 where we came from. So it all starts with Mr. Ridley. It's at the plaque at St. Thomas's Hospital in London. And when ESCRS was in London when you're on the lay down on Crandall and I'm my own travel buddy, we tracked down the Ridley plaque. And it was interesting, we went to the hospital at St. Thomas's and went to the information desk and say, where's the Ridley plaque? And the people at the desk said, who? And so they really had no idea what was going on. So there was no security. And so we just wandered the hospital and we found it in a lower hallway at St. Thomas's. So here's the plaque commemorating the first intraocular lens put in in the room. It's the Ridley and it's St. Thomas's. And Mr. Ridley, he retired to a cabin out in the woods of England. And this year, he tide flies. And so he was an avid fisherman. He was eventually knighted for the work that he did. And it was interesting, his original IOL, he said, OK, where is the crystalline lens in the natural eyes in the posterior chamber? So he went to Rainer, which was a company that still makes IOLs to this day in London, and said, make me a lens that fits in the posterior capsule. And so this original Rainer lens, now interestingly enough, when we looked at the material that was going to be in Mr. Ridley was in London during the Blitz when the Nazis were bombing London in World War II. And he was noticing that the Spitfighter pilots, they would have their cockpits shattered by machine gun fire. And as this cockpit material went into their eyes, it was in there. It didn't cause any inflammation. And it turned out fortuitously to be PMMA or Plexiglass. So they said, OK, this is a good material to make an IOL. So they made this IOL made to go in the posterior chamber when you take out the cataract. And here's one of the original Ridley lenses. It was this large, bulky PMMA lens. And it was not very well polished. And the problem at that time was Ridley was doing incredibly crude extra capsular surgery, including no microscopes. I mean, they were doing a lot of it through loops. And he was doing extra caps. And so a lot of these would dislocate. They would cause problems. They'd cause inflammation. But if they were well-fixated within the capsular bag and were not exposed to the solar soles and inflammation, this was a Miyake view of an eye that had an original Ridley lens in it for 30 years. And so when we do the Miyake view, what we do is we take a donated eye that someone has donated. We cut it in half coronally. And then you look at it from the inside. So it's like you're sitting at the optic nerve looking out. This was the view that Miyake from Japan first pioneered. And so we do a lot of our analyses of eye wells to this day, if you know as well, from the Miyake view. So this is the old Miyake view. So if these lenses were well-fixated, they could actually do quite well. Now Ridley did his first one in 1951. See, that's been over 70 years now. So it was pretty amazing that he did that. Now, he had to do it in secret because people thought these were really dangerous. And so he had to have a student come in and help him. And he did it in secret. It's interesting because if you look at the history of Faco, Charlie Kelman, when he came up with the Faco administration, thought this thing is dangerous. This is going to blind people. So he kind of got a medical student and snuck in on a Saturday and did a surgery with his first Faco. So it's very interesting how, when you look at the history of eye wells and Faco modification, how a lot of the progress was fought by the establishment. In fact, fought tooth and nail by the establishment. Poor Mr. Ridley was sent out into the wilderness. In fact, when Mr. Ridley tried to come to the US and speak to the American Academy of Ophthalmology about eye wells, the president of the American Academy said, if anyone puts one of these devices in a patient's eye, I will be glad to testify at the trial for the lawyer that's suing the doctor. So a huge amount of inertia that they had to overcome to develop intraocular lenses. And this is the Ridley lens on a scanning EM. You can see, look at the ridges. And look how thick that thing is. I mean, that was just huge when they put it in. So needless to say, with the crude extra caps, there wasn't really a good way to put lenses in there. And so at that time, people were starting to develop what we call intra-counselor surgery, meaning you take out the entire lens, in the bag, everything. And so you've got nothing to support an eye well. So people said, well, where could we put this eye well? Well, the next logical place would be, can we put it in the anterior chamber? And so this is just a schematic showing some of the early anterior chamber eye wells. And interestingly, one of the students of Mr. Ridley, Mr. Peter Choice, came up with the first anterior chamber eye well, again, this is made of PMMA. And you can see, he shaped it. It's almost shaped like an arrowhead or like a bullet there. And he would put these in the anterior chamber. Now, this went through many different modifications. This was the Mach 1. And so this was the time in the early 60s. Mach sounded cool. The planes were flying Mach, speed of sound and things. And so this was the Mach 1. And eventually, he