 All right, so we're going back to Portugal. And this is Cintar. It's an area south of the capital. And this is where the old imperial castle was. And this was also, it's a hilly fortress area. And so there's a lot of Moorish castles that are there that you can wander through. But this is the old castle where the king of Portugal used to live. It's very interesting castle. It's a combination of Moorish influence and Dr. Zeus. So it's weird. It's got pastels. It's got these areas that you see in Moorish castles. But then it's got weird stuff. And it's a mishmash of different types of architectural patterns. But it is up on a hill. And this area has got about a half a dozen hills. And there's like palaces or winter homes or fortresses on all of the hills. So very interesting place. And you can see it is very much on a hillside. And so you have to go with these special buses or you can hike it if you'd like. But again, pastel colors, very weird pastel colors, domes, kind of almost minarets. Actually looking here. So very much a mishmash of conditions. And then again here, you've got kind of a coat of arms. But again, you've got this pattern. It almost looks like kind of the stuff that Gadi did in Barcelona. And he was a little bit later. He was like 100 years after this. But very much the same bizarre architecture. And again, your gargoyle protecting things. But yet you're arched Middle Eastern looking entryway. So very, very interesting mishmash of stuff. So if we're going to talk about IOLs, we have to go back to Mr. Ridley. Mr. Harold Ridley, a surgeon from London. And so this plaque is in St. Thomas' hospital. That's very interesting. Alan Crandall and I were there. This is many years ago. You see a little bit less gray hair. And Crandall looking a little younger. But St. Thomas' is right across the hospital from, right across, I'm sorry, the river from Parliament. So we went over, we said, where is the Ridley plaque? At which time the information people looked at us like we'd asked for where the moon landing was. I mean, they had no idea what we were talking about. So you didn't really need IDs in that era. So we just kind of wandered the hospital. And sure enough, in a lower hallway, away from everything, we found this plaque. The first intraocular lens for the treatment of cataract was implanted by Mr. Harold Ridley at St. Thomas' hospital. And so this is interesting. This plaque is there. We found it. We took our pictures. So Mr. Ridley, there's Mr. Ridley. He lived to be 94 before he finally passed away. But he was very interesting. He was a surgeon in the Royal Medical Corps during the Second World War. And during the Blitz in London, the British Spitfire pilots were trying to protect London from the Nazi bombers. And their cockpits would be hit by machine gun fire. The cockpits would shatter. And bits of the cockpit would go into the pilot's eyes. And what Ridley noticed is that these were inert. And just by fortuitous circumstance, it turned out that the British RAF cockpits were made of plexiglass, which is PMMA, polymethylmethacrylate. And so Ridley was smart enough to say, gee, this material is inert inside the eye. Maybe we should consider this for making materials that go inside the eye. Now, legend has it. I don't know. I didn't get this from the horse's mouth. But legend has it that he was doing surgery, showing a student in the late 1940s taking out a cataract. And the student asked an innocent question of, well, what are you going to put a lens back in? And no, of course not. We give people glasses. And so I'm not sure if that's what really spurned Ridley, but Ridley decided that he wanted to go ahead and to develop an intracutal lens that you could put in after doing cataract surgery. The second fortuitous thing is that Ridley was doing very crude extra caps at that time. Now, surgery at that time was with loops. And so you'd go into the eye with what's called a graphe knife. It was a sharp, long knife. You punctured the limbus on one side, go all the way across the eye, punctured the limbus on the other side, saw the cornea in half. Then you lift it up. And you go in there and you grab the lens caps and you just tear it off, kind of like you guys do your rexies at the VA. I don't even have anybody here who's ever done a rexisee, even though I'm talking about. And then you would manually squirt out the hard nucleus and flush out the cortex and then Ridley designed a lens to go into the posterior chamber where the normal crystalline lens was. And what Ridley's lens was is it was round, like our normal lens. It was very thick. It had a little rim around it. And if it were placed into the capsular bag and centered well and surrounded by the bag, this is an eye that had a Ridley lens for 30 years. And this was the eye with what we call the Miyake view. You cut an eye in half coronally. You look at it from the inside. So it's like you're sitting at the optic nerve looking out. Here is the capsular bag. Here's the pupil we're looking for behind. Here's the scleric processes. And here's this Ridley lens within the back 30 years later. Well, unfortunately, with those crude extra caps, the lens didn't end up in the bag. And in fact, would end up getting captured by the optic, would scrape on the