 So we actually have a pointer that works today. This is good. I guess we just needed battery's minor detail. All right, so we're going back to Ferris, the Notre Dame. Sadly this is the spire that collapsed when Notre Dame caught on fire and it's now dark and they're going to try to rebuild it for three years. But this is what it looked like prior to the time when the massive fire about took it out. This is what it looked like on the inside. Really gorgeous. Pretty amazing when you think they built it in like 1100 by hand. So pretty impressive when you see that. And this was the one window that they kept showing when they were trying to put the fire out. This is the side window that survived. This is Paris City Hall. So we're just continuing our tour of Paris. And there's a plaza out here where protesters always hang out. There's always protesters and people on strike. It's kind of a national pastime in France is that you just go on strike all the time. All right, so we're going to go back and talk about IOLs. And we can't talk about IOLs without going back to Mr. Ridley. So this is Mr. Ridley's plaque in St. Thomas' Hospital in London. And so Alan Crandall and I were there for the ESSRS. As you can see by our hair, this was several years ago. Although Alan's hair is always brown. I'm not making any comments. It's always brown. Mine has gotten a lot more gray. But in any event, we went to St. Thomas' and we asked the information person. We said, where's the Ridley plaque? And they said, who? And so unfortunately, Mr. Ridley, who's really the pioneer of intraocular lenses, was completely unknown in St. Thomas' Hospital, which is where the first implant in the world was put in. And so after going down many, many hallways and back stairs and things, we finally found the Ridley plaque in a back hallway at St. Thomas' Hospital in London. All right, this is Mr. Ridley. When he retired, he liked to go fly fishing. And these are his flies that he tied himself. So you really need to understand the story of intraocular lenses. And so legend has it that Ridley was operating with a student and they were taking out the cataract. And then the student said, well, aren't you going to put a lens back in? And of course, nobody did that back then. You took out the cataract and then you would leave the patient with a fake spectacles. And if you've never seen a fake spectacles, you may not see people with them in the clinic. They're those huge plus 15 spectacles. And people can be 20, 20. They can be 20, 15 with these. Yet they have a huge scatoma peripherally because of the way that the light rays are bent, if you can imagine. And so these poor people would experience what's called the jack-in-the-box phenomenon. So you're driving down the road and you look at your side mirror and there's nobody there. And then suddenly a car pops up out of nowhere because you've got this scatoma there. This was very disturbing to patients. It magnifies things about 25%. It was very, very, very disturbing. And so Ridley at the time was, you know, in London during the Blitz when the Nazi planes were bombing London and the RF fighters were going up to intercept the Nazi planes. What was happening is, you know, machine gun fire would hit their cockpits in the plexiglass and the cockpit would go into the fighter pilot's eyes. And so as Mr. Ridley is taking these pieces of cockpit out, he finds that they're completely inert. The eye is not responding to him. There's no inflammatory reaction, very inert. And it turns out serendipitously that these plexiglass cockpits, plexiglass is PMMA, polymethymethacrylate. So Ridley finally put it together and said, hey, if we're going to put a lens back inside the eye, why don't we put a lens, you know, back inside in the posterior chamber where it belongs. And so he had Rainer, which is a company that's still in business now, make him an intraocular lens. This is what it looked like. It was a disc. It was very thick. It was very heavy. And you would put it in the posterior chamber. Did they ever try using like a glass lens? They did make glass. There was a company called Linel, which made a glass lens in the United States. There was one minor problem is that when the glass lens first came out, this invention called the Yag laser came out. And if you're yagging a capsule behind a glass lens and you hit the glass lens, it completely fractures it. So that company lasted about a week after the Yag laser came out. But if you could get this into the bag, these lenses were amazing. This was a cadaver eye that came to our laboratory 30 years after a lens that was put in by Mr. Ridley. And so you can see it was totally encapsulated within the capsular bag and it lasted for 30 years. Well, the problem is this is what the edge of it looked like. They weren't very, very well finished. And now surgery at this time, you have to imagine how crude the surgery was. And the surgery at this time was using loops. There were no microscopes to do this. They're using loops to do this. They're making a 180 degree incision with a graphe knife. So you poke through the limbus on one side, go all the way around to the limbus on the other side, and you basically saw the corny in half. Then you lift it up and you go in there and you grab the capsule and just tear it off. And then squirt some fluid in there and squirt the contents of the cataract out. So you can imagine there's not a capsular axis, there's not an intact capsule in a lot of cases. And so putting these lenses in the posterior chamber, if you got it in the bag, it was fine. But oftentimes they were just in the posterior chamber somewhere. They would dislocate, they