 to relax because you didn't have to read anything but it still doesn't mean you can't be pimped especially you guys know this you guys can't be pimped so today we're going to talk about the IOLs from alpha to omega and which alphabet does that come from from the Greek of course all right so we're going to go back to Barcelona since I think I'm going to run out of Barcelona pictures before I run out of lectures this year I may make you look at puppy pictures but I don't know how to decide that it's a captive audience so I have to decide so this is back to the cathedral again that they're redoing in Barcelona the old cathedral and it is it's pretty amazing they've kind of redone the the inside and I mean it's it's the ultimate high-resonance cathedral and so just incredibly elaborate icons and statues and just very vibrant very exciting so yeah seriously this would like bring Spain's unemployment at below 20% here just use this on a public's work project but I mean it's just the detail on some of these are fantastic you get in there and you look at it and you go wow I mean through the years the colors have faded and they're working to try to kind of restore some of the colors but it's a difficult task but you could imagine these in there in their glory you see the robes on the king there you know we're rad and so it's really pretty amazing look at it and it's that way through the entire one there's you know it's a typical Catholic cathedral and there's little you know alcoves all the way around the whole thing that each one of them as elaborate as the one before and so I just picked a few of them and took pictures and they're just they're just fantastic the problem is is this is just an old dark one and they're trying to as I said to revise it but it's still kind of dark and you know grungy inside that they're doing their best although this probably all shut down five years ago so and then this is a miniature gold kind of we're supposed to take pictures of this I felt like you know James Bond and I had my camera on in my hand and there's these guards and they're going like so if you turn on your camera here that you know or your you know your phone they're all over because there's no pictures allowed but so I clandestinely you know some pictures now it's actually the reason why they're all kind of dark there's no flash on any of these so that's why they're dark but very pretty and I forgot to erase that one that's the beefier in London last year all right so we can't start with talking about I well without talking about Mr. Ridley and so Mr. Ridley was in London at St. Thomas's Hospital he was working on IOLs it this is the plaque at St. Thomas's so Alan and I found this when we went to London in 2006 and and it was very funny because we went to St. Thomas's and we asked him at the desk we said where is the Ridley plaque and they would they went who yes I mean they didn't know so we kind of wandered the halls of St. Thomas's and eventually found it this was in a kind of a back hallway and you know St. Thomas's is a big hospital it's literally right across the river from Parliament I mean it's right next to the big Ferris wheel the big eye and so it's right downtown and so we did find the plaque with where Mr. Ridley had done had done the first IOL and so this is Mr. Ridley and his little fishing his fishing hooks he retired to a small village in the countryside in England but basically when you go back in history Mr. Ridley was a surgeon in the British Army during World War II and it's interesting in that he was initially in the Pacific Theater and has contributions to the field of of like tropical medicine you know how they affect the eyes and all so he wasn't just IOLs but then he ended up in London during the Blitz and what was happening is these British fighter pilots were going up trying to shoot down the Nazi bombers and they would get I mean a machine gun fire in their cockpits and the cockpit would shatter and then some of the cockpit material would go into the pilot's eyes well this material was actually made of plexiglass which is PMMA and so very fortuitous thing and so Mr. Ridley found that it didn't cause any inflammation was very inert inside the eye and you know at this time people were doing either crude extra caps or intra capsular surgery and then patients were getting a fake expectables and so what happened was is that a rumor has it I don't know I've never talked to Mr. Ridley to see if this was true because he's passed away since but that a student said well you're taking out the lens why don't you put in another one and so that just may be legend but in any event he started figuring out you know a fake is not a great way of treating people and that he also will tell you the story when he was first training they were still doing intra caps without IOLs and he's very proud of himself he did the surgery at UCLA and you know the patient ended up 2015 you know with like a plus 10 spectacle and he was patting himself on the back and the patient basically said can you put my cataract back and so a fake expectables if you can imagine you get a 25% magnification you get this huge prismatic effect in the periphery so you get a large ring scatoma so these poor patients would have what they call the jack-in-the-box effect where you know you'd be attempting to drive and you'd look and there'd be nobody there and then you'd go to turn and suddenly a car would appear you know out of nowhere out of like a jack-in-the-box bouncing out and so and without your spectacles you're functionally blind and you can't see anything so you know he really worked with a company called Rainer which is still you know one of the big IOL manufacturers in England and Rainer put together an implant for him and he thought he was doing these crude extra extra caps and he said you know since the we're taking out the cataract from inside the capsule bag why don't put an implant right back where it was he had a great idea the problem is this is 1950 mind you and so Rainer designing the lens the first one turned out to be way off they didn't have the optics worked out but they worked out the optics by the second one and this is a page this is patients where they would do they didn't have capsillotomies then and so basically they would go in with the force that grab the