 You know, it was kind of nice to be king. You get to build summer palaces and winter palaces and, you know, places to hang out. So this is the nice little, you know, summer palace. It's probably got, I don't know, 130 rooms in it. But once the French figured out how to build Versailles, everybody wanted to copy it. So this is kind of a scale down copy of Versailles, basically. And there's some, you know, tourists there looking at the place. You guys say there's never any. You can see the weather in Vienna is always lovely. It's September and it's like, you know, 40 degrees. So these are the gardens in the back. And they've got, again, it's a direct copy of Versailles. You've got these gorgeous gardens in the back. They've got a fountain in the middle. And then you've got this kind of quasi, you know, Prussian Nazi columns with eagles on them in the back. And so that was added later. Obviously that's not from the 16th century. But here's the fountains. You've got Neptune in the middle. You've got various, you know, gods around there and huge fountains. You know, this is always done on a massive scale. And then, again, there you can see this that was added with a Germanic eagle on top. So this is at the top of a hill. You can zigzag back and forth. You can climb straight up to it if you want to see it. So if we're going to talk about Iowels, we have to go back to Mr. Harold Ridley. And he did his first Iowel surgery at St. Thomas' Hospital in London. And the interesting thing about it is there was supposedly a plaque there. So when Alan and I were at the ESCRS in London, our mission was to find the Ridley plaque. And so it took us a good half hour of going through back hallways and down in basements through St. Thomas' Hospital. And nobody had any clue what we were talking about. Nobody who works there had any idea. But sure enough, we finally found it. Here's the plaque talking about the first intraocular lens implanted by Mr. Harold Ridley. And so there you see it. Now, there are people who swear that date is wrong, that they found the original records and that that date is wrong. But in any event, Mr. Ridley is known to be the first person in the world to put in an intraocular lens. And so here's Mr. Ridley. After he retired, he went out to his country home and he was a fisherman. And when Mr. Ridley got this idea, it was very interesting. He was a surgeon in England during World War II, during the Blitz, when the Germans were bombing London. And the RAF fighter pilots were going up to try to shoot down the bombers. And when they were being hit by machine gun fire, the cockpits were shattering. And pieces of the cockpit were getting into these pilot's eyes. And so Mr. Ridley was treating them at the hospital at St. Thomas's. And basically it turns out, fortuitously, that the cockpits were made out of PMMA, Plexiglas, which is what it was called. And Mr. Ridley was smart enough to say, gee, this material is inert inside the patient's eye. And so as he was looking at patients who at that time they were doing surgery, they were removing the crystalline lens and you were giving them glasses that were aphakic. So if you can imagine a plus 10 glass, I mean, they're hugely thick. You've got all kinds of problems. You get a prismatic effect around the edges where light is bent around the edge and then you don't even see it. So these poor patients would have what we call the jack-in-the-box effect, which means there's a blind spot right here. So you'd be driving down the street and then a car would pop into the next lane out of nowhere because they were in your blind spot. And of course it would magnify everything 25%. And so these people really had a difficult time. And so legend has it that a student was asking Ridley during surgery, well, you're taking out the cataract, aren't you gonna put in another lens? I don't know if that's true or not. But Ridley's idea was interesting in that he was doing crude extra caps. This was the time when everybody was doing intercaps where you were removing the entire lens. And so as a result, his first lens was designed to go in the posterior chamber, which is very interesting. So that's what Ridley's first lens looks like. And he was also fortuitous in that company Rainer in London, which still exists, still makes IOLs, was the one who made the IOL for him. So it was a disc, it was a very thick disc made of this PMMA, polymethymethacrylate or plexiglass. You know, the problem is, is these were just kind of hand polished. So they were very rough, it was very difficult. But this is an eye that was donated to our lab many years ago. And this is one of the original Ridley lenses, which was inside the lens capsule and lasted for about 30 years. So if it stayed in the capsule, this lens actually did okay. But the problem is, is this was the edge of the lens. And so you can imagine that stripping against UVL tissue, you know, you didn't have capsillotomies then. And so this is what the lens looked like. And so as a result, they ran into a lot of problems. A lot of chronic UVIS, chronic UGG syndrome, pigmentary glaucoma, dislocated lenses, a lot of problems. What I'd like to do now with maybe Becca's help here is I want to show you one of Ridley's original videos. So this was, this was copied from a 16 millimeter tape. So this is one of his original videos. Sorry, our mouse is not working. And so I don't know how to work these without. There you go. Yeah. Is it the keyboard? All right. Let's make that bigger now. Oh, I don't know if I can do that. Sorry. All right, so here's Mr. Ridley. Let's see if you can see that. That's a graphing eye. Controller. You go into the eye and you saw all the way across it. What? Yep, yep, this is