came up with the Mach 8. This was the lens that was in widespread use in Europe, mind you, not in the United States. This was in Europe. This was the Choice lens in the anterior chamber. And this was the Mach 9, the last one that he did. Now, the problem with these lenses is they fit in the anterior chamber. And they scrape on the iris. And so what happens when you get an IOL that can strip on the iris? This is blood. You can get hyphema. And if it was not fit properly, this is a donated eye with the cornea removed. Look at that cat's eye pupil. Here's one of the footplates in a PI. You had to do a big PI. You could put your block with these. And so we used to joke about these when we'd evaluate them in the lab. These lenses came in two sizes, too big and too small. And so if they were too big, you'd get a cat's eye pupil. If they were too small, you would get propellery of these around there. Now, this is all going on without OVDs. And so when people are trying to put these in the eye after taking out the cataract, they're putting them in under air. And so you can imagine how difficult that would be to put these in. This shows you an eye that had an early choice lens and then look at that iris tuck. And so you'd be doing surgery from above, making a large incision, taking out the whole contents of the lens, an intracap, and then basically just cramming this lens in under air. And so you can see where superiorly it wasn't uncommon that you get iris tuck. Look at the pigment in the angle. And so you could get pigment dispersion glaucoma from this. And in fact, when they started making copies of these, and one of the first tucks I gave is the Dave Appel Fellow, I was innocently sitting on the podium talking. And of course, the discussant was Peter Choice. And so he immediately corrected me and said, this is not my lens. Young man, this is a copy and illegal license of my lens. It's very perturbed because his lens is a whirl polish. So this was a choice ripoff. Look at the edge of that. That's a scanning EM. And I wish I had the pictures here. When I was a fellow, we went out and we took a Coke bottle, broke it on the curve, and then took an EM of the Coke bottle and it looked like that. So you can imagine what this would do. So this was the original UGG syndrome. You hear that even right now. UVI-DIS glaucoma hyphema UGG. And so these porty finished lenses crammed into the anterior chamber would cause chronic UVI-DIS, high pressure glaucoma. And so this was the original UGG syndrome. So people said, all right, if the lens is a solid PMMA, maybe it doesn't fit quite properly. Maybe it can cause problems. Why don't we make a lens with open loops? Or closed loops, I'm sorry. And so A-ZAR, now this was at the time when there was an IOL company on every corner. And so every cataract surgeon would design his own lens and then the IOL company would make it. So this was the A-ZAR, 911Z. And you can see it's this closed loop. Now by this time, they discovered that you can make these loops out of polypropylene or proline. And so they would make these proline loops in a PMMA optic once again. Now the problem with these is that if you squeeze on those loops, the optic would vault either forward or backward. But these were very easy to put in. And in fact, by this time they were starting to put lenses in in the US. Daring US surgeons were starting to put these in. They're very easy to put in. And in fact, these lenses had very good results for the first two years. And then slowly but surely what started happening is people started to develop corneal edema and voluscatopathy and other things. This is another variation. This was the Lyski lens. And he just took those haptics and squared them off. This one was a closed one on piece PMMA. But same idea. They had the open loops, I mean the closed loops. Now people said, OK, it's vaulting. Why don't we make something with more open loops? So this was called the stable flex lens. And it was open. The idea was is if you squeeze that, it wouldn't vault so much. But if you look at those, imagine what that's going to do in the angle. And so unfortunately, these were put in by a lot of surgeons here. In fact, when I first got here in the mid-80s, this was one of the lenses that was being used here in Salt Lake by some of the busy surgeons. And these are just awful to take out because it makes eight little synecial tunnels around these haptics. And so these were very, very difficult to take out once they caused problems. And you can see what some of these lenses would do. That picture is clear. It wasn't a fellow's picture. And you can see that the cornea is edematous. The eye is very red and angry. So chronic uveitis, corneal edema, cystoid macular edema, we call this UG plus. So there's a problem with all these clothes in the banterial chamber eye wells. And what would they do? They'd cause corneal edema. Okay, so we can actually, oh, we can pimp someone here. All right? Oh shoot, I didn't show the picture. Ah, I can't pimp you. So this is a cornea, totally edematous from one of these anterior chamber eye wells. So Pseudophagic Bull's Care Topathy. In 1989 Pseudophagic Bull's Care Topathy was the number one reason for doing a cornea transplant here at Moran. And so this was a large amount