would scrape the iris, they would cause pigment dispersion, glaucoma, all kinds of problems. And so these really did lead to problems when these lenses were put in. Now because of that, the people in Europe, this was all going on in Europe, by the way. And so I have to say our wonderful American Academy of Ophthalmology, or Mr. Ridley, he came over in the mid-50s to the United States, very excited to give a talk on this wonderful invention he had. And basically the American Academy of Ophthalmology president said, if anyone in the U.S. puts these dangerous devices in the eye, I will personally come and testify at their malpractice trial. And so this was the reason why the ASCRS was developed, because the Academy was against IOLs, they were against FACO, they were against these cowboys out there with these new techniques, and we should stick to the tried and true traditional techniques. And so this was the reason why the Inter-American Intrural Implant Society, which became the ASCRS, was developed. And so the ASCRS was a rebel society. They were out there, they were the rebels against the establishment AO. So all of this took place in Europe. So there were several doctors that said, hey, you know, doing these extra caps isn't working really well, we're not having good work, and about that time, a guy named Percy Amoels from South Africa was working with a cryoprobe. And sometimes if you really look carefully at the cryoprobes you use for retina now, you look at it, it'll say Amoels on there somewhere. And so he figured out you could take this cryoprobe and you could stick it to the lens capsule and you could break up the zonions and you could pull the whole cataract out of there, which was really good at getting the cataract out of there, but there's no capsular support. So a lot of people said, hey, why don't we put an implant in the anterior chamber? And so one of Mr. Ridley's residents, Mr. Peager Choice, decided, well, you know what, since the posterior chamber lenses aren't working well, people are now doing these intra caps. Let's get a lens made of PMMA and put it in the anterior chamber. So this was Choice's first one, and this was the time people were flying jets faster than the sound barrier, so Mach 1, Mach 2 sounded really cool. So this was the Mach 1 lens. And this was the lens he put in, and he went through several different designs, and eventually the Mach 8 was the design that stuck. And so the idea is it's a one-piece PMMA, it's got four-foot plates which rest on the iris. And now, again, we're making large wounds here. These are, you know, 11-millimeter wounds that people are making, and so you're putting these in the anterior chamber. And this lens, the materials in there, if it was fit perfectly, it did okay. But we didn't have ultrasound then. We didn't have OCT then. Didn't have a lot of other things. I wasn't born yet then, so I'm not that old. But Cretol, you know, he was around then, so. But in any event, the problem with these is they have to be sized perfectly, and it was very imperfect ways of sizing these. So what would happen? Now this was, again, this was the Mach 9. This was his most recent one. So this was the one that he did. So the problem is, is when you put these in, if they are too big, they tend to tuck the iris and oval it and scrape against the iris. If they're too small, they would move like a propeller. You could see these things, you know, you'd be trying to take these out of the eye and you'd go in with your irrigating solution and just go boom, just spin around. So this was one that's too big. And what you see is, you see that it is, it is actually digging into the angle. It's causing a hyphaema here and causing just chronic, chronic inflammation. And so this is a cadavera high now. We removed the cornea. We're looking at it anteriorly, and it looks like a cat's eye. And so you can see that this, these foot plates are tucked into the iris, ovaling it, and this particular one rotated right into the peripheral aeridectomy. So you'd get pupillary block with these and so you had to do a large peripheral aeridectomy. And so sometimes these would actually rotate right into the, right into the peripheral aeridectomy. And you see that cat's eye pupil that you'd have with these. You can imagine that's not real good for, for, you know, not, not causing inflammation and sitting in the eye for a while. So, and this is what it looked like when it would tuck the iris. So as we're looking right here, this is a trabecular mesh work. Look at all that pigment in the mesh work. So this has disrupted the pigment. Look how thin that iris is. It's tucked all the way behind the ciliary body. It's disrupted pigment. The pigment is clogging the trabecular mesh work. You're getting a pigmentary glaucoma. You're getting chronic inflammation. And look, it's tucking that iris all the way back almost to the parched planar. So the problem with these, unfortunately they came in two sizes. You've heard the joke always, you know, too big and too small. So those were the two sizes. And so you take a caliper that was humor. Or humor, okay, so you take a caliper and you measure the light to light and you would add one. Well, if you've ever looked at an eye under the slit lamp, light to light, and you can be off a millimeter on that. It's very vague where you call the light starting. And so you would end up with lots of problems with these. And the other problem is when they started making these, companies in the U.S. saw, hey, you know, these new implant things, you're going to be a good idea. Let's start making them. And so this was a ripoff of a choice lens, an unlicensed