 Okay, we can't talk about IOLs without going back to Mr. Ridley, the original maker of the IOL. This is one of his surgical videos from 1951. I have to show you this. That's a graphe knife. You go across the eye and just cut the cornea in half. That's a graphe knife. Now he replaced some, some four-row silk sutures in there. Now you go in there and you basically tear out the capsule. You just tear it out, as some of you guys do in surgery. Now you'll see he's just squeezing out the nucleus and of course we didn't realize about endothelial cells there. That's about 20,000 endothelial cells. And then you just flush out the cortex and wash it out. And then this is the, this is the Ridley lands being plighted. This is done with loops. No microscope. And no gloves. Yeah, yeah. So 1951. All right, very good. So I just need to show you that before we go back to our talk. So bear with what's been done to this point. So we want to go ahead and just, just go over IOLs from alpha to omega from start to finish. And of course we have to go back to Copenhagen and see that this is the canals and this is the famous street where all the shops and restaurants that are full of tourists. It must drive the people who live there crazy because there's always a bunch of tourists sitting down there, taking up all the good places in their restaurants. And this is just showing you the, the old parliament building from behind. And of course you've got all your classic spires. Now there's kind of like dragging gargoyles climbing up here and snakes going up the tops. I'm not sure what the point of snakes and gargoyles were, but obviously very important when they were carving these out. And there's another close-up. There's the gargoyle and eating the snake that's going up the top of the tower. Well, if you're going to start talking about IOLs, you have to start talking about Mr. Ridley. And this is St. Thomas's Hospital in London. And this is right across the street from part of it. So of course Crandall and I were there. This was at least 10 years ago when we went to there because you can see I still have brown hair. Crandall's hair hasn't changed any so, but that's all natural. He just says good genes. So we decided that we wanted to find the famous plaque for Ridley and St. Thomas's. So we went to St. Thomas's and we said, where is the Ridley plaque? And, you know, of course the response of the people at the desk was, who? What's Jeff talking about? You know, so we finally found it. And this was in some bottom hallway tucked in the back of the hospital. We found it and we took a picture now. So here this says this was the first intraocular lens that planted by Mr. Harold Ridley. Since that time, Mr. Ridley became a Sir Harold Ridley. So he was actually knighted by Queen Elizabeth. And then they've actually moved this plaque up and they've had a little bit of a kind of a little shrine there to honor him. But when we first went, we had to really go down a back hallway to find this. So this honors Mr. Ridley. Here's Mr. Ridley and some of his fishing lures. And he lived to be into his mid 90s. Unfortunately at the end, he was quite deaf. And so if you had to try to have a conversation with him, he just couldn't couldn't hear anything, which was too bad. And when they honored him at the ASCRS meeting, sadly, he kind of got his notes mixed up and fumbled around. And so it was, you know, just thought a happy time, but he couldn't hear anything. But in any event, the bottom line is people honored Mr. Ridley. And that was the important thing at the ASCRS. So this was Ridley's original lens. And what was interesting is that Ridley was a surgeon in the United Kingdom during World War Two. And he started off doing tropical medicine, which is interesting. So he was in Southeast Asia. And then at the beginning of World War Two, and then he was called back to England. By then he'd become, you know, just an ophthalmologist. And he was treating Royal Air Force fighter pilots during the Blitz when the Nazis were bombing London. And what was interesting is as these planes were being attacked and hit by machine guns, the cockpits were shattering and bits of the cockpit were going into their eye. Fertuitously, the cockpit was made up of plexiglass, which is PMMA, Paulingotha methacrylate. And Ridley noted that this material was very inert in the eye. It did not cause any inflammation. And so as he started thinking about ways to treat cataract patients, you know, legend has it that he did a cataract surgery and a student in the OR said, well, what do you put in to replace the cataract? And, you know, Ridley said, well, nothing. And I'm not sure if that's true or not. He sadly didn't live long enough for me to ask him. But in any event, during the cataract surgery that was done in the 40s and 1950s, we would remove the cloudy cataract and give people a fake expectacles. I don't know if you guys still see people in clinic with a fake expectacles. They're pretty amazing. They're like a plus 20 coke bottom, basically really thick in the middle and thin in the periphery. And although people could conceivably see 2020 with these, they had just terrible quality of vision. They would have it would be magnified 25 percent. They'd have this rim in the periphery where it would just go around the edge of the lens and you just couldn't see. So they had what's called the jack-in-the-box phenomenon where you could be driving your car and there'd be a car next to you and you wouldn't see them. And then suddenly they pop up out of nowhere. So very, very difficult. So