iris, would get dislocated. And these lenses really did not do well afterward. They turned that to be kind of a disaster. And one of the reasons is this is the edge of the lens. And so they didn't have sophisticated polishing techniques. You can see that's very rough, very irregular. So it's a big, rough, irregular lens. And so lots of problems with that. So I just want to give you a little bit of a background of issue with Mr. Ridley. So Mr. Ridley put these lenses in. And so he came to the United States, crossed the pond, went to the AAO, Academy of Ophthalmology and Otolaryngology meeting in Chicago, and presented this data on his intraocular lenses, at which time the president of the American Academy stood up and said, if anybody in the United States puts these disastrous lens in a patient eye, I will personally testify at the malpractice suit. So this was the response of organized ophthalmology in the United States. And I must add that response continued for 20 years. So the organized ophthalmology, especially the AAO, was vehemently opposed to intraocular lenses and FACO, I might add. So did their best to try to retard progress for at least two decades, if not three. So poor Mr. Ridley went back to the continent, continued doing his work there. One of his students, Peter Choice, said, well, you know, these extra caps are pretty crude. Most people are doing what we call intracaps. You're removing the entire lens with the capsular bag and everything, and so you don't have anything to support an IOL. So why don't we put an IOL in the anterior chamber? And so Choice worked on many different lenses in the anterior chamber. In his first one, this was the Choice Mark I. And so I don't know why you call it Mark, but it sounds kind of space age and sounds kind of cool. I don't know if you remember the shaving blades, the Mach 5 shaving blade. And so it sounded very, very good. And so this was his first one, and it's a solid PMMA again. This is very solid. And so Mr. Choice played around with these for a while, and eventually came out, this was the Mach 8. So this was his eighth one. So this was the one that really attained widespread use. And this was the Mach 9. He cut down the bulk a little bit. But the idea is it's a one piece PMMA lens. And so the problem with these lenses is that you have to size them perfectly. And the sizing then was very crude. You take a caliper, you'd measure the limbus, the so-called white to white, and you'd add one. And you'd say, OK, the anterior chamber is 11.5 millimeters in diameter. Therefore you put a lens in plan of this. And so the standing joke at that time was that these lenses come in two sizes, too big and too small. And so what happens is when these lenses are too big, you get them to scrape against the iris. You'll get little hythomas that are going along here. And this is an eye that is viewed now anteriorly. We've removed the cornea because it was totally clouded. But you see the basic, the cat's eye pupil. And so you can see when these are too big, you get a definite overlaying of the pupil. This particular lens happens to have one of the foot plates stuck in a peripheral aridectomy. Because you do a peripheral aridectomy to prevent pupil area blocks of lots of problems with these. And you can see if they were too big, the other thing is when you're putting them in, you tuck the iris. So this is the anterior chamber angle. Here's the cornea. Here's the trabecular mesh work. Here's the iris with the IOL haptic tucking that behind there. Now I want you to note something. Look at all the pigment in the trabecular mesh work. You guys are going to know all about this next week. About Coleman next week. So you ended up with pigment dispersion. You ended up with chronic inflammation. And so lots of problems. When these were too small, they would propel it. And so they could literally turn around inside the anterior chamber of the eye. So some issues. From scraping, literally from scraping on the iris. Now the other problem with these is they were poorly fixed. Poorly finished in addition to being poorly fixed. And so the problem is American companies started to try to rip off these lenses in the late 70s, early 80s. And this was an early American rip off. This is the edge of an IOL, believe it or not. So I wish I still had this picture one. I was a fellow with Dave Apple. We took a Coke bottle and broke it. And EDM of the edge. And the edge was no worse than that. So you can imagine what this is going to do inside the eye. I had the displeasure of being a young fellow presenting a paper on these lenses, saying how bad they were, at which point Mr. Choice was the moderator and made it very clear that these were an unlicensed rip off, not his normal lenses. So he was very perturbed that we were presenting this as a choice lens. So it was a rip off. But this lens caused so much inflammation that the term UGG was coined. And you guys may hear of that now. UVitis glaucoma hyphema. So they would cause chronic UVitis from scraping on the iris. You would get hyphemas from rubbing on the vessels and you'd get glaucoma from the pigment dispersion. So UGG syndrome really was named with these choice rip off lenses. So American companies started getting into this finally now. This, we're talking