HEADLINE ANATOMY OF THE BY MARIE-JOSÉ TASSIGNON, MD, PHD, FEBO RETROLENTICULAR SPACE New insights into a long-neglected part of the eye are emerging. y interest in the retrolenticu- The BIL design was originally manu- in the retrolenticular interface. Later, lar space started in the early factured by PhysIOL in PMMA and other individuals, including Robert 1990s. At that time, I was later by Morcher in foldable hydrophil- Stegmann, MD; Albert Galand, MD, more involved in the posterior ic versions. It was first used in a clinical PhD; Lisa Brothers Arbisser, MD; and segment. My mentor was Jan study in 1999 and was approved by Rupert Menapace, MD, FEBO, pro- MWorst, MD, of the Netherlands, who the Belgian National Social Security in moted the idea of the primary poste- fascinated the world with his beauti- 2004. Only one draft was drawn for rior continuous circular capsulorhexis ful images of the vitreous cisternae. the original lens, and the result is now (PPCCC) to be used alone or with the While I was helping him in his lab in used in the clinic in adult and pediatric optic capture technique. Groningen, we were able to color the cases. Modifications have since been Albert Galand was convinced that Berger space in a young adult’s post- developed to provide the lens in a use of the PPCCC alone, without optic mortem eye. toric version and a version for use with capture, would prevent posterior cap- This was, for me, the start of a new a loose, torn, or nearly absent capsule. sular opacification (PCO). We showed, journey. I became convinced that this In 1990, the ophthalmologic however, that reclosure of the PPCCC space was big enough to accommodate world was convinced that the poste- occurred in about one-third of cases in a new lens design, and I filed the idea rior capsule was the most precious which PPCCC was used in combination and concept of that new lens design structure in the eye. Behind that with a regular BIL IOL, and this occurred with the US Patent Office in October membrane, the vitreous was consid- within the first 2 postoperative years.1 1997. The lens was named the double- ered a black box, eagerly waiting to The reason was that lens epithelial cells rhexis lens to accentuate the fact that prolapse and cause macular edema, were able to grow either on the anterior both an anterior and posterior capsu- retinal detachment, etc. vitreous hyaloid or on the posterior sur- lorhexis were required to implant the It was hard to convince the oph- face of the IOL.2 lens properly. Another name for the thalmic community that this was concept that was mentioned in the not true, but I had the help of giants ANSWERING THE SKEPTICS original patent application was the such as Howard Gimbel, MD, MPH, As my colleagues and I developed bag-in-the-lens, and that is the name FRCSC, who invented the posterior the concept of the BIL, animal mod- used for the lens as it exists today capsulorhexis and who used the optic els showed excellent results. This (Bag-In-The-Lens, or BIL, Morcher). capture technique to place the optic encouraged us to proceed to using