik iol power tool.
note: references not provided for iol formulas based on topographic measurement variations.
a discussion of the main formulas and respective refractive outcomes follows.
originally proposed independently by eiferman and holladay, the “clinical history method” represented the first method to overcome the intrinsic iol calculation issues in post laser refractive surgery patients [27,28]. for many years, this method remained the so-called “gold standard” for comparison . the methodology remains relatively simple. the effective keratometry value is calculated by subtracting the change in refraction induced by the treatment from the preoperative mean corneal power. this method effectively bypasses the index of refraction error. the main disadvantage of the clinical history method and similar formulas is the reliance on preoperative keratometry and refractive data. the effectiveness of these methods may be reduced by the possibility of further errors including but not limited to: the use of inaccurate central corneal measurements, variation in measurement units before and after surgery and the potential impact of index myopia [7,9,30]. practically, the follow-up required to obtain the data may be particularly cumbersome if the patient had their refractive surgery elsewhere or a number of years previously. in a large study, wang et al. found that formulas requiring both the preoperative refraction and keratometry values performed poorly compared to other available methods. results showed significant variability with high iol prediction errors and relatively low percentages of outcomes within ± 0.5 d and ± 1.0 d . this has been mirrored in subsequent studies and these methods should no longer be used [31-33].
several approaches aim to bypass the need for preoperative keratometry and represent valid alternatives.
a number of methods propose applying a correction, based on the change in refraction, to the postoperative keratometry value. this value is then appropriately inserted into the double-k formula to provide the final iol power [34,35]. the “adjusted effective refractive power (effrp)” and “adjusted atlas 9000 (4 mm zone)” methods are commonly used examples available through the american society of cataract and refractive surgeons (ascrs) iol calculator. these methods rely on the availability of the particular topographical unit and require the examiner to directly assess the measurement to confirm the quality of the reading.
masket and masket recognized the difficulty in obtaining accurate postoperative corneal measurements and effectively bypassed these potential errors by creating a formula based on the change in laser correction . the authors determined that the chief corrective factor in post-refractive patients was the amount of pre-ablative myopia. subsequently, a value based on a simple regression formula deriving the change in manifest refraction, was added to the standard iol calculation. other authors have undertaken similar approaches with basic variations of the regression formulas [37-41]. walter et al. described an even simpler approach: by assuming the patient never had myopic laser surgery and replacing the standard iol target with the pre-laser amount of myopia . although the authors reported excellent results, the initial study has been criticized by the use of a small sample size to derive the formula.
the risk of index myopia related errors remains considerable for methods based on the change in manifest refraction.
common to all previous formulas is the requirement for preoperative keratometry and/or refraction data. this is often unavailable to surgeons and alternative approaches therefore remain necessary. formulas based on postoperative information serve either to re-measure or recalculate the current keratometry values prior to entry into existing iol calculations.
the over-refraction of a hard contact lens has been described previously [30,43]. this effectively re-measures the corneal curvature rather than providing a recalculated value. this approach has been limited by technical and time constraints. difficulty in achieving an adequate refraction in patients with poor visual acuity further reduces the effectiveness of this method.
shammas et al. previously described a simple equation modifying post-laser keratometry values to determine the corrected corneal power to be used in iol calculation formulas . other researchers have taken similar approaches. the maloney and koch-maloney methods convert the post-laser keratometry values from corneal topography to the exact power present at the anterior corneal surface and then add an average negative power value for the posterior corneal surface . these latter formulas have been based on values obtained by the atlas topography (zeiss, germany) and thereby remain of limited value to practices without this unit.
as described earlier, the haigis-l formula bypasses the various errors through the use of a correction formula then applied to the standard haigis formula. the relative availability of the haigis-l formula across several platforms including both instrument and web-based programs, has led to the formula rapidly becoming a focus of many comparative studies albeit with varying results [46,47].
mackool et al. suggested an alternative approach . the cataract is first removed and the patient is required to wait for an hour before an aphakic refraction is undertaken. an algorithm is then applied to the refraction to determine the true iol power to be inserted. ianchulev and leccisotti also described “on the table” approaches with reasonable postoperative outcomes [49,50]. sheppard, however, compared all three intraoperative aphakic formulae with mixed results . the author suggested that intrinsic differences within the formulae determine the most appropriate use in patients, that is, both the leccisotti and ianchulev formulae appear to provide better results for posterior iol positions and the mackool algorithm more appropriate for anterior chamber iols. intraoperative reforming of the anterior chamber either with balanced salt solution or visco-surgical devices and variable refractive indexes remain significant obstacles for these methods achieving consistent postoperative outcomes [49-51]. more recently, the use of intraoperative wavefront aberrometry has been described to further refine outcomes . results using the wavetec intraoperative wavefront aberrometer were compared with several established formulae in post refractive patients. the wavetec readings were more accurate than predictive formulae, most often predicting to within ± 0.5d of emmetropia. tellingly however in this study, no method was able to achieve this accuracy more than 50% of the time, which highlights the relative inaccuracy of the post refractive formulae. ianchulev and co-authors recently described more optimistic results with intraoperative aberrometry. they detailed results achieved with the optiwave refractive analysis (ora) system wavefront aberrometer that appeared to surpass those with comparative preoperative methods of iol calculation .
