 Austrian government are what's interesting about this particular place is you can rent out the room under the dome and have a Dinner in there, so it's kind of fun have a dinner in a palace so you can do that So it's a tradition the president of the ESCRS always picks either a palace or a castle or something To have their dinner and so they had their dinner right under that dome Pretty cool because you kind of eat and you go This is the one on the other side so there's matching Bookends here and then in the middle there is a Statue with the obligatory fountains, and this is Maria Teresa She was the queen of the Austrian Hungarian Empire and not only was she queen and expanded the empire But managed to have 11 living children During her reign 11 that lived and I think there was three more who died and several of her daughters were married off to try to You know intermarry all of the European royalty to keep them from attacking each other and so one of them of her daughters was Maria Antoinette who was the Unfortunate wife married off to Louis the 16th when the French Revolution happened and kind of lost her head in the guillotine So this is the statue to Maria Teresa This is the opera house And so this is the the main opera house and what's interesting is they've got a big screen TV Around the corner there and you can actually sit your chairs out there and watch it outside the opera on the big screen TV Of course, here's Mozart And you can see he's checking out his emails there and so Mozart's come into the 21st century. So, you know, I love how the sunglasses and the Cell phone the obligatory cell phone so even Mozart's you know modernizing All right, so we're going to talk a little bit about the lens and so I think we need to go back and spend a little bit of time on the Pathology and the embryology of the lens so Tina what embryologic layer does the Crystal lens come from Surface ectoderms if you guys remember of that very first lecture when we talked about the lens you get the outpouching of Neuro ectoderm, you know, which is going to form the most of the eye it comes forward it touches the surface ectoderm What happens is is this induces the surface ectoderm to start proliferating the surface ectoderm will then proliferate and you'll get Invagination of the optic cup and then eventually this surface ectoderm will pinch off and it will form the crystalline lens And so the crystal lens remember surface ectoderm derived and here it is In I think these are chick embryos if I'm not mistaken which look just like human embryos You know for the first few weeks of gestation and here it is just an ischematic now What's interesting is once it pinches off You will form a circle and then the fibers on the posterior part of the circle will then begin to Proliferate and they will fill that circle and make the lens solid the reason that that's important is as the lens grows throughout life You do not normally have lens epithelial cells posteriorly And so if you do have lens epithelial cells posteriorly something's going on that's either pathologic or abnormal So normally you have the cells when the lens grows will go out to the equator and then fan out But they do not Normally have endothelial not have nuclei posteriorly and here's a picture of that embryologically as they this is human and as the cells will grow from the posterior surface they'll grow anteriorly and Then eventually the crystalline lens becomes solid and that becomes the embryologic nucleus now the crystalline lens Grows throughout life much like you're putting yarn around the ball And so throughout life the center part of the lens gets more and more and more condensed and then the periphery Grows more and more also as you go throughout life that lens comes from round to a more oval shape that you used to see And here you could just see a lens in a slit lamp It's a bicon Vex so the easy way to think of that football shape You know by convex football shaped and here it is In a pathologic section you can see that you know It's really hard to tell by the time you get to an adult, but there really is a compacted embryo embryo Embryologic nucleus in here. You've got a fetal nucleus. You've got an adult nucleus then around that you've got cortex around that You've got capsule and here you could again see that in a schematic view So the embryonic nucleus the regular fetal nucleus the nucleus and then of course surrounded by cortex and then surrounded by lens capsule All right, so what are we showing here Chris? What's what stain is this Exactly so remember our PIS stain is the stain we use to Dissert a base of memory. It'll stain that nice magenta color So there's the anterior capsule posterior capsule epithelial cells anteriorly non posteriorly now note the thickness of that posterior capsule That's just a few microns thick. That's all there is between your 30,000 Hertz ultrasound Jackhammer and vitreous So please respect that capsule when you're doing surgery because that's all there is that Keeps the vitreous back where it should be and so very thin and if you look you see that the anterior capsule is about 50% Thicker than the posterior capsule in a normal eye. What are we illustrating right here Catherine? Actually, the anterior capsule would be up on the roof here. So what part of the lens are we looking at? Why would I be showing you this? This is actually the equator and so we're trying to illustrate here is what we call the lens bow And so when the lens is growing throughout life Let the lens epithelial cells are come out here to the equator once they hit the equator instead of migrating all the way back They'll migrate along the disc and along the edge of that on the inside and they send fibers both anteriorly and