 Wow, we got a big turnout today. I'm impressed So everybody have a good holiday? Yeah, it's kind of hard to get started nothing like doing pathology the you know Morning that you guys come back from a nice holiday. So all right, so we're going to go back to Copenhagen, so this is the Classic tour boat the funny thing is is they keep the bridges really low So in high tide when you go through there You have to like fill your head sideways if you're on the end or you know bang your head underneath the bridges as you go Various canals and waterways, but it's a good way to see the city Copenhagen interesting city It's you know a lot of 400-year-old buildings and then interspersed with some really ultra modern Architecture, which is kind of interesting. So this is their opera house Right on the water very nice You know glass and steel and very very ultra modern and of course you've got your old You know government building here, you know Castle that the King had lived in and so that was built probably in the 1600s And so a real juxtaposition of old with new in here This is the new Main library, so this is kind of their the country's Library kind of library of Congress again if they call it the black cube and so it's it's black glass It's a Cuban. It's got a big atrium kind of like Moran and these are all escalators going up. It's it's pretty cool inside What's interesting is is again the juxtaposition of old with new it's a bunch of musty old stacks And then a bunch of computer terminals and so again mixture of old and middle And this this kind of summer as a scope, but you can hear the ubiquitous quaint crane There's cranes everywhere. I think that's their national bird is the crane So you see cranes everywhere building and you see the old Tower so a good mix of old with new so we're going to talk about lens path today and You know if you remember Five weeks ago. I know it seems like an eternity, but last year when we talked about Embryology since you're in the the hot seat there Reese Tell me a little bit about the embryology the lens. What layer does it come from and how does it form? Okay, what kind of ectoderm Surface so it's really important to remember remember the important parts of the eye the retina the pigment epithelium come from neural ectoderm Whereas the surface ectoderm gives rise to not only the skin The epithelium of the skin the epithelium of the conch in the cornea, but it gives rise to the lens itself So early on in gestation You'll get this neural ectodermal out pouch Then it'll touch the surface ectoderm and then we'll induce it to thicken and then you'll get an Invagination and so this neural ectoderm forms the you know the sensory parts of the eye But the surface ectoderm eventually pinches off Informed the lens itself. So the lens is it's coming from the surface ectoderm and when you look at these these are in Embryos, I think mice or something. I mean they're very much like humans at this stage But they've highlighted it here. You see the here you see the pinching off and here's the surface ectoderm And then eventually it pinches off and forms the lens All right, so this just shows it schematically what's interesting is as the lens begins to form its first of all just a round ball But then the cells in the back Will migrate forward and as they migrate forward they fill that in that's an important point because throughout life There normally should not be Lens epithelial cells along the posterior capsule we've migrated anteriorly and when the lens grows throughout life These cells will go out along the equator No, thank you. This is not an Apple computer. So I really don't think we need new Apple software So what happens is is the cells will then grow out along the equator And then fan out and that's how the lens grows throughout life So this just shows this in that this is actually human embryo You can see the cells have come from the posterior surface growing anteriorly Feel that circle with the lens fibers themselves All right, so this is what the lens looks like with the slit lamp On something you rarely see at the VA at least when you're there, which is a nice clear lens But you see as we become older the lens goes from round to being more of an oblong So it's more of an oval than it is a circle itself. This is what it looks like in pathology And let's go a little bit You know, there's several parts of the lens you want to think about and and you can put it into different layers The embryologic nucleus the fetal nucleus the adult nucleus the cortex the capsule And then the zonials around it All right, ashley. What kind of stain are we showing here? They look closely at what's picking up a lot a lot of bright stain there All right, so this is this is PAS because what is PAS stain? basement membrane. So what is the lens capsule? The thickest basement membrane in the body. All right, so we're number one So the thickest basement membrane in the body is the lens capsule You got to remember that the lens capsule is truly