now early 80s. And so this is a long time from 1949, 1950. But American companies started to say, okay, these IOLs are gonna be something we better start making. So they started making what we call open loop IOLs. And by open it means that the optic is still PMMA, polymethylmethacrylate, the loops are made of polypropylene, proline. You know, proline's a main plastic that make Gore-Tex out of it, all kinds of other things. So proline is what these were made of. And people started designing these. And so this was the era where guys were drawing these on napkins and IOL companies were popping up left and right. And so this was the AESAR 911 Z-Lens. So AESAR was an ophthalmologist down in New Orleans designed this and it was closed loop. And the idea was, is that you didn't have to size these so well. They wouldn't cause so many problems. And indeed, these lenses looked pretty good for about a year and a half to two years before they started causing problems. And so companies jumped on the bandwagon right away. This was another lens. They squared it off a little bit. Same thing, PMMA haptics. I'm sorry, PMMA optic, proline haptics. And you can see various different kinds. But they're all the same idea. They're all closed loop lenses. This was an interesting one. This was called the stable flex. And it had literally eight of these little loops all over the place. And this was one, unfortunately, there was someone in town here who put a whole bunch of these in. And even into like the 10 years ago, Alan Crandall and Andy Olson were removing these. These were a bugger to remove because these little haptics would get sneaked into the angle. And so heck of a time getting these out. But this was when, you know, again, there was a new lens coming out every week. Now what happens with these lenses? It turns out that these closed loop lenses, if you put pressure on them, if you squeeze them, the closed loops would not take that squeezing and so they'd vault the optic forward. So if people rub their eyes or you can just squeeze their eyes, that optic was bouncing up and down on the cornea. So what would happen is you would get corneal edema, what we called pseudophagic bolus carotopathy. And there was a rash of them. In fact, from 1984 to 1989, the number one reason for doing a corneal transplant worldwide was pseudophagic bolus carotopathy because of these lenses. And so you'd get edema, but the second thing that would happen is, so here's the chronic edema. You're gonna get this bolus carotopathy. This is a cornea, believe it or not, cut in half, totally opaque. These loops would go into the angle and the angle that you'd get, fibrotic bands all the way across them. This is a gonioscopic view into the angle. And you would get that. And so what you would do is you'd get chronic UGG syndrome. Also you'd get chronic glaucoma from the angle closing off. And so these closed loop lenses would look good for a while, but then they would look bad. And so you don't see these anymore. Here's one of the loops digging into the ang, digging into the Irish roots. So this is cornea up here, iris pigment thin. Look at that loop. That loop was dug in almost to the major iris circle. So these would really cause significant issues. And here you can see again an eye, the cornea has been removed. And this is one of these stable flex lenses. Totally synecd into the angle. And you've had these crudier edectomies that were made when we put them in. So these caused real problems. This was an interesting lens. It's called the Dubrov lens. We just saw one of these in the lab being the last month, which I was really surprised. You can still see these once in a while. This had three loops like propellers. And it had three loops. And the problem is, is it was the worst of all worlds in that these loops would go into the angle and totally close off the angles. If you can imagine three broad loops, you would close off half your angle. So these caused lots and lots of glaucoma. And here again is a person with chronic UG syndrome plus corneal edema. So real issues with these implants. And here, remember from the corneal lecture, here's a balei. What the heck is this? Anybody? To retina. What's going on with that retina? Edema. Cystoid macular edema. So you could get with chronic UVI, they should get chronic cystoid macular edema. So they call that UG plus. So it's UG plus cystoid macular edema. Okay, so with that, Charlie Kelman, the guy who invented the FAKO machine, by the way, said, well, you know what? These closed loop lenses are causing real problems. The solid one-piece lens is causing problems. Why don't we make an open loop lens? And so he played with an all PMMA lens that was shaped like a seven. And so in fact, we used to call this the pregnant seven because it looks like a seven that's pregnant. And so the pregnant seven, turned out these were pretty unyieldy. And so he thinned down the haptics real rapidly, made them a little bit more flexible and called this the tripod lens or the omni-fit lens. And so Kelman would argue at that time that three was better than four. So you notice there's not four little foot plates, there's three. And the argument was that if you're in a bar, you've got a three-legged bar stool on an uneven floor. That's more