posteriorly And so when the lens is growing throughout life The nuclei come to the equator the lens bow then they fan out all the way around Some fibers go anterior some fibers go posterior. What are we showing? What are we showing right here? Okay, so when the zonules attach we think of them as attaching at the equator But they really do go a little bit anterior and a little bit posterior So you have to be careful if you're doing a capsule of Rex's you know You don't want to make an eight millimeter Rex's because you can get out Into where the zonules attach, but what I also wanted to illustrate on this is What are these down here? Those are the ciliary processes and so when we say that you know the zonules insert on the ciliary processes Not only do they insert on the ciliary processes, but some of them come clear the heck back here I'm sorry. This battery's dying, but they come clear back here and they almost insert clear back here almost to the par's placata and So the zonules anchor to the ciliary body, but all the way back some of them attach on the ciliary processes Some of them attach even between the ciliary processes. So the lens is supported very nicely by the zonules 360 degrees and think of them as springs on a round trampoline and So they go all the way around and they tend and they support the they support the crystalline lens nicely What are we illustrating here? Okay, so when the fibers come in Again that lens is not perfectly round. It's becoming a little bit more oval as time goes on So those fibers that come anteriorly and posteriorly they can't really meet at a point So because of that they end up meeting they form this Y and so when you're looking at lenses You know your mission today when you're at the VA or at the U and you're looking at you know lenses through the slit lamp Look for the sutures you can see them every time We don't pay any attention to them because we don't really look at them Look for the sutures and they'll be there'll be a Y and an inverted Y you can see an anterior and a posterior year Why suture where those fibers come together and so you can see this just illustrates it right here I kind of forms a Y instead of a single point now This is just trying to show you those cortical lens fibers and when you look at them in Cross-section, what does this remind you of? Yeah looks like a honeycomb almost and so you see you've got these They're almost hexagonal and they've got all the organelles. They've got a lot of proteins in them There's a lot of proteins in there, but remember the nuclei are out at the Equator and sending the fibers anterior and posterior so there's no nuclei at this point It's just the the content of the fibers that form the lens. Yes No, but they sense in both ways so the nucleus will send in both anterior and posterior and they kind of meet in the middle there So this is what it looks like. It's almost like a hexagonal looking little or overlooking honeycomb All right, what are we showing here? It's an external photograph lens is dislocated Actually, what is that? So the lens is subluxed So the lens is subluxed, but what was the second thing you said? It's actually just a fake it contact lens So this this round thing that you see right here. That's a fake it contact lens So this patient has the lens dislocated and it's dislocated superior Temporally does that have a particular entity that's classic for that Or fans and so this is a Marfan's patient. And so I don't know why but Marfan's It's a zonylopathy. It's a weakness of the zonyl Just like a weakness of connective tissue else from the body But for some reason the lens will dislocate superior to a temporary now, you know If I were to think about it, I'd say, okay, wait a minute the lens the zonions are weak It's going to drop down, but it doesn't it dislocate superior temporarily. That's kind of anti gravity So I'm not sure why that is but it's a sign of a diffuse zonylopathy And so sometimes if these patients are doing okay, and that lenses are moving around a lot of causing inflammation You can just fit them with an a fake it contact and they do okay And this is that patient And I've been following this guy for years You can see he's about 611. He's got long spindly fingers and because Marfan's is a is a diffuse disease of Connective tissue these people are at risk for such things as aortic aneurysms aortic arch aneurysms Things like that. And so this was this actual guy. And this is so old this picture. This is before there was a Moran This is when it was on that, you know The eye clinic was on the a level of the old hospital And so that's one of our original tax and you see this guy was 611 He went for almost 20 years before that dislocated lens cost problems And he had to have a sutured PCI well, but he was wearing a fake it contact lenses for that whole time Okay now Tina, this is another picture here I had to borrow this out of a textbook We see external photograph and you actually see that the lens is subluxed looks like probably inferred nasally Which would be more consistent with the most assistant area Exactly. So again, why I don't know. I mean for some reason you just have to memorize it Marfan's is superior temporal homocystin area inferior nasal Why I don't know but again sides of diffuse onulopathy So leaks on yields and eventually it dislocates All right, what do we see in here So what entity do you have where you can get a spontaneous dislocation of a lens? Anteriorly I'll say this was you know trauma you can obviously give this dislocation much likely, but let's say this was spontaneous Okay, so how do you and then what is there an entity where they're really famous for micro sphero fake you Like one of those other things you have to memorize