capsule and tear it off and then they would I'll have to show you the video I've got the you know Ridley's original video and and then they would take a like a muscle hook and just push it against the cornea and lock that lens nucleus out and just push it out you know big 13 millimeter wound and then they would just irrigate a little bit and then they just crammed that implant back in and believe it or not when these actually made it back inside the bag they did okay but when they were you know who knows they'd be in the sulcus or partially in the bag then they would cause some real problems and so you can see this is what it looks like on on EM and it was a disc lens to fill the capsule bag so interesting idea and this is an eye that was donated to the lab many years ago that had been this is a Ridley lens that had been in the eye for about 40 years and you can see it was actually within the capsular bag and was tolerated quite well over that period of time now unfortunately with with mr. Ridley he was doing this work in England he had to do it in secret because you know the same the hierarchy said this is radical idea this is very crazy you shouldn't you shouldn't do this and so mr. Ridley came over to the American Academy of Ophthalmology and Otolaryngology meeting in Chicago and proudly presented this data at which time the president of the Academy stood up and said if anyone in the United States puts one of these dangerous devices in the eye I will personally volunteer to testify at the Mount practice trial for the patient and so basically no IOL research was done in the United States for 20 years so I mean the hierarchy in the United States shut this down they said these are dangerous these are terrible and so really nothing was done in the US at any time so this is one of the problems this is the edge of the implant you can see it's you know these were hand polished you know people using a round makeup mirror you know and hand polishing these guys you can imagine what that's going to do to the plus your surface of the iris if it's not within the capsule bag so people at that time were really not doing extra caps in fact right about that time people started to do more and more intra caps where you remove the entire lens and its caps or bag and so there is no caps or support so other surgeons in Europe said hey why don't we look at putting an implant in the anterior chamber because you know we've got the support there and so we'll put an implant and of course they're all made of PMMA all non-foldable and so one of Mr. Ridley's residents Mr. Choice Peter Choice actually came up with some anterior chain rivals and this was his first one it was and he ended up with nine different iterations so this was the Mach 1 you know because that sounds cool like you know Jets go Mach 1 and so this was the Mach 1 idea and then he went through various different iterations this was the Mach 8 and so this was the one that was most widely used and so he went ahead and he worked with Rainier again to put these together and in Europe maybe in America not not least early on was there any research being done on these but the problem with these lenses is they they're PMMA so they're non-foldable they're one piece they had to be fit perfectly and the joke when I was a fellow 30 years ago was these came in two sizes too big and too small so you would do a white to white measurement with a caliper if you can imagine how crude that is then you cram one of these guys in there and so if they were too big you'd get a cat's eye oval pupil and chronic uveitis if they were too small they were propeller in the anterior chamber and so it's very difficult to get these to get these fit well this was his last design the Mach 9 and so just a little bit thinner now one of the problems with lenses like this is they would scrape the iris you'd get the bleeding in there hyphaema you'd get chronic uveitis you get glaucoma so that these syndrome was called UGG uveitis glaucoma hyphaema syndrome we still talk about it now and the problem is is the UGG syndrome was caused by ripoffs of choices lenses you know copies that were made not of his design not of his design and not with his quality control and so when we when we look at some of these this is what they would look like this is a cadaver eye with the cornea removed it you can see the cat's eye pupil on this now mr. choice I was a Dave Apple fellow and so I was sitting on a panel at Ascrus with mr. choice on the panel and I gave a paper showing these terrible results and he got very ticked off because he made a point that these are not my lenses these are unlicensed ripoff lenses and so he was very upset about that and of course I was a pre-residency fellow so like so I made it clear we never said choice we would say choice like or choice style or choice copies and so this you can see what would happen when these lenses were too big and so let's see where we're gonna start here Ah Eileen yeah exactly you could see that's been tucked and so what happens is is that foot plate of the PMMA lenses caught the purple irises pushed it right behind the ciliary body so it's really tucked back there since it's thin it's at your feet you can imagine a syndrome from this you can cause a old cat's eye pupil and so these were real problems now these were being put in before viscoelastic so people were putting in an air bubble in the anterior chamber and just cramming these in so very difficult to put in and this was one of those ripoffs so this is the edge of that polished IOL now just for fun I wish I still had the picture showing as a fellow we took a coca-cola ball and broke it and then EM the edge and the edge was was like didn't even look this bad so you could imagine what this PMMA with that type of a finish would do inside the eye and so they really did cause a lot of problems with these well as time went on and eventually you know different companies started to get involved finally finally now in the early 80s people in the United States you know started to get permission to do these different IOLs and to come up with different designs and so this was the time when there was about 20 startup companies coming up all popping up every day and each doctor would sit down with one of the companies and come up with their designs and they name it