 Okay, good morning everybody. We're gonna get started here this morning. We have dr. Mamelis There's a little bit of a erroneous title on the grand round sheet there But he's just gonna talk about the history of intraocular lens is not not just the bin course lens So don't worry. We're gonna delve into other things that besides that Thanks, can everybody hear me? Okay Well, I looked at the title yesterday when it came across and I says guy Nobody's gonna show up who wants to hear about being course IOL. So sorry for the confusion. This is the bin course talk I gave it the SCRS meeting in April and so when I was asked to give grand rounds I thought that a lot of people chance to go to the ACRS meeting So I thought I'd just go ahead and just give the talk that I gave when I was in San Francisco So basically the idea is is intraocular lens evolution what a long strange trip. It's been unfortunately I didn't bring the audio with me. So I played, you know the song with a long strange trip It's been from trucking when I went out So I should have brought the audio if those of you who are older smile those of you are in the back Have no clue what I'm talking about So when we're talking about IOLs Basically, I do have to give my obligatory Disclosures so when we're talking about IOLs cataract surgery over the last 30 years has really Evolved and there's been a tremendous evolution actually not over 30 years, but over 60 years So not only has cataract surgery itself evolved, but intraocular lenses have evolved tremendously So I want to talk a little bit about going back to the beginning of IOLs and then bringing you up to what's going on now And then lastly we'll talk about some of the things that are coming in the future and some of the work We're doing in the laboratory on new types of IOLs, but we need to go back to mr. Ridley Mr. Ridley was a surgeon in England and during World War two He was taking care of Royal Air Force fighter pilots who were fighting off the the Nazi blitz and notice that Pilots who had their cockpits shattered and got pieces of cockpit inside their eye the material of the cockpit Was inert when they looked at their eyes and it turned out fortuitously that the cockpits were made of plexiglass Which is PMMA polymethymethacrylate? So as Ridley was starting to contemplate ideas on Ways to go ahead and and to replace Introcular lenses then he looked at this material and said you know this material is very inert Maybe this is something that we could consider making an intraocular lens out of and so he worked with a company Rainer in England who is still there and Rainer put together an intraocular lens for him And so this was Ridley's first intraocular lens It's interesting in that he put his first lens in the post of your chamber where our crystalline lenses are now and This is a Ridley lens in a cadaver in a autopsy eye that is 30 years out and Fortuitously they had a round capsulotomy and this implant was actually within the capsular bag And so you can see this is a disc lens It was a very heavy very thick disc lens and it was made to go into the capsular bag Now this is the original one of the original videos from 1951 And you have to understand what the surgery was like. This is a von Grafey knife Now I know some of our more senior members in the front here may have seen this but you basically Under loops no microscope you took this knife and you sawed the corny in half You just sawed it in half then you go in with the four-set you grab the capsule and just Grab it and peel it off now. This is kind of how our second-year residents do capsulotomies, but Usually we try to be a little bit more You know a little bit better circular tear than that now you go in and you express The hard nucleus and of course they didn't realize the effect of the endothelium there and you basically flushed out the cortex And then once you just flushed out the cortex. There was no Ina. You just basically flushed out and you put this disc lens back in behind the Iris in the post to your chamber and you sewed these Forosilk sutures back together again the patient stayed in bed for about a week And that's how the surgery was so you can imagine with that surgical techniques That even the best of Iowell's are not going to do terribly well and unfortunately mr. Ridley's post to your chamber lens Didn't do well and a lot of the cases they didn't have an intact capsule the lens dislocated It came forward they had pupillary block and so it did not turn out to be a big success so some of Ridley's colleagues and some of his students that were under him Started looking at different ways of making intraocular lenses that could fit in the anterior chamber And this was one of them. This was by mr. Choice Peter Choice also from England one of Ridley's original Trainees and he came up with the various designs of the solid PMMA lenses to go in the anterior chamber This was his final design right here. He went through nine different designs. So this was the Mach 9 You know, it sounds like those shavers, you know Gillette Mach 9 And so he went through nine of these and this was the eventual one and this was made to fit in the anterior chamber Now these did pretty well if they were sized well And we used to joke when when we were starting to study these in the laboratory 30 years ago that these that lenses came in Two sizes too big and too small And so the problem is if they're too big They would tuck the iris over the pupil and give chronic ugg syndrome uveitis glaucoma hyfema syndrome if they were too small They would move like a propeller blade inside the eye also giving