stable. That was his argument. And so people barely even use these and Kelman immediately figured out, you know, three isn't better than four. So again, like a month later, he made his present lens. Now, does that look familiar? Okay, this lens came out in like 1984. So here we are 34 years later, this is still our anterior chamber lens. And so you can see it's one-piece PMMA, but it's open looped. And so the idea is if you squeeze that, you know, rub the eye, squeeze the eye, instead of vaulting that optic up and down, the haptics would take the squeezing. So almost like the leaf springs on a big truck. You see them all the time, right? When you go hunting, you know, you got them big leaf springs on that truck. And so the leaf springs take up the slack and so these don't vault. And so this is the lens we use to this day if you use an anterior chamber lens. So one-piece PMMA, open loop, four-point fixation. And the other thing is you have these haptics instead of curving out where they block the angle they curve in. And so there's only a couple little points where this intersects the angle. So these are well, well-tolerated. So this is kind of the ultimate anterior chamber lens. So here's the old Apple Core. I don't know who the guy with the mustache is, but we didn't have a big enough office so we would take the corner of the old cafeteria and this day of Apple would dictate stuff when you had fellows and students and we'd lay, you know, EM papers out here and write chapters and all. So this is how it was done. And this is the predecessor of the ocular surgery news which you still get today. So we held that up because we were on the cover of that when they took this picture. So this is the Apple Core. Well, at the same time that all this evolution with anterior chamber lenses was going on, people in Europe were looking at iris fixated lenses. So they were saying, hey, we can't put a lens in the posterior chamber. There's no support anterior chamber IOLs are causing corneal edema. Why don't we clip an IOL to the iris? So this was the original Bincorst. Bincorst is an ophthalmologist in, I never forget, because Bincorst had worse. One was in Belgium, one was in Netherlands and in any event, one of those two countries in Europe. And so the idea is, is that two of those loops go in front of the iris to go behind it and it clips it to the iris. This was the worst lens, and we used to joke about it because this truly was the worst lens because what he tried to do is he put a little peg on here that would clip it to the iris and hold it on hand. And then he put two holes in here so you could suture it to the iris if you had to. And so these would cause iris atrophy, they would cause Ugg syndrome, they would cause glaucoma, they would cause all kinds of problems. The other problem is these haptics were made out of proline. If you put proline next to uveal tissue, proline degrades. So this was the so-called mud flap degradation. And again, you think you never see these last month in our lab, we saw proline haptic with degradation, so it's still to this day, you can see that. So this was the impetus to get away from proline with the haptic materials. So when proline wasn't working well, they said, why don't we make a loop out of titanium? Indestructible inert, very, very heavy. And so it didn't work, it didn't work. So this had titanium, if you think about it now, imagine someone goes in an MRI and they flip the MRI scan and that goes, yeah, probably not a good idea. So those lasted, not even a week, those lasted about two days, you know, with the titanium haptics. No, no, these are all going into humans, yeah. These are all going into humans. So here is a worst lens, beyond worst, and here is the positioning hole here and there's a suture in here that's broken. A little suture here that used to go from here to here that's broken. And there's a tab here, trying to hold it on and look at the irises all chewed up and chronic edema and chronic ugg syndrome. So these really didn't work that well. This was a haptic that was behind the iris and this is all iris and lens tissue attached to it. So these could cause some real problems and again they looked good initially and then 18 months, two years later they'd start having problems. So here's the idea, you would clip it to the iris, loops in front, loops behind. Now, what happens if you dilate the eye widely to look at the perforate now? Sometimes these would fall into the vitreous, so. And people would have to turn people over and put them face down in the operating room and operate underneath them so that that lens would come forward. So it was very interesting. So my favorite is the ads were coming out. So there's a company called Copeland that made an IOL that looked like a propeller. Two loops anteriorly, two loops posteriorly and here's the Copeland elves wishing you married Christmas and so they'd send these ads out, little elves making the IOLs. And so Copeland was an interesting one. It was shaped like a propeller. Two loops in front, two loops in back and you would get a square pupil. So here's the loops in front, the loops would be behind here. Look at the pigment on the surface of the implant. Look at the iris stuck to it. So again, chronic UG syndrome, difficulty