done under loops. There's no microscope. So you saw it in half, then you go in there and you grab and tear the capsule. I swear, this is how you guys do capsillotomies sometimes, tear it. Then you go in and you mash on the lens and push it out. Now look what that's doing to the endothelium. About 10,000 endothelial cells are dying but he pushes it out. And then you go in with a manual cannula and kind of flush out the liquefied cortex. Just flush it out. So this is again, all done with loops. Now here's his, here's his lens. Push it in into the posterior chamber. And then you close it. Oh, I'm sorry, they didn't show how you close it. You close it with four oh silk sutures. And so you put two four oh silk sutures and you tie it under loops and you tie a big loop on there. And then when the patients come back to clinic, you actually just cut out the sutures and take them out. So this is how surgery was in, you know, 1951. And so pretty amazing how, you know, surgery has come in greater than 60 years. And so that's pretty phenomenal. So the one that made me cringe was the grafie knife. You'd go limbus to limbus, then you just go, just saw the cornea in half. So you can imagine with these sutures on here, how much astigmatism you're gonna get. Which is why people wouldn't do cataracts until the cataract was mature. I mean, patients had to be at least 2,400 before you would dare do a cataract surgery. So it's come a long way. So that was Mr. Ridley surgery. So because of the complications and because people weren't used to doing extra capsular surgery, most people were doing intracaps, meaning you remove the cataract with the capsule bag in text. There's nothing to support it. So people started working at anterior chamber eye welds. And so putting an implant in the anterior chamber in front of the iris. And so these went through various designs. Now, one of Mr. Ridley's residents, Mr. Peter Choice, was one of the designers of the anterior chamber eye welds. And so this was the original choice lens. Again, made of PMMA. So it's a big piece of plastic that goes inside the eye. And he went through nine different iterations. So this was the Mach 1. And so this was the time people were trying to fly planes faster than the speed of sound. And so Mach sounded really modern. And so this was the Mach 1. And he went through various iterations. And this was the Mach 8. So this was the one, this was even in use when I was starting training. And so you see it's got the foot plates on there. It's got PMMAs, we had to make a big incision. But again, you're doing a big incision surgery anyway. You're doing an intercap. So you're putting it in there. We used to joke that these came in two sizes. Too big and too small. And so it's very difficult because we didn't have anterior segment ultrasound and OCT to measure it. And so you had to kind of do a caliper and you'd measure limbus to limbus and then subtract a millimeter. And that would be roughly your size of the anterior chamber. It's a very crude estimate. So this is Mr. Choice's lens. This was the Choice Mach 9. This was the last one that he made. All right, so again, we say, what are some of the problems with these lenses? Well, this is a Choice lens. You can see it there in the anterior chamber. And what these would do is they would scrape on the iris. And as they scraped on the iris, what do you get? You get microhyphemis. So you can see this little hyphae here. And so that was the problem with these lenses is if they were too small, they would propeller around the anterior chamber of the eye. If they were too big, they would tuck the iris and pinch it off. And so you would get chronic low-grade hyphaemus. You'd get ovelling of the pupil. This is a donated eye, cornea cutoff. You can see it's got this ovelling of the pupil. And you always had to do a perfiliridectomy with these because you'd get a pupillary block in these. And so you can see that the ovelling of the pupil. And this is where an actual foot plate of the IOL has tucked that iris posterior to the ciliary body. So they didn't have OVD when they were putting this in. There was no heel on. They were just kind of putting these in. Sometimes they put air in the anterior chamber. Sometimes they just shove them in. And again, you're doing this with loops. You're not doing this with a microscope. And so oftentimes the iris would get tucked posteriorly and look how thin that iris is. You get this thin-day trophic iris. But look at the top. Trubacular meshwork, something you're going to learn about next week. And you see that there's pigment, all this clogging the trubacular meshwork. So you get pigment dispersion from these anterior chamber one-piece plate type lenses, the choice lens. The other problem is this is the edge of a choice lens. And so again, the finish was you just took it and kind of rubbed it and it made it smoother. And so this was actually the edge of a lens that was removed. And just for fun, I wish I had this picture. When I was a fellow many years ago, we took a Coca-Cola bottle, broke it on the curb, and then took an EM of the Coke bottle and it looked just like that. So you can imagine what this is going to do in the anterior chambers, the pupils moving in and out. And so you could really get significant problems. And in fact, as these lenses were coming out, there was actually a surgeon in South Dakota who coined the term UGG, UV-Irosclochroma-hyfemosyndrome. And he never, I never met the guy. He never came into meetings. His name was Ellingson and it was called the UGG syndrome and it stuck. And so we use that to this day, UV-Irosclochroma-hyfemosyndrome. And that was chronic inflammation and hyfemos caused by poorly finished choice lenses. Now, choice