chronic inflammation And we can see here some of these these are Autopsies again and you can see a lens that was just too big You can see the ovelling of the pupil you can see that the iris was tucked Inside and here you see a chronic hyfema here from this now the other problem is is these were beginning to be manufactured Polishing was not very good. And so this is the actual edge of an IOL. That's what it looked like So you can imagine what that's going to do scraping on the iris and Just for fun when I was a fellow we took a coca-cola bottle and broke it and Then did he did he emma the coke bottom the coke bottom was actually less rough where it was broken than was the original IOL Now Binkhorst who this talk was named after was an ophthalmologist who decided that well Maybe post your chamber lenses didn't work and your chamber may not be the the correct place to put an IOL Why don't we fixate them to the iris? And so the Binkhorst lens was one of the first lenses that was made to fixate to the iris And so since he was one of the real founders of intraocular lenses this talk has been named after him So this is Cornelius Binkhorst and You can see this was his original lens It was a four-loop lens and the idea is is that two of the loops would go behind the iris Clip it to the iris and then to the loops would go in front of it. So the idea is is it would be clipped Now there was a colleague of well a colleague from the next country over from being coarsed named Jan Worst and Worst took this theme and decided that he would try to make it fixate a little bit better So what worse did is he put two? Fixation holes in here So the idea is you not only clip this to the iris But you'd suture to the iris because a problem with lenses like this if you dilate the pupil to look at the peripheral retina They would fall into the vitreous or fall into the anterior chamber, so you couldn't dilate So what worse did was he came up with ways that you could suture To the iris or he even put little tabs on here that stuck it to the iris And so we used to joke that this truly was the worst Lens because basically it caused chronic uveitis chronic ugg syndrome uveitis glaucoma hyphema syndrome So lots of problems when you suture something and clip something to the movable iris Well about that time now we're now getting toward the early 70s now Just to give you a little bit of an aside when mr. Ridley was doing this work in England and in Europe He was working to continually try to improve these Iowales He came to the United States and gave a talk at the American Academy of Ophthalmology and otolaryngology And he was absolutely vilified This was the most dangerous thing we could possibly put in our patient's eyes The president of the Academy at that time wrote a letter to the editor and he basically said If anybody in the US dares put one of these dangerous devices in the eye I will be the first one to testify at your malpractice trial So basically Iowale research for the better part of 20 years went on in Europe not in the United States So finally in the late 70s Early 80s, you know some Americans started to dip their toe into doing some research and decided hey Maybe these Iowales aren't such a bad idea. So at that time we were still doing Intracapital or surgery there was no capsule or bag support So they started looking at different ways of putting implants in the anterior chamber because of the problems with Sizing of the choice lenses a lot of US manufacturers started making these closed loop Anteer chamber lenses. This was the azar 9 1z. This was the Lyski lens And of course people named them after themselves Everybody who invented a lens came up with a name and this was a time of great innovation Guys would be at the scrs meeting sitting at a table drawing Iowales on napkins and giving them to the Iowale manufacturers who were then you know trying to manufacture them so This was an interesting lens. This had some Two sets of closed loops and unfortunately we were seeing those quite a bit here in Salt Lake The problem with these is if you decide to take them out These are a bugger to take out because these get Seneke I around them on all eight of these little loops So these were difficult to take out And the problem with these closed loop anterior chamber Iowales is if you rub the eye or touch the eye What would happen is the optic with a vault and so it would bounce up against the cornea or the loops would dig In to the iris they would form Seneke I in the angles and as a result you would get chronic Ugg syndrome again, and you could even get Bulliscare top of the here's a cornea a bullion to there so you get bullscare top of the This is a cut of the macula you get Cystoid macular edema The nice thing about these lenses they were very easy to put in you do your Intercaps or surgery you'd slide these guys in they'd go in and they look beautiful for two years and Then slowly, but surely complications started to show up with these lenses So Charles Kelman the same Kalman who invented the ultrasound said well if the problem is with the closed loops Why don't we make an open loop anterior chamber lens so his first attempt? This lens was called the pregnant 7 and so that's what we call the jokingly So it was the pregnant 7 and This was too stiff. This is made of PMMA. It was very stiff So Kelman immediately recognized that and said well, why don't we make these loops thinner and give it more? Flexibility and you started again with the tripod design, but realize that it still wasn't stable in the anterior chamber So he decided to do a quadruped design and you can see these