of people doing this. You know, now you hardly see Pseudophagic Bull's Care Topathy. This is what these would look like. Here's this Lyske lens. Look, where does that haptic go when you're looking in this cadaver? I read the cornea. Here's the IOL. It disappears. Why? Because you get a huge cocoon over that haptic, that round haptic in the angle. Thus, thus you would get glaucoma, you'd get vaulting, you'd get corneal edema. And here you can see a loop. Here's the root of the iris. This is the trabecular mescalic up here. Look at that loop, it digs all the way back to the ciliary muscle. So these loops would dig all the way back and you get these synechia tunnels on them. So when you had to cut these out, you couldn't just pull them out because it would cause a huge hemorrhage. You had to cut these, right where the synechia tunnel went in, take out the optic and then try to slide that haptic out of the tunnel. These were very, very difficult to remove. Here's the other one that lends the stable flex. We said, look at these eight, four and four on each side. Those would form these synechia tunnels. These you'd have to cut them twice and twice. These were just held to take out. Very, very difficult. This was an interesting one. A doctor named Dubrov said, well, if you can't take the loops out, why don't we make propellers here on this? And so this had three loops on it. The problem with this is these loops, they're very broad, they would go all the way into the angle and there's three of them. And so this would cut out, block off about two thirds of the trabecular mesh work. So these caused a tremendous amount of glaucoma. Plus they were poorly fixated. So they're associated with a lot of hug syndrome. This is what they would look like inside the eye. Again, corneal edema, angry, angry and flamed eye. All right, now I can have a pimp question. Jordan, what is this? So this actually looks like corneal tissue. Okay, and what do we see in here? Exactly, so bolus keratopathy. See, I had to put path in here somewhere. I can't let you guys snooze. What else have we got here? What's this one? It's like a retina. Retina, what's going on in that retina? Well, first off, before I even say that, what part of the retina are we in and how can I tell that? So I think you're getting at this v-macula. Why? And I think that would just be, just based on like the density of your receptors. Nope, why is this v-macula? Is it that there's more than one mix? Exactly, so that is how a pathologist defines the macula. The ganglion cell layer is more than one cell you would think. So we're in the macula. What is this stuff? Vivian, what layer are we in and what is that stuff? That is the external layer. Powder what layer? Outer plexiform layer. What do we call the outer plexiform layer in the macula? How fast do you guys forget that? Layers, what do we call that? Is it Henley's layer? Henley's layer. So then what is this stuff? Drusen? No, Drusen are actually way down here. What is this stuff? That is serum, it's exudate. So this is CME, Cystoid Macular Edema. Another problem that you see with chronic inflammation with an anterior chamber IOL, chronic Cystoid Macular Edema. See, you had a path you guys thought you had. Thought it was safe, you wouldn't get pimped today. All right, so Kelman, as in Charlie Kelman, who invented the Phaecos, said, well, if we're having all this trouble with these closed lube IOLs, why don't we make an open lube IOL? So his first one made a PMMA. We used to call this the pregnant seven. So it looks like a seven, who's nine months pregnant. So the pregnant seven. This was really awkward and unyieldy to put in. So then Ridley thinned down those haptics and made him thinner. And so this was called the omni-fit. Now, he would go around and he would lecture and his theory was that a three-piece IOL is better fixated and more stable than a four-piece with haptics. And his argument was the bar stool on an uneven floor. So if you're in a bar, the tile's a little bit warmth and uneven. If you have a three-legged stool, it's really stable. If you have a four-legged stool, it wobbles. And so he did this one. Well, people put him in and said, nah, this goes in fine. That one digs into the iris. So Ken was a pretty sharp guy. So those people put these in and said, nah, this is not working. He immediately chucked that argument out the window and made this lens. Now, does this look familiar? You guys don't do anterior chamber IOLs anymore, but if you do see an anterior chamber IOL, this is the lens we use to this day. And so this is now in the early eighties. And so this is called the multifax lens. And this was the lens we use even to this day. In an anterior chamber IOL, four-point fixation because you've got these open loops, PMMA. And what happens is if you squeeze those haptics, instead of the optic vaulting up and down, the haptics take that squeeze. So this doesn't vault like a closed loop. So this has a lot of advantages because you've got this little curve going concave instead of convex, you only have four-point fixation in the angle. So it doesn't block the angle out. So you don't get chronic or coma. So very good idea. And this is the anterior chamber lens we use to this day. This is the old Apple Core. David