copy. Look at the edge of that. That's an EM looking at the edge. So for fun, when I was a Dave Apple fellow, we took a Coca-Cola bottle, we broke it on the curb, and we took an EM and it looked like that. So you can imagine what that's going to do scraping on the iris and cutting it. And so one of the first talks I gave was as a Dave Apple fellow, I hadn't even done a residency yet. I was at the American Intracurricular Implant Meeting I was giving a talk about these horrible lenses and unfortunately Mr. Choice was on the panel. And so he immediately stiffened his back and he clicked his mic and he made it very clear to me that these were unlicensed ripoff copies. These were not his lens. His lens was much more well polished than that, which was absolutely true. So I made a point to stop calling these choice type lenses because he was very upset about that. All right. So what could you do to take care of that problem? And so again, this is now in the early 70s, people in the U.S. companies are starting to say, hey, we're onto something. These implants are going to be the future. So let's start designing them. And so what's happening is people were designing IOLs on napkins of cocktail parties. And so they'd be sitting down with an IOL company and they'd say, hey, I've got an idea. They would draw it out and they would name it after themselves. So this was the Azar lens. And so you have to put numbers on the lens. It sounds pretty cool. So this was called the 911Z because Z sounds cool. So this was 911Z. And at one time, this was the largest selling lens in the U.S. And what it has is it's got a PMMA optic, but it's got these haptics made out of polypropylene. And the advantage of these is they have loops in them. And so if you put them in, instead of having these flat footplates, digging in, these loops supposedly would fit right into the area of the angle. And these would be easier to put in and that they would be better tolerated. And indeed, for about the first year and a half, these things did pretty well. They did pretty well and they were put into the ass. This was the Azar 911Z. At this point, sorry. At this point, how did our FICO come out? At this point, people are doing manual extra caps or incher caps. Actually, at this point, the average American surgeon was still doing an incher cap with a crowd probe. So no capsular bag intact. So Lyske from New Orleans decided he's going to design one. The difference is Lyske made one that was square. But same idea. Prolene haptics, PMMA optic, and these were called closed loop lenses. And again, people came up with all kinds of ideas. This was one that was made strictly out of PMMA. This was PMMA. But again, it didn't have that solid footplate. It had this open loop that was right here. And lastly, this lens drove us crazy here. This was the stable flex. This was the lens that people, yes. I don't understand the timing because I thought FICO comes out in the 60s. Now we're in the 60s. Calvin invents FICO in the 60s. FICO doesn't really become the primary mode of surgery in the United States until mid to late 80s. Okay. Yeah. So it's really not widely used. Again, because the Academy said it's crazy. It's cowboys out there doing it. You don't need to do an extra cap. It's fine. So this was the stable flex lens. And the idea is you make these open loops and they don't close them off completely. They open a little bit, which makes it more flexible. And there was a surgeon in town here who put in like hundreds of these. And the problem is, is these loops would get totally fibrosed into the angle and into the iris. And so you would have to cut this in like eight different places to take these damn things out of there. So these were just a nightmare. And what would they cause? Basically what would happen is, is these closed loop lenses would dig into the iris. So these little round loops would dig into the iris and they would cause chronic UGG syndrome. Hopefully you guys have heard the term UGG. Uveitis glaucoma hyphema UGG. And UGG was first named by a guy, Ellington in South Dakota who saw these people with these old choice lenses that would get this inflammation. So they called it the UGG syndrome. This is a different closed loop. This was the Hesper glands. This one looked like a T that came out here. And this you can see, corneal edema, chronic inflammation, high pressure, inflamed eye, UGG syndrome. So these loops would dig into the iris. They would cause chronic uveitis. But again, they would cause the angle to close off and cause glaucoma. This is a cornea of a patient with a 9-1 Z lens. And so the first paper I ever wrote as a Dave Apple Fellow, we had 14 corneas from patients with 9-1 Z lenses that first one I showed you that had corneal edema, boluscotopathy. And the guys in town here who were putting them in were going around saying that this is the greatest thing ever. I've put hundreds of these in and never had any problems. Well, and we say it to this day, well, of course you don't have problems because when there's a complication, you don't see them, they go to the university. So it's the same thing now with multifocals. People say, I put them in, I never take them out. Well, of course you don't, because they come up here with a complication and Alan and I take them out. So it was the same idea back then. And so this guy in town was touting this lens, it was a wonderful lens, and I was giving talk, saying, well, wait a minute, this has problems. This is maybe not the best design. And so in Dave Apple's lab, we were looking at IOL complications and we found that these closed loop anterior chamber lenses cause bolus caritopathy. So