z-shaped haptics now if that looks familiar to the residents That's basically the lens. We put in the anterior chamber right now So that design has stood the test of time for the last 30 years and this is the lens We use now this is in the early 80s He came up with this and so it's got open loops and the idea is if you squeeze that it wouldn't vault forward The haptics would kind of take up the shock and so this if you put it properly in the eye And you don't tuck the iris does pretty well and as I said, we're still using that lens to this day Now finally in the early 1980s people started to make the transition from Intercapsular surgery to extra capsular surgery So we were leaving an intact capsular bag Which would allow us to go back to the posterior chamber where mr. Ridley had put the first lens in and so Steven Shearing from Las Vegas came up with an idea of you make the optic and you put these small Umbrella J-shaped haptics in there That will fixate it within the capsular bag better than Ridley's original lens Well people again rapidly saw that these lenses these haptics were too straight and too stiff so Simcoe decided that he would make a broad C-shaped haptic and since key as in the since key hook made this modified J haptic and This was the lens that you know was was in vogue when I was training and this was actually a very good lens It was a three-piece lens if you got it in the bag again. This lens was very very well fixed So what very well fixated so a tremendous amount of innovation in posterior chamber lenses took place in a very short period of time Now you can't look at IOLs without looking at the evolution of cataract surgery itself So to show the residents because they've probably never seen one of these an Intracap surgery basically what you did is you opened the cornea about 11 and a half or 12 millimeters you put some stay sutures in you'd put in alpha chymotrypsin to dissolve the zonules And then you take a cryoprobe Stick it to the lens and pop the lens out whole and Then you'd suture it back up again. And so the problem there is you have no capsule or support so people started to look at ways of getting the Lens out of the capsule bag and leaving the bag intact and they went back to really a modification of what Ridley did only now We had surgical microscopes. We had better ways of doing this. So here's an extra cap You'd make your grooved incision here, and you'd go in you'd use a bent cystatome You'd make a can opener capsuleotomy and you would get this Lens to start coming out of the bag you put a loop in there and you take it out And then by then we had irrigation aspiration so you could suction out the cortex better and put one of these posterior chamber lenses in And of course Kelman worked on developing the fake emulsification which allowed us to go through an even smaller incision and Take out the cataract itself with ultrasound now the problem with all these lenses is we had this great Ultrasound system now that could take a cataract out through three millimeter incision But we had to open that incision to six millimeters to put the implant in And so people started thinking about that saying now wait a minute, you know something something's wrong with that What what can we do to make that better now? I also want to talk about just the evolution of surgical wounds, too You know originally we were making these scleral corneal incisions and then realized that when we started to get implants that could go through a smaller smaller incision We made the evolution to a clear corneal incision which we use right now and it allowed us to do procedures without sutures So Tom Misako from Southern, California started working with a company to say hey, we've got this three millimeter incision Why would we open it to six millimeters? Why can't we make an implant that goes through a small incision? And so he developed a plate silicone lens and it looks like a rolled up taco shell So they called this the Misako taco and that was the first foldable IOL that allowed us to put an implant Into the lens caps or bag without opening up the incision So of course again this led to an explosion of different IOL materials It led to three-piece silicone lenses. It led to the development of hydrophobic acrylic lenses and the development of the Intracheal lenses that we use right now that we can put through an unopened incision. So What happens is is IOL development and development of cataract surgical techniques go in lock step and sometimes the surgical Technique drives the IOL sometimes the IOL drives the changes in surgical techniques. And so there's continually Evolving along both fronts which then allow innovation to go on in both areas both surgical technique and So this is the original Apple core and I don't know who that brown-haired swarmy looking guy with the mustache he is but In the early 80s Dave Apple came to the University of Utah and he and Randy established a center of IOL research And so David had a group of fellows similar to what I do right now And basically we didn't have a big office space at that time So we would commandeer the corner of the old cafeteria and spread out all of our pictures here This is pre-computer days and look at the pictures and David would dictate and the secretary would type up all the things that he was doing So we were really the first center worldwide to look at IOLs and look at their complications And as a result of the work we did here it led to a couple of seminal publications. The first was a Review on complications of intraocular lenses, which was in the survey of ophthalmology This was really