a basement membrane but if you look the anterior capsule is probably 50% thicker than the posterior capsule So when you're looking at pathology specimens, you're not quite sure where it came from The thicker of the two is the anterior capsule And ashley, what are these underneath the anterior capsule? Those are the theos cells. Remember we said there should normally be none posteriorly So that looks really thick in this big picture, but that's really only about 10 microns thick. So that's all that's between You and vitreous when you're in there with a 40,000 hertz ultrasound machine with suction going full blast So always be sure that that's all that's between you and disaster So be really careful around that lens capsule when you're operating All right, what part are we showing here Chris? The equatorial region of the so-called lens bow And so as you look right here when the lens fibers grow throughout life, they come to the equator And then they fan out and if you see this in three dimensions, they fan out along the edge of the equator So if the if the lens were flying saucer there on the edge of that flying saucer And then they send fibers both anteriorly and posteriorly Nico, what are we looking at? I'm sorry, renais pulled out there, but you're still in order renais What are we looking at here? Zonior fibers So it's important to know here's the lens Here's the ciliary body. This is a scanning EM Look at where those zonials go they go some of them attached to the ciliary processes Some of them go all the way back here Almost to the par's planus. So it's really anchored in tightly Those zonials really really hold that lens in place And so I like to think of the zonials as like the springs on around trampling And so they're the ones that hold the lens in place But if you look the anchor way back here, so they can go back all the way from the process These almost to the par's plan of the flatter part of the ciliary body Nico, what are we showing here? We're seeing kind of the y-suture Well, actually if you look carefully even in adult lens, you'll see some variation of a y-suture So, you know, if you guys want, you know, you'll say, yeah, I don't really notice y-sutures You know, when you go to clinic today, just take a second and somebody nicely dilated look at their lens And see if you can't find the y-sutures. Why do they form? I think it's like the intersection of Migrate Well, it's where their processes come anteriorly and posteriorly And so remember because that lens is more oval than round Those fibers don't come to a complete point because it's not perfectly round So they come because it's oblong they will come to a different point Often form a y and what's interesting is you can see a y up and down and a y inverted Depending on when you look at the lens itself And oftentimes the inverted y is in front and the straight up and down y is in the back But these kind of denote the nucleus, especially the anterior part of the fetal nucleus And then the beginnings of the adult nucleus And here you can see the fiberverse The lens fiberverse And when you look at them, they're shaped almost like a honeycomb Which is interesting and so the nuclei are at the equator, but those fibers go both anteriorly and posteriorly Okay, so taro, what is the what's in those lens fibers? What are they mostly made of? Well, they've got a lot of proteins in them That's what you want to remember and you've got alpha and beta crystalline proteins and they tend to form Certain networks with the proteins and the reason that they're important is As you get older and older Or sometime the proteins in those fibers will clump together and then they'll start cross-linking And when they do, that's when the lens becomes both harder and less transparent So as it becomes cloudier, it becomes harder, it becomes a cataract as we age All right, what uh, sorry, I'm on this slide Sranath, what do we look at right here? No, this is a contact lens And it's a special type of contact lens because what else is going on with this patient? Here's the pupil right here. What is this? Now look at it. It's actually still behind the pupil So what's happened to that lens? Yeah, it's dislocated And note the direction if this is a left eye, it's dislocated superiorly And temporarily does that tell you anything? Actually, that's the pattern of lens dislocation that you see in Marfan syndrome Now why that is, I have no idea. I mean gravity pulls down, it doesn't pull up and out So why Marfan's dislocates superior temporarily? I don't know, but it does. It's very weird And so Marfan's tends to dislocate superior temporarily in the zonio's giveaways If you saw Nealopathy, and this is an AFAKE in contact lens And this is him. This picture is so old. This is the original Maran clinic Which was in the old building on the A level, which is now I think he had tea But in any event, that's when the whole Maran had 10 exam rooms. There was no Maran department of ophthalmology This is one of our old tags