Ridley started thinking about it and saying, you know what? Why don't we come up with a lens implant that goes back inside the eye to replace the cataractless lens that we removed? Now, during this time, a lot of people were doing intracaps where you would remove the entire lens, its caps or bag and its contents. So there's no place to put an eye on. Well, but Ridley was playing around with crude extra caps, as you saw in that video. And so his thought was, you know, we're going to put this implant where God intended it in the posterior chamber. And so he invented this round disc. This is what it looks like. This is an EM of an old Ridley lens. It's this round disc with a little flange around it. The idea is you should put it back inside the lens capsular bag. This was an eye that had a Ridley lens in it for greater than 30 years. And you can see fortuitously it ended up inside the capsular bag. The bag kind of scored around it. Well, as you can see from the video, there were really crude capsule atomies. And so the idea of putting this in the bag was, you know, not a real good idea. I mean, it was a good idea, but it didn't happen much of the time. And so these implants ended up in the sulcus. They ended up dislocating. They ended up with pupil area block. And so lots and lots and lots of problems with this implant. But the idea was set. So that was the idea. And here's the edge of it, too. And so you could see a little bit of rough edge there. They were kind of hand polishing these. Now, interestingly, the company that made this was Rainer, which is still in England and still making implants all these years later. So, you know, 65 years later, Rainer is still making these original implants. So just to give you a little bit of a history of what Ridley went through. So Ridley did these secretly. I mean, the hierarchy in the hospital was very suspicious of, you know, change. Not a, you know, 1950s, not a time of really radical change going on anywhere. And so as a result, Ridley did these in secret and had to really be careful about people knowing about this. And so slowly, but surely, he started presenting this in England and in Europe in this new idea, this intraocular lens. So he came to the United States and he did a presentation at the American Academy of Ophthalmology and Otolaryngology. Following which, the president of the Academy stood up and said, if anyone in America puts one of these dangerous devices inside a patient's eye, I will personally testify for the lawyer that's suing them. This is the chairman of the American Academy of Ophthalmology annual meeting. So this was 53, maybe 54. So needless to say, organized ophthalmology was not in favor of implants or not in favor of fake emulsification. I find it really ironic that this year is the 50th anniversary of Charles Kellman inventing the fecal machine. And the Academy is going to do a big gala. This followed their meeting in New Orleans celebrating that. Again, after the Academy said that fecal was, you know, the, you know, made by the devil and was just these cowboys and buccaneers and sharks using an extra cap is just as good a surgery. So we find it really ironic that the Academy is actually honoring Kellman for his invention. Now, ASCRS, because our meeting is first, it's in May, we're actually doing the true 50-year anniversary because the ASCRS was actually a rebel organization founded to oppose the Academy's opposition to intracular lenses and fecal. So, you know, at that time it was called the American Intracular Implant Society. It was a real rebel organization, so just to give you some background. All right. So bottom line was Ridley came up with this idea and said, you know, I think this is a great idea. Americans were banned from doing anything. So all IOL research that took place for the next 15 years took place in Europe. Now, because most doctors were not doing extra caps as Ridley did, they were doing intracaps. So what you would do is you would put in some alpha chymotrypsin, you would dissolve the zonules, you'd pop the whole lens out, bag and all, nice clean surgery, put in lots of stitches and give them any fake-head glasses. So that did not leave you a lens capsule to support an IOL. So doctors said, well, why don't we put an IOL in the anterior chamber? So here you see kind of a schematic of one of the crude anterior chamber IOLs. Now they hit on a good material. PMMA is very inert, still material that we use today. And so one of Mr. Ridley's students, Peter Choice, decided, OK, why don't we develop some anterior chamber IOLs? And so Choice went through nine different iterations of his IOL. So this was the, you know, this was the Mach 1, the first one that he did. And I don't know why, but, you know, like Mark is a speed thing. It sounds pretty cool. Like, you know, the Razors, the Mach 8, you know, Schaver from Gillette. So this was the Mach 1 and he went through nine different iterations. And now this was the one that took hold. This was the Mach 8, Roman numeral 8. So this was the Choice lens. And you can see it's a one-piece PMMA. It's got these foot plates on it. And if this lens were well-finished and well-sized and placed under the eye properly, it did OK. And so this lens was the lens that most people started using when they were starting to use IOLs. This was the later version. This was the Mach 9. This one didn't take off quite so well. Now some of the problems that these lenses could cause is that they're in the anterior chamber. They're scraping on the iris. They're, you know, going into the anterior chamber