the first comprehensive review ever written on IOLs and the complications And then secondly the textbook that we did looking at intraocular lenses and the complications and so this helped To lead industry and to lead people who are making IOLs To make better lenses and so this helped to lead to better polishing techniques better materials and better designs and intraocular lenses So what about the present IOLs and so we can see Evolution of mankind there and this is now our present residents, you know, they've just Devolved into computer junkies So when we look at the evolution of modern cataract surgery, obviously we're at the point now where we have Small incisions we're able to put in foldable IOLs We don't have to suture these incisions and we've got excellent refractive results The problem is is when we put in a standard IOL we still don't have Accommodation or near and intermediate clear vision So one of the ways people have looked at trying to solve that problem is multifocal IOLs And these are a couple of the various designs of multifocal IOLs They're made now of mostly hydrophobic acrylic materials. Some of them have a defractive Apodized pattern on the surface of the optic others have a Refractive pattern where there's different refractive zones But the problem is all these have the same theme and the theme is that you somehow break up the image as it comes through The IOL so that part of the image goes for near part of the image goes for distance some even goes for intermediate When you do that though it does create some problems and the problems is are usually related to visual aberrations So you get decreased contrast sensitivity You get dysphotopsies a so-called Vaseline vision with these and so these really aren't the final answer for giving people clear Distance intermediate and near vision So looking at potential ways to solve that one of the ways of doing that is doing a truly accommodative IOL Instead of a multifocal IOL and these accommodating lenses would have less problems with glare Conscious sensitivity dysphotopsies because they don't split the image So one of the first lenses that did that was the crystal lens, which was a flexible lens It's got hinged haptics here. It's made of silicone There's some other varieties here with the same idea and the idea is that when you accommodate these lenses will move forward and Give you near vision and when you disaccommodate they'll move backward. Well That's a good theory, but in practice. It really doesn't work very well. There's a limited range of accommodation in fact when people have done dynamic Studies of these lenses. They often don't move at all And so the joke in Europe has been the last few years as the crystal lens is the lens that only accommodates in the United States And so there you know these really aren't going to be the answer also at best You maybe will get point seven five or maybe one diopter of accommodation and for those of you who are 45 to 50 years old that's not enough to give you good clear reading for a long period of time So again, these are available now, but these are probably not the solution to the final problem of how we're going to give People clear vision at all ranges. So what have we got coming up in the future? So it's hard to predict the future because I don't know if you remember the Jetsons You know, we were going to have flying cars by now and cities up on stilts and none of that happened But the Jetsons certainly didn't predict the internet and didn't predict You know the way we would have cell phones and DVDs and iPods and iPads and so hard to predict the future, but So what do we got coming in the future? Well one way to solve the problem of accommodation with a single Lands a single optic is to look at a dual optic system The idea of a dual optic system if you've got an anterior optic with a high power You've got a posterior optic with a variable negative power And there's a spring unit between the two some haptics between them to allow them to come together and go apart The idea is you would get clear near and distance vision without sacrificing conscious sensitivity and dysphotopsies So the first lens to do this was the synchrony lens and synchrony lens is ingenious because it's a very complex looking lens here It's got the two optics It's got these haptics They're much like the leaf springs on a you know pick up truck And so they tend to let it come together and go apart But it's got a lot of channels and knobs and the whole idea is that this holds the capsular bag open And doesn't allow the capsular bag to sit against the silicone materials So it helps to limit fibrosis and capsular bag of pacification The other ingenious thing with this lens is the injector and so we've been working with Vizio Gen We started working with them almost 11 years ago And the fun thing about our laboratory with Lilliana and the fellows and I is that Companies will come in with some ideas. We'll put them in cadaver eyes We'll put them in rabbit eyes will give them our impressions and then the engineers will work on it Come back with the next variation. So we've seen about 13 different variations of this particular lens And it's a very ingenious Injection device that allows you to fold it over put the optics in front of each other and actually inject the lens So we've really enjoyed working with this. This is a schematic showing you how it works And the idea is is that the lens can come together and go apart and so when you are Putting it inside the eye If you remember during accommodation as as Helmholtz, you know Sad eat more than a hundred years ago when