And this gentleman has got Marfan's, look at his fingers And his legs in his arms. So that was him, Marfan's And he wore AFAKE lenses for years, and then that Nuclea or that lens started to get a little bit more dislocated and there was risk of people are in block So he eventually ended up with cataract surgery So dislocation of the lens is a common thing that you see in Marfan syndrome Because Marfan's is a disease where there's You know disruption of some of the strength of the fibers And so these people get aortic dissections They get all kinds of other things that that are due to the Problem with the strength of the fibers So because the zonular fibers are weakened in Marfan's, they tend to get dislocation This is one I've never seen one of these. This is another common cause of dislocation. This is homocystinuria And the only reason I have to show this is because they put it on like OCAPS every other year And I've never seen one in 30 years, but they exist and the weird thing is in homocystinuria They dislocate inferior nasal Whereas Marfan's they dislocate superior temporal again. Why I have no idea Becker, what do we see in here? I'll give you a hint pupil is Exactly so lenses can also dislocate enter in this particular gentleman. It was a trauma This is a traumatic dislocation. And so if you have a severe bone trauma, it's not common But you can have a lens dislocation the anterior chamber now There's another condition you have to memorize for boards that can cause Dislocation of the lens into the anterior chamber. What could that be? It's actually sphero fakia So sphero fakia is an interesting disorder where the lens is spherical shaped instead of oblong. It's round and it's small So sphero fakia literally sphere shaped lens So sphero fakia and they are at increased risk of a spontaneous dislocation Enter because these lenses tend to be small and you get the weak zonials and then they can pop anteriorly Here's a man I can't blame the fellows on this one. This is a copy of an old AFIP slide This is probably 50 years old, but you can see that there is lens that spontaneously dislocated Into the anterior chamber all right now Chris This is a younger child With a cataract and I'm not sure why the eye was removed the child died or not But and this just shows you that the eye is small As you see in terms of the size it's only it's only about 12 milliliters down a very small line. What do you make of the shape of that lens? The left over so it's cut in half I'm sorry. This is a normal size for the kid and this is one next to it just showing the difference. Okay, so it's very round correct So what could a child Have that can cause a smaller round or lens in addition to maybe some damage to their retina and other things Elsewhere in their body Of the infectious process the kids hear exactly and what's so infectious process that can give you Smalls, you know, micro-sphere Rubella exactly so this is a rubella cataract And that's important to remember because you may be seeing these more often because that well-known physician Jenny McCarthy Has told people that vaccines cause autism and so therefore a lot of people are not vaccinating their kids And so you're going to start to see outbreaks of things like measles and rubella as people are not Vaccinating now I find it interesting that you know somebody who listens to Jenny McCarthy Well, maybe they're not sophisticated, but there's a pocket of people in park city You know very intelligent very bright people are not vaccinating their kids now And so you're going to see clusters of these You know infectious diseases that we thought were wiped out coming back And so you may actually see rubella And it can cause this micro-sphere of fakia And the other thing that's weird about rubella is is that you get retention of these Rubella you get virus fibers even in these lens nuclei So even after they've had the virus there still be viral particles there within the lens itself So very very interesting entity All right, so we're going to talk about cataracts so so leave what kind of cataract are we looking at here Well it Polar means kind of in the anterior posterior Center this Is bigger than just that what part of the lens is this taking up? That is actually the entire field nucleus And so this is a congenital nuclear cataract And what's interesting also is with this one there's kind of the male symbol. There's the female symbol So I call this the prince cataract, you know You know when prince was a male female symbol Come on you guys aren't that young This is a prince cataract. So this is a We shouldn't say that now because he died this year. So that's really steep because he laid prince And so this is a congenital cataract involving the lens nucleus So it's involving the center of the nucleus the field nucleus Right here and this woman is interesting. She never had it removed. She's she's like 70 And her vision in that eye is count fingers and yet she functions through in life She's been functioning