the principles of ray tracing suggest that using this method for iol calculations may provide more accurate, reproducible results compared to existing alternate keratometric methods. ray tracing technology is currently available in many topographical systems although results may be enhanced with the addition of external computational programs such as okulix (oculix, dortmund, germany). savini et al. indicate that ray-tracing avoids the systemic issues involved with post refractive cases . calculating the refracted ray at both anterior and posterior surface avoids the use of the average, fictitious corneal refractive index. the ability of the ray tracing software to be performed over any corneal diameter minimizes potential instrument and thereby radius error. finally, formula errors are avoided as the iol position may be calculated without respect to the single anterior curvature value . hoffmann et al. suggested that although the prediction accuracy of ray tracing remains only comparable to third-generation formulae, the accuracy in abnormal eyes, those with long or short axial length and those with prior refractive surgery is improved . the results obtained by savinni and co-authors in recent papers further highlights the potential of using values based on ray tracing principles [12,17,53].
although a number of formulae may now provide improved refractive outcomes in post laser refractive surgery patients, it remains a difficult and time-consuming action to derive the iol powers using multiple formulae. this task however, has been made significantly easier with the advent of several available web- or app-based programs.
developed with the support of the ascrs, the ascrs post refractive calculator (www.iolcalc.org) remains an efficient method for obtaining multiple iol formulae. the program utilizes several referenced formulas and provides an average of all available methods. recognizing the increasing reliance on non-historical methods, the website recently introduced a further value representing the average of all non-historical methods. the formulae from the ascrs website have been used in several studies and appear to provide consistent, reliable outcomes [24,25,29,52].
the hoffer-savini lasik iol power tool represents a similar approach, albeit through the use of a downloadable spreadsheet (available from www.iolpowerclub.org/post-surgical-iol-calc). the user enters the available keratometry and biometric values from which the spreadsheet provides the recalculated corneal power values to use in subsequent iol formulae. the spreadsheet also calculates the iol power directly through several available formulae. although the iol power tool replicates some of the formulae in use with the ascrs web tool, the use of alternative formulae may provide further information for the surgeon.
several other websites or applications remain available albeit without the range of the aforementioned sites. the asia pacific association of cataract and refractive surgeons (www.apacrs.org) provides the barrett true-k formula for post-refractive iol patients. the mccarthy post refractive iol calculator (www.mccarthyeye.com/post-refractive-iol-calculator) provides several relevant formulae based on the outcomes of the authors’ prior study of 173 post-lasik eyes . several applications are available for use with existing ios or android devices. these include the eye pro application, which utilizes the besst post refractive iol formula and the pak post refractive iol formula. [note: the besst formula requires the input of keratometry values obtained by the pentacam topography unit (oculus pentacam, germany) [55-57]].
within the uk national health service, figures of within ± 0.50 d for 55% and within ± 1.00 d for 85% have been used to provide a standard for refractive outcomes following cataract surgery in normal eyes . while this gauge underestimates the visual outcomes now expected, it supplies a benchmark standard that has been used in previous studies [29,32,39]. table 2 delineates comparative results from past papers evaluating a variety of formulas in post laser vision correction cataract procedures.
the range for values occurring within ± 0.50 d and ± 1.00 d remains highly variable. the lowest percentage is reported by canto et al.  at 39% and 60% respectively, for their small series detailing the use of an intraoperative wavefront aberrometer. this would suggest that recording the simple intraoperative value does not take into account the impact of all surgical variables. conversely, masket and masket reported 93.3% and 100% of patients within ± 0.50 d and ± 1.00 d respectively of the intended correction . both geggel and hu similarly reported 100% of their patients within ± 1.00 d following surgeries in their respective cohorts [59,60]. although masket and masket’s original paper was based on a relatively small sample size, which may have biased the final outcome, importantly the success of the formula has replicated with consistently good outcomes in further studies [31,32,61].
a criticism of most post-refractive iol formulae remains the relatively low numbers used to derive the accompanying outcomes. the range amongst the listed publications remains significant from a minimum of 10 patients to a maximum of 246 (median of 27 patients) [46,59]. the availability of formulae and relative number of post refractive patients proceeding to surgery would suggest that further audits might provide additional important information to assist surgeons in choosing the most appropriate formulae. similarly, it might provide a platform for a revised methodology.
the optimal correction of post-refractive iol patients represents an ongoing concern for surgeons. the use of available programs and existing formulas serves to improve upon prior results however literature suggests that consistent outcomes similar to those obtained in virgin eyes currently remains out of reach. the continued audit of post-refractive iol outcomes, the development of corneal imaging technology, and improved intraoperative wavefront aberrometry may provide the best opportunity for surgeons in the short to medium term.
all authors participated in the design of the review and helped. all authors read and approved the final manuscript.
asia-pacific association of cataract and refractive surgeons (apacrs): http://www.apacrs.org.
hill w, wang l, koch dd. iol power calculation in eyes that have undergone lasik/prk/rk. http://iolcalc.org.