angle. If you look right here, there's a little bit of blood here. In fact, when the U.S. tried to jump on the bandwagon and copy these, several U.S. companies popped up and said, hmm, this is maybe a good idea. Why don't we start making these? They started making choice rip-offs. And the problem with the choice rip-offs is they weren't well-made. And that caused the beginning of what you guys now know as the UG syndrome, uveitis glaucoma hyphaema for anterior chamber inflammation. You can see another problem with these lenses. They came in two sizes, kind of like cutting knots, you know, too long and too short. And so if they were too long, or if you were putting them in and pinch the iris, you would get this oval cat's eye pupil. And of course, you'd get the chronic uveitis, chronic glaucoma, and the UG syndrome. And so here you see, this is an eye, this is an eye that's been cut in half. Here's the anterior chamber angle there. You can see that it's actually tucked. The root of that iris behind where that foot plate was that actually caught it and tucked it, gave it cat's eye pupil. What do we have? Ah, Eileen, we do have a senior. What's going on here in the angle? There's a lot of pigment there. Yeah, so pigment dispersion, pigmentary glaucoma. So you're right into a lot of problem with these, these anterior chamber lenses. This is the edge of a copy choice lens that was made in the U.S. Look at that. I mean, just for fun when I was a fellow, I wish I still had that picture. We took a Coke while it broke it and then did an EM of the edge of the Coke bottle and it looked smoother than that. So you can imagine what that's gonna do, scraping the iris or scraping any part of the anterior chamber of the eye. So these lenses had to be properly sized, properly finished. And so choice, I made the mistake. I was a young Dave Apple fellow presenting our work on these choice lenses and of course, choice was on the panel as I'm presenting this and he was very upset, very huffy. These are not my lenses. These are unlicensed copies. So we had to say at that point, choice copy or choice-like lenses after that because his lenses did not do this. All right, so because these one-piece lenses were hard to fit and couldn't go well in the anterior chamber, companies started to say, well, why don't we make three-piece lenses? And as the technology improved, the optic was still made out of PMMA. It still wasn't foldable, but they were able to fashion haptics out of proline, polypropylene. Okay, so those of you who are outdoorsmen, polypropylene is Gore-Tex basically. And so they took a very low-water content Gore-Tex and they made these polypropylene haptics. And so these were the beginning of what are called the closed-loop IOLs, closed-loop anterior chamber lenses. And this is the Azar 9 lens Z lens. This was an interesting lens because at one time, this was the most popular lens in the United States. Very easy to put in. You did your intracap, you just slipped the thing in the anterior chamber, put in some sutures. These looked really good for about 18 months. So all these papers started coming out, saying, oh, these are great. Well, the problem is is after a while, these lenses were not so good and caused some problems that we'll talk about. So immediately people jumped on the bandwagon. So this was, and you named it after yourself. So if you were a surgeon, you would design one of these, the company would take it and you'd name it. So this was the Leiske lens, Larry Leiske named it after himself. And this one instead of the loops being a little bit rounded, they were more rectangular. And then they would even make them out of one piece PMMA. If you look at these carefully, look at these that were removed, look at all that pigment and stuff on the edge of the haptics that are there. And then finally someone said, oh, why don't we make it just a little bit more open? And then you see these around. These were called the stable flex lenses. Now, unfortunately, these were used length by a couple of busy surgeons here in Salt Lake. And so Alan Crandall and Randy Olson took out more of these than they want to talk about. And these were a real bugger to take out. These would fibrose into the angle and these were just held to remove. So bottom line is what happened to these? What did all these closed lube IOLs cause? Well, first of all, if you take a closed lube IOL and you squeeze it, that optic will either bound forward or bound backward as what's called vaulting. And so every time a patient rubs the eye, which patients never do, right? They never rub their eyes. These haptics would bounce off the endothelium. And so one of the side effects of these closed lube anti-chamber lenses is you got significant corneal edema. These closed lube would dig into the iris. And as a result, you'd get breakdown of the blood, aqueous barrier, you'd get chronic ugg syndrome. So they'd get corneal edema, they'd get chronic ugg syndrome. These were very, very difficult to do. And this is a cornea from one of them. And so one of my first projects when I was a Dave Apple fellow is we gathered about 18 of these Azar 911Z lenses that cause corneal edema. And so I had 18 corneas sitting in jars on my desk at which time an ocular surgeon here who set up the first cataract institute in Utah, the so-called Eye Institute, was sending limos around to pick up patients from their house to drive them for surgery and giving them flowers afterward. And was lecturing all over Utah that this lens was fantastic and he was advertising in the papers that he's the only