that's a cornea that's edematous. And this is a cadaver eye. Again, we've removed the cornea, so we can see it because the cornea is cloudy. Look at these loops. They're literally into a tunnel almost in the angle that's fibrosed over. And so you can imagine what that would do in terms of glaucoma, but again, that would scrape on the iris and cause chronic ugg syndrome. This is what it looked like. This is the angle. This is the iris posterior surface. And look, this loop digs all the way to the root of the iris. So it completely buries itself in there. So these closed loop lenses, even though they look good for a year, year and a half, were probably not going to be the answer. Were those loops like springy, or are they like pretty stiff? Well, the idea was is that they would give a little bit. But one of the problems is if they're closed loop, like the one we showed you previously, if you compress them, the optic tended to vault because they were closed loop. And so the person would rub their eye, and we did tests in the lab where we would squeeze them with a little squeeze gauge, and what would happen is the optic would vault forward. And so you can imagine that vaulting forward and literally bouncing on the cornea when someone would rub the eye. People like leaf springs on a big truck that you see driving around. It would vault forward when you would do that. So the idea is they tried to make these open loops with the idea is that it wouldn't vault as much. But the problem is these things would just get fibrosed into the angle, and you can see they did two giant perfleuridectomies, and these were just held to get out. This was an interesting idea. This was a doctor in Washington, D.C. who said, well, if these closed loops are bad, let's make open loops. And so he put these three broad loops. It looks like a propeller on an airplane. One, two, and you can barely see the third one up here. And so the problem is these would literally close off the angle, about two-thirds of the angle, so these patients would get a severe glaucoma. And so, you know, and again, there was a guy in town who put tons of these in, and so we had lots and lots of patients who would come in with these with severe glaucoma. And, you know, bottom line is these lenses would give you corneal edema, they'd give you chronic glaucoma, they'd give you chronic ugg syndrome. And so when I first was a fellow in 1984, the most common indication for corneal transplants in the United States was pseudophicic bolus carotopathy. And so I just shot way up, so you're getting tons of corneal transplants because of these lenses. There you see a cornea with bolus edema there, bolus carotopathy. What else would these cause? All right, anybody? What do we look at at right here? CME. CME, exactly. So what part of the retina are we in? Outer plexioma. But we're in the scope of the retina. We're in the macula because you see the ganglion cells are more than one cell layer thick. And sure enough, here in the outer plexiform layer, what do we call that layer that's right near the fovea? Henle's layer. And so you actually see exudate, cystoid macular edema from the chronic inflammation from the ugg syndrome. So you could get CME from ugg syndrome. So we call that ugg plus. Ugg plus CME. So finally, Kelman. The same Kelman who invented the ultrasound said, you know what, if these closed loop IOLs are really causing this ugg syndrome and causing problems, why don't we make an open loop IOL? Except let's not make it really stiff and bulky like the choice lenses were. Let's make one that's more open. So his first design was a tripod. And we joked about it. We called this the Pregnant 7. And so think about it. It's a 7 and it's pregnant. So the Pregnant 7, we called it that. And so Kelman had an argument and he said, you shouldn't have four point fixation in the angle because if you were in a bar and you have a stool with four legs on it and the floor's uneven, it'll wobble. But if you have a three-legged stool, it won't. That was his argument. He used to go around and give lectures saying that. So he came up with this tripod design, the Pregnant 7. Well, the problem is, is this thing was really stiff and this would poke into the eye. So I'll give it to Kelman. He would figure things out pretty quickly. So people would tell him, no, no, that's too stiff. That doesn't work. So he changed it. So he called this the OmniFit lens. And so he made it thinner. Still made of PMMA, thinner haptic so they'd be a little bit more flexible. But again, the tripod design just didn't work. And so, again, Kelman being a bright guy said, all right, he chucked the three-legged stool out the window and he went to the Kelman multiplex lens. Does this look familiar? I don't know if you guys ever see it in your chamber. I don't know. But this is the lens we use now to this day 35 years later. So this design stuck. So this is PMMA. It's open loop. And so when we would test these in the lab, if you squeeze those haptics, the haptics take the squeezing without vaulting the optic. So if you rub the eye and those squeeze, they're cantilevered. And so they would take the pressure on there but without vaulting the optic forward. So big advantage there. Secondly, these foot plates, you notice that they go concave in instead of convex out. And so the idea is, is they just kind of touch the angle in two places. So they don't completely occlude the angle. And because these foot plates are a little more oval rather than round and a little flatter, they don't get the tunnel growing over them of fibrous tissue. So this really was the answer to anterior chamber IOLs. And indeed 35 