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lowercased:
become part of the fast-growing area of the cryptocurrency world. our [crypto exchange development team provides a holistic solution to launch a successful bitcoin exchange to buy, sell and exchange cryptocurrencies.
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how can there be no technical supporting in opening up the market?
opens a new experience in global real estate and tourism!


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The "Caucasian Knot" has reported that on March 13, the Parliament of South Ossetia expressed distrust to Foreign Minister David Sanakoev for his publication in the media of the draft treaty on cooperation and integration with Russia. According to Anatoly Bibilov, the Speaker of the Parliament, the actions of David Sanakoev "caused the public split within the country."
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lowercased:
the "caucasian knot" has reported that on march 13, the parliament of south ossetia expressed distrust to foreign minister david sanakoev for his publication in the media of the draft treaty on cooperation and integration with russia. according to anatoly bibilov, the speaker of the parliament, the actions of david sanakoev "caused the public split within the country."
it is assumed that the ex-foreign minister will take an office at the presidential administration, the "interfax" reports.
let us remind you that on april 14, david sanakoev sent an appeal to the supreme court of south ossetia to recognize invalid the parliament's decision of the vote of no confidence against him.
cec: tibilov was elected president of south ossetia by 56,12% votes, cec of south ossetia declines presidential candidates' proposals on election control, cec of south ossetia announced the results of the first round of the presidential election.


text: Life has been a deluge for the past month and a half since my last posting. The flurry of the holidays never subsided, but rather seemed to mark the pace for the new year. I am extremely grateful for the many gifts and blessings that have found their way into my life amidst the torrent: family time, new employment opportunities, travel, and hatchling plots to highlight a few of my life's notable boons. All in all there is far too much to include in this brief post. At the moment, I write mostly to state my intention of returning to my pet project here at www.HGLMD.com invigorated by the rich experiences of the past few weeks. Thank you all who read my musings. I am looking forward to sharing more of my Happy Go Lucky adventures in the coming days, weeks, months, etc.

lowercased: life has been a deluge for the past month and a half since my last posting. the flurry of the holidays never subsided, but rather seemed to mark the pace for the new year. i am extremely grateful for the many gifts and blessings that have found their way into my life amidst the torrent: family time, new employment opportunities, travel, and hatchling plots to highlight a few of my life's notable boons. all in all there is far too much to include in this brief post. at the moment, i write mostly to state my intention of returning to my pet project here at www.hglmd.com invigorated by the rich experiences of the past few weeks. thank you all who read my musings. i am looking forward to sharing more of my happy go lucky adventures in the coming days, weeks, months, etc.


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