That's a wheel Marcazani So will Marcazani syndrome and it's kind of the opposite of Marfan's because Marfan's are tall People long spindly fingers will Marcazani or short people with short stubby fingers And so kind of the total opposite of Marfan's but they tend to get smaller lenses sphero fake you and then but again Azonulopathy and so they are at risk not for that dislocating posteriorly, but dislocating anteriorly So will Marcazani sphero fake you a short people short stubby fingers so kind of the total opposite of Marfan's syndrome and here you can see I'm sorry that's out of focus This was one that actually spontaneously dislocated In the end They're still within the capsule bag exactly so the entire lens you know those onions a week the entire lens will dislocate. All right This I'll give you a hint this is a child Okay, what are we showing here? This is actually one cut in half so don't worry cut in half and the lens itself looks Looks more Okay, so again sphero fake you what's another entity where you can get sphero fake you and kids Exactly and so this actually is one I pulled this out of an old file. This is congenital rebelling. Thank goodness It's something we don't see much anymore, but we may I mean, you know There's this feeling now that vaccines cause autism and cause everything so there's a huge amount of our population not being vaccinated and so we're just you know one outbreak away from seeing a huge amount of You know rebella come back again But one of the things with congenital rebella is that you get a sphero fake you once again They don't really dislocate, but these kids just don't do well their eyes Or smaller than normal the lenses are smaller than normal and they have other Problems CNS problems associated with the rebella. So but you just need to remember that congenital rebella is another cause of sphero fake you and What you need to memorize about this also is sometimes they retain the nuclei within the cells in congenital rebella So when you look at some of the pathology those nuclei are retained more than you would normally see No, no this you'd have to you'd have to have light microscopy to see you wouldn't be able to see either with Slit lamp or or you know grossly when you look at the kid. All right, what are we looking at here? It's hard to tell because with the retro elimination you can't really see slit lamp, you know, you can't see depth, but that is actually dead center So that is actually a fetal Nuclear cataract So this is or you know people may call these congenital cataracts. They may call them infantile cataracts But this is actually a cataract in that fetal nucleus The rest of the nucleus which comes out here is clear in the cortex is clear So it's just in that fetal nucleus. So this is a congenital cataract So congenital cataracts can affect all parts of the lens, but in this particular case It's a congenital nuclear cataract What I thought was interesting about this is this is is got the That's kind of the male Symbol there and then this is kind of the female symbol there So I call this the prince cataract and he remember Prince before he died He was wasn't sure if he's male or female so he became this symbol of both and so that's what this has So this is kind of the prince cataract. So this is a congenital nuclear cataract And here's just another one now with the slit lamp on it So what you see is you can see here's the edge of the pupil and you've got this opacity in the center of the nucleus The adult nucleus is still clear and the cortex is still clear So if these are bilateral and they're not too dense these people can grow up and have pretty decent vision Actually, if they're unilateral and dense they get severe amblyopia So if you've got a child with a unilateral dense cataract, that's a real emergency You got to get that out of there right away, but if they're bilateral, they're not bad Sometimes these people grow up and I've had several people make it into adulthood and I mean they're not 2020 but they've got functioning, you know 2100 vision now. What are we looking at right here? that's some condensed vitreous here and even a Little liquefied vitreous here, but what do we see in here? This is a dense nuclear cataract in an adult and so you see that that nucleus is taking up almost the whole lens here This is just a dense, you know nuclear cataract very very dense And then we kind of look at it from behind This is the Miyake view and you're sitting at the optic nerve looking behind yours the zonules and you see in the center part of the Nucleus, it's all white or yellow and so this is an adult Nuclear cataract most common type of cataract that we see actually is a nuclear cataract in an adult So this is the nuclear cataract in an adult Pathologically, it's interesting. We really don't even look at these anymore because if you look at Lens nucleus, you know with just light microscopy whether or not it's a dense cataract or not If compared to someone of the same age it looks the same And so it just doesn't look that different on on you know doing H&E stay in and you know light microscopy What do we see in right here? It's a renaissance or brown like This is kind of the end stage of a nuclear cataract They become very very brown some people even call these black and so it's rare that we see these in the first world I mean if we see him it might be from parts of Wyoming or something, but I'm from Wyoming you're allowed to make comments of your own kind that's not considered Prejudicial, but no it's really uncommon in the US to see a cataract this dense if you see him It might be from someone who's you know a mount man or a rancher or somebody doesn't like doctors and you know Doesn't come in for 20 years and so but