years later, this is still the IOL that we use now. I should look familiar to you guys. This is the old Apple Core. And so Dave Apple worked by taking his dictaphone, laying out a bunch of pictures on here, and then having his fellows and students sit around and run around and order the pictures and do, you know, you see we've all got these black and white EM pictures and all that. So I don't know who this swarming Greek guy with the mustache is. And these were another couple, another fellow of these guys who were a couple students. And so this is how we would write papers. And so the lab was churning out papers like every month. And so it was an incredibly exciting time to be a fellow because this is uncharted territory. No one was looking at IOL complications. And you see we had these folders and all these EM pictures crammed in him. So this is the so-called Apple Core. And he loved it because he's German. So we even had shirts made up, you know, this is the Apple Core. Get it? You know, okay. We had shirts made up with the Apple, from Apple computers with a little bite taken out of it. So the Apple Core. All right. So also in Europe, at the same time, people were looking at, okay, enter your chamber IOLs. Maybe they're not the best place to do it. Why don't we take an IOL and clip it to the IRAs? And so there were a couple of people who did it. Jan Worst, there was, you know, Worst did it in Binkhorst. A couple of guys in Holland and Belgium decided they were going to do it. So this one, I'm sorry, it's not a great drawing, but these would have these loops too on each side. One would go behind the IRAs. One would go in front of the IRAs. It would literally clip it to the IRAs. And so four loop plans would clip it to the IRAs. And finally, while Worst said, okay, these clip lenses, if you dilate the pupil widely to look at their perforatina, they'd fall out. They said, we can't have that. So why don't we make a hole here and suture this thing to the IRAs, but still keep the clips posteriorly, hold it in place, and even we'll put a little peg on here to hold it. And so we used to joke, because this truly was the worst lens we'd ever seen in the lab. This was, but his name was John Worst. So this was the worst lens. Now the problem is, is these loops were all made out of proline, polypropylene. If you put proline into uvial tissue, like the IRAs, like the angle, it would start to hydrolyze and you'd get these mudflap cracks on it. And so this is the so-called cracking. Now, that's even pertinent to this day because if you're suturing an IOL to the IRAs, now, post your chamber lens to the IRAs, what do you use? You use proline suture. So if you use a 10-0 proline and it starts to degrade like that, it can spontaneously just disintegrate and break. And so always use 9-0 proline. Don't use 10-0 proline. 9-0 even though it doesn't seem like it's much bigger, it's about 40% stronger. And so this is what proline sutures do also. This was a proline haptic and proline would degrade in uvial tissue. So somebody said, well, proline degrades, let's make these out of metal. So they made them out of titanium. Well, first off, titanium is really expensive. Secondly, titanium you can't polish. Thirdly, titanium is really heavy. And so these lenses would literally drop into the vitreous and would dislocate and would cause huge problems with ugs. So again, titanium didn't last long. The reason I'm showing you all these is every once in a while, I'll get a resident and we'll pop up and say, hey, I've got a great idea for an eye well. Why don't you do this? And my answer is, well, yeah, we did that 30 years ago. It didn't work. And so this was actually metal and this was titanium. So they said, titanium's inert, this would be a great, but it didn't work. Was it easy just to experiment on patients with all these different eye well? Oh yeah. This was the wild days. These were the cowboy days. These are people who are putting them in left and right. The FDA did not have a device section yet. Well, I guess this is a good time to tell the story. Since you brought it up, we'll tell you the story. So at this time, this is now the early 80s. People are starting to put in a lot of eye well. And again, the academy is grumbling. These are crazy ideas. This is blinding people. So Ralph Nader, you've heard of Ralph Nader, right? Nader's Raiders. So Ralph Nader decided these things are blinding people. And so Nader's Raiders looked into this and said, we've got to, you know, shut these things down. These are dangerous. And so the FDA said, my God, we really should look into this. And so they had congressional hearings and fortuitously, Dick Crats, who sadly just passed away in Southern California, great guy, he did a cataract surgery on an actor who at that time was the lead actor in the number one show in America. So at that time, there was a TV show called Marcus Well BMD. And Robert Young was the actor. And he was America's dad. He had been in a show, Father Knows Best. And he was this well-known actor. And this was the number one show in America. And he was a private practitioner who would see, you know, two patients a day and go to their houses and take care of them and go to the hospital. And was the doctor everyone wanted to be? Well, so he was the number one actor, the number one show in America. He had cataracts and Dick Crats took out his cataract, put it in an IOL. And Robert Young came and testified in the House Committee when this was going on and said, this saved my career. This saved my life. This is the greatest thing that's ever happened to me. And because he was the most famous man in America, he had all