after them so this was dr. Azar and dr. Azar was a real interesting guy from I think he was from New Orleans or you know mid lower Midwest somewhere but in any event he's a bodybuilder and so he has this you know huge physique and would wear like skin tight sweaters when he gave talks to show off his muscles and he had a fake tan all the time he's an interesting guy I don't even know if he's still alive but everybody would name them after them so because the choice lens was solid you know the problem was is there's no give in that so you have to fit it exactly so what they started doing is saying well why don't we do a looped IOL and so these were the closed loop IOLs and you can see on the optics still made out of PMMA but now the haptics were made out of proline or polypropylene which is kind of like a variation of almost like a Gore-Tex locked material but polypropylene is very flexible material and so these were closed with lenses are very easy to put in they wouldn't catch the iris you know as you went in they wouldn't give you a cat's eye very very easy to put in and then immediately a whole bunch of copies started up so Lyske came up with his lens he just squared them off and there was another one a solid lens that was like this there was even one Hesburgh in Michigan came up with this lens and you can see now this has actually four closed loops with eight little things on there so these are the ones there was a surgeon Salt Lake that was putting these in in the early 80s and these are the worst lens I've ever seen to remove and again Randy and Alan they'd all get referred up here when they would go bad and so this would form little cocoon like synechia over eight individual loops and so you'd have to go in there and cut them like eight different times when you're trying to take these out these were just a nightmare to remove but this is when all that this was all exploding this was all within about a year all these different IOLs came out and the problem is is that with these closed loop IOLs and this one effectively behave like a closed-loop lens if the patient rubbed their eye the whole optic would vault and so if you imagine if you've got like like you know these closed haptics and you squeeze on them they wouldn't the haptic wouldn't take up the squeeze the optic would vault so it would either bounce forward and bang off the cornea or those closed loops would dig into the IOLs now the problem is is these things look great for the first year or two so these look really good and so when I was a fellow there was a surgeon in town who founded the Eye Institute who was advertising all over the TV that was the first main advertising is putting in these miracle lenses and he had zero complications and he would give a lecture I'm having no complications these are the greatest thing and as he's saying that I have you know 12 corneas in jars on my desk with these IOLs in them you know that we had to remove well of course if someone has a complication they don't go back to the original doctor they go to somebody else and so this kept the cornea surgeons at Moran busy the azar lens for at least a decade you know fixing corneas from those and so this is one of the lenses this was the Hesper lens if you can see that's actually well focused and so the reason why you don't see while they're cornea is edematous so you got corneal edema the eye is red and in flames you've got chronic hug syndrome and again these are real buggers to remove all right so cost us what is this we're looking at believe it or not this is one of those corneas that was on the jar in my lab this was half of a corneal button that's how thick they would get so this is a totally edematous corneal button so you get corneal edema from these IOLs and then the other thing is this is the Lyske lens look at this is a cadaver I we've removed the cornea we're looking in as if we have a goniomere on here look at the Senekiel tunnel in the periphery and so they would form these Senekiel around these round loops and this would cause them to just fix it in this you'd get glaucoma from this but these are a bugger to remove so when you would explain these you would actually have to cut the haptics and just leave them in the angle just cut them and then take them out because you would if you went to pull that you'd get a narrow dialysis so it would be these are just just terrible to remove and this is what one of these loops looks like this is again that the Irish root and here's that IOL I mean it would dig in almost to the ciliary body in fact the first IOL that was ever seen here when I was a student IOL number one we're up to what are we up to now six seven thousand IOL number one was a looped enter chamber IOL and it dug all the way through the root of the iris to the major iris circle and then blocked it off and the patient had ischemia and lost the eye so that was IOL number one so it's interesting and so these could cause some real problems this is one of those other lenses with the eight loops on it and you can imagine when you look at the big purple iridectomies these would rotate into the iridectomies and so these would just form a total synecial tunnels of these will just awful to remove these would have you'd have to cut them in eight different places to remove these so they were very tough so there was a guy named Dubrov in Washington DC who said well if the closed-loop lenses are difficult you know they're causing vaulting and all why don't we put an open loop on them so what he did is he put three C-shaped loops on his IOL like propeller blades now if you can imagine these broad C-shaped loops you would actually get synechia that would close off about 270 degrees of the angle and get severe glaucoma second thing is this was a fly-by-night company that very much did not polish these well didn't have good quality control so they would these patients would get chronic ang syndrome again there was a surgeon in town who insisted on putting these in even until the late 80s and so he kept putting these in and we kept putting these out and the surgeon has since passed away but it's Dr. Crandall said he was the leading cause of preventable blindness in Utah and he was still doing intercaps in the late 80s when people were starting even to fake a little on entry caps they do an intricate