was the first one to defend him. I was an innocent Dave Apple fellow speaking on my first Askers meeting. And of course, Mr. Choice was on the podium while I was talking, you know, he immediately stopped me and said, these were unlicensed rip-off copies by American companies of his lens. So these were not his lens inside. We're finally apologized to him. So these were Choice rip-offs, but companies were starting to make IOLs at this time, even in the U.S. and this was one of the U.S. made choice lenses. So because of the difficulties with one piece plate lenses, people said, well, why don't we make a lens instead of being one solid piece of plastic, a lens that has loops on it? And therefore, you can put this into the anterior chamber a lot more easily. It's less bulky, easier to finish. And so this was the first one. And those people who were inventing these, they put their name on it. So this was the Azar lens. It was called the Azar 911Z. They had come up with a way to make plastic loops out of polypropylene. And for those of you who were in the lab with me last week, we actually saw a pair of polypropylene loops, which underwent some surface degradation. And so these had clear polypropylene loops. And again, a PMMA optic, these were very easy to put in the eye. You just slide them in, they're very easy. And these eyes did great for about six months until they started running into problems. And so this was the Azar 911Z, but there were other ones, Larry Lyske male lens. This was the Lyske lens. All he did was he squared off the polypropylene and that's what that looked like. And some of them even made solid loops, various different ideas on the same thing. But the idea is you have these loops, these closed loops around there. That's right. Sir. What material of those optics are those? That was actually, this was all PMMA. So this was a whole lens out of PMMA. And then this was one, this was the ultimate one. This one had, look at all those little wires coming out. And so this was very popular in the early 80s here in Utah. And so they put a whole bunch of these in and boy, Randy and Alan could tell you, when you remove these because of UGG syndrome, these were a nightmare to remove because there's eight little individual loops that would go into the angle and then get cocoons of fibrosis around them. And so removing these was just awful. Trying not to cause irritodialysis and you'd have to cut them in two different places and back the loops out. These are really tough to remove. But again, they would cause just that chronic UGG syndrome. This is what an UGG syndrome looks like. This was another one. This was the Hesburgh lens. And this lens, the two things would come out and then they'd form a big U and go in. But if you look at this with the slit lamp, it's got corneal edema. The eye is extremely red and irritated from the chronic UVitis. So this is chronic UGG syndrome from these. And this was one of the side effects. This, believe it or not, is a cornea cut in half. And so it was interesting when the A's are 911Z came out, the company was touting this as safe, as a wonderful lens. Everybody should be using it. There was a high volume surgeon in town who had founded the Eye Institute who would advertise on TV and give people roses and send a limo to pick them up so that he could do their surgery and all. He was the first high volume guy. He was giving talks saying, I put these in and they're fantastic. I've never taken one out. And as he's saying that, I had 14 corneas in a jar on my desk from his patients with chronic corneal edema because of course, if you have a complication, you don't go back to the doctor who put it in, you get mad at him, you go to somebody else. And so you don't ever see a lot of your complications. So this lens, the A's are 911Z led to corneal edema, chronic ux syndrome. This is actually a cornea from one of those original ones. Why? Well, what happens is when you've got these small round closed loops as they go into the angle, which is what we're looking at here. They actually dig into the peripheral iris and the iris forms little cocoons over them. And so what happens is, is you get chronic irritation of the iris, but the other thing is when people rub their eye, which unfortunately people do after surgery, there's nowhere for that force to go. And so what was happening is these closed loops, as you push in would cause the optic to vault forward. And we did a bunch of studies in the lab where we literally put a bunch of them in there and squeezed them and saw what happened and they would vault forward. And so not only would these dig into the iris tissue and cause chronic irritation there, but they would bang forward and bang on the endothelium. And so you would end up with chronic corneal edema. And this just shows you, this is an IOL loop in the anterior chamber angle as it dug into the tissue. So this is what these closed loop anterior chamber IOLs would do. This was again one of the lenses I told you about the eight different little haptics. Look how they're digging into the angle there. This is an anterior view of a cadaver, a corneal remove so you can see it. And those loops are digging into the angle. So really, really difficult to remove once that happened. This was the lens we saw in clinic last week. This is a Dubrov lens. And so this guy Dubrov said, well, if the closed loops are a problem, why don't we make open loops? So he designed his IOL with three broad loops that would go around like propeller. The problem is is those loops would go into the angle and would totally close it off with, you know, synechia on top of them. And so you would literally shut off two thirds of the angle with this lens. And