one to use this and that there's no complications. And as he's doing this, I have 18 of these in a jar on my desk saying, no, no, there are complications. And so we did our best through Dave Apple's lab to get the word out that maybe this isn't the best lens to use. Here's a close-up of one of these open loop, I mean closed loop enter chamber lenses. This is an autopsy, I just had the cornea removed. Here's the iris, here's the edge of the eye well. Look at the open loop, look at it going into the angle now. Where does that go? It's buried in a tunnel. So you get this tunnel of iris growing over it in the angle. Here's what it looks like pathologically. Here's the root of the iris, iris stroma and loop digging in. So you can imagine what this would do. It would cause chronic glaucoma, oxyndrome, corneal edema. Here's another one with one of these stable flex lenses. These were really difficult because you could get all four of those little loops to have an individual tunnel over them. And so when you remove these, these were tough. What you had to do is you had to cut the hapics off right there and then take out the optic and then you could hopefully cut it there and then pull these out of the tunnel. If you pulled directly toward the center of the pupil, you'd get an aerodialysis and a massive hyphema. So you had to really cut these on the edge and then back them out of the tunnel. It's very, very difficult to do. Now this is an interesting lens. A guy named Dubroff in Washington, D.C. said, well, these closed loops are causing problems. Why don't we make them open looped? And so this, you see it's got a propeller. It's got three loops on it. These broad, C-shaped haptics. The problem with this is these broad, C-shaped haptics would go into the angle and would close it off. And so you'd get like two-thirds of your angle closed off. You'd get a severe glaucoma. And these were not very well finished. So you'd get a chronic plug syndrome from these. Unfortunately, there was an old stubborn surgeon in town here who bought a whole consignment of them and insisted on putting them in up until 1987, when I came back here as I'm attending. And he did intracaps in 87 when everybody's doing extracaps and put in these anterior chamber Dubroff lenses. And so he's since passed away, but Alan Kendall said deftly that he was the leading cause of preventable blindness in Utah. And so I had the uncomfortable position of actually testifying against him as his privileges were being pulled, so. But doctors are stubborn. Sometimes we stick with what we believe, whether it's correct or not. Does that sound familiar with an election? Post-truth era, sorry about that. Okay, so what are the most common side effects of these lenses? Corneal edema. If you look right here, you can see significant corneal edema. All right, so what are we looking at right here, Chris? Some corneal edema. What do we call that? It's a bolus carotopathy. Bolus carotopathy, exactly. So you see that big boli there, separating the corneal epithelium from underlying bone layers. Bolus carotopathy, very commonly seen. Why would I be showing this? Let's see a second here. Ashley, why would I be showing this? What is this? This is retinase. What part of the retinase are we in? See, so it's also, it's not in the macula. It's in the macula. What are we seeing right here? That's actually exudate, sitting in the outer plexiform layer in the macula, which is called Henle's layer. So this is cystoid macular edema. So that's another side effect of chronic breakdown of the blood aqueous barrier, cystoid macular edema. So in two weeks, you will know these layers cold. Lots of layers in the retinase in two weeks, you have that to look forward to. So these chronic inflammation could cause corneal edema, could cause glaucoma, could cause, ux, not drugs in German, could cause cystoid macular edema. See, I mean. All right, so finally, Charlie Kellman, the guy who invented the fake emulsification, said, all right, these lenses are causing problems because they're closed loop. Why don't we make an open loop into your chamber IOL? And so his first iteration, we used to call this the pregnant seven. So if you look at it, there's a seven and it's pregnant. The pregnant seven. And so he had this, it was shaped like a seven and it was three piece, three point fixation. And Charlie's argument was, if you were in a bar and had an unstable, unlevel floor, a three-legged stool was more stable than a four-legged stool. Four-legged stool would wobble, three-legged stool would be stable. So that was his argument behind this. The problem is that if you put this in, it was very stiff. And so you would get, overling of the pupil, you'd get a lot of problems with these. And so he tried to make the haptics thinner, which was good, but still that three-piece design just didn't work. So Kelvin being a smart man within about a week decided, okay, maybe I was wrong with the three-piece. And so he, or with the three-point fixation. So he immediately jumped in and said, okay, four-point fixation is better. So the nice thing is, is you never have to say, gee, I was wrong. You just have to say, here's the latest, most improved version of Tide. It gets your clothes even wider. It's not that the old Tide was worse. It's that this is even new and improved. So the new and improved Kelvin lens, called the Multiflags, now had four-point fixation in the interior chamber. And it's open looped. And the nice thing about that is if you compress those haptics, they take the compression and the optic doesn't vault. So