me put these guys in and so again these kept our anterior segment surgeons busy for a decade just was the Dubrov lands and you can see what these would look like again chronic edema red inflamed eye lots of inflammation and Nick what are we looking at here yeah so you see a what do we call this a bullseye see both care top of these so they would cause both care top of the actually looking at here why that would I be showing you this picture oh boy chances to pimp here see you guys thought you were free what part of the retina are we in how the heck can I tell that by looking at this picture I'm sorry I got a Star Wars printer I mean a Star Wars pointer for for Christmas and I forgot it's up in my briefcase so if you look at the top layer the ganglion selling you see instead of being one cell layer thick it's multiple cell layers thick so we know we are in the macula and then if you're looking and we're going to know these two lectures from now you're going to know these layers cold you can see that there's some exudate in the outer plexiform layer of the macula and so-called Henry Flare so this is systroid macular edema and so with chronic ux syndrome chronic inflammation you can get Cornelia Dima bullseye care top that you can also get chronic CME systroid macular edema all right so Charles Kelman who was the inventor of the fake home machine Kelman said well you know if these closed lube IOLs are causing these problems why don't we get an open lube IOL and so this was his first attempt at it we used to call this the pregnant seven so if you look at them it's like a seven that's pregnant you know so the pregnant seven the problem with this is it's a stiff again PMMA and so you put these in it was very awkward to put in and so Kelman being a smart guy you know this was out on the market for like a day before Kelman figured out it's not going to work so he thinned out the haptics again still want these PMMA but he left the tripod design in there now I was interesting because Kelman would go around to lectures and give lectures and he said a tripod with three point fixation is better than four point fixation because if you have a bar stool on an uneven floor and it has three legs it it stays fine if it has four legs it wobbles that was his argument and so again this lasted for maybe a week and then people realize that this still wasn't the best idea so again Kelman went right back to the drawing board and he came out with his multiplex now does this look familiar it should because now 32 years later this is the enter chamber IOL that we used to this day and so very smart idea it's an open lube so think about open lube like the leaf springs on a truck you know them big trucks guys from my drive you know the big leaf springs on them so if you compress that the haptics take the compression and the optic doesn't vault so one of my fellow fellows actually did a study put it between two vices and measured the how far it would vault when you do it and the open loops wouldn't vault nearly as much as the closed loops and so this would not fall now instead of a round loop these are almost flatter so they're kind of rectangular in shape and flatter so these will not dig into the angle and the other smart thing Kelman is if you look it's not convex it's concave and so when you look those round loops wouldn't close off in the angle you would basically just have four points that would touch the angle and so this is the lens we use to this day and so very rapidly evolved you know this is this was 1984 that these first came out and so those have stood the test of time those are still the enter chamber we use now if you're going to pull one out this is the one you use this is the old apple core and this is how we did work but we would lay out all of the pictures that we had taken all these EM's and the Dave Apple would dictate his chapter and we would all sit in there and put in stuff and we were holding that up that one that says IOL that was the precursor to the ocular surgery news because we were on the cover there and so we you know we were holding that up there and say ha ha see we're on there when we took this picture so some of these other people the woman in there is now a co-op person at Oshner in New Orleans the guy with the white coat went into Las Vegas and had a very busy practice down there and sadly was riding a four-wheeler and flipped and broke his neck and so he's now quadriplegic which is very very sad and the other student I don't know what happened to him I lost track of him sorry but this is the so-called apple core and so this was how we would do IOL work all right now I would be remiss if I didn't talk a little bit about iris-clipped IOLs because again when people were developing all these enter chamber IOLs there's big groups in Europe mainly saying okay if we're still doing intercaps here why don't we come up with a implant that clips to the iris and so this was one of the original being course so Cornelius being course was in the the Netherlands and he came up with these and interestingly enough the being course lecture at ASCRS is the named lecture now named after being course so that's the big lecture every year at ASCRS and so being course came up and you can't see these I'll show you a side view two of those loops come out planar with the optic and then two of them go down and then back so basically you clip this to the pupil so this was iris fixated lenses now young worst who just passed away recently actually said well you know the problem with these lenses is if you dilate the pupil to look at their peripheral retina well falls out so minor detail you know it kind of dislocates into the vitreous for the anterior chamber so what worst is first of all we can put sutures through there and suture to the air so those holes are where you would put a big suture through that are sutured to the iris but then people didn't like to do that so again he put a little clip on there so you had this little tab that would clip it through the iris and so we used to joke that this was indeed the worst lens and that was the the inside joke because these behave very badly in the eye but again young worst was was a giant in Iowals and it said he just passed away and so he had to be in his 90s when he passed away now the problem is a lot of these haptics