it was very sharp. The edges were very sharp. You can see where it's kind of scraped on the iris up above. So these turned out to be quite a disaster. And here again, here's an eye with just chronic UG syndrome with corneal edema. So eventually when you get corneal edema, they even called that UG plus. So you'd get corneal edema and your chronic UG syndrome. What is this? Bowie, all right. So there's a cornea. There's a Bowie blister with chronic corneal edema. What is this? We haven't done this this year yet. Exactly, so we are now in the macula and you see, exudate here in the outer plexiform layer, the layer of Henleys. So we're going to talk about that when we talk about retina in a couple of weeks. So that you would get chronic cystoid macular edema from all the inflammation. Well, Kelman, who was the man who invented the ultrasound. I mean the same Kelman. Charlie Kelman said, If the problem is with closed loops, then why don't we make an open loop by a well? So his first one, it was made out of PMMA. We used to call this the pregnant seven. And so you can see it looks like a pregnant seven, literally. This was a very stiff one piece PMMA. And so this didn't work very well. He immediately went away from this and made an open loop with again a tripod. And so Kelman's argument, he used to give these at talks, is that if you go to a bar and the floor is uneven, if you have a four legged stool, what happens? It wobbles. But if you have a three legged stool, it's sturdier and it doesn't wobble. So that was his argument. This didn't work well either. And so he, you know, he's, Kelman was smart. He about six months later said, okay, forget that argument. And he designed his Kelman lens. Now, does this look familiar? And this is our anterior chamber, Iowa, to this day. And Kelman designed this in the early eighties. And so this was a design that worked. It's open looped. So if you squeeze that, much like leaf springs on a truck, it will take up, you know, the pressure that you're squeezing it and that optic would not vault. So this was very good in that situation. Also, those little haptics were flatter. They weren't round. And so they didn't dig into the angle. And as you can see, he put a little kind of an anti-curve on it. So it would only kind of touch the angle in two places instead of along the whole arc. So this turned out to be a very good design. And as I say, we use it to this day. So this is our present day anterior chamber, one piece PMMA IOL. So that's kind of the evolution. Just to go back to Kelman's idea of the FACO, I thought this was a great idea. Kelman was a brilliant guy. He was a real showman. He played saxophone and was like on the Johnny Carson show. And his office was in the Empire State Building, seriously, in New York. And he did very well doing his surgery there. And so one day he decided he'd never played Carnegie Hall. So he rented Carnegie Hall and invited all of his patients that he'd operated on and did a concert for him. So he played tenor sax and sang a little and felt like a lounge lizard act. And so he did that. So he's quite a showman, quite a showman. So when Kelman was thinking about ways to get out of cataract, you know, because we were doing surgery with large incisions that were taking out the lens as whole, he said, God, we gotta have a better way to do it. He is at the dentist's office. And the hygienist is sitting there with the ultrasound cleaning the plaque off his teeth. And he's asking the hygienist, what is that thing? He said, well, it's an ultrasound. It grinds up the plaque. And so he had the aha moment. And then immediately went back and started working on using ultrasound to break up a lens to remove it. And that's, again, what we use this day. So Kelman was the one, that was his aha moment was at the dentist getting his teeth cleaned. So I always think of that when I was at the dentist last week and the hygienist is doing what she calls her deep clean where she takes the ultrasound and kind of goes into your mandible, take off the plaque and goes, oh, does that hurt? Oh, not really. Ah! So that's how Kelman got the idea. And that's how we ended up with fake emosification. Okay, so this is the original apple core. So I don't know who the guy is with the swarmy mustache, but this is how Dave Apple did things. You'd go to the corner of the cafeteria because we didn't have enough space in the lab yet then. You take up the whole corner, you'd spread out all these EM pictures that we did and then he'd take his dictaphone and he would just randomly dictate and then the secretary would try to put it into sentences and do it all. So this was all the original apple core we called it and we would sit there and go over the pictures and then dictate them all. So this is how papers were done in that era. All right, so while people were looking at anterior chamber, and again there were issues with anterior chamber, people in Europe said, why don't we come up with a way to clip the IOL to the iris? Now again, we're still doing intercaps, still not having any capsular support. So they said, okay, why don't we clip it to the iris? So this was Cornelius Binkors lens. And what he did is he said, okay, we'll put two loops in front of the iris, two loops behind the iris and we'll clip it on there. So this was the original Binkors lens. Now, because minor detail, if you like dilated the pupil widely to look at the peripheral retina, sometimes the IOL would just fall out. And so minor detail, so Jan Worst said, well, we've gotta find a way to fixate this IOL to the iris better, so it doesn't fall out. So he did a couple of things. He put two molds in here so that you could suture it to the iris, but he also put this little