we did a bunch of studies in the lab, squeeze them and these would not vault. And so as a result, you get much less corneal edema, much less Ux syndrome with these. And is this a familiar? Yeah, this is a lens we use right now, 30 years later. And so Kelvin hit on a nice idea. The other nice things about these is these were relatively flat rather than round. So they wouldn't dig into the angle they'd slide over them. And so if we have to put in an anterior chamber IOL to this day, this is the one we use, the Kelvin Multiflags. All right, so here's the old Apple Corp. Sitting in the corner of the cafeteria. Dave Apple couldn't do this in the lab. So he had to go to the cafeteria to get coffee and we lay out all of our stuff here. And he would dictate and we would put these pictures together beautifully, fellows and students. And we now notice we held that up right there because we were on the cover there. So we held that up for the picture. The original Ocular IOL and Ocular Surgery News. You'll recognize that it's still the Ocular Surgery News. It still comes out, you know, twice a month. So there's the original Apple Corp. All right, so we had t-shirts made too. We took the Apple Apple and took a bite out of it and said Apple Corp. So at the time that people were doing these anterior chamber IOL modifications, people said, well, why don't we just clip an IOL to the iris? And that's a good idea, right? You clip it to the iris, it's gonna be away from the corny. It's not gonna cause any problems. So this is called the B-course lens. B-course was an ophthalmologist in the Netherlands and so this is the B-course lens, this is the for loop. And the idea, let me see if I've got one in cross-section. But the idea is two of those loops go in front of the iris, two go behind it. You literally clip it to the iris. And so that was the B-course lens. And then another doctor named Jan Worst, who was in Belgium, came up with this and a nice thing, the funny thing we had a good time with this one, this was the Worst lens. And so we agreed fully in the lab that this was the Worst lens. And so the idea is is that you would put this little peg on here and it would help clip it to the iris with the loops. And then it even had these suture holes so you could suture it onto the superior part of the iris. And so the problem is when you put these for loop IOLs and what happens when the retina guys won't examine the peripheral retina, you dilate them lively and the IOL would fall into the anterior chamber, fall into the vitreous. So these Worst lenses, you put a suture in them, they would hold them in place when you dilated the pupil. But the problem is is all this hardware rubbing against the iris, you can imagine what that's gonna do. These caused lots and lots of ugg syndromes. The other problem is these haptics that were made out of proline degraded. So this was the mud flap degradation that you could see in the proline when proline touches uveal tissue. Now, how is this applicable now? If you take a proline suture and you suture an IOL to the iris or to the silvery sulcus, a 10-0 proline will degrade just like this. And eventually that suture will break and that will dislocate. So you don't wanna use 10-0 proline when you suture an IOL. You wanna use something bigger and stronger, at least 9-0 proline is not Gore-Tex sutures. And so this degradation happened to proline haptics. It also happens to proline sutures. So it's a surface degradation. So because of that, a company said, hey, why don't we make these out of titanium? Great idea, right? Titanium, does it degrade? It's good stuff. Well, first of all, titanium is really heavy. So these IOLs will like sink down. Also, if you're gonna put them in any kind of a magnetic field, that may be an issue. So titanium lasted for about three days. So that lasted about as long as the pregnant seven. So not a very long. But again, I'm showing you this to say, look, people thought of all kinds of stuff. Very many people had ophthalmology. All right, so here's one of the worst lenses. It was held on here by a suture, which is since broken. That little tab that was attaching it to the iris caused a tremendous amount of iris atrophy there. You can see corneal edema here. And look how irregular that pupil subussed the worst lens. Now, what happens to these lenses that were attached to the iris? This is the haptic of one of these iris-fixated lenses. It's literally fixated to the iris. I mean, there's iris attached to that. When you take this out, you couldn't remove it without removing part of the iris. So these were very, very difficult to take out when you were taking them out. So this was the one, the four-loop lens. The idea is you would put it into the ciliary sulcus. And then as people started going to extra caps, they even started trying to put it in the bag. Now, this was fun. Copeland, a company came up with IOLs that are shaped like a propeller. Two props would go forward, two would go backward. You'd fix it to the iris. These are little Copeland elves at Christmas time, wishing you happy holidays, making a little IOL. So this was an ad from the journal that was there. These were pretty cool, because it gave you a square pupil. So here's the tabs in front of the iris. There's the tabs behind there. She'd get a square pupil from these. Imagine the retina guys. They must have loved these, because it was really difficult to see the peripheral retina. There are the pigment granules on the surface there. And you can't even see through this. This is because of the corneal edema that