the ciliary body is relaxed The zonules are loose and the lens comes together when the ciliary body contracts the zonules relax And the lens comes apart giving you near vision So this kind of shows you a schematic of that when they're together You focus the distance when they're apart you're focused at near And again, so now that the it works much like the human crystalline lens works And so this is in our laboratory. This is a cadaver eye that's been glued to a slide This is the Miyake view posterior. This is a simultaneous anterior view This is the injector and we're putting it in so you can see slowly but surely the posterior optic comes out And when it comes out it slowly unfolds now once the posterior optic is out The anterior optic comes out immediately. It's like when you're delivering a baby You know in the shoulder comes out and then suddenly boom the kids in your lap same thing here So it unfolds very rapidly, but you see it's completely within the capsular bag And then we just do some gentle centering here again anterior view with the corny removed Postier your view and you see it centers nicely So we were one of the centers that looked at them in phase three studies here in the US And here you can see a patient actually putting it into their eye here a little bit of maneuvering with the since key hook Fixating it within the capsular bag centering it There it's centered and this is what it looks like post-op So the people that Alan and I had put in these patients originally four years ago are all looking good now at four years Still have adequate Accommodation in most cases now the problem with this lens is is the FDA and You'll see my bias by the tone of my voice This should have been approved two years ago, but basically the FDA did not approve it They said well you need to show us more that it truly accommodates and that it's safe in the eye and that you can do Yeah, Glaser capsulatomy and so the FDA has now gone from protecting patients from dangerous devices to impeding The evolution of devices now and so basically in the last three or four years intraocular lens Evolution has moved out of the US again Basically due to FDA and transgen so fortunately the FDA is getting pressured now And they just had a group getting together here recently to try to come up with some more reasonable standards for accommodating IOLs And so hopefully in the future there'll be some more reasonable ways to do this I mean they're basically making Visio gen who was bought by AMO redo the entire study and So there are now dozens of lenses available all over the world Including Japan Asia Europe South America that aren't available here in the US And and I look at the Japanese regulatory agency who's incredibly strict and they're approving these and yet we're not So hopefully something will change in the future because people used to come to the ASCRS to learn about the new Techniques now we go to the ESCRS to see what's going on everywhere else in the world So hopefully things will change and we'll get more lenses like this approved Well another way of getting you accommodation There's a company from Israel called New Lands that is based Their lands on the principle of water birds And so when you look at a penguin what a penguin does is it has to you know It has to live on land, but it spends 70% of its time in the water So when you jump in a swimming pool without goggles on you know what happens how you know suddenly everything becomes Magnified you lose that corneal refractive surface well You can't have that if you're a penguin because you're not going to be able to catch fish and you know swim away from killer whales So basically what they do is they have a very stiff iris and a very soft lens And when they jump in the water, they'll constrict that and the lens will pop through the iris giving them near vision And so New Lands has taken this concept and they've got a lens where when you Put some pressure on this there's a silicone material inside here Which will change the curvature on the surface of the lens and ideally give you near vision And so we worked a lot with this in the cadaver eyes now What's interesting about this lens is is these forks fixated in the sulcus? It's not made for bag fixation. It's actually made for sulcus fixation And so this is a cadaver eye we remove the corneal in the iris and you can see that these prongs now will be placed into the ciliary sulcus Now there may be disadvantages to this this may not be the answer either But one potential advantage is you could theoretically put this in an eye that already has an IOL in it to give people accommodation And so just for fun We took an eye that has a plate silicone lens already in there and we piggybacked this lens on top of it in the Ciliary sulcus and so theoretically this lens could be put in an eye that's already had an IOL giving you accommodation Well, there's another company out of California called power vision and they came up with kind of a similar idea This is called the fluid vision lens and the idea is is you've got these floppy haptics that have a silicone oil in them and when you constrict the capsular bag by Using your accommodating mechanism inside the eye the silicone flows into the optic and Changes the curvature giving you And so again, here's a schematic kind of showing that so these balloon like haptics have the silicone in them And as you squeeze them the silicone goes centrally and Changes the curvature on the anterior surface of the eye This shows you it in another view again as you squeeze them Silicone comes in through these channels and it changes the