peg on there so it would hold it to the iris more firmly. We used to joke that this was the worst lens because it would cause horrible UGG syndrome. And you can imagine that suture going through there and then this pin on there. So these really caused horrible problems. The other thing is the haptics were made out of polypropylene. And this again, we saw one of these literally last week in the clinic, they're still out there. This is a polypropylene haptic. And as it gets in touch with UVL tissue, i.e. the iris, the angle, even the solar body, it would undergo what we call this mudflap cracking. So when it rains out in the desert and then the rain dries, you get this mudflap cracking on the road. That's all surface degradation of polypropylene. So you can see that. So it was fun because this was at a time when people were just kind of taking out lenses and there was no center in the world to study them. So Dave Appel was smart enough to start an IOL center. When I was his fellow, we would just do EMs on hundreds of these lenses. And every day you look at them and go, wow, what is that? And then try to figure out what it is. And so we were the first ones to really report degradation of polypropylene. Why is that important now? We're suturing an IOL to the ciliary sulcus or to the iris. What suture do you use? You use proline sutures, polypropylene. And so if you use a 10-ohl polypropylene and you suture an IOL to the iris or to the ciliary body, that can break down just like that. And eventually that suture can break down enough that it will literally break. So we use 9-ohl because 9-ohl, believe it or not, much bigger than 10-ohl. It doesn't seem that way, but it is. It's much bigger and so it lasts longer. This is interesting. What do you think this material is? It's titanium. So people said, wow, titanium never breaks down. Why don't we put that on there? Yeah, okay, so this is an iris fixated lens with titanium. The only problem is that titanium, even though you don't think of it as being really heavy, in an IOL it was pretty heavy with titanium and they had trouble polishing it really well. So it would, plus it was expensive. So titanium lasted for about a millisecond in the market. But enough so we saw one. So this was actually a titanium loop. So this was a worst lens. And as we joked about it, look at the irregularity of the pupil. The suture that goes through, I'm sorry, my pointer must be out of the battery, but there's a little suture coming up to suture that to the iris. There's a peg holding it there. So look at the iris atrophy all the way around. And so you get chronic Ugg syndrome, chronic pigment dispersion, glaucoma, all kinds of further problems. And this is an EM of one of these lenses that the loop that was behind the iris, and you can see all of the material stuck to that loop. So this was the two loop mink course. Of course, this is now when people are starting to do extra caps now, finally. And so you can see there's still a little bit of a caps that are back there. And so what they decided is they said, well, if we've got a caps that are back back there, we don't need to put four sets of loops. We can only do two sets of loops. And so eventually they made loops that would go back toward the caps or back. So what's funny is at this time, IOLs, they're going all kinds of designs, all kinds of advertising. This was an ad from the journal Copeland, was a company that made these propeller shaped IOLs. Two tabs in front of the iris, two tabs behind. And here's the Copeland elves making IOLs for Christmas. So this was actually an ad from journal ophthalmology. There's the Copeland elves that are making that. This was an interesting IOL because you'd get a square pupil. So you had two tabs in front of the iris, two tabs behind the iris. So you'd get a square pupil, again, chronic pigment dispersion, chronic UGG syndrome, all kinds of problems with these. This is what one of those Copeland lenses looked like. Corneal edema, UGG syndrome, pigment dispersion. And so these could cause really serious issues. My favorite is this one. This was one of these irritable capsular lenses. Look at it, proven, safe and effective. Discontinued. And so this was pulled off the market. And it was actually, a lot of these were pulled off the market by work that was done here. Dr. Olson and Dave Appel would literally go back to Washington and testify before the FDA. And so these were lenses that eventually were pulled off the market because they really weren't successful. All right, so now let's see something familiar. So again, people went the whole route. The original Ridley lens was made for the posterior chamber because he was doing crude extra caps. Well, everybody started doing intro caps for many, many years. Eventually people started getting back saying, wait a minute, if we can leave that capsular bag intact, not only are there advantages of vitrious not coming forward at all, but we can also consider putting an implant in there again. So Steve Shearing in Las Vegas was the first one to come up with a posterior chamber IOL, years later after Ridley. And so he came up with this J shape. And you can see it's got that J shape on there. And the idea is you put it in the posterior chamber and with capsular support. There was a great idea. So ophthalmologists are an innovative bunch. Once somebody saw this, he said, wow, what a great idea. And so immediately within like six months, there were a couple of variations of this coming out. And so guys were literally drawing IOLs on cocktail napkins, you know, at Academy meetings, and well, I shouldn't say Academy Academy, it was totally against IOLs and FACO from the first. They should say early Oscars