this publicity going on. And so as a result, they didn't shut down IOLs. The FDA set up a product division, which it hadn't had before. And they set up a study. And so at this time, all IOLs were part of an FDA study. And so when you were putting in IOLs, you had to fill out an IOL investigator form for every single company. You know, at this time there were like 14 companies. And so when you're putting these in, you had to fill them all out and then the results had to be reported to the FDA. But bottom line is we were allowed to keep IOLs and the research went on. And all because Dick Kratz operated on a famous actor. So, sorry. But it's always an interesting story. This is stories today anyway, so. All right. So what would happen when you put these in? This was a worst lens. And the suture here broke. And look at that iris. They're regular. They're synechia. The pigment's all blotchy. There's a big PI here. And so these would again cause UGG syndrome. And again, cause corneal edema just from the chronic inflammation. And so these caused problems also. And if you did, this is an EM now of one of these lenses that was removed. And this is actually part of the iris just completely stuck to it. And so taking these out again was really hell without disturbing the iris. So very, very difficult. So at this time, people were starting to do a magical kind of surgery called an extra cap where you were leaving the capsular bag intact. And so as a result, they started putting loops here that would fit in front of the lens capsule. The idea was that this would have capsular support on it. Now, what was funny is as these companies were doing these, these were the ads that were appearing in the journals. So this is Copland. Copland would have wishing you happy holidays. These are the little Copland elves making these Copland IOLs. And so these guys came up with an idea, why don't we make an IOL that you put two loops behind the iris, two loops in front of it. And it holds it in place. So this was the Copland lens. And it would give you a square pupil. So here's the loop in front of the iris. Here's the loop behind the iris. Here's pigmented giant cells all over the IOL. Here's synechia forming here. So again, these didn't work really well, but the cool thing is you've got a square pupil so you can always recognize these. You'd go, oh, Copland lens. Now, the problem with a lot of these is if you dilated the eye to try to look at the peripheral retina, sometimes these would dislocate. So that was an issue with a lot of these iris fixated lenses. Retina guys did not like these. And again, this is a Copland lens. You can barely see it because of the severe corneal edema. This is a patient with corneal edema. This was my favorite ad. This was from one of the companies. I loved that. I made a copy of this. Proven, safe, and effective, discontinued. So, you know, they wouldn't come out and say, yeah, this was bad. We're pulling it off. They would just, they'd have this whole page of all their IOLs. You know, proven, safe, and effective. Oh, but by the way, we discontinued it. So these would eventually all be discontinued. All right. At this time, again, people were starting to now do not only extra caps, but FACO was starting to come into practice. And so as a result, because of that, we now had the abilities to leave the lens capsule intact. Now also, people started using microscopes to do surgery, so you could see much better what you were doing. And so as a result, you have an intact posterior capsule. So finally, someone said, hey, wait a minute, maybe Ridley was right. We have an intact capsule. Why don't we put an implant in the posterior chamber where it should go? Away from the cornea, away from the iris. And so a guy named Shearing in Las Vegas, interesting. These are names you don't even hear of now because they thought of one brilliant idea, and that's what they did. And so Shearing said, why don't we put some little J haptics on this round optic made of PMMA and put it in the posterior chamber? You know, where it should be. And so soon as this came out, ophthalmologists are a very innovative bunch. Immediately they said, wow, that's a great idea. And so things just exploded right at that point. And so a guy named Simcoe in Oklahoma said, hey, those little J loops are pretty hard and pretty narrow. They look like an umbrella stand. Why don't we make ones that fit better? So he made this broad C loop. This was the Simcoe loop. The idea was that this would fit into the capsule or bag better and would fill the bag completely. Now, you ask, what are these things? Those are positioning holes. So this is before we had OVDs. So you would put these in and chamber would be collapsing and put hooks in there and try to maneuver these. You couldn't see what you were doing. Some people put air in there to try to keep the chamber formed. And so you have no idea what a great invention Helan was. So Helan was the first OVD, how you're on a gas it. And so Helan was like a miracle because you could keep the chamber formed and you could maneuver inside the eye. Well, when Helan first came out, it was expensive. But it was almost like there was a drum roll. You'd say, get the Helan. And so they would go to the back to the secret refrigerator and they'd put it on a golden pillow. They'd bring it out to you, the Helan. So you would use it. But it was a wonderful invention because you could maneuver inside the eye without causing damage. But before we had that, these IOLs all had these big positioning holes. And look, there's pigment stuck to it. Can you imagine these positioning holes scraping on the iris? So Bob Sinski, and