this caused. My favorite is like this one, proven, safe and effective. Discontinued. So I love that ad, you know? It's like proven, safe and effective. But we discontinued it anyway. You end up with safe and effective. So over time, as surgical techniques evolved, people went from doing intracaps to doing extra caps and then eventually fake go. And so because of that, as the capsular bag became available again in the early 80s, then people started saying, wait a minute, why don't we put an IOL inside the capsular bag, which is where it belongs, right? In the posterior chamber and the capsular bag away from the anterior chamber. And so Steve Shearing, which is interesting, invented this posterior chamber lens now. Again, I've been doing IOL research forever. This is all he ever did. I mean, he's a private guy in Las Vegas and he invented the lens, which is fantastic. But he never did anything after that. So this is the Shearing lens. And you'll see it looks like an umbrella. It's that little J-shaped lens right there. It looks like a little umbrella stand. So the problem with that is, as you can see that J was straight out and it tended to ovalize the capsule. So this is when people saw this and immediately jumped on it. IOL evolution was taking place at this point by the day. And so a guy named Simco in Oklahoma City said, well, if those J-loops aren't very good, why don't we make C-loops? You know, make it fit better in the bag. And so he made these broad C-loops. So the idea is you put that in the capsular bag, these are all fixation holes. Why so many fixation holes? Well, remember, we didn't have fiscal aesthetics then. There was no heel on yet. It was just coming on board. And so people had to try to squeeze these in just under air or under BSS. And so he had these various little holes to try to put them in. And then Bob Sinski came up with his variation of this, which was the modified J. And so you can see his modified little bit instead of coming off in the middle, it came off to the side and he put this to the look. And now in IOL, one of the first companies to make these, of course they put their name on here and the power. So you would never have any question. That was the IOL power. The problem is, is these would act as a little nitrous. So you'd get little inflammatory cells around these and so that you don't want raised letters on an IOL optic. But this is the lens I trained on. This was the ultimate lens. There would never be a lens better than this. I caution you guys as you're going through residency, you're gonna go through very good and say, wow, we have the most up-to-date surgery that's ever been invented in all of mankind's history. It'll never get better than this. And 10 years from now, you're gonna be looking back saying, oh God, can you remember when we were doing fake holes? Geez, that was so crude. So just wait, 10 years from now you'll be laughing on what you're running now. But this was the ultimate. You did an extra cap. You put this implant in, you tie off the eight stitches 12 weeks later, patients would come back and you'd give them their glasses. No CME, no UGG syndrome, oh my God, this was the ultimate surgery. It would never get better than this. So this was the Sinsky lens. Well, initially people argued about where you should put that lens. And there was a group at Johns Hopkins at Wilmer because they were Wilmer, they were obviously correct, that said you should put it in the sulkas. Because people can't get it in the bag, they're just not good enough yet. So just put it in the sulkas and you won't have any tilting in their regularities. So again, Dick Green and Dave Apple went the rounds for a couple of years saying we said put it in the bag and they said no, put it in the sulkas. Well, okay, I'll let history judge. Where do we put the implants in the bag? So the Apple Core was correct on this one. So what's the problem if you put an IOL in the sulkas? What's going on here? Well, even though you're not a senior, you've had more years than anybody. What's going on here? It's like iris atrophy. And look at the pattern of the iris atrophy. How come it's shaped like that? Because of where the haptics are. Exactly, so if you put haptics in an optic in the sulkas, they can scrape on that posterior iris, you can get atrophy there where the haptic optic junction is, you can get atrophy where the haptics are. So the idea is don't put it in the sulkas, put it in the bag. And so this is an eye, here's the iris, here's the angle back here. So look, big, peripheral anterior synecine. Here's that Iowa loop all the way back, almost at the major Iowa circle. So you put a loop like that, a big Iowa loop like that in the sulkas, it can erode all the way in there. So the idea is you want to put it in the bag. And this was an old Sinsky lens. This had been in the eye for about 20 years. And look how beautiful that looks. I mean, it's completely in the capsular bag, there's no transillumination, there's no iris scraping. So we really want to put Iowels in the capsular bag. And there's a nice path picture, here's the root of the iris, here's the ciliary body, look at that loop in the bag, look how beautiful that looks. So that's what we put in right now. All right, so as companies got better at making Iowels, they started making now one piece instead of three piece poster chamber lenses. This is PMMA, and they came up with a technology called lathe cutting. And so you could actually do a micro lathe that would cut this out like a cookie cutter. You'd cut out this one piece lens and look at