meetings. And then companies would go back and literally make these. And so they were coming out. And so if you look at this, it's got this stiff J coming out from the middle. So if you think about it in the capsular bag, that would really ovalize the bag and it wouldn't fit well. So a guy named Simcoe in Oklahoma said, why don't we make these loops C shaped? So, you know, they'll more adequately fill that round shape. So he came out with these really big C shaped loops. Now, what are these things? They're actually positioning holes, we call them. And so, you know, we again didn't have OVDs then. And so you would literally shove these things behind there and you'd put a hook in there and move them around. And so this is how they would get in. And then this was the lens that I trained on. This is Bob Sinski's lens. And so he came up with what we call a modified J-loop. So he moved the J more to the periphery, angled a little better so it would fit inside the bag. And it went to two positioning holes. And so this was the Sinski modified J-loop lens. And this was the lens in the mid 80s that was the lens. I mean, this was the lens. And it really nicely done. ILab was one of the first U.S. companies to make implants in Southern California. You can see they literally wrote their name on it and they had the power on there. Turned out later on, we realized that you don't want raised letters on there, because again, they could scrape on things and cause nitices to form on there. So they eventually got rid of that. But this was the Sinski lens. And Sinski invented a hook to put it in, which you guys, we use to this day. So, and Sinski just passed away last year. I mean, he lived until his mid 80s. Life was good when you were one of the first IOL people. He bought a huge winery and Napa and it's called Sinski. And the label of his wine bottles, if you look carefully, he's got the little IOLs on it. And so his family now runs it, but still they make a wonderful Pinot Noir. So you can even get it in Salt Lake, it's funny, we found a restaurant here in Salt Lake, you could order a Sinski Pinot Noir, but so life was good in those days. All right, so then the argument became, where should you put an IOL? Should you put it in the capsular bag or should you put it in the soak us? And so at this time, we hadn't invented a capsule rexus yet. So we were making capsule atomies with a sharp Cystitone. The idea is you'd make a dozen punctures around the anterior capsule with this sharp instrument and then you tear off the capsule. And so you do an extra capsule, you take the nucleus out whole and that would split the capsule in a bunch of places. So people said, well, you really can't get that in the bag, we should just put it in the sulcus. You're arguing just put it in the sulcus and that was safer that way. And so we did some studies on IOLs that were in the sulcus and so this is actually a view from the back, a Miyaki view where there was an IOL in here, but look right here, look at that pigment broken up. And where was that? That's right where the haptics scrape on the posterior iris. And so Dave Appel and all of his fellows, myself included, argued very forcefully to put it in the bag. And so there was an argument back and forth with the people of Wilmer. And because it's Hopkins, Wilmer, they were obviously correct because Dick Green can never be wrong and so, but eventually you're not putting it in the sulcus anymore. So you know how that argument went. So this is an IOL that was put into the sulcus. That's the iris. First of all, notice that the anterior chamber, which we can measure is back here. So that iris is totally pushed forward and adhered to the cornea. Look at that loop. That loop is down here in the ciliary body. And so that loop dug in here. And again, so you've got synechia, you've got chronic glaucoma. This just shows how bad our surgery was. This is a huge summering drink in the capsular bag. But I would be bad as a weatherman and I keep getting in the way here. Going this and you watch the weather on TV. So finally, we got the ways to do a capsulotomy where you could have an intact anterior capsule, you could put an implant in the bag and sure enough, there's a Sinsky lens in the bag. Apple may I'll give you a look how beautiful that looks. And again, that's where we are now. I mean, it's all different kinds of IOLs but that's where we are now putting it in the bag. And here you can see, here's the iris to the front, there's the capsular bag, there's the loop of the IOL in the bag. And you see no UGG syndrome, no pigment dispersion, beautifully fixated within the capsular bag. And again, that's where we are today. Now, as technology was improving, polishing improved too. And so when we had these, this is an original one-piece PMMA lens and originally those were hand polished. It was funny because when you'd go to the IOL manufacturers, they were all in Southern California at that time and so there was rows of tables just like this, only sterile. And there was all these little Hispanic ladies with hairnets and makeup light polishing IOLs. I mean, literally tables of them just like this and that's how they fixed them. So people finally figured out a way to tumble polish these. And tumble polishing is you put little beads coated with polishing material and you tumble them in a cylinder. So those of you as kids, did you ever polish rocks? So remember you put those rocks in there and you'd churn them for like a week and then they come out all polished. Well, that's what you do with IOLs basically. It's a glorified rock polish. So you put some little beads in there and some polishing compound and you tumble them for a long time and look how beautiful this looks