Apple, I don't know who that guy is. Kind of swarming, looking mustache, brown hair. And we didn't really have a big lab yet then because David didn't have the money yet. And so this is the corner of the old cafeteria in the hospital. So we would take over the cafeteria. He would dictate the legends to the pictures. Then we'd take all of our EMS and all these pictures here and lay them out. We would write papers in the corner right there. So that was the old Apple Core. All right, so anterior chamber IOL, some of them were working out. People in Europe were looking at other ways of fixating an IOL while you're doing an intracap. How about iris fixated? And so there were a couple of people, Bink Horse and Works, were the people working on these in the Netherlands and in Belgium. In any event, they were working on different lenses. And so they said, why don't we come up with an IOL that clips to the iris? You have these two haptics go in front of the iris and two haptics go behind the iris. The problem is you dilate a pupil. What does that lens do? Falls into the vitreous because these people had intracaps. So that didn't work too well. And so they said, why don't we put a little stake on here and actually stick that to the iris? And in fact, if that doesn't work, why don't we put two suture holes in here? Why don't we suture that superior part of that to the iris? So this was the worst lens, John Waters. And again, we used to joke as fellows, this truly was the worst lens. And so this would cause chronic ux syndrome, iris atrophy, glaucoma. Now the problem is, is the haptics at this time were made out of PMMA. I'm sorry, proline, polypropylene. And so polypropylene, if it was in touch with vascular tissue like the iris or the silversocus would break down. And so we call this mudflap degradation. And so this is mudflap degradation. And again, that brown-haired mustache guy, this was the second paper I ever wrote, was describing this. And so we found that proline haptics would eventually break down as do proline sutures. And so if you take a 10-0 proline suture and you use it, suture aniole to the sulcus, eventually that suture will break down. That's why we'll use 9-0 proline instead of 10-0. So somebody said, well, if they break down, why don't we make something that won't break down? This is titanium. So this lasted for about two days because titanium is very expensive, it's very heavy. And so these would dislocate and these would really chafe it, but they're pretty cool when you look down them. So they actually made titanium haptics. So again, if you guys are thinking of, wow, why don't we make it out of this? Don't do titanium. Now, all right, so this is one of the worst lenses and this little peg is up here. Look at the iris atrophy where that peg was. We've got the sutures in here. Look at the irregularity of the pupil and the atrophy of the pupil. Oh, I've been waiting to say this all morning. No, you didn't. Thank you. All right, so this is one of those haptics from the iris fixated lens and look at the iris stuck to it. This is an EM, iris adherent to it. And so these would cause problems also. So this shows you in a schematic now. People were beginning to start doing extra capsular surgery instead of intracaps at this time. So this is an iris fixated one. So somebody said, well, if we've got a capsular bag here, why don't we change the haptics and allow them to go into that bag and fixated? So this was one of the ads. Copeland was a company that came up with this propeller lens where you'd have two tabs in front, two tabs behind and this is the Christmas card they sent out. So Copeland Lab wishes you happy holidays. They're sent as elves making the little Copeland propeller lenses. So this is one of the cards they would send out. Well, if you look at this, this was interesting because you'd get a square pupil, two tabs in front of the iris, two tabs behind the iris. And so you'd get synechia, you get a pupil that wouldn't dilate, you get a square pupil. And so these were not put into wide use. And this was what these lenses would cause. Again, it's not that this picture's out of focus, that corny is totally indemnus. So these could again, just like some of the anterior chamber IOLs cause edema, cause conical sclerotopathy, cause systolic macular edema. So this was my favorite ad. Proven, safe, and effective, discontinued. And so I love it. They still left this in their ad. Proven, safe, and effective, yet they discontinued it, so. So finally, finally, finally people came back extra caps. And finally got microscopes in surgery, people started doing extra caps. They said, hey, we've got an intact capsule. Why don't we put an IOL in the back? And so this is one of the first lenses. This is Steve Shearing, came up with this lens. If you look at it, it looks like an umbrella handle. So J-shaped lens on there. And he started putting these in and people said, hey, what a great idea. And the nice thing about the early 80s is tremendous amount of innovation. People would look at it and say, hey, that's a great idea. Why don't we change this and change that? And there were more IOLs designed on a cocktail napkin, you know, in the bar after a meeting than there were actually in the laboratories. And so people looked