with this since she was a child And this is just showing you a different view. Here's the edge of the pupil dilated here And this is a slip beam. I was trying to show this on here. See how that Fade opacity is in the center of the nucleus Again in the fetal nucleus so congenital Nuclear cataract in the very very center. So they're very discreet very very central nuclear opacity. So What's that? This is a different patient. Another patient. All right, what do we see in here back to Vectories So it's a White lens and then This is just what you normally see You know in an aqua one it's been kind of this is just showing you kind of a A dense dense cataract from an eye that's been cut sagittally Okay, so now we're looking this is called the Miyake apple view So Miyake's a guy in japan who figure out if you cut an eye in half and go to a slide You can actually look at the inside at the same time as you're working You know enter as you move posters So this is if you're sitting on the optic nerve looking out And so you can see here's the ciliary body and then the zonules are here And so you can see right here. This is a nuclear Cataract and so nuclear is the most common type of cataracts we see in an adult So an adult nuclear cataract. This is the ultimate nuclear cataract. What do we call this actually? Renneson means brown light And so you can have a remeson cataract you can even get I don't see them in the first world But in the third one you can even get cataracts at all almost from black. They're so hard So this is a remeson a brown light cataract. That's a dense dense dense. That's a nucleus The lens nucleus gets so big it takes up the entire You know the entire cataract itself And then you know people often say well, what does the cataract look like in histopath? We usually don't do the path of cataracts that are removed because you don't really see anything Here's the nucleus And here's the cortex you could say well, yeah, that's Kind of denser. It's taking up more stain. But to be honest I couldn't look at this pathology and say is that a trace nuclear or a three plus nucleus They all look the same pathologically So it's really hard to tell anything on the pathology of a nuclear cataract Chris, what do we see in here? Cortical cataracts. Cortical cataracts. You see the classic wedge pie shape cataracts So they come to a point in the center and then they have this wedge or this pie shape So these are the cortical cataracts and then here's one posteriorly you kind of see the A little wedges there of the cortical cataract and what happens to the fibers that causes a cortical cataract? So they get fluid filled? Exactly. So you get liquefaction, so you actually get fluid in there And so it's kind of fun Next time you guys are with me I'll show you when you have a the cone with really distinct cortical spokes when you go to start the capsule raxus if you just push the lens Push on the capsule those bubbles will just go away. So it just liquefies and so there's these little liquefaction bubbles all over here that are really The sign of a cortical cataract And this shows you severe liquefaction of the of the cortex So you've got these fibers broken up with little globules and then you've got just fluid basically liquefaction And you know as the cortex breaks down Renee what we see in here? sunny side up this looks like Hyper mature like we have more gagmian cataracts. Okay, and what causes more gagmian cataracts? What causes that appearance? Exactly so this this is an example where the cortex completely liquefies And so it's basically just a bag of liquid and then what happens is is that dense nucleus in the center? Drops down and so you'll see these that nucleus will be sinking down and Instead of the capsule being really tense like you see in uh Intimacy of white cataract the electricity still wrinkles in the cataract because as that liquid leaks out the cataract Actually shrinks a little bit in the capsule bag And as Renee said it's got the sunny side up look to it. So This is the more gagmian sunny side up cataract And there you see one that was actually removed. Here's the dense nucleus Here's the what's left of the capsule and you see there's virtually no cortex in there It's all completely liquefied Nico what are we seeing here? Yeah, if you look right here, look there's the anterior surface of the lens right there You can see we're focused really deep. So this is actually What we call a posterior subcapsular psc And here it is on retroalumination. So these really show up well on retroalumination There's a higher probability. This is a student volunteered in my lap this summer He said oh someone told me how to cataract one. So we dilated him and looked at him sure enough Pse cataract and they're showing you a more diffuse one And so these show up best on retroalumination So when you look at these you put that beam straight on Move it to the temporal side of the pupil and then look at the orange light coming back And you'll see these outline