curvature on the surface So the idea is as you accommodate you'll get near vision as you Disaccommodate you get your distance vision. This has actually been put into patient's eyes in South Africa We've done a lot of these in in rabbits and in cadaver eyes The interesting thing about this is there's a totally different advantage that we hadn't anticipated and that is in The rabbit model they have a tremendous regenerative Capabilities of their lens cortex so we put a standard IOL in a rabbit at four to six weeks. They get tremendous PCO I mean equal to many years in a human when we put this lens in there these big Haptics hold that capsular bag open and they don't get PCL So it's very interesting in the rabbit that this is preventing PCO and so if that turns out to be True in humans also that's going to be a big advantage because you don't want Capsular fibrosis you don't want PCO you want that capsule to be clear and still able to move and so Potential advantage to a type of lens like this Right now we're putting it through about a 4.5 it does have an injector, but it does require 4.5 Which means you'd have to stitch it they're trying to work on a smaller inject injector But if you can imagine that thing is huge And so it's tough to get in but originally when we're doing them in rabbits We're putting them in an 8 millimeter incision So we're down to 4.5 now with an injector and it does work you can actually inject them into the bags So hopefully then get it down to 3.5 then you could use a sutralis incision Now a totally different way of looking at this is there's an electromechanical accommodating IOL and this is activated by pupil contraction It's got a liquid crystal optic the very complicated device But it's got liquid crystal optic here and basically when your pupil comes down as you're trying to do an accommodating movement this will signal for the crystal to change the Optic properties and so it's interesting it's got a battery in it that you charge from the outside and You have to you know continually recharge it. They have to plug your eye in you know every night Recharge it, but the idea is is that this will be all self-contained so it'll be safe and then it'll actually change the optic Refractive error that will allow you to see up close. So totally different way of looking at things So the fun thing about accommodating IOLs is that there's there's a lot of different ways now to solve this problem You know injectable IOLs are interesting because when I gave my first talk on IOLs in like 1987 My last slide was somebody injecting an IOL And I said okay in 10 years. This is going to be where we are this we're going to be injecting IOLs well You know that was 26 years ago, so we're still not there There's obviously several problems of this but people are still working on this and the idea is you make a tiny incision You find a way to remove that Cataract through the tiny incision you refill the capsule bag with this magic lick with polymer that then acts like the normal crystalline lens And so we've been doing some some work with various companies on this now Disadvantages are you need a small capsule rex is obviously which we can't do yet You need material that is cures fast enough, so it doesn't leak out the cures slow enough So you can put it in and let it cure evenly. We also have to solve the problem of capsule pacification Now Nishi from Japan has come up with a way to try to solve this He's come up with a three-piece lens that fills the anterior capsule rexus and blocks it off And then you inject the material behind it So he's worked on various Different designs on this and this shows you this is a cadaver eye with the iris and cornea removed And you put it into the bag as if it's a three-piece IOL and it's got this collar button configuration so then you take a Sinsky hook and you basically put the Capsule rexus right into that collar button So this is like putting a bicycle tire on the rim and you basically just tire iron it all the way around And the idea is is it completely plugs off the opening Then what you do you make a tiny Now this is a posterior view you Put the cannula in there and you basically fill up the capsule bag behind it This is a posterior view showing you fill it up. So I mean in theory this could work again. We still don't have that perfect palm One of the researchers down at Baskin Palma of Jean-Marie Perala has been working on this what Liliana 30 years maybe I Mean he's been at least 30 years working on this as a hopefully someone will have a breakthrough eventually But this may be a little more more into the future So when we do have an accommodating lens I mean our challenges is we want to provide not only near and distance vision But we want to provide that intermediate vision to so you want to try to mimic the natural lens as best we can You know, we've got to provide an adequate amplitude for accommodation And so again, we want at least two and a half diopters of amplitude of accommodation or even more if possible And then of course we have to solve the issue of PCO Capsar fibrosis we need a clean capsule in order for these to work. We need biocompatible material now There's some other additional issues incorrect lens power when we look at our yearly survey of why Foldable IELTS are being expanded is still the number three reason We're a why why IOLs are coming out and so incorrect power is still a Common problem and especially with the group of baby boomers coming up who have had refractive surgery LASIK or RK That makes IOL calculations very difficult So as a result we often will get people with an