were made out of polypropylene proline which does degrade in the body when it's in touch with uveal tissue so this was one of the first ems that was ever done some you know again swarming Greek guy with a mustache wrote this paper up and what we saw is the so-called mudflap cracking and so when you had these proline loops in uveal vascularized tissue they would degrade on the surface like when it rains and then it dries out and get the mudflap even mudflap cracking this picture looks familiar because right now if you take a proline suture you can actually get degradation of proline just like this of the suture so if you suturing an Iowale to the sulcus or to the iris and you use a 10-0 proline it will degrade like this the reason I'm saying that is Walter Stark from Wilmer says that doesn't occur it's all mechanical trauma scraping on these so it's okay to use 10 sutures in spite of the fact that I've shown him you know 30 pictures like this he still doesn't believe me so don't use just 10-0 proline sutures if you're going to be suturing in an Iowa use at least 9-0 that is that is much bigger or even Gore-Tex but this is actually a proline haptic and so these would break down also now because of that you know one company said well hey let's do something that doesn't degrade at all let's make this loop out of titanium this was again one of those companies that lasted for about a day because titanium is really heavy and so you would put these things in there and they would just sink I mean they were really heavy and and and now I mean there were no MRIs then but can you imagine if you had a titanium loop dial on you went into the MRI scanner that would cause some real problems and so the titanium lasted again about a millisecond before that was taken off the market so this is what one of the worst lenses would look like you can actually see the positioning holes you know there and there with that the suture that broke and so the suture broke there and then here's the little tab try and hold it in you've got Senekia you've got inflammation and so these really would beat up the iris and then this is what one of the loops would look like on EM when it was removed this is actually iris tissue adhering to it and so the iris would get very adhering to it okay so when people started doing extra caps when they went from just removing the entire lens and its capsule to opening the lens removing the contents and leaving the capsule in there kind of like we do now people said well you should clip these in front of the capsule but then somebody else was smart and said why don't we actually change those loops so that those loops are going to the capsular bag so they call it irritable capsular fixation now you know this was interesting because at this time all these companies would come out this is the Christmas ad I love this for this company Copeland these are the little elves in the workshop making the Copeland Iowals Copeland was interesting because Copeland is shaped like a propeller and you would put it in there and two of those propeller blades that go behind the aris and two would go in front and so when you put these little Copeland lenses in there you ended up with a square pupil so two of those loops in front of the iris two behind it would clip to that and so these were really wild you see them in the clinic and they would be square so square pupils again iris fixated Copeland lens and this is what could happen again with these corneal edema ag syndrome synechia glaucoma all kinds of a fun thing this is my favorite one because this was these irritable capsular proven safe and effective stamp discontinued so I love it they like didn't even take it off the ad they just stamped the discontinued on it so eventually I'll give it to Dr. Olson and then Dave Apple they literally flew back to Washington and kind of testified at the FDA and said you know these really aren't very good lenses you should pull these off the market so they did eventually lead toward these unsafe lenses being pulled off being pulled off so we're always in research you're always on a teeter-totter between trying not to stifle research out on the edge but on the same time trying to protect people from really you know dangerous products and so that's always that balancing being that you're looking at and so I mean here we were really pushing hard at you these off the market yet we were pushing hard for the FDA to prove vial miles and so I have to tell you my second story Dick Crats is a really nice nice gentleman who was a real innovator in Southern California he's the one who really would teach Faco to the masses for years he and Bob Sinski would teach these courses and I had the pleasure I actually gave the Bincourt talk two years ago and sitting in the green room you know behind the stage when you're waiting to go on he got the honored guest award he was like 92 so I got to sit with them and chat for about 40 minutes which was fun so I was asking him to tell me stories about the old days and his best story is Ralph Nader you've heard of Ralph Nader his group goes around and tries to take unsafe products on they jumped on IOLs early on that these were unsafe and so Nader was attacking these and so Congress was having hearings that they were going to ban all IOLs and so at that time Dick Crats is one of his most famous patients we put an IOL was a guy named Robert Young and that means nothing to you guys but in the days when there were only three TV networks and everybody watched TV at night I mean a 50 million people would watch a single show and most popular show in America was Marcus Welby MD and he was this MD who had a private office who would take care of patients in the hospital he'd go to their house he would take care of maybe one patient a day because he would spend all day doing that and he was the most trusted man in America more trusted than Walter Cronkite and so the actor who played him had an IOL put in and it resurrected his career and so Dick Crats went and testified in front of Congress you know to refute these Nader's Raiders contentions nobody paid any attention and then Dr. Welby got up and testified again the most trusted man in America he said this is a miracle this saved my career and so immediately the press jumped all over it and there's a huge press conference