posterior What's the pathology characterized by? Exactly. So I guess that the proper ostium would be vatal W e v l vatal cells And so you get these very decon bladder cells and they're very swollen Now the other thing this is the posterior capsule. By the way, this picture is upside down Next year, I'll ask you if that's right side up or upside down. Let's see if you remember it But this is actually the posterior capsule and you can see we've had migration Of nuclei along the posterior capsule and then they become very swollen like bladders There's the nuclei in the center. And so this this is what we see characteristically in The posterior subcapsular now. They always love asking this Tara, what's a differential diagnosis for causes of a posterior subcapsular cataract? Okay, so cortical steroids trauma trauma One other main area main area that can cause pscs Diabetes can't help another one Drop then not really I have a main area that can cause pscs inflammation And so you see these often in uvias You'll see these in like especially like people with intermediate uvias so called pars planias We get a lot of inflammation You will get these psc cataracts and so some of it can come from the inflammation Some of it can come from the treatment of the inflammation Which is the cortical steroids that the tarant said right at first So cortical steroids are a common cause of these Diabetes inflammation and then some of the less common causes So pscs are one where we can actually Find a particular cause that these can also be due to aging But oftentimes they come on earlier and they come on secondary to other things All right back up what we see in here What what part of the lens are we looking at at this point? That's actually part of that. That's some denuded iris at the top Part of the lens are we looking at here? This is the anterior part. So this is the iris here This is the anterior part. Look, there's a capsule completely intact and then underneath the capsule You see this area of opacity So this is called an anterior subcapsular So believe it or not you can get anterior subcapsular just a giga posterior subcapsulars These are a little bit different because these are caused by Those anterior lens epithelial cells Undergoing a metaplasia meaning they change their characteristic and they become fibrous And so anterior lens epithelial cells can actually undergo fibrous metaplasia This can be congenital. It can be due to an insult Now a good example of that is when you guys are looking at somebody you had counteract surgery 10 years ago with a beautiful rexis And they're dilated look at them. What do you see? You see the edge of the anterior capsule look kind of white Or it leave and constrict it will cause what's called thymosis That's anterior fibrous metaplasia Of the anterior lens epithelial cells so you can see that every day in clinic But this is an anterior subcapsular counteract, which is actually not very common And here's what it looks like boy bonus points if you can name this stain anybody Tri-chrome very good. Is that ashlyn? Sorry, I'm under the lights here so I can you guys are like just outlines So this is actually a trachrome stain and the reason it's very interesting is it stains Fibrous type tissue collagen blue And so you can see right here. This is fibrous metaplasia those anterior lens epithelial cells start laying down fibrous And that capsule's still intact And the normal cortex is down here and you get this focal area this anterior fibrous metaplasia So anterior subcapsular cataracts can be congenital they can be post-traumatic Other entities are very weird obscure Syndrome don't worry. Well, they may show up once in a while, but don't waste neurons at this point What do we see in here chris? Actually, this is a normal eye. It's just been cut in cut Sagittale and these are the this is the central collage. It's been cut off with the lumbos on both sides and this in the center So it's like a white thick lens there I don't think it's mostly anterior. What's the shape of that? It's bone or horseshoe. Yeah, it's kind of a horseshoe shape And if we have a cut that went On all the way around believe it or not, this would go all the way around almost like a ring This is called a summering ring and and it's not summer like the season Summerings was a was a pathologist so e m m e r i n g s summerings This is called a summering ring. These are initially seen As people would have trauma. So if you had a traumatic rupture of the lens And the lens nucleus gets extruded But you have some cortex left in the periphery. Remember at the At the fornix there you've got all those little lens epithelio cells and they can grow And so you end up with this is a traumatic summering ring cataract But more commonly We see that leaf What are we looking at here? That's a summering string, but what's this this patient hasn't had trauma. What have they had? Cataract surgery. So believe it or not, there's an iol bearing here They've also had glaucoma