though. I mean, you can get a really smooth, smooth IOL surface from this. So you can't talk about IOLs without talking about evolution of cataract surgery. And they really went hand in hand. And so as cataract surgery got better than IOLs would change to match it. And so again, initially we were doing intra caps. And so how did you do an intra cap? You would make this huge incision stem to stem, I mean, limbus to limbus. Now we would put a couple of stay sutures in there because if you got an expulsive hemorrhage, you want to be able to tie that down really quick. And so then you would have a little tag of conjunctile on the cornea. You'd lift up the cornea and then you'd go in there with a cryo probe, you know, like the retina guys use now in the sclera and a cryo attire. You'd put in some alpha chymotrypsin which would digest the zonules. You'd leave it there for 30 seconds and then you take this cryo probe and you'd put it on the anterior capsule. Push the pedal down equal. This ice ball would form on there and then you'd yank that entire lens and capsular bag out in one piece. Just, it would come out. And then you'd put an implant either in the anterior chamber or put to the iris and then you'd tie down all those sutures that you had. And so, you know, this is an 11 millimeter incision. It's a huge incision. There's no capsular support. So people started doing extra caps. And with an extra cap, what that means is you'd leave the capsular bag intact. You would go in much like Mr. Ridley did originally. Now you can see our wounds got a little bit smaller. We even made a little corneal sclera tunnel. You'd do your capsulotomy and then you'd go in there and you'd either use fluid or counter motion and motion. You'd pop the edge of the nucleus up. Then you'd go in there with a loop and you'd grab that nucleus and pull it out. And then you temporarily tie those two sutures and you'd go in with a manual irrigation aspiration cannula called a simco cannula and you'd squirt some fluid in and then you'd pull back. It was interesting because you would pull back on a syringe. And so you could generate anywhere from zero to 400 millimeters of mercury pulling manually. And so when you wanted, you'd go in there and then you'd start pulling back, pulling back and start grabbing cortex and then you'd strip the cortex and yank it back and it'll gobble up the cortex and you'd squirt in a little more fluid. So that's how you did extra caps. Well, again, Kelman finally said, hey, we gotta be able to remove an IOL, I mean, a cataract from the eye without making a big incision. And so he invented the ultrasound. So the idea now to this day again is we use the ultrasound to fragment the hard nucleus so we don't have to bring it out whole. So as a result, we can break it up into tiny pieces. You can suction it out. This will allow smaller incisions. And you have better control. Yes. Was it true that someone was at the dentist's office like listening to the ultrasound? It was Kelman. It was. Yes, I'm sorry. You missed that story when you were answering your page but absolutely, it was Kelman and the hygienist was working on his teeth with an ultrasound. Absolutely, that's absolutely true. So the second thing that this allowed is it allowed us to modify our wounds. And so initially with those extra capture, making just a big incision right at the limb bus and putting lots of sutures in, you'd get a stigmatism and all. So as people started saying, hey, wait a minute, we can use an ultrasound, make smaller incisions, we started making these stepped incisions. So you'd go back about a millimeter back, you'd go down partially into the square and then you tunnel forward and then eventually enter the clear cornea. And so that was this shelved incision that you'd make. Well, Howard Fine in Eugene said, wait a minute, you know, if we're doing these smaller and smaller incisions now, why do we even have to go through the sclera? Why can't we just go through the clear cornea? And so he was really the one who pushed these clear cornea incisions that we did now. Now that did a couple of things. First of all, you didn't have to go back in the sclera where it bled, you could do clear cornea. But second of all, we could now do surgery with topical anesthesians that are retroboar block. You know, if you're digging through the sclera at all and taking down conjunctiva, you can't do that with topical anesthesia. You need a retroboar block. And so this allowed us to start doing topical anesthesia. And the other thing people figured out is we used to operate superiorly. You tilt the eye down, you'd sit at the head and you'd work that way. People said, wait a minute, if we're doing a clear cornea incision, we don't have to be superior. What we worry about, you know, the lid covering overware incision is we could move temporal. And so that allowed us to sit comfortably, gain access to the eye without it turning down so it's interesting how technologies are all interspersed. And so we were able to, with this incision, to jump to topical anesthesia and sit temporarily, which is what we all do to this day. And so, again, better access to the eye. You didn't have to tell. We used to do with our extra caps. We would grab the patient's superior rectus muscle up above through the conge. You'd pinch it and you'd put a big 6-0 suture through it. Then you'd pull that out and you'd clip that to the drapes and then the eye would be tilted downward and that way you could gain access. Then you'd take down the conge, you'd make your big incision in the sclera, into the cornea, and then you'd do your extra cap. Well, again, you didn't have a reflex. You didn't have good depth perception there, but so all of these