and so the Congress could really not shut down IOLs nor could the FDA because of all this press and so they did set up a study to quote study IOLs and their complications but it allowed us to go on and keep using IOLs so when I was a resident you would have to be a quote study participant in order to put an IOL in and so there are about 13 different companies making IOLs at that time in the US and so the first day of residency you filled out 13 IOL investigator forms and you'd be an investigator and then you could put in the IOLs so Dr. Welby you know kept IOLs from being shut down Would they test the IOLs at the almost first? Yeah, maybe they would do the standard things they did but again you know rational science sometimes doesn't have anything to do with decisions that are made of bureaucratic life so well the thing about some of the IOLs is they would look really good early even in the early human studies they would look good for the first two years it would only be later the complications would show on that's why I love this proven safe and effective dissuade to you so so we make the swing from the original posterior chamber IOL and ridley heat to anterior chamber IOLs I was fixated IOLs slowly but surely in the late 70s and early 80s a surgical techniques evolved people started going from intra caps to extra caps so when you do an extra cap surgery you remove the hard lens nucleus you'd suction out the cortex but you'd still have an intact cap for a bag and so a smart surgeon named shearing decided well you know if we're going to have that intact back why don't we go back to the posterior chamber like like Ridley said so this was the original posterior chamber now interestingly shearing was a guy in Las Vegas who nobody knew who he was he did this implant and never did anything else in his entire life and so huge but he was smart enough to figure this out so ophthalmologists tend to be very innovative people soon as somebody saw this I mean there was an explosion of innovation I mean we're talking within months people were tinkering with this design now if you look at this design the problem is is those loops come out fairly near the center and they come out straight like an umbrella handle with a little J on the animals we put these in the lens capsule they would tend to really oval the capsule and not fit well so a guy named Simcoe in in Oklahoma again a guy you've probably not really heard of that much said well why don't we make these loops out of broad C shape instead of a J ship so I made these broad C shape loops and this would be the ideas it would center better in the eye and you can see with those broad C shape loops it would but these were very tough to put in again we didn't have viscoelastic yet so those little holes are positioning holes you put an air bubble in there you go in with the Sinski hook and you know pretend you're putting it in the bag who knows where it went and go behind the iris somewhere and so you put these in and so Bob Sinski who you guys use the Sinski hook all the time now who again just passed away all these old giants in the last couple years have just passed away so Bob just died last year and he came up with a modified J loop so what he did is he took that loop and moved it off to the side where it came off where it doesn't come off in the middle and he put a little modified J in there this was the IOL that I trained on and so this was like the ultimate IOL in the mid 1980s this was the modified J loop Sinski Sinski men's and so this was again pro lean loops though so three piece IOL pro lean loops now initially there was an argument about where to put this IOL and so the argument was do you put it in the bag or put it in the sulcus and there was some arguments again coming out of Johns Hopkins that said you should put this in the sulcus because you can't be sure if you're going to get it in the bag or not so again our lab had to write a major paper that said no no there's advantages to putting it in the bag and we actually wrote a paper on that unfortunately people said yeah you're right we should put it in the bag and so the idea of putting it in the sulcus you know faded real quickly and you know nowadays we put them all inside the capsule or bag where it should be and so this is why you don't want to put them in the sulcus all the time this isn't an eye from behind we okay up with you it's been sectioned this area right here you see that little c-shaped translimination there that's where the haptic was rubbing against the posterior iris and so you see that on the other side here you kind of see part of the tip of the haptic there and so if you put them in the sulcus these lenses were not really designed to go in the sulcus and so you would get significant problems pigment dispersion chronic glaucoma chronic ugg syndrome so really put it in the bag and so this was an IOL that was in the sulcus you can see again that loop went all the way back to the root of the iris and then you can see up above not only that you've got a post peripheral anterior synechia so that iris is stuck to the angle blocking it off and lastly you don't have an IOL in the bag you get a huge summering drink huge summering drink now so this is where it should be it should go into the capsule or bag and so this was a nice capsule or bag fixated IOL and you can see now those modified j-loops still they don't really fit that bag nicely you still get some ovelling of the bag and so people did tinker with them and eventually we came up with a modified C you know kind of a short C lip which again is what we use now you know it's a little short C shape rather than the J shape but you can see once it's in the bag that's pretty well tolerated pretty well tolerated and there you can see this is a picture that's the posterior iris that's a solar solar body underneath IOL loop surrounded by the capsule very quiet very well tolerated all right so as the technology evolved so did the way we make IOLs and so initially the IOL optic was carved you know from a block of PMMA it was hand polished three pieces of the haptics were staked in there well people start coming with a good technology where you could make them out of a one piece and this was a lathe cut guided by a computer I mean this was as good as computers got in the 1980s and so it