at this, they put it in, they said, you know what? Those things just poke into the capsule there. They're not quite round enough. Why don't we change the shape? Why don't we make it into a big C? And so a guy named Simcoe in Oklahoma City said, yeah, why don't we put a big C loop on there? So we put a big C loop on there, but those were awkward to put in. So finally, Sinsky, now you guys have heard of the Sinsky hook, we use that in like every case. So Bob Sinsky said, hey, why don't we take that original J idea, but why don't we bend a little bit? So modified J, so this was the Sinsky lens. And so IOLab was one of the first ones and they actually stamped it on there. So they knew it was IOLab, it was an 18.5 lens. Now those aren't a good idea. Put in there, because that will induce some irritation and some inflammation, but this was the lens that really took off as opposed to chamber IOL. And in the 80s, this was the lens that everybody went to. So this was the Sinsky lens. Now some people argued that we should put these in the ciliary sulcus because we can't put them in the bag. And the problem is, is we didn't have this capsular rex system. Nobody had figured that out yet. And so when we were making these capsulotomies, we take a 25 gauge needle and we bend it. And you know what that needle is now, that's a little systotome we use when we're starting a capsulotomy now with weak zonules. So we would custom bend one of those and you'd go in and you'd puncture that capsule in 20 places, kind of like the punctures around a postage stand. Then you'd pull out the capsule and then you'd make two slits on both sides and then you'd remove the lens, the lens nucleus hole and you'd suck out the cortex and you'd put the IOL in. Well, people said, well, you can't really get it in the bag after that. We should put this in the sulcus. So another paper that we wrote from the Apple lab is we said, no, sulcus is not a good place to put the IOL because those haptics can scrape against uvial tissue. So we said, put it in the bag. And this was an IOL that you can see here. Look at what that looks like there where it was scraping along the iris posterior. So you don't want to put them in the sulcus, you want to put them in the bag. And so this is an IOL, this is an IOL, this is the iris. Now, trabecular mesh work is way back here. Look at that, there's per-frontary synechia, summer injuring and look at that loop. That loop is penetrated into the sulcus all the way back to the major iris circle. So not a good idea to put these things in the sulcus. So we wanted to put them in the bag and that's what we recommended. Now, here's a Miyake view years later, Sinsky lens in the bag. Look at that, how beautiful that looks. So nice, beautiful lens. And so that's where we put the IOLs right now. And look at that, here's the iris, iris root and sulic processes, capsular bag. Look at that nice loop sitting in the capsular bag. So that's where we put things right now. Now, as people were getting better at companies, getting better and better at making IOLs, one of the things they improved on is polishing. And so they came up with the technique of tumble polishing. And I don't know if people still do this, when my daughter was little, she saw her friend had one of these rock polishers. And so you put a rock in there and you've got these little beads and this stuff and you spin it around for a week and then that rock comes out beautifully polished. So IOL companies said, hey, why don't we do this for IOLs? So they put these little beads in there and some polishing compound. You rotate them in a kind of a big cylinder for seven days at a time and you get these beautifully finished IOLs. Now, to this day, we still polish IOLs like that tumble polishing. And see, this actually happens to be a one-piece PMMA IOL. Look at how beautiful IOLs. It's a very, very beautifully polished. The company's got better at polishing. All right, we can't talk about IOLs without talking about cataract surgery. So the cataract surgery, the evolution of the cataract surgery is pretty amazing what was done. And so this was one of the early cataract surgeries. We're operating superiorly. This is superior. Look at that wound. That wound is 11 millimeters. Now we pre-placed sutures in here so you wouldn't get an explosive hemorrhage. You'd leave a little flap of car and lift that up. And then you go in with a cryopro and you put a freeze ball on that IOL and then you wiggle it and pop that whole thing out. So the zonules were pretty strong and they would really resist that. So people came up with alpha chymotrypsin, which melts zonules. So what you do is you'd inject alpha chymotrypsin in there, you'd wait a minute and then you'd put your freeze ball on and you'd pull that out. This is called an intracap. So there's no capsular bag. Now look at that cornea when you're doing this. And so we didn't have corneal endothelial cell counts yet then. So as people started to figure out how to do spicular microscopy, you'd realize that this surgery caused a 50% loss of endothelial cells. So that's about the equivalent of what a second year resident does now with a FACO. Sorry. Okay, so 50% loss of endothelial cells. And so, and you wouldn't have a capsular bag. So people said, wait