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Intraocular Lens (IOL) Surgery Opacification Eye (2002) 16, 217–241 2002 Nature Publishing Group All rights reserved 1470-269X/02 $25.00 www.nature.com/eye RH Trivedi1, L Werner1, DJ Apple1, SK Pandey1 REVIEW Post cataract- and AM Izak1 intraocular lens (IOL) surgery opacification Abstract opacification; anterior capsule opacification; silicone; calcification; glistening; snowflake; Intraocular lens (IOL) implantation has no interlenticular opacification; piggyback; doubt been one of the most satisfying posterior capsule opacification advances of medicine. Millions of individuals with visual disability or frank blindness from cataracts had and continue to Introduction have benefit from this procedure. It has been reported by ophthalmologists that the Implanting an intraocular lens (IOL) into an modern cataract-intraocular lens (IOL) adult eye after cataract surgery is an surgery is safe and complication-free most of extremely successful procedure since its 1 the time. This makes the watchword for any invention by Sir Harold Ridley. It is often cataract surgeon to be ‘implantation,’ difficult to imagine another medical specialty ‘implantation,’ ‘implantation.’ In the mid- implanting foreign material with such a high 1980s, as IOLs were evolving rapidly, the success rate. Decreased incidence of watchword of the implant surgeon was postoperative complications of cataract-IOL ‘fixation,’ ‘fixation,’ ‘fixation.’ Most surgery led us to become complacent and less techniques, lenses and surgical adjuncts now vigilant regarding assessment and careful allow us to achieve the basic requirement for testing of new ocular prosthesis and surgical successful IOL implantation, namely long- procedures. However, despite the positive term stable IOL fixation in the capsular bag. evolution of cataract-IOL surgery, but However despite this advancement some concurrent with this era of probably decreased items ‘slipped through cracks.’ In this article, vigilance, we are now unfortunately we would like to alert the reader to a new identifying some serious problems. Table 1 watchword, namely ‘opacification,’ describes some entities related to post 1 ‘opacification,’ ‘opacification.’ Here we will cataract-IOL surgery related opacification. Center for Research on Ocular Therapeutics and be talking about the good, the bad, and the Ophthalmic surgeons have responded to these challenges and continued research is now Biodevices ugly. Examples of the ‘good’ include the Storm Eye Institute recent successes now being achieved in ongoing that will even further improve the Medical University of South reducing the incidence of posterior capsule outcome of the cataract-IOL operation in order Carolina opacification. Examples of the ‘bad’ include to help surgeons to provide better care to our Charleston, SC, USA various proliferations of anterior capsule patients. Correspondence: cells, problems caused by silicone oil Our research center was founded in 1983 by David J Apple, MD and Randall J Olson, MD, DJ Apple adherence to IOLs and problems with Storm Eye Institute piggyback IOLs. The ‘ugly’ include the in Salt Lake City, UT, USA. The research and Department of sometimes striking and often visually specimens analyses during this early period Ophthalmology disabling opacifications occurring on and were almost totally focused on cataract-IOL Medical University of South Carolina within IOL optics, both on some modern surgery, hence the center was named the Center for IOL Research. Following David J 167 Ashley Avenue foldable IOLs as well as a poly(methyl PO Box 250676 methacrylate) (PMMA) optic degradation Apple’s move to Charleston, SC in 1989, the Charleston occurring with some models a decade or scope of the work expanded and we therefore SC 29425–5536, USA more after implantation. changed the name to a more inclusive one, the Tel: (843) 792 2760 Fax: (843) 792 7920 Eye (2002) 16, 217–241. DOI: 10.1038/ Center for Research on Ocular Therapeutics 2 E-mail: appledjȰmusc.edu sj/eye/6700066 and Biodevices. As of December 2000 we had accessioned more than 16500 IOL-related Presented in part at the specimens including more than 7800 Oxford Ophthalmologic Keywords: intraocular lens; complication; pseudophakic human globes. From January Congress, 2001. Post cataract (IOL) surgery opacification RH Trivedi et al 218 Table 1 Post cataract IOL surgery related opacifications described in this review article (1) Front (anterior) (A) Anterior capsule opacification (ACO) (B) Silicone oil adherence to IOLs (2) On (surface changes on the optical component of IOLs) Calcification on the surface of the Bausch & Lomb Hydroview IOL (3) Within (alteration inside the IOL optic) (A) Degeneration of ultraviolet absorber material and calcium deposits within the optic of a hydrophilic IOL (manufactured by Medical Developmental