this is a third world cataract and these are not uncommon And so you can imagine if you're you know you're you're on one of our International you know cataract missions, you know faking that's going to be really really difficult And so this is where the you know small incision manual Extracap surgery really comes into play it'll be interesting to see now with this new my loop That we're starting to play with to see if a my loop can cut a lens that dense So it'd be interesting to see I don't know we haven't done them yet and could ever eyes that dense But hopefully it'll be able to do it, but in any event this is a hard nucleus to fake Oh, you know you really want to maybe remove this hole. All right, and this is showing you on a light microscopy This is a nuclear cataract and again, you really can't Tell a whole lot of difference there between just a normal adult cataract All right, what kind of cataract we looking at here? So you see the spokes and that's the classic thing in a cortical cataract is it'll start peripherally Come centrally and it'll look like a pie or spoke so you see spokes or you'll see pie shaped Wedges and it tends to be white tends to be more fluffy looking rather than yellow or brown And of course, it's more peripheral both the anterior and posterior. So this is the classic Cortical cataract and then this is looking at it from behind Again, you see the spokes There's the classic spoke. I mean there's a little bit of nuclear cataract in here, too Yes Yeah, it's the fibers there aren't any nuclei left or they're in that central nucleus and so that central nucleus It's just the empty fibers and then you know within there. There's lots of proteins the proteins will start to de-nature They'll start to cross-link. There's other elements that start to get in there and then they become harder become That's the million-dollar question if we can understand that we could prevent them I don't think we fully understand why yep, that's a that's a good question I'd love to have that answer because then we could stop cataracts before they you know before now when we look at Cortical cataracts what we see is a little bit different than the nuclear cataract These fibers tend to get swollen and they tend to get liquid in between them And so if you look right here these spaces here are all liquefaction And so with cortical cataracts not only do the fibers you know become a pacify But they become swollen and you even get liquid in between so sometimes when you're in surgery with me We have a cortical cataract. I'll show you every once in a while they'll even have little bubbles in them It's kind of fun you press on the capsule the bubbles all move all over the place So I'll show you if you're in surgery with me But so cortical cataracts you tend to get liquefaction and Those fibers will liquefy and then you get liquid in between them That's why you get that kind of fluffy white appearance to them and here you can see more posteriorly again I'm sorry. It's not that clear, but again all this space is fluid So you get a lot of fluid in here you get liquefaction of the cortical fibers Okay, what are we seeing right here? This looks like the nucleus has become so dense Area around it that it's almost kind of falling down And what allows it to fall down? It's so dense compared to the liquefaction around it. Okay, the keyword you said is liquefaction So in an end-stage cataract not only is the nucleus dense, but the cortex liquefies And so as a result the lens tends to sink down into the intact capsule still what do we call this cataract? It's more gag me Remember that term. It's more gag me and so more gag me is a cataract where the Cortex is so liquefied that the dense nucleus sinks in it now the capsule bag is still intact But you see it's wrinkled and a lot of fluid can leak out of the capsule even though it's intact A lot of fluid even proteins leaking out of it, but it liquefies and it sinks down And so one of our fellows thought that it kind of looked like a sunny-side-up egg And so there you see so the more gag me cataract kind of like the sunny-side-up egg look to it And so that's kind of the end-stage cortical change where the cortex liquefies so much It's just totally water and then the nucleus sinks in it And this actually shows you one that we had removed. Here's that dense Nucleus, here's the capsule or bag not much cortex left in it And it's really tough to take these out with an intact capsule because the capsule is really soft and wrinkled and these are real real bugger to remove There's boopy would say bugbear bugbear Because that was more downward traction on the zonules It does the zonules get really loose with this as the bag shrinks And so the zonules aren't really intact in an end stage more gag me and cataract All right, what are we looking at right here? This is a slim photo. We see this It looks like a posterior opacity on the lens Excuse me All right, so this is now more posterior because we've got the slip beam in there. So what kind of cataract usually do we see posterior? PSC or posterior subcapsula So these tend to be more in the center They tend to be sometimes they can be round sometimes they can be irregular and it almost looks like kind of fish eggs or ground glassy Look on there and then you can do them in retro illumination and again these really show up. Well In retro illumination. There's a little bit of a close-up. So you see it's got kind of that Ground glassy look to it kind of that salmon egg look to it Here's just another one, you know retro illumination is a good way to look at this now Remember I said there's normally not Lens epithelial cells along the posterior capsule. Well Here you see now I usually ask you what's wrong with this