the finish on there. I mean, it's just beautiful, they would tumble polish them. And so I wanted to still do that to this day, and you put them in a vat, a bunch of little beads and some polishing compound, and you literally tumble them for seven days. And it would micro polish these beautiful, I don't know if you guys as kids had rock polishers, and you put a rock in there and you tumble them for like two weeks, and then it would make them really smooth. It's the same idea with Iowels. And so this is a one piece modified C. lube, PMMA poster chamber Iowel. Look at how beautiful that looks. So the late 40s and 50s women really started doing these and then he spoke here, and so no one was doing any sort of cataract surgery at that point or at least they did in Iowels. So then at what point does the US start doing things again? In the 1970s, Americans snuck over to Europe and smuggled these illegally in their bags, and then came back and tried to put them in. And then- They just were doing only AC, only cataract chamber. Anterior or iris fixated, that's what they were at that time. Yeah, yeah. So again, I gotta tell you the story. Some of you guys who were in path readouts heard the story, but I have to repeat it for everybody here. When Iowels first started being widespread, and this was in the very, very early 80s, people started putting these in, I was a climber, put these in and put a minimal Ralph Nader, and his Nader's Raiders got with of this, that surgeons were putting these dangerous devices illegally in people's eyes and they were gonna shut it down. So they got a hold of a congressman that were very receptive to them, and so they set up a big congressional hearing to shut down the use of Iowels in the US. Well, at that time, fortuitously, Dick Kratz, who was a surgeon in Southern California, his one of his patients was an actor named Robert Young. And so you gotta realize, this is pre-cable, pre-internet, there were three networks, and so on, you know, whatever, Thursday nights, you know, two thirds of Americans sat in front of their TVs and watched the same shows, and so the number one show in America was called Marcus Weld, MD, starring Robert Young. And he was America's doctor. He was the most trusted man in America, more trusted than Walter Cronkite, and he was a character in a TV show. He would see two patients a day, he was a private practitioner, he would visit them in the hospital, he'd go to their houses and bring them medicine, he was America's doctor, well, he had cataracts, Dick Kratz put an IOL in his eye. And so when it came time, they did all this testimony against Iowels, and then Dick Kratz testified, and then they brought Robert Young out, and he testified that this device saved his career and his sight. And so afterward, he walks into the hallway and there's a million cameras and lights and flashes, and so the press is always, you know, Dr. Weld, these are the greatest thing, and so Congress couldn't shut it down, which is really fortuitous. And so because of that, they set up a quote IOL study, and that went on for years, the FDA sponsored it, and so even when I was a resident, you had to sign up to be an investigator for every company to put in an IOL. So at that time, there were like 20 of them, so it would be like the first day of your internship, you would have to fill out 20 investigator forms to be an investigator, and you have to report your results for these, and so they did this, and it did show that Iowels were safe, and so the rest is history, but it's fortuitous that Dick Kratz was operating on America's doctor who testified, or else they would have shut these down. All right, so we can't talk about Iowels without talking about cataract surgery technique evolution because you can't understand that, so this is how cataract surgery was done in the olden days when Crandall was a resident, so this is an intracap. So you would make an 11 millimeter opening, you put some stay sutures in there because you didn't want to let the eye get any explosive, you lift up the cornea, and then you'd put in alpha chymotrypsin, dissolve the zonions, and you'd take a cryoprobe, just like retina cryoprobe, and you'd stick it to the anterior lens capsule, it would freeze and hold it, then you'd go through it, and pop the whole thing out, and then you would have just nothing posteriorly, and then you'd put in your anterior chamber, your eye was fixated, Iowel, and then you'd close all those sutures. So, a little bit less olden days when I was a resident, then we went to extra caps, and the advantage of extra caps is you leave the capsule or bag in tech, so we'd go in with the best histotone, you'd make a bunch of little punctures, you'd call it a can opener, just like little punctures on a stamp, and you'd take that out, and then you would squeegee that lens nucleus out of the eye, you'd put a lens loop under it, and you'd pull it out whole, and then you'd tie down these pre-placed sutures, and you would suction out the cortex manually with a little simcal cannula that had a little squirt bottle attached to it, and a little 10cc syringe, and you manually suck it out. It was kind of cool because you could vary your aspiration rate from zero to 500 millimeters of mercury, depending on how hard you pulled back on the syringe, so you really did have good control of doing that, so you would suck out the cortex manually, and then you could put an IOL in the posterior chamber. Look at these pretty wounds we made. You made this nice 11-millimeter wound, and then when you were done, you put in about