again, you guys have heard the Sinski hook. He just passed away recently. Sinski said, well, you know what? The J-loop is a good idea, but it's too stiff and too straight. So let's modify it. So he did a modified J-loop where he put a little bit of a bend to it here. Bend to it or still a positioning hole. Interestingly, IOLab was the first big manufacturer in the U.S. to have their name on the IOL. So this is great. This is a great NITIS for giant cells to attach. And they would put the power on there too. So you could see that when you looked in there. So this was the Sinski modified J-loop. And this was when I was training in the mid-80s. This was the most popular lens in America. This was the lens. And so as a matter of fact, we would sit around its residents and say, wow, look how far we've come. We're doing extra caps. We're cutting the IOLs in. We're cutting the sutures at eight weeks. Patients are, you know, 20, 25. This is great. This will never get better than this. How could surgery get any better than this? So you guys are laughing at this now. You know, we got clear corneal incisions and foldable IOLs, and people can see the next day and FACO. And so this was great. This was a huge leap forward at the time. Now, there was an argument then about where to put the IOL. You know, this is an ancillary sulcus in front of the bag. Where do you put it inside the bag? And so there's a big argument. And the guys at Johns Hopkins were arguing that you should put it in the sulcus. That would be better. So again, we looked at a ton of cadaveris. We said, no, no, sulcus is a really bad idea. You should put it in the bag where it is sequestered from uveal tissue. And obviously, where do you put it now? In the bag. You don't put it in the sulcus anymore. And this is a problem if you put it in the sulcus. That's why we're looking at it from behind from the Apple Miyake View. This is where the haptics were. You can see where that haptic in the sulcus scraped on that posterior iris and scraped off all that pigment. So definitely, I'll put it in the bag. I'll put it in the sulcus. So this is what it looks like in the sulcus. Here's the iris. This is a big summering's ring because you've got nothing in the bag to prevent it. This is the loop digging into the root of the ciliary body all the way back behind the iris, almost to the greater iris circle. So that's an Iowa loop. And you can see there's synechia here where this was pushing it forward. The iris is stuck and the mesh works completely blocked off here. And here's that haptic way back there. So that's what would happen if you put them in the ciliary sulcus. And so if you put them in the bag, if you look, here's a modified J loop IOL sitting in the capsular bag. Look at that, it's beautiful. There's no inflammation, there's no scraping of pigment. It's situated inside the bag. That is the ultimate. Put that lens in the bag and that's the ultimate. This is what it looks like. Here's the iris. Here's the capsular bag. Here's the ciliary body. Look at that, nicely protected behind the iris. So this is what they look like and you can see why the results are better when you put it in the bag. Now at that time people were saying, okay, these are fine but what else can we do here? And so Iowa Manufacturing got better and so this is a one piece now PMMA and they got a computer laid that would cut this. You know, prior to this time you would have an IOL and then someone would hand polish it and so now they came up with a computer laid that would cut an IOL out of a block of PMMA and you would tumble polish it. Look at the edge of that. It's beautiful and so they still do it to this day. It's almost like, did you ever polish rocks when you were a kid? You know, you do that. So what you do, you put them into this thing and there'd be a bunch of little beads in there and some polishing solution and you'd spin it for like seven days and that's still what they do with IOL. So you put some little beads in there and some polishing compound and you tumble polish it and you get this gorgeous finish and so these IOLs were beautifully finished. Now, we can't talk about IOLs without talking about how cataract surgery evolved and this is where your question was was pertinent. So the way that surgery was done in the 70s and even into the early 80s you would make an 11 millimeter incision. You'd pre-place a lot of sutures because you didn't want the whole idea to expulse just in case it did. You could close it. So then you'd lift the cornea up. Imagine what that's doing endothelial cells. We didn't have endothelial counters yet then. Imagine what that's doing endothelial cells and then you'd go in there with the cryoprobe and you'd stick the cryoprobe to the capsular bag. Now by this time we wouldn't just break the zonules. We would have alfacima trypsin so you'd squirt alfacima trypsin and it would dissolve the zonules and then about a minute later you'd go back in with the cryoprobe you'd stick it to the capsular bag and boy, you know, you just pop that thing right out and so you'd get that huge lens out whole, the capsular bag and all. But again, no lens capsules so the capsular bag is not intact. So a big advance was when we started doing extra caps and basically you'd make a bunch of little punctures like a stamp punctures into a capsule we'd call it a canapher capsule on me and you'd push on that and get the edge of the haptic to come edge up, sorry, the the nucleus to come up and you'd slip a little loop underneath it and you'd pull the nucleus out and so this was called an extra cap and then you'd go in there with a manual simcoe unit and you'd suck