would cut it and then they would tumble polish it and so I don't know if you guys as kids or those of you have kids put the little rocks in there and you tumble polish them and make the rocks all shiny it's the same idea you put a bunch of little beads in a big cylindrical drum with some material in them it's got aluminum and other stuff and you tumble these guys in there and it would polish them and so you get these beautifully finished IOLs these nice one piece PMMA IOLs all right so we can't talk about IOL evolution without talking about evolution of surgical techniques because they go hand in hand and so this is a case when I was a resident and my chief at that time still was doing extra caps and so your job as a first-year resident was to assist the chief and that's me holding the corning up so basically you would go in and you'd make this big 11 millimeter incision at the limbless you would pre-play sutures because the problem is is when you remove that whole lens you know they would get an expulsive sometimes and other things you want to have sutures under control and so my job you'd leave a tiny flap of some of some conjures my job is to pull up the cornea and then you pull up the cornea and you'd go in there with a cryoprobe and so you would first put in alpha chymotrypsin to dissolve the zonus I can't imagine talking about test syndrome what that's going to do the inside of the abbey you put alpha chymotrypsin in there it would dissolve the zonus then you take this cryoprobe and you'd freeze it to the anterior lens capsule then you just just pop that whole thing out of there and so how it would come intracap and so you know most of the time the vitreous face would stay intact most of the time you wouldn't lose V most of the time then you put in an anterior chamber IOL so that was an intracap so people rapidly figured out that you know there are advantages to leaving the posterior caps on intact you put an implant in the posterior chamber and so this was the way I was trained you'd make a groove just back from the limbus again 11 millimeters and you tunnel it forward just a little bit you pre-place some sutures you do a canopy or capsuleotomy so you take a sharp sistatone and you make about 20 punctures just like you know the punctures where stamps are stuck together make a bunch of punctures in there take out the capsule and then you would take a muscle hook and you push on the limbus inferiorly and then the lens center would pop up the nucleus and you'd slide a loop underneath it and take it out and then you temporarily tie those sutures and you'd go in with a manual IA cannula it was actually a simcoe can that's the other thing simcoe invented and you'd squirt fluid in with a bulb and you'd suck with a with a 10 cc syringe with your other hand and you'd strip out that cortex and then you'd put in the IOL well okay so Kelman again same Kelman as the Kelman IOL again he is the story he puts it he's at his dentist's office and the hygienist is you know grinding plaque off his teeth with an ultrasound and so Kelman looks at it and says you know what you know what is that that you're using they said oh it's a high frequency ultrasound so he puts two and two together and says hey why can't we break up a cataract with ultrasound and so he went to you know the company was called Cavitron at that time and they actually designed an ultrasound that would break up the cataract now the first one that he did took like an hour of ultrasounding to get it off but he persevered he designed this and he kept working on it and eventually he came up with a usable ultrasound so the idea is now you don't have to make that 11 millimeter incision you can make a smaller incision and still go in there and use the ultrasound to grind up the nucleus and so at the same time as he was inventing that you know people were looking at ways to do better capsuleotomy and this is one of those things where for once ophthalmologist didn't fight about the same time Howard Gimbel in Canada and Thomas Neuhann in Germany came up with the idea of a capsule orexis and so they gave each other credit I'll give it to them they're fine but of course in ophthalmology there's always some obscure guy someone who did it first and so there's a video of this guy in North Dakota I don't remember his name actually did the first rexus before they did but he never you know published or talked about it did you have an idea yeah they did have an eye and they come up with the automated eye with this too yeah so when the capsule rexus came out we could now remove the IOL I mean the lens off the lens nucleus within the capsule bag without making a big incision and so people came up and that's where Dick Krauts and Sinske came up they came up with what's called the divide and conquer technique where you'd make a groove and you'd rotate it 90 degrees make another groove and then go in there with a second instrument and crack the you know crack the nucleus into four pieces and then take it out and that's what you guys start to train on this is divide and conquer so that was the way you could do it through this closed capsule orexis and the reason I'm showing all that is when we were doing all this people said hey this is great you could take out a cataract the three millimeter incision then you'd open the incision to six millimeters to put in the IOL and it's like well that's stupid why are we doing that so again it bounced back to the IOL manufacturers who said why can't we design a foldable IOL that will go through a three millimeter incision and not have to open it up and so we started playing with different incisions we were making a this was a you know corneal scleral incision you'd go back a little bit you'd go down you tunnel forward reason I'm showing you this is this is in essence the wound we make now for manual small incision extra caps except we curve it you know we do the frowning incision but the same idea you go through the sclera through the corneal and then eventually enter the eye so this was a incision that would seal real well and of course eventually we've evolved now to just the chlorocornial incision with these IOLs so the first foldable IOL was a plate silicone lens and Tom Masako who was one of Kratz's partners came up with this idea and so we used to call this the Masako taco