a minute, this is not very good. Let's try to preserve that capsular. So we put an IOL in posterior chamber. So you would make, now we're looking at a little, kind of a little smiley flange there. So you'd be able to suture a better sclera. And again, 11 millimeters out. But now you would, you would do your little canopter capsular, you pop the optic up, one edge of the optic up, you put the serrated loop in there and you pull the optic out. I mean, the lens, not the optic, the lens nucleus out whole. So this is called an extra cap. Then you went in there with a manual IA and you'd suck and squirt and suck and squirt. You got the cord next. But you could put an IOL in the capsular bag. So this was a big advance. Is that like the sclera? I don't always talk about just that RK patient. Yep, you're making me, it wouldn't have to be that big. I'll say it because you're gonna think of it. You see how your back about a millimeter and a half from the limbus? And you'd make a little perpendicular incision here and then you tunnel forward. And so you'd leave a little flange in there and these sutured very, very nicely. Now what would happen after these, those, what would you have to do? You'd have to put in eight sutures. And so, and again, I don't mean this facetiously. Residents would get very good at putting sutures in. You guys now, you guys are unbelievable. You guys can do, you know, feco with no stitch and put an IOL in the bag and you guys are wonderful surgeons. You guys don't know how to put a stitch in anymore because you don't get a chance to do it much. And so the cornea people go nuts because you guys don't know how to put in sutures. Well, you were very good at putting in sutures. We just weren't very good at removing IOL, removing cataracts at that time. So you'd put in eight individual sutures here, close that down. Of course, patients would have, you know, two diopters of sill and you'd cut the sutures over 12 weeks and eventually the sill would settle down. So this was an extra cap. Well, you know, the problem is, is you're making this huge incision. You've got to be able to make it smaller. And so, so Charlie Kelman was at his dentist's office and when you're at the dentist, what do you do when you have plaque on your teeth? They clean it off with an ultrasound. So he talks to the young hygienists, what is that thing? They said, oh, it's an ultrasound. It breaks up the plaque on your teeth. So Kelman put two and two together and said, wait a minute, why can't we use an ultrasound to break up a cataract? And so he made his first crude ultrasound and you would use the sound waves to break up the cataract. And so again, this first one, the first case he took, took like an hour and 15 minutes to do the case. And of course, you know, probably 80% endothelial cell loss, but he stuck with it and worked with a company that made the original cavatron and they would make the ultrasound that we use to this day again to remove an IOL. Now, the ultrasound at that time had on and off. There was no variable pedal. So you would preset the power. You want 50%, 60%, 70%. As soon as you put the pedal down, you got 70%. So it wasn't controlled at all. It would go from zero to seven. You just, but, so then the company said, hey, why don't we make this variable? So they made the ultrasound variable and they changed how you actually do that. And we talked a little bit about ultrasound. In fact, I'll talk to all the second years early next year and talking about ultrasound settings and what we use. So it's come a long, long way, but it was Charlie Kelman's idea that made this. Now, Charlie Kelman was a real interesting guy. His office was in the Empire State Building in New York in Manhattan and he also was an entertainer. He played saxophone, he sang. And so his dream was always to play Carnegie Hall. So eventually he had a concert in Carnegie Hall and invited all of his cataract patients in data show. And so that was, he was quite an interesting guy. So he invented the ultrasound. So we're always thankful to Kelman because now we can make, you know, we can take an IOL after a small opening. And so people said, hey, this is great. We can make, take out this IOL through three millimeter opening. Now the problem is what were optics made of then? They're made of PMMA. So you do this beautiful three millimeter FACO and then you'd have to widen it to six millimeters to put the IOL in. So again, company would say, now this was interesting because you would have innovation in IOLs and then an ultrasound and then in IOLs and then an ultrasound so they would feed on each other. So people went back and they said, well, first of all, I'll talk about incisions a little bit here. This is our three-plane shelved incision. As we got better and better at doing FACO and we finally started getting foldable IOLs, people said, why are we going into the sclera? Why don't we just make a clear corneal incision, which is what you make now. And so then we went from sutured sclera incisions to non-sutured sclera incisions to non-sutured clear corneal incisions. But all of these require a foldable IOL. So the first material that people came up with is silicone. This was the first IOL and this was a plate type silicone. And the guy who designed it, it's