picture Well, what is wrong with this picture? Yeah, well, why is that so but it's upside down and so remember we always usually have anterior or up posterior down That's upside down. So that's the posterior capsule on the top and there's lens epithelial cells there Not only that but you see nuclei In them and look at these big swollen cells. They call these Um bladder cells or fatal cells, you know with a w w e d L I think fatal cells and so When you get a posterior subcaps or cataract you get an abnormal proliferation and migration of lens epithelial cells Along the posterior capsule then they get very swollen and and fibrotic And so they're called the bladder cells the swollen cells Catherine what are some systemic entities that are associated with posterior subcaps or cataracts? Most common one would be diabetes So people with diabetes high blood sugar can get posterior subcaps or cataracts, uh, rachel, what are Interocular entities that can be associated with psc cataracts uveitis or inflammation And so pscs are interesting because they're often not Just you know coming with aging as other cataracts do and so Diabetes systemic entities like that can give you that You can get them in any kind of inflammation or uveitis anterior uveitis Intermediate uveitis posterior uveitis you can get psc cataracts Other things Surgery can well actually if it's right no surgery the cataract most commonly is nuclear not psc But you can get psc. What's another um large group of of Potentially the logic factors that can cause psc cataracts Different different group something else could cause Stereoid use and so okay what I wanted to think about is medications And so you can get psc cataracts from Um things like diabetes systemic diseases you can get it from inflammatory Problems within the eye you can get them from medications most common being cortical steroids And so people who are on systemic cortical steroids can get psc cataracts also So you want to always remember those are three big groups that can cause psc cataracts Now this is kind of interesting What are we looking at right here? Give you a hint here's the iris up here. So it looks like the now it doesn't look like a pas stain So this is kind of still an h&e stain And so you see the lens capsule is still intact anteriorly, but there's all this stuff Going on underneath it. So indeed this is called an anterior subcapsular cataract So not as common as posterior subcapsular cataracts if you can get anterior subcapsular cataracts And what it's characterized by is for some reason these anterior lens epithelial cells get stimulated They undergo a fibrous metaplasia So this is a trichrome stain and what it does is it shows you that these lens epithelial cells have start laying down collagen And so basically the undergo fibrous metaplasia and you get this Sub you know anterior capsule focal cataract anterior You know instead of a posterior subcapsular cataract, this is an anterior subcapsular cataract These are pretty uncommon. You can see them congenitally It's interesting. You can see these after a fake kick Post-ear chamber IOL So we don't put many of those in fortunately here, but occasionally it's called the ICL It's a fake kick lens that goes between the iris And the lens and if you get one that's too flat and kind of scrapes on that lens capsule It can disrupt the metabolism you get a focal anterior subcapsular cataract All right, so we're kind of changing gears completely Tina. What the heck is this picture? Here's to be misshapen. It's not round but I can't tell if there's fibrous banding coming from the back Um hard to tell on this but you can see that you've got this Kind of again and this let's see we've cut that a little bit. It's not it's not cut completely But this would even look like a big donut if you looked at it completely So what could this be? Anybody This is called a summering's ring and so this can occur in two ways first of all you can have a traumatic rupture of the lens capsule You lose a lot of your intraocular contents, but there's still some lens epithelial cells in the periphery They start to proliferate and you get this donut Proliferating now when we first started doing extra capsular cataract surgeries in the early 80s You know we're very good at doing it and so we're leaving behind a lot of Cortex in the periphery and then again these lens epithelial cells will proliferate and you'll get this big donut of proliferating lens material in the pharynx So here's what it looks like. This is a Miyake view again. This is an eye from the early 80s Here's an old iol in here and look at this proliferative cortex now We say this is old, but we just took out a dislocated iol that are dislocated in the vitreous and had a whole Summering's ring associated with it that we took out separately. So This is proliferation of the lens epithelial cells that are in the pharynx No matter how good of a cataract surgeon you are You can't get all those lens epithelial cells out of the pharynx And so you may not get a full summering's ring, but you'll get some proliferation in the pharynx in the periphery So summering's ring is what this is called in summer. Not the season summerings the Englishman so E-M-M-E-R-I-N-G-S summering's was his name You can see this is just a you know later one. This is now a three-piece iol But again, you see this hazy donut Of proliferation this summering's ring that's still there even with a well done more modern cataract surgeon You still see that to some degree here. It is in cross-section in cross-section. It looks like a dumbbell And so you can see that it's proliferation of cortical material in the pharynx on both sides And then of course lens capsule in the center is still Fairly clear. It doesn't