Research) (B) Glistening of the AcrySof IOL (C) ‘Snowflake’ or ‘crystalline’ alteration of poly(methyl methacrylate) (PMMA) IOL optic: a syndrome caused by an unexpected late biodegradation of PMMA (4) Between (opacification between ‘piggyback’ IOLs) Interlenticular opacification (ILO) of ‘piggyback’ IOLs (5) Behind (posterior) Posterior capsule opacification (PCO) 1988 through December 2000, 6425 eyes with posterior Pathogenesis chamber (PC) IOLs were analyzed including 1109 eyes When the anterior surface of the IOL optic biomaterial implanted with foldable IOLs. is in contact with the adjacent posterior aspect of the anterior capsule, the remaining anterior lens epithelial Anterior capsule opacification cells (A cells) may undergo fibrous metaplasia leading to anterior or posterior capsule opacification.10 The Introduction cuboidal cells lining the anterior capsule (A cells) are the cells of origin of ACO. Some authors3 Like posterior capsule opacification (PCO), anterior demonstrated two phases in the formation of ACO: an capsule opacification (ACO) is also actually a early phase consisting of proliferation of lens epithelial misnomer since it is not the capsule which opacifies, cells and a late phase involving degeneration or but rather the cells lining the capsule3 (Figure 1). A disappearance of lens epithelial cells and the presence more accurate term is anterior subcapsular of extracellular matrix. opacification. However, the former term is firmly established in the literature and in clinical usage. ACO generally occurs much earlier in comparison to PCO, Factors that may contribute to ACO sometimes within one month postoperatively.4,5 It has Three major factors have been postulated to affect the been demonstrated that the area of the anterior capsule degree of ACO: (1) the initial size of the continuous opening seems to gradually decrease for up to 6 curvilinear capsulorhexis (CCC); (2) the IOL material months postoperatively.4,6–9 and design; and (3) pre-existing conditions, eg the The process of opacification of the anterior capsule quality of the zonular support. may progress in four stages: (1) fibrosis/opacification of the capsulorhexis margin at some places; (2) the (1) Capsulorhexis size: With a CCC smaller than the entire anterior capsular edge in contact with the IOL diameter of the IOL optic, the contact of the optics’ optic’s biomaterial then becomes progressively biomaterial with the anterior capsule will induce opacified; (3) formation of capsular folds; and (4) fibrosis/opacification. It is postulated that the more advanced/excessive and/or asymmetric fibrosis and epithelium that is left, the greater the potential for shrinkage may result in some complications such as opacification. The magnitude of the postoperative eccentric displacement of the CCC opening, IOL changes appears to be related to the initial CCC decentration, and capsulorhexis phimosis. size, although some authors did not find any An excessive anterior capsule fibrosis/opacification correlation between these parameters.11 Tsuboi et may lead to major clinical problems and sequelae such al12 have studied the influence of the CCC and IOL as difficulty in examining the retinal periphery, which fixation on the blood-aqueous barrier. Their results leads to difficulty in diagnosing and treating retinal indicate an unfavorable effect of in-the-bag fixation problems. It can also lead to fibrous contraction of the with a small CCC, and thus a broad contact of the capsule, capsulorhexis phimosis, and IOL decentration. IOL optic with the anterior capsule. The important Eye Post cataract (IOL) surgery opacification RH Trivedi et al 219 Figure 1 Anterior capsule opacification (ACO). (a) Gross photographs of pseudophakic human eyes obtained post-mortem (anterior or surgeon’s view) showing ACO with silicone-plate intraocular lens (IOL). (b) Photomicrograph taken at the CCC margin of pseudo- phakic human globes obtained post-mortem (Masson’s trichrome stain, original magnification × 400) showing anterior capsule fibrosis. subset of ACO, capsular phimosis, relates to the haptic IOLs is probably due to the relatively large CCC size. Although no correlation between the area of contact of the plate haptic silicone material initial CCC size and the postoperative CCC with the anterior capsule, in sharp contrast to 3- constriction has been found by Gonvers et al,11 piece IOLs where the contact is limited to the some authors have postulated that performing surface of the optic. Thus, the plate IOL has a large small, intact CCCs strongly increases the risk for surface exposure that may stimulate cell capsule fibrosis and shrinkage.7,9 proliferation and fibrosis. (2) IOL material and design: Werner and associates (3) Pre-existing conditions: In conditions such as from our laboratory performed extensive
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