out the cortex and then you'd put an IOL in the back. Well, you can imagine what a great advance Faco was and again, even though Kalman was playing with Faco in the in the 60s when he was doing this it really didn't take off in the U.S. until the mid-80s and so as Faco took off the idea is hey we can make a three millimeter incision and take out this cataract and we're still doing little scleral tones we weren't doing corneal incisions yet and we were coming up with ways to do that the second invention that was really good is in about 84 a guy named Thomas Neuhann in Germany and a guy in Canada came up with an idea Gimbal to do a circular capsule on me so again, at that time we were using a cystotome we were making a bunch of punctures in the capsule so that capsule would not be completely intact well, they came up with the idea why don't we make a circular tear and that was a great invention and so that's again, we're doing that now we ensure that that capsule is totally intact we can put the implant in the bag the problem is is that you had to make the incision bigger to put in an IOL you know, we didn't have foldable IOLs then and so you would make this three-plane incision you'd go through the sclera then you'd tunnel forward and then you'd enter the cornea but as foldable IOLs got invented and people started using foldable IOLs then we could proceed to a clear corneal incision so that was a great advantage because you didn't have to use a retrobober block you didn't have to operate superiorly you could sit temporally where you had better exposure and you could make a clear corneal incision that you did not have to stitch so the sclerotunnels would always be superior? yeah, the sclerotunnels would be superior because you wanted to have them covered by the lid and you put lots of stitches in there so you really wanted the patient not to be bothered so much by them so you did it all superiorly so if you're sitting superiorly when you did the surgery you'd take a suture and you'd put it through the superior rectus muscle and then you'd pull it up and you'd pin it to the drapes and that would turn the eye down so imagine you get a terrible red reflex with that but that'd give you exposure to work so when we went temporally you had easier access to the eye you had better red reflex and you could now do a clear corneal incision so again technology would go lockstep and of course this was only made possible by the invention of foldable IOLs can you do sclerotunnels now? you can do them temporally now because they're smaller a lot smaller and you don't stitch them now we're making these big smile incisions now that you don't have to suture so those are tolerated better temporally so technology in removing a cataract and technology in IOLs went lockstep and so when people jump to FACO you know when you were doing extra caps the wound is 11 millimeters there's no need to have a foldable IOL but as soon as people started saying hey this FACO we can remove a cataract from a smaller incision why should we open it up to put it in an implant is what pushed IOL companies to make foldable IOLs and so again the technology would change it would force other technological changes and so they would go in lockstep and of course that led to the development of foldable lenses so this was the first foldable lens this was a silicone lens it was a plate lens but it rolled up like a taco so Tom Masako is the guy who invented this so they called it the Masako Taco so it would be like a soft shell taco you put it in there it would unfold it was made of silicone well silicone was maybe not the best material and this is what it looked like this was a silicone plate lens and so people started saying hey there's better material and the material was hydrophobic acrylic which is what we're you know used now in the majority of IOLs in the US at least and so the first lenses the hydrophobic acrylic you would fold them up in half and you put them in now other companies then started jumping in this was Starz lens they looked at different materials this is now made of PVDF a whole different material then probably more resistant to degradation and even now hydrophilic acrylic lenses started coming out and so this was a hydrophilic acrylic lens that had grafted haptics on it so the idea is there's more than one way of getting a foldable IOL into the capsular bag that still centers well in the bag and then finally of course this is the Alcon Acrosof and you know this was the again the ultimate lens it would have good you know low yagrates it had a sharp edge on it it would limit PCO it was thin it didn't have a bulky you know bulky mass to it and so you know again this was this was the material that Alcon settled on and now of course we've got the one piece with haptic IOLs but it's still this hydrophobic acrylic material and I stopped there because you know you guys are going to learn all about IOLs now that we're using at the moment this is a Notre Dame this is a group now why Teschi is at a cornea meeting I have no idea because it was in Paris and so he signed up for the meeting and came and hung out for three days but in any event this is our this is our little group here Liliana Werner who lived in Paris for seven years gave us the grand tour of Paris and this is the bridge across the Seine where Notre Dame is so this is Paris alright so next week we get back to path okay I believe it's glaucoma we can see I think it's glaucoma yes that's correct okay so read glaucoma because next week you guys are going to talk not me okay alright questions we've got four minutes questions about IOLs or cataract development alright very good