really go across the center. It's limited to the pharynx on both sides Here you can see this is a trichrome stain with anterior and posterior capsules even fusing In that area this actually is a rabbit, but just to kind of illustrate All right, Chris, what are we seeing here? Is this consistent with? Okay, so this is something that kind of crosses between lens and glaucoma And so in fact at one time they used to call this pseudo exfoliation of the lens capsule The lens capsule is really not You know where this disease comes from it's it's made this material is made from a lot of cells in the anterior segment of the eye And so it just happens that this exfoliative material deposits on the anterior lens capsule Why does it have this kind of bullseye appearance? So we see the deposits in two areas I think What I've been told is because the iris as it dilates and constricts it kind of causes chafing It's like a windshield wiper So when the iris constricts and dilates constricts and dilates it pushes that exfoliative material around So it's usually you see a ruffle of it near the pupillary border in the periphery And you'll see a little bit centrally and that kind of denotes where the iris moves in and out So this material is deposited on the lens capsule, but it's not the lens capsule itself That's abnormal. So it's just kind of the innocent bystander that's sitting there Here you can see a really nice little lamp picture. It's got that kind of scalloped edge look to it now This is very common in in utah This is a disease that we see more frequently in people with scandinavian and northern european ancestry You know, you look at the salt lake city phone book You know, I had a neighbor named peterson. I was trying to look up his phone number There's like eight pages of peterson's let alone Sorensen's and you know, so a lot of people in utah have roots in northern europe And that's where this disease is seen more frequently. So we see lots of exfoliation here. So you guys will see tons of it There you can see a nice retro illumination view Kind of that scallop look look to it But again, sometimes it can be subtle. Sometimes you see just little ruffles Of the material just sitting at the pupillary border. So it's it's very subtle and it's asymmetric So sometimes people say they see Unilateral exfoliation. There is no unilateral. It's a bilateral disease, but it can be very asymmetrical where you see A lot in one eye you hardly see any in the other eye This is what the pathology looks like they call this the iron filings And so I don't know if you ever took a magnet and some little iron and you grabbed in those little iron filings sit up on the magnet That's what this looks like pathologically. So it's on the anterior lens capsule And you've got this little exfoliative material sitting on and now this stuff Gathers in the trabecular mesh work so you can get severe glaucoma It deposits on the zonules. You can get weak zonules. It weakens the capsule You can even get this in endothelial cells. You can get this in the sphincter muscle and the dilator muscle So this is you know, ambiguous in the anterior chamber The reason that this is important is if you're going to be doing cataract surgery you kind of got a triple whammy The zonules are bad The capsules weak and the endothelial cells can be affected off quadruple whammy and the pupil doesn't dilate So these can be difficult surgeries. You have to be really careful and you really need to Plan ahead of time when you're operating on people with exfoliation So we'll talk a little bit more about this when we get to the glaucoma lecture What do we see in here? Into your capsule. There's some They're peeling of the anterior capsule or some separation Yeah, look at that little it's almost like there's a little scroll if you will A vent to your capsule. What the heck is this? So it could be separation of some of the layers of the anterior capsule or exfoliation So this is actually true exfoliation as opposed to pseudo exfoliation So initially when people were first describing these they called it pseudo exfoliation because they thought it was Somehow related to a problem with the lens capsule. So this is so-called true exfoliation. This is very rare I have seen two of these in my career So very very rare. This was the second one. This was classically described in people who were glass blowers And you know, I don't know if you've ever seen pictures people take that molten Bowl and they blow on it and spin it around and they make this nice big glass on it. Well that puts an intense Um infrared heat and you know light From that and that will make the anterior lens capsule fragile and make it scroll The other people we would see this in as people who work in in blast furnaces, you know making steel Again intense heat and and infrared But you know now a lot of that's getting Automated so we don't see it. This lady had no exposure of anything. I have no idea why she had this So this was um sam basket sent me this from la And this is his video during the surgery and you can see here's this scroll. He hasn't started the capsule rexis yet So he got in there to do this lady and he said wow, this is really weird. Look at that. There's this scroll On the capsule. So he you know sam being that smart guy. He said this is something really interesting So he carefully did a rexis Around that and preserved the anterior capsule and sent it to me And so we did this and sure enough There's the anterior capsule. There's the lens of steel cells inside of it and look at this split There's actually a schesis a splitting Of the anterior capsule. So this is called true exfoliation and we put this in Eye world you guys get the eye world, you know, it's the academy