eight interrupted stitches, and you would cut them periodically to fit your stigmatism. Well, of course, finally, Kelman invented the FACO 50 years ago in this year. Interesting story because Kelman was at the dentist, and the hygienist was treating his plaque with his gums with an ultrasound. And so he says, well, wait a minute, if ultrasound can, in a removed plaque, can't we use ultrasound to grind up a cataract? And so that was his idea, and his first ultrasound machine was like, as big as this whole platform, and this high, and of course took him three hours to take out the IOL, but that was the cataract, but that was the impotence, and from that, we have the FACO mostification we have today. Along with the evolution of the equipment, the wounds evolved too. And so as we were able to make smaller and smaller incisions, we were able to make better incisions. So this was the standard three-plane incision we made. If you'd start about a millimeter and a half back from Lula, and we should go down halfway, then you dissect out, and you enter the corner, and that was your standard three-plane incision. As foldable IOLs were invented, then we're able to make our clip-coating incisions like we do today. So that's our clip-coating incision. So it didn't make any sense if you're doing this wonderful FACO through a three-millimeter incision, then you have to open your incision to six millimeters to put in an IOL. So because of that, companies started working on foldable IOLs. And the first foldable IOL was the plate-type silicone, Tom Masako invented it in Southern California, so they called it the Masako Taco. And you can see you put it in an injector and roll up like a soft-shell taco, and you just put it in the eye. You could put this through a three-and-a-half-millimeter incision, you'd have to expand the incision. So interesting idea, so silicone was the first available material that they could make an IOL out of. And here is a plate-silicone lens, and whoever was in the lab with us last week, we had one of these. They still put in ones in a while, and it was a plate-silicone lens that had these large holes in it, and you were just injected right in the bag. Well, immediately, companies jumped on that and said, hey, why don't we make these three-piece? So they would put proline haptics on this, make them three-piece, you could either put them in with a force-up or an injector. Initially, the injectors weren't good enough to put in three-piece lens, yet put them in with a force-up. But silicone still, low refractive index, not as bio-compatible as some of the other materials. So not the ideal material for foldable IOL. And so people started looking at other materials that they could use. And I'm not gonna talk a bunch about star, but one of the other materials they looked at is a hydrophilic acrylic, a water-loving acrylic, or so-called hydrogel. This was one of the original ones that was made in the US. They would graph the haptics on it. This was the hydrophilicone lens. And these look great, again, for about 18 months. The problem is, is that these early hydrophilics would calcify. And so in the US, the two most popular brands, both would calcify after a couple of years. And so you can imagine that killed both companies. So these died in the US. In England, Rainer kept working on these, and there are companies in Europe now that make very good hydrophilic acrylics, and they're used a lot in Europe, not so much in the US. Well, finally, we came to the present, at least gold standard, the hydrophobic acrylic. And so Alcon was the first one to make the AgriSoft, and the idea is that it's a very high refractive index, and so you can make it thinner. It has relatively good biocompatibility. It's got relatively low capsulotomy rates, and so this is the material that we do now. And initially it was a three-piece, and now it's a one-piece with half-take. And so hydrophobic acrylic is pretty much the material that we use now. And the rest is history. You guys know the rest, because you live it every day. So this is the Oddfellows Palace. So we had our triple IC dinner there at the Oddfellows Palace. Kind of a cool, 400-year-old palace there in Copenhagen. So I think we say goodbye to Copenhagen now, so next week I'll find some other travel slides with you. So next week, you're back on the hot seat again. I believe it's called Khoma, and then Retina. So look up your schedule. I think that's the next two weeks. So look, you know, read that section in the BCSC, okay? Questions in four minutes? Why is it called the Oddfellows Palace? Ooh, good question. Oddfellows is an organization that's been around for about 400 years, and I'm not sure what the organization stood for, but it's an organization that built this. But very ornate in science. I love these European palaces and very ornate. Oh, so I can tell you the triple IC story. Triple IC is the International Inplant Club. And basically, Mr. Ridley, and by another dozen people, started their own society, their own club in 1967. And so it's written by him that it is a society that is by invitation only. So who special people are invited? So every year, about four or five new people who have done work in Iowa are being invited, and it's just an excuse to get together. So you get together at ESCRS and at ESCRS, and you have a big dinner, and you just see a bunch of people that, you know, and everybody dreams one eye, and you tell stories, so that's kind of a fun organization to belong to, the triple IC. I am. All right, all right, make sure your attention. Thank you. Thanks.