a guy named Tom Masako. So you look at it, it kind of looks like a taco. So we used to call this the Masako taco. This was the first IOL foldable silicone and you could put that through about a 3.5 millimeter incision. So companies again started making these plate silicone lenses, but look how well finished that is. They would finish these almost like the PMMA lenses and so beautifully finished silicone lens. The bag, well, people said, well, that's kind of bulky and it doesn't fit in the bag well. Why don't we make a three-piece silicone lens? So there's a silicone lens folded in half, haptics here, haptics there. And the idea is you'd fold it up, put it inside the bag, turn it over and unfold it inside the bag, so three-piece silicone. People came up with all kinds of different ways of doing this. This is a haptic made of PVDF polyamide, they called it. Now, if that sounds familiar, this is the material that's made on the CT Lucia lenses that we now use for sclerophyxation for the Yamani technique. So this is just a different material. It's not as brittle as PMMA, but it stands up a little bit better than this ProLens, a PVDF. This was a hydrogel. People were looking at hydrophilic acrylic lenses. So this was a hydrogel with some grafted haptics on it. This is a rabbit eye with a Miyaki view, but again, nicely fixated within the counselor bag. But the problem with hydrophilic acrylics is they can calcify inside the eye. So there were various different models of hydrophilic acrylics that would calcify. So finally people said, how about a hydrophobic acrylic? Very low water content, very sturdy. You can make the edges sharp, high refractive index, meaning you can make the IOL thinner, get more bang for the buck. And so this was the very first Acrosoft lens. This is the material we use to this day, hydrophobic acrylic. This has extruded PMMA haptics. And of course, then they went on and made the one piece lenses, which we use now. And so the hydrophobic acrylic is what we use mainly in the United States. Now, outside the United States, they still use a lot of the more modern hydrophilic acrylics, which don't calcify as much. And so I'm not gonna go anywhere beyond this because I just wanted to give you guys an idea of the history of IOL development because we'll give you plenty of talks through the years and grand rounds about newer IOLs, but this is where we came from. And so this is our crew at the ESCRS meeting in Paris. There's Notre Dame, there's the sand underneath there. Now, why is Mike Teske at an IOL meeting because it's in Paris? Of course. Liliana Werner lived in Paris for seven years where she studied so she would always gather the crew and give us a tour of the city and we'd go out to dinner. So if you're ever gonna be in Paris, talk to Liliana before you go. So that's our group at the ESCRS in Paris. All right, questions about IOL, FACO history? Thank you. That tri-planar scleral wound you guys make, is that with a unique blade that allows you to do that or are you just literally going at a certain angle to another angle? Believe it or not, you could do it with a crescent blade. So those are still there, those are the rounded crescent blades. So you take a crescent blade, you turn it upside down, you make a little half thickness scleral groove about a millimeter and a half from the limb because then you turn it over and you would dissect underneath almost like you were doing a trabeculectomy and you dissect just beyond the limbus and then you enter with a sharp three millimeter blade. And what do we do with that now? That's how we do our rabbit research now because rabbits clear cornea doesn't seal well in a rabbit and so we make this now in all of our rabbits when we do this and so it seals nicely. Now, because it's a huge incision now, people, especially from Moran outreach, have been working a lot with the group in Nepal initially to come up with a small incision extra cap. And so now those of you guys who'll be doing the work, especially when you go to Nepal, instead of making that incision like parallel to the limbus, they would make it a frown instead of a smile. So now small incision extra caps, you do a large frown incision, which is maybe six millimeters across, but on the inside diameter is about 10 millimeters and so you can remove an entire nucleus there and it self seals, you don't have to suture it. So in the developing world, that's critical because issues with sutures, you may do this surgery on these patients, you may never see them again. And so the idea now is you do a capsulotomy, you take out that nucleus hole, you suck out the cortex, you put a one piece PMMA IOL, which they can make now in Indian Nepal for $5, put it in the bag and then that self seals. And so we've gone from making that kind of smile that you have to suture to making that large frown incision. So when you guys are doing the work in the developing world here with Moran Outreach, you will learn how to do that small incision extra cap, they call it, other questions. All right, so next week we get back, you actually have to read something back to glaucoma next week, okay? I think it's glaucoma, right? Pretty sure it's glaucoma. So in any event, then you get time off for Christmas. All right, thanks. Thank you.