dilating, all kinds of problems. And here is a Copeland lens looking through the cornea. That's the view you got with the severe corneal edema these would cause. So my favorite is at this point, a lot of companies were advertising, this lens has proven safe and effective, discontinued. So it was interesting, it was safe and effective but they still discontinued it anyway. All right, so finally, we get to the more modern era. And now remember, Ridley was doing a crude extra caps. It didn't work well. Most people were doing intra caps. You'd remove the whole lens, capsule bag, the whole thing. But in the late 70s, early 80s, people started to use microscopes when you did your surgery. They didn't do loops. And they started to think, gee, maybe we could try to preserve that capsule bag, started going back to doing extra caps of surgery. So Steve Shearing, who was an ophthalmologist in Las Vegas, said, well, if we're gonna put in a posterior chamber lens, why don't we put a little haptic like a J on there to support it in the back? So this was the first posterior chamber lens. So people looked at that and they said, wow, that's a great idea. But that J was very stiff and came straight out. It tend to overlives the capsule. So immediately people started looking at different ways to do this. So a guy named Simco put a broad sea loop on this implant. And then Bob Sinski put a modified J loop. He moved that loop over and he made it a little bit less severe. And so this was the kind of standard lens that we used for a decade. And you guys will use a Sinski hook in surgery. So same guy. Sinski just passed away a year ago, but this was our go-to lens in the mid-80s. So this was a Sinski lens, modified J loop. And the idea is, is you try to put them in the capsule or bag. If you couldn't put them in the bag, you put them in the ciliary sulcus. Again, we still do that if our bag is not intact. But the bag is better than the sulcus. You still get scraping of the iris. You still get other problems. So put it in the bag if you can rather than in the sulcus. Here's what happens if you put an IOL in the sulcus. Look at where the haptics have disrupted the posterior iris pigment. And then the optic can scrape on there. So you can get some pigment dispersion. And here is a haptic that was in the ciliary sulcus. You've got a Vicksum ring ring here. Iris, cornea, peripheral anterior, synechia, haptic all the way again into the ciliary body there. So you want to put them in the bag, not in the sulcus. And finally, here is a Miyake view of a modified J loop IOL in the bag. Quiet eye, tolerated for 30 years, doing well. And that's where we want to put them. So here you can see the haptic surrounded by the capsular bag, away from the pigment, not digging into the iris, not causing disruption. And so we finally started putting implants within the capsular bag. So as implants got better, as we started putting them into the capsular bag, the companies got better at polishing them. And so this was now a lens that's what we call tumble polish. So remember I showed you the one look like a broken Coke bottle. Tumble polishing is interesting. And again, they still use it to this day. You put the IOL in a cylinder with a bunch of beads and some polishing material and you tumble it for like seven days. And it polishes it. So when you were kids, did you ever have a rock polisher? You know, you put the rocks in there and you grind it for seven days. You have to put it in the garage because it makes so much noise. But same idea when you polish IOLs, look at that finish on that. So when you do scanning again now of IOLs in this area, they're gorgeously polished. So you don't get any problems from that. Okay, so I just wanted to kind of show you what the previous surgeries used to look like because you guys never see these now. But this was an intra cap. So you would make an incision from stem to stern. Now, because the eye is wide open, you really worry about it. So you put some special stay sutures in here. Then you lift up the cornea. You'd go in there with a cryoprobe. You'd stick the cryoprobe to the capsular bag. You'd put in what's called alpha chymotrypsin to dissolve the zonules and you would pop the whole lens out. Now, sometimes the visions would come out, sometimes not. But this would leave a nice clear view. These guys, once you refract them would be like 2015, but you can imagine there's a high incidence of systolic macular edema. You had some real issues with the intra caps. So we started going to do extra caps. And the idea is, is now you do a capsulotomy, you'd go in there, you dislocate the nucleus, you put a lens loop behind it, you pull it out. And then you put these two little stay sutures in there. You time down temporarily and then you'd go in there with a manual IA and you'd suck out the cortex and you'd put it in your IOL. So these are extra caps. Now, those of you who are going on some third world trips were now doing small incision extra caps. The difference is, instead of making this incision that you have to put sutures in the smiles, we now make a frown incision way back on the sclera that self seals. And so we can do extra caps in the third world without stitches. So hopefully you guys will get a chance to learn that on