incorrect lens in there And then we have to either exchange the lens do a piggyback do a LASIK And so we need to come up with ways to correct The lens power especially with high patient expectations, you know when I started training doing extra caps people would be 2100 we would do the surgery on them They would be 2050 for a few weeks and then 12 weeks later you'd cut the stitches and be 2030. They'd be ecstatic now Patients come back after surgery the next day and they're 2025. It's kind of blurry. You know, I can't see it You know so expectations are getting really high and so as a result We've got to hit that IOL power right on the money So one of the ways we can do that is the light adjustable lens And so we've been working with Calhoun vision for many many years and and I know that that we had Josh one of my fellows talked about this at length, so I won't talk too much about it But this is a lens that you can change the power after it's already been implanted So very interesting device and basically you have a silicone lens with partially polymerized silicone in there You shine a UV light in there and these little UV activated moieties on the edge of these will cross-link with each other giving you a cross-linked silicone now the unperlimarized Partially polymerized silicone that wins in the proof. We will then flow to the center Thickening the center of the IOL giving you a hyperopic correction Then once you have the correction you want you shine UV light on the whole lens you lock it in place and Then you've got a permanent change so the idea is you could put these in for Into the eye let the eye heal for two weeks look at the refractive air and make a change Now the problem is as the lens is now you make the change then you lock it in But in the future they're trying to come up with ways where you don't have to lock it in and you know as the Stigmatism changes over the years you may even have a chance to change it down the road So very very interesting device and we've been working with these guys now for 12 years on this particular lens now for a Myopic change you shine the light in the periphery of the lens Now these will then completely polymerized forming these chains the partially polymerized silicone will then flow into the periphery Flattening out the center giving you a myopic correction then locking it in now There's there's no limitation to the corrections you can do you can also do an astigmatic correction And so you can go ahead and you can shine it in such a way that you actually get This is the wave front analysis here And this is the pattern density that you put in when you shine the light on here the laser light You can get an astigmatic correction. You can even correct wave front aberration So this is for fun. We just did a tetrafoil one in the lab this I call it This looks like that the dipping Doritos that you have you know it looks like kind of the four corner dip and Doritos for the Super Bowl So you can even put a tetrafoil pattern on here So the idea is is that you can put many different patterns on here depending on the patient's visual aberrations astigmatism hyperopia myopia and you can correct these post-op So this is an in extensive use now around the world. It's now in phase three studies here in the US So something that's coming up. So in Conclusion, I think the future of IOLs is very bright And so if the last 30 years or any indication I'm looking forward to the next 30 years to see what's coming up Now as part of a being course talk, you always have to give your obligatory Thank-you's and I have to give a big thank you to David Apple who Established the original IOL research center here at the University of Utah and really gave my career a start without him I wouldn't be where I am now, but The people that we're working with here Dr. Olson is probably the best possible chairman You could ever have in a department. I don't know if you guys realize how lucky you are to have someone like Randy Here he gives you all the backing you need yet let you do what you you know What you want to do when you're doing your research Alan Crandall who we've worked with for many many years Who's probably one of the best? Surgeons I've ever seen and one of the best teachers of surgery and of course Lilliana my co-director Without whom we wouldn't be able to do all the work that we do over the last 10 years in the laboratory Now there's also an unsung group of people here And these are the ophthalmic pathology research fellows and these are the fellows who do all the work in the laboratory through the years And we just got a collage of various pictures. We don't have a picture yet of our new fellows We're gonna do that at ask us this year But we couldn't do all the work we would do without a hard-working group of fellows throughout the years that help us to Do the work and last but not least you can never get very far without the help of your family So with that I thank you for your attention. I'd be happy to answer any questions That's a good question because when you look at the pathology of an aged ciliary body the ciliary muscle does look fairly atrophic But the answer to that is enough and so when you're looking at the phase three studies of these dual optic Accommodating lenses they really do work. So there is enough Ciliary muscle that's still there in order to contract enough to let those onions relax and let those optics come apart So it's certainly not going to be as strong as the ciliary muscle in a younger person But it's strong enough that you can get that Those lenses coming apart to get that two two and a half doctors