surgery. There's a A tube in the anterior chamber, but you can see that the lens implant is here and you see this this proliferation. So Initially people were doing What we call intra capsular cataract surgeries meaning they would dissolve the zonus and yank the whole lens out And then give the patient thick coke bottom glass as they take expectacles But as intraocular lenses Were invented and people started going down to extra capsular surgeries So what you did was you would extrude the nucleus and then you'd suction out as much cortex as you could but you know without a Capsule rexis and feco you really couldn't get that all out. So there'd be lots of cortex left in the fornix But there'd be lots of lens epithelio cells left and as they grew We saw summering during very commonly In the early extra capsular surgeries with poster chamber iol. So this is circa 283 And so you see it was very common to see this summering dream proliferation And even in more modern surgery, this is now maybe 1990s Here's a three-piece iol in the capsular bag this patient had feco You could still see a peripheral summering dream these lens epithelio cells growing And this is what it looks like in cross-section It literally looks like a dumbbell or a dome it So if you take a dome it or cut it in half it looks like a dome And you've got for the first of the cortical material here in the fornix on both sides But in the center it's still clear All right, so lea a chance to redeem yourself. What's the thing is this? Try growing very good. So here's the anterior capsule. Look how thick that is Compared to the posterior capsules. You see it's twice as thick And they will almost fuse together at the edge of where the capsule raxus was and here's proliferative cortex In the fornix. So this sort of summering dream looks like pathologically All right back to Reese. What are we seeing here? um Looks like there's maybe Exfoliated material from the iris Large and then on the interior lens capsule. Okay, so this is a classic picture of exfoliation syndrome now People used to call this exfoliation of the lens capsule And it's not so much that that the lens capsule exfoliates It's that exfoliating material gets deposited on the lens capsule and the reason why you see this pattern is Where the pupil? So the pupil goes back and forth almost like a windshield wiper So as your pupil goes in and out it kind of sweeps that material more to the center more to the periphery And so when you look at a lens with exfoliation syndrome, you'll often have a clear zone here where the pupil normally goes back and forth So this is a classic picture of exfoliation syndrome Here you can see the so-called scalloped edge. Now, this is blatant Now oftentimes when you see these in Crandall's clinic, it's much more subtle than that You maybe you'll see a little ruffle at the edge of the pupil You see the pupil may be not dilating quite so well. So not quite as Dramatic as this, but here's a nice dramatic Scalloped edge that's set material on the lens capsule and then you can see on retro-lumination Again that nice scalloped edge. So this is blatant exfoliation syndrome Now um Ashley What is this showing? The iron phyton. So when you were kids you ever take a magnet and Put it on those scrapings of iron and they would stand up on there So this is what they call the iron phyton pattern. So when you look at Pathologically here's the lens capsule. Here's lens of the cells underneath and this is the anterior capsule Here you see the exfoliation on the anterior lens capsule. So What is the importance of exfoliation to a cataract surgeon? Okay, in what ways? Well, it's a triple threat. And so it does weaken the zonials, but it weakens the zonials by where it deposits And so this exploitative material can deposit anteriorly where the zonials insert the lens capsule So they make that insertion weak They deposit on the zonials themselves which makes them more brittle And then even posteriorly you forget this stuff can be deposited posterior on the ciliary body Where the zonials insert to the ciliary body so it weakens them in three different places So when your cataract surgeon not only does the pupil dilate poorly the capsule is more brittle too So it's a little bit more brittle, but the zonials are weaker. So you got to be really careful And the reason that that's important here in Utah, we see tons of exfoliation in Utah Chris, why is that? Yeah, so what what populations didn't have more exfoliation Cocculations, but there's a subgroup you finish Yeah, even just Scandinavian in general and even northern Germany And so where do a lot of you know people's families from Utah come from? The yasha area, you know speed Norway and Denmark yasha, you betcha And so where do you see a lot of exfoliation? It's interesting in the u.s You see it in minnesota and you see it in utah And so that's where Scandinavian populations have come and so you see very commonly Exfoliation you may not necessarily see this in like alabama, but