Then you get and I always do a cool picture of a case And so this was a cool picture one month And so this was really nice because this is the only pathology I've ever gotten on True exfoliation very uncommon entity, but again, you gotta know it for boards It's a true exfoliation And there you can see here's the lens of the cells. Here's the anterior capsule and look at splits There's actually a little mellar splitting and it scrolls. So as opposed to pseudo exfoliation, which is not really In the lens capsule itself. It's a deposition on the lens capsule These people have like if we're thinking, you know, it's heat and stuff from glasses Do you have like point of pathology as well? Interestingly, you don't it's which is really weird. You don't so it may I think it's more infrared Than actual heat heat but it's infrared and heat But these are so rare as I said when you see two of these in in like 35 years I mean, this is really really rare All right, I guess we're back to what the heck are we seeing here, right? So you get a it looks like you have it, right? So I'll give you a hint this hurts pressures 50 Wyoming rancher Actually take a peg this guy was in Nevada rancher So since we're in the Exactly, what do we call this entity? It's not fake olytic. It's the other one. No, it's actually fake olytic So it's kind of a misnomer fake olytic means like lens splitting But what's weird is this is almost like you would see in a margagian cataract But it's a mature cataract Where the cortex is liquefied and the proteins leak Through the capsule into the anterior chamber And so you actually get Leakage of proteins then you get a macrophage reaction to it and you can get a severe unilateral glaucoma And so if you look that corny is cloudy that reason it's injected the pressure is 50 You get this fluffy flocculant stuff underneath it So this is what they used to call fake olytic glaucoma So what kind of cells are these? Leave it or not. These are macrophages And so macrophages come in and they start eating up the protein and so then they're like little pac men You know, they go They start eating that up and look how swollen they get you get these big fat swollen macrophages They are so big when you see these patients if the corny is clear enough for the slow lamp You can actually see cells. I mean pretty big cells floating around in there So the problem is is these macrophages are engorged with protein There's protein floating around here anyway, and they clog the trabecular mesh. So you get a severe glaucoma So the treatment is you actually Evacuate the whole lens, but you flush the heck out of the anterior chamber You get all this material either. So again, this is a sign of a hyper mature cataract Leakage of proteins through an intact lens capsule, then you get proteins and macrophages again, if you want to be smart you say macrophages So you say everything with a British accent makes you sound more intelligent. So You you know, you go ahead and you get this and you get a severe glaucoma with these And so the key is you just evacuate that and you'll take care of them We'll talk a little bit more about this again in the glaucoma lecture. So a couple of entities exfoliation and The fecalitic glaucoma that are linked between lenses and glaucoma They actually diffuse through the intact capsule. You have proteins and fluids diffuse through the intact capsule back at so this is This was like your last surgery here What what are we seeing here? There's in looks like there's an IOL I'm looking at that haptic. It's kind of in front of this is not an acol. So this is a PCIOL, right? So, uh, yeah, so we've just got IOL dislocation anteriorly through the lens through the iris Maybe from trauma. Um, and then there's some in fact quite a lot of cortical material So this was a difficult surgery ruptured capsule Thought they had the implant in place. It wasn't a lot of cortex left behind didn't get cleaned out properly. So you could get a severe Inflammation from, you know a cataract surgery that's been complicated You've got even without that IOL in the anterior chamber if you had all that cortex left over you get a tremendous inflammation People kind of call this a fecal toxic uveitis. And so it's it's an inflammatory Syndrome you can get severe glaucoma from it And if you know you've got a surgery what was difficult surgery you've ruptured a capsule You can't get all the cortex out of there you get this inflammatory reaction again They kind of call this a fecal toxic uveitis, but you can get this inflammation These guys can get a really severe glaucoma very difficult to treat and oftentimes you have to just clean out everything You have to take out the IOL do a complete protractomy and then end up suturing an IOL to take its place This is not the same as the it's a misnomer Just stole you just stole my pimp questions for shrawb. So So what she said So you could thank your colleague there for making that all right so speaking of fecal anaphylactic endothelitis and so this is that other double misnomer that you You know have to memorize and so fecal anaphylactic anaphylactic means IGE You know mediated inflammation and end up the miters means infectious. So it's not infectious. This is again a Kind of an autoimmune inflammatory reaction that you can get Now interestingly enough this entity fecal anaphylactic endothelitis was seen a lot in the 1920s And believe it or not people were doing crude extra caps in the 1920s no microscopes loops Kind of tearing the capsule and trying to flush out The you know the cataract and weren't very successful So you're seeing this a lot and then people started going to doing what's called intra capsular surgery where you actually Broke the zonules or eventually