of accommodated amplitude Thanks. Oh, that's a real good question because people ask you that and it's funny that we're doing all this great new stuff That's coming up and when it comes to IOL choices, I'm very conservative and in IOL choices not not politically But in IOL choices so very conservative and the reason being is Unfortunately, I still explain a lot of multifocal lenses And Alan explains a lot of multifocal lenses Randy explains a lot of multifocal lenses And so multifocal lenses have the advantage of giving you near and in distance vision But they have significant disadvantages and I've actually explained in multifocals from patients who have 2015 J1 vision and are miserable and just because of the dysphotopsia is the Vaseline vision and the decreased conscious sensitivity So I just don't think that's the answer and I'm waiting for a truly accommodating lens before I start using them You know in my patients, so I still use a one-piece hydrophobic acrylic You know wavefront type lens. Oh God That's a touchy topic so After doing research for ten years with Calhoun vision when the time came to do be a clinical center to do the research We're gonna be the clinical center and somehow Alan and I were leaving to go to a meeting and didn't fill out the proper form And Debra didn't know we didn't fill it out We didn't know she didn't fill it out bottom line is we didn't fill out of the paperwork Calhoun got into a snit and wouldn't give us the site so they gave it to Hoops vision And so now Hoops as you see in the newspaper has a full-page ad now It's a it's a phase three study and so they're saying is it boy everybody walks in and they get this lens No, it's a phase three study to do it and and they're just one of the study centers And so they're doing the actual phase three study after we've done here 400 of these probably they're doing the phase three study at Hoops vision So sort very sort topic But that's what they're advertising. They're gonna be the center in our city for the phase three study for the log just blends That that's another good question because one of the significant issues with an accommodating lens is the issue of PCO And so the lens capsule is indeed a basement membrane and people have theorized that there's something about the lens epithelial cells That are in there that put out some trophic factors that keep that from being brittle and keep it healthy The problem is is those lens epithelial cells are also the ones that will make proliferating cortex in the periphery of the lens which then goes along plus your caps and gives you PCO and Interiorly if those lenses are right against an IOL especially a silicone lens They will undergo fibrous metaplasia which gives you that capsule or Phymosis and that whitening you see the anterior capsule So the best idea we were looking at ways to totally wipe out all those cells and just leave an empty capsule But some have theorized that that's an issue So now people are looking at ways to make it so the lens epithelial cells are still there But don't proliferate and so that may be the best possible answer You know I don't know at this point because there are a lot of Factors that we don't understand that that the lens epithelial cells put out and that also affect the lens epithelial cells So I think we certainly don't want anterior capsule or fibrosis and Phymosis constriction We don't want PCO, but we maybe don't want a totally empty capsule with no No little epithelial cells in there. Oh, that's a good question I you know, I don't know I mean ideally it'd be nice to get all the measurements before you do a refractive surgery exactly and But but fortunately now the formulas are getting better and now using the IOL calculator, especially on the ASCRS site I mean it'll automatically take whatever data you have and then optimize the formulas that fit in that particular date and give you a Better readout. So we are getting better in that the incidence of Incorrect lens power peaked about four or five years ago and has dropped And I think one of the reasons is we're using the laser interferometer Which is a very good way of measuring the axial length as opposed to now the the B-scan using the water bath is very good, but it's extremely technician dependent So if you don't have a good tech doing it, which we have here you can get bad results So I think the IOL master and the lens star have gone a long way toward solving the axial length problem And then these new calculators available online using different formulas to optimize Your IOL calculations and someone who's had previous LASIK or RK are also very helpful So hopefully we're going a ways toward solving that Well, it's interesting That's what a lot of the companies aren't willing to say because they don't want the FDA to shut them down But once this is approved you can use a device off label And so you can imagine that you know there's going to be people who are hitting middle-aged who are upset about having more reading glasses and You know you could see a clear lens exchange or a refractive lens exchange they call it We don't say clear lens extraction refractive lens exchange putting an accommodating lens in and so that that would help solve the problem And so once these are approved you may actually see that Now other people are interest, you know interesting when they say they say this may actually save the government money because People will pay for the surgery themselves when they're 50 rather than have Medicare pay for it when they're 70 So interesting so it may actually save us all money other questions. All right. Thank you