your international travels. And last but not least, finally, Charlie Kellman invented the FACO, which allows us to take out an IOL through a small opening so that we can put in an implant that we don't have to expand the incision. So we can make a smaller self sealing incision. Kellman was a smart guy. He was at his dentist. And the hygienist was using an ultrasound to take off the plaque. And he said, what the heck is that? And she said, well, it's an ultrasound. It grinds the plaque. And so he was trying to come up with ideas on how to take out a cataract. So he went to the company that was at that time called Cavatron and they developed the first ultrasound to grind up the cataracts. Now, the first time he did a FACO, it took like two hours to do and tremendous amounts of energy. He was doing out on an I that was functionally blind. But still it again was the basis of the FACO we use today. Incisions have also changed. And so we used to make scleral, corneal incisions. You make an incision through the sclera. You would tunnel forward into the cornea and then you enter the cornea. Howard Fine said, well, wait a minute now. You know, why do we need to go back in the sclera? Why do we need to even disturb that? Why don't we make our incision in clear cornea? And again, that's what we do today. So here's a clear corneal incision. You don't use stitches on it. You don't disturb the sclera. You don't worry about bleeding. So clear corneal incision. Now, the final step in all of this, sir. So I was reading in the BCSC quarter cataract book and I talked about, you know, the rates of endothemitis, different things you do, like get your camera on. One thing I talked about was having lower rates of endothemitis of scleral tonsils. Yeah, 12 years ago. And so again, the BCSC is put together by the Academy. Everything the Academy puts out is a decade behind the times when it comes to cataracts and IOLs. And so when people first switch from scleral incisions to clear corneal incisions, there was a bump up in endothemitis. As people got better at making clear corneal incisions that didn't leak, that bump immediately went down. And that was 10 years ago. And so, but again, it's in the BCSC books. If it's in the book, you have to put that on boards even though it's not true. So there is no increase in endothemitis right now with clear corneal incisions, but there was initially. Okay, so people said, wait a minute. Now we've got this fake O, we can make a three millimeter incision. Why would we expand it to six to put in an IOL? And so this was the impetus toward making a foldable IOL. So it's interesting how cataract removal technology and IOL technology have gone kind of footstep with each other. So you'd get an advance in how you do cataracts or then you'd get an advance of IOLs and they'd move up. And so the smaller incision really was the impetus to foldable ends. And this was the first foldable IOL. It was a plate silicone and guy named Tom Mazako invented it. So they call this the Mazako taco. Looked like a rolled up taco. This was the first foldable IOL. So this is what it looked like was a plate silicone lens would go into the capsular bag nicely well. People looked at that and said, well that's good and fine but why would we get away from our standard three piece lenses which work well? So that led to the development of a three piece silicone lens. So the idea is you fold it with a folder put it in the eye unfolded in the bag and it would work well. They eventually came up with injectors that did this. And people looked at silicone and said, well okay silicone is a relatively low refractive index. So these lenses had to be pretty thick. You saw how thick that silicone lens was yesterday because in order to bend the light they'd be pretty thick and they weren't terribly compatible. And so they looked at different materials. This is a hydrophilic acrylic what was called hydrogel. And then they started looking at different ways of doing hydrogels. This is in a rabbit, very compatible material. And lastly, they started looking at hydrophobic acrylics. And this is the acrylic material we use to this day. So this was when Alcon first came out it was a three piece hydrophobic acrylic. And now we've got one piece with half the hydrophobic acrylic. So I'm not talking about modern Iowals. Lilian will talk to you guys about that. And why don't you do this as a history? Because you're still gonna see these. You know you saw in the lab the other day we still see these lenses 30 years down the road. You're gonna be at the VA, you're gonna see one of these and you're gonna go what the heck is that? But I'm hoping that by giving you guys a little bit about the history of these lenses you'll know what the issues were at the time but also if you see these in clinic what the issues that you have to look for now. So that was just to call that a trip down memory lane. And again this is like going to Whoville here. So going back to the main cast of the very interesting English mash of different architectural styles. But again up on a hill beautiful views out onto the ocean from here. So next week we can get back to real pathology. Read your glaucoma and we're gonna talk a lot about glaucoma next week, okay? Questions? All right, very good.