because you'd roll it up like a taco put it in the eye and unroll it and this actually went in with an injector it's very clever idea the problem is is it's a plate lens and it's silicone but that was the first of the two we had so this was truly the first foldable IOL and so this allowed you to put an IOL into an unopened incision so you can put this in through a 3 millimeter incision and truly allow small incision feco. Now you see we were still doing a mini squirrel tunnel and we were actually still putting stitches in there we didn't believe this would seal and eventually people figured out that hey this does actually seal up if you make it right so this was the original Masako taco you could you could polish it pretty well but if you look you get this little molding flash on here now do you guys ever build model planes as a kid or model plastic stuff it would have a molding flash on there so I'm looking here this is so sexist the girls on who the guys go oh yeah yeah we built those so very you know you guys were still in the era where things were separated don't feel bad when I was in junior high the boys took shop and the girls took home ec then we're talking this is nineteen you know 69 this wasn't like back in the stone ages and so it was like and everyone's supposed to say well can't girls take shop no no no heavens no it's a home ec shop and so same thing model planes mostly a guy thing but you look at those model planes they'd have this molding flash around and same thing with the silicone lenses they would have this little molding flash runs they weren't that well finished so as companies started to look at ways they could make it better somebody said well why don't we just take the design that we've got now you know modified seal 3-piece lens and make it out of silicone instead of PMMA and so indeed the 3-piece silicone lens now silicone has some issues it's got a relatively lower refractive index they got to make them pretty thick there were some in there are some problems with you know compatibility of silicone like if you put silicone oil in an eye that had a retina surgery it would stick to the silicone eye well and so there were some issues with this so and this was the silicone once it storming does that look familiar that's our sulcus lens of choice right now or piggyback lens of choice right now the star silicone all right so people started looking at other materials the silicone wasn't good one of the things they looked at is a hydro philic water loving acrylic and so this was Bosch and Loam's hydro view this was a hydrophilic acrylic material it was very biocompatible they grafted some haptics on it we did a bunch this is a rabbit we did a bunch of rabbit studies are very compatible very good looking lens problem if you put it in and two years later they would calcify and so there are a whole bunch of reasons why these hydro philic acrylic lenses that were used in the US would calcify but bottom line is as these lenses calcified Americans refused to use these now hydrophilic lenses that don't calcify are available all over Europe and they use them a lot but not in the US because of the problem we had with this and with the memory lens calcifying and for those guys in the lab we still see memory lenses to this day coming out that have calcified so the problem with the hydrophilic acrylics is if the surface changes somewhat it allows the calcium to come out from the aqueous and eventually calcify on the lenses and so the hydrophilic acrylic material didn't work out in the US and so the material that we've used most commonly now is hydrophobic acrylic very low water content these are what we think of as acrylic lines isn't this is the lens we use now this was the original three-piece Alcon lens this has a high refractive index it could be made thinner it's very strong it's you know moderate biocompatibility but it definitely doesn't calcify and nowadays of course we've got the one piece hydrophobic acrylic I was and those are the ones we use now so that's what are the Europeans to make it so it doesn't well if it's well manufactured and you don't have materials in there that shouldn't be there some of the reasons why the US ones calcify is someone in the manufactured process you get some stuff in there it's complicated but you get some stuff in there that would make it so the calcium would would you know precipitate out on it there were other ones that were poorly made where the calcium would actually be drawn into the polymer using calcification not only on the surface but inside the polymer itself people were saying some of it is the UV blocker that was bad others it was the way they were sterilized there's all kinds of different reasons why well made hydrophilic acrylics do not calcify well that's that's a different thing now they're beginning to show up with intracameral gas or air so if you're doing a desig and you've got a hydrophilic acrylic those will actually calcify on the anterior surface outlining the capsule rex's so those that's just new though that just been in the last two years we recognize that so we've seen now got probably 20 of those and we've seen quite a few of those so I just I stopped there because you know I just wanted to give you the history nothing modern I'll give you the history and Dr. Warner will talk to you a little bit about modern I won't so that's our crew and Bartholona the tourists you can see of course the shorts and the white tennis shoes you tell we're just so American so because you look like an American doing that I've quit doing that and so I actually bought some black tennis shoes and we're Levi's now because then you don't look like an American because nobody wears you know in Europe people were Levi's with black dress shoes I never figured that out so I don't know why that is but they do so I hate that because I were tennis shoes when I walk around so I bought black tennis shoes so you can't tell and I wear those with Levi's and I stopped wearing shorts because you're just such an American when you do so next time we're going to do I believe glaucoma to look and see you want the schedule is I think it's glaucoma glaucoma? Okay very good so please read up on that because this is your this was your day off and so glaucoma know it well for next Tuesday okay all right thanks everyone