were intertwined. And so the clear corneal incision allows topical anesthesia, allows temporal removal of a cataract. Well, this was all good. People are making smaller incisions or doing fecal, except you'd have an IOL made of PMMA. So you say, wait a minute, we're doing this great surgery. Now we have to expand the incision to six to put in an IOL. Well, that doesn't make sense. So again, it went back to the IOL manufacturers. And so Tom Misako in Southern California said, well, why don't we make an IOL out of something foldable? So he went to one of the companies and they made the first silicone plate lens. And it was smart because he came up with a way to put it in an injector. And so when you see this, it comes out. It kind of looks like a softshell taco. So we call this the Misako taco. And so this was his Misako. And I just had a ball when I was at Ascrus. I was giving what was called the Binkorch taco. It's a really big talk. And you get to sit in the green room behind the stage like Johnny Carson, you know? And so you're there and we were honoring one of the old giants of the field who was like 94 and Tom Misako was introducing him. So I was sitting in the green room. You know, this was my research, right? These guys were gods when I was a fellow. And so talking to them for 20 minutes, asking them about what it was like in the old days. It was great because these guys were just, they just loved somebody who actually, you know, knew about their work and knew who they were and all. And so I spent 20 minutes chatting with them, which first was fascinating to me, but secondly made it so I didn't get nervous before, you know, standing in front of 2000 people and giving a talk. And so it was really neat. And so Tom Misako was telling me about how they worked with the companies and what they did. And then the other doctor was talking about how he was doing Faco and all. And it was very interesting because I got to tell you my one story. It turns out that, you know, because of this disasters with Harris fixated lenses and early anterior chamber lenses, Ralph Nader, you know, you've heard that name, Ralph Nader and Nader's Raiders, you know, talking about all these unsaved products. He jumped on the bandwagon and said, these things are dangerous, they're blinding people. And so they did hearings in front of Congress to ban IOLs. And so there were some serious hearings going on and Nader's Raiders were talking about banning IOLs. And so the doctor from Southern California, one of his patients was a guy who played a TV character called Marcus Welby MD. So you have to remember now, this was the time of three networks. No cable, no internet, three networks. And so every week, you know, 80 million Americans would watch Marcus Welby MD and he was, Robert Young was his name. He was this actor and he was a general practitioner. He would see, you know, one patient a day. I mean, he would take care of him in the hospital and drive to his house and he was America's doctor. I mean, he was like the second most trusted man in America. And so he had cataract surgery with an IOL. And so they brought him to the congressional hearing and he said, this device saved my career. And then afterward, you know, there was cameras and flashes and pictures and all. And so the Congress congressional committee voted to not ban them, but to do a quote FDA study. And so it was good cause it didn't ban them but then, you know, all these devices had to be studied under FDA auspices. And in fact, this was the device arm of the FDA. This was what caused the FDA to form a device arm. But because of, you know, the doctor taking his patient back to Washington in testify, it was great having him tell the story. He said, yeah, we came out in the hallway and there was cameras and lights and everybody and nobody was paying attention to Nader. And so as a result of that, the IOLs did not get banned but they went into an FDA study. And so it was interesting when I was a resident, you had to be a quote investigator for each company. And at that time there were probably 15 IOL companies. So first thing you did during your resident orientation is you'd fill out like 15 IOL investigator forms. And then after each surgery, you had to fill out these check boxes on the investigator forms. But because of, you know, Dr. Marcus Welby, the second most trusted man in America saying this saved his career, that saved IOLs. All right, so this was the original mozaco taco silicone. And so we figured out that silicone may not be the best material. And so people started working on this new material, hydrophobic acrylic, does that sound familiar? Because it has a high refractive index, you can make it thinner, you can make it three pieces or one piece and sure enough, these are some of the different materials. This is a hydrophilic acrylic inside the capsule or bag. And of course this was our latest hydrophobic acrylic. And I'm stopping here because, you know, you guys, we get all kinds of lectures from, you know, Alan Crandall and from everybody about how we do surgery now and how we do IOLs. But nobody ever tells you the history about what happened and why it happened and how we got here. I think it's just fun to know that. So we'll stop here and go back to the Shonbrun Palace. Now, next week you do have an assignment. Is it glaucoma? I believe, I'm not sure, but check and see. I think it's glaucoma because we did lens last week. Okay, so glaucoma next week, right another week after that. So please study your glaucoma. We're going to talk about anterior chamber anatomy. We're going to talk about various diseases that affect glaucoma. So study that and I won't talk so much. You guys are going to talk again. Questions?