you see this more frequently in People of northern european ancestry and so we see tons of exfoliation here in utah All right, boy, this is kind of subtle lene Here's our answers that we They ground a little bit of scrolling. Yeah, let's scroll over that capsule. What causes that? True exfoliation true exfoliation So we had to call it true exfoliation to differentiate from the pseudo exfoliation exfoliation sensor So this is truly where the lens capsule has split Now this was just a normal You know nine-year-old lady with no real history. What have we historically seen true exfoliation in? Yeah, people exposed to heat or infrared heat especially so glass blowers people used to work at steel Blast furnaces, you know nowadays it's mostly automated, but they used to be people who would open the things up and push stuff in there And this you know hot stuff would come out and a glass blowers especially And so you would get a very brittle anterior capsule and it would actually scroll And so this is uh sam masker. Give me this picture. This is actually intraoperative And you can see that little scroll Of that anterior capsule curled up. So it's interesting He was going to do a rexess And realize that that's not the entire anterior capsule Sam's a good observer. So it took a nice picture of this and He set me the capsule which was fun. We actually put this in you know how they do that Inet It's the academies little magazine that comes out every every month and they put interesting stuff on the cover So we got an inet cover with this and so this is the anterior capsule and here is There's lens up through cells and there is and it's literally In the capsule itself. So you get splitting of the capsule. So you truly get an exfoliation True exfoliation a true splitting of the capsule And there you can see there's lens up through your cells. There's the capsule. There's the split So true exfoliation Nico what do we see in here? So this is an external photograph of the You can't see iris So not only is that corneal pacified that cornea is pretty quality but there's almost like some Stuff here some whitish stuff in the anterior chamber if you look at it Now this is a nevada rancher I've been hurting like crazy for the last week because you know nevada rancher never come in right away Well, how long have you not been seeing a lot of that? I spent a while Any history of trauma? Well, I've been kicked by horses a lot, you know, and I was like more than one time So it's kind of got that, you know kicked in the horse, you know, um brain too. So You see this pressure's 50 50 Not well, yeah, it could be antigenic if the lens has been ruptured What else could it be? What if the lens capsules completely intact? Exactly. So there's an entity called fecal lytic glaucoma. It's really weird because lytic means splitting and so it's not Nothing's really split. But what happens is is in this fecal lytic glaucoma the lens liquefies So this can be from an old trauma, but it's just from a long-standing Intimescent liquefied lens And in fact it liquefies so much the proteins leak Through the intact lens caps on the anterior chamber and when they are I'm leaking into the anterior chamber. They induce an inflammatory cell reaction of these cells. What kind of cells are these? Exactly. So they're macrophages So again, if you put an english accent it sounds intelligent Macrophages and in fact the eyes are often enlarged. They often measure two centimeters And so you see these macrophages and look how big they are. I mean, that's a normal macrophage right there Look, they're just totally engorged and so they try to eat up this pigment And as a result these engorge macrophages not pigment protein So these engorge macrophages and the protein Clog up the trabecatal mesh work and so you get a severe glaucoma It's called fecal lytic glaucoma What do we see in right here? Tara, yeah, there's even optic capture here. You can start to see the eye well through that thin Um, iris it's really been thin. There's optic capture and there's all this white stuff in here This eye has high pressure. They've got chronic uveitis What's this condition called? Well, it could be if you had hythema it could be an ugg syndrome exactly you guys call coma hythema But this is an entity where you get inflammation and then secondary glaucoma from Reaction to leftover cortex And so the setting here usually is there's been a capsular bacteria They haven't cleaned up the cortex well. They try to put an implant in the sulcus They got out to capture that you get this it's called a phaco toxic uveitis So it's due to inflammation from leftover cortical material in there and so You see these non uncommonly capsular back here cortex left in there Difficult to control glaucoma difficult to control uveitis. You don't have to clean everything out to get rid of that Eye, that's right. What do we see in here? Exactly. In fact, not only are those crusadic erratic precipitates we abbreviate as kp, but look at the size of them