dissolved them with alpha chymotrypsin and remove the cataract hole with the lens capsular Bag intact. We call that intra cap And that's how people did surgery for the better part of 30 years 40 years And so only when people started going back to doing extra caps late 70s early 80s We started seeing fecal anaphylactic endothelitis again. So it's interesting that was a Total historic entity until we started seeing it. And so what you see right here? What are we showing here? You can still pin something here Exactly. So these are the big keratic precipitates and what a mutton fat kp's have in them that make them so big like that Even more than that. They have even like macrophages too. And so they have not even just lymphocytes, but even macrophages So you've got these big mutton fat kp on here And this was a globe unfortunately was lost because of fecal anaphylactic endothelitis and you could see this huge ring here Around the area. So this big cyclinic membrane, you know in the area of the ciliary body in the area of the lens capsular bag This patient even had an organized hypopia on here from chronic inflammation. This inflammation was totally localized around the capsular bag Now you can get this from trauma also not just from surgery. So this was a A guy who got kicked in the head by a horse So ruptured his lens capsule. This is what's left of the Central nucleus here rupture lens here. This is all Exudative retinal detachment. You can see unfortunately he's going into tisus bulbide at this point But he had again a fecal anaphylactic endothelitis So people are trying to get away from that term because again, it's a double misnomer And some people are just calling this fecal toxic or something like that But it's in the literature. And so you just need to know it now again very uncommon We haven't seen these now as we've gotten better at doing Cataract surgery now and removing all the cortex and not causing an inflammatory reaction But what's interesting here? This is another traumatic case and here is the central leftover lens Here's the lens capsule rupture and here's the inflammatory cell reaction around it. Now remember when we were talking about Granulomus inflammation We had said that the third type of granulomus inflammation is is the you know Focal type around rupture lens capsule. And so this is a zonal type You'll get you may even have some lymphocytes in the middle and then you'll have some giant cells Around it. So you'll get kind of a zonal inflammation in here. You can see again Here's macrophages coming in here just trying to munch up That liberated lens cortical material from the traumatic cataract. So munching it up here And then around that you'll often see lymphocytes. So have kind of zonal granulomus inflammation And here is a little piece of lens capsule That was ruptured and it's got some little macrophages There's actually a macrophage kind of sitting on the lens capsule munching that lens protein material So this was a cool case because we published this in 1980 or When I was a Dave Applefell and this was the first time they'd been published again for since 1924 So I mean it was literally 60 years between when this was published And then again, it's kind of faded away now because we've gotten much better But double misnomer, but you do have to remember a fake one fly began up the Midas It's due to large amounts of liberated Lens proteinaceous material that then incites an inflammatory reaction It's it. Okay. There's the opera house at night I guess Mozart was in there working instead of cell phone Questions on lens Yeah, you know fake otoxic is more when you've had a Camera X surgery you've left cortical material in there Maybe there's vitreous mixed with it and then you get this uveated reaction to it It's not as we're going to flag to get them from Midas They even think there's even some immune reaction that's associated with that But you know, they're probably along the same spectrum It's probably just total amount of liberated cortical material and how it's liberated that that decides the inflammation Questions. Sorry. I have a lot of questions today. Um, so the posterior capsule pacification Is that the same mechanism as like L-shing pearls forming? It is so when people talk about posterior capsule pacification It's not the capsule that's so pacifying it's lens epithelial cells again from the foreign eggs Growing along the posterior capsule postoperative And that will cause that capsule to pacify. So when you do the yag laser You're creating an opening in the capsule But it's because you've got these cells and this fibrotic reaction along the posterior capsule L-shing pearls are lens epithelial cells that have grown anteriorly Instead of posteriorly and you'll get these little salmon eggs Kind of at the periphery of the anterior lens capsule where the capsuleotomy is and even going out into the pupillary space We see a ton of these in in rapids. We don't see them So much in humans, but yeah, so if you've got a lot of anterior proliferation of lens epithelial cells You get what are called the L-shing pearls And those are very rarely or ever visually significant? Yeah, they're usually not unless they come all the way across the pupillary space They're pretty uncommon in humans. You see them a lot in little kids You know that you do cataracts in youngsters and you see them in rabbits a lot All right, so next week you get a reprieve because Monday's a holiday So no lecture Tuesday, but Tuesday the 29th We're actually talking about history of IOLs So there's really nothing in your book you can read so you guys get a reprieve And we're going to talk about IOL history not we're going to stop 20 years ago So nothing modern. This is all going to be history