They're they're kind of big and even greasy looking. What do they call these? Mud and fat kps. And so what's that indicative of? It's usually due to an inflammation and in fact, it's indicative of a granulomus inflammation So those big mud and fat kps big greasy fat kps are usually a sign of a granulomus type inflammation And this eye was eventually nucleated and here you can see an organized Hypopion And here's the pupil here and look at this. There's a ring of this inflammatory material surrounding And involving the lens capsule. So we call that cyclic meaning the space of the ciliary body So what other inflammatory entity can you get involving the lens? Exactly. So the proper word you need to remember now is facoantigenic uveitis meaning you get an autoimmune reaction To some of the proteins in the lens. They used to call it what Actually, it used to be called facoanaphylactic endothelitis. It was you know, again, it was one of those misnomers. It wasn't anaphylactic. There was no IgE involved in this but You didn't this was reported all the time in like the 1920s Believe it or not people were doing crude extra caps in the 1920s They were going in there carrying off the capsule and then kind of flushing out the lens And then of course as I said people went to intra caps for about 30 years Where you remove the whole lens and the lens capsule. So this disease disappeared Well in the early 80s people started doing extra caps again Where you would do a counter capsillotomy try to force out the nucleus suction up cortex And there was a resurgence of facoanaphylactic endothelitis because we were leaving behind lots and lots of cortex So you would trigger an immune reaction to it And the only reason I know all of this is there was a Swarmy Dark-haired guy with the mustache and Dave apples lab that wrote Up the first case that had been reported in like 30 years And so this is indeed that case we see this very rarely I think I've seen about two or three of these since then why because we now do capsillotomies with a brown Rexis was totally intact and we're better at sucking out the cortex So there's not a whole lot left over And so this is actually a reaction to the lens cortical material and it's You can also occur due to trauma And so again, this guy literally got kicked by a horse And It's a similar reaction of fatal toxic is actually due to the cortex itself causing inflammation It's not very momentous and it's not Antigenic induced, but it's the same idea Here's an eye this gentleman lost this eye Here's what's left of his lens. It's ruptured here and then you've got this big inflammatory cell reaction around it So dramatically ruptured lenses will give you this also Here's pathology here. I know it's hard to tell Where we're looking at here, but believe it or not. This is the lens capsule here. This is the Corning up here. That's what's left of iris solar body And you can see there's some lens cortex here There's capsular bag and you just see this inflammation and it's a zonal inflammation Remember when we talked about differentiating lumbar simplifications? And so you will often see Giant cells epithelial cells macrophages here Munching up that cortex and then around that you'll have a zone of some lymphocytes around it So this is the so-called fecal anaphylaxis or now they call it fecal antigenic UBI this is the proper word. There's a lens capsule And it's hard to see there's some giant cells here Some macrophages There's a giant cell Sitting on the lens capsule munching up that stuff And so this can occur In a dramatically ruptured lens, but also in a very badly done surgery Lots and lots and lots of cortex left over Now people have argued about what triggers this immune reaction and initially in the 1920s When they were describing this you do cataract surgery in one idea would get this You would do it in the other eye no matter how good you did the surgery They'd still get an inflammation So there's some kind of immune component to this that we don't understand But as we've gotten better at doing cataract surgery, I just not seeing this anymore Okay, and there's this almost looks like the Horseman that you have above the Grandinburg gait and the lander. This is actually getting So next week You guys get a reprieve because next week we're going to talk about eye allowance And there's really nothing about iowls in your bcsc books, so you get a reprieve But we're going to talk about history right now talk about anything you guys use now We're going to talk about the history of iowls because I think it's important to understand how we got where we are now And I'll often have you know residents and students will come up and say, oh, why don't you do this? You know, it's like, you know the light bulb lights up and you have this brain idea and you say well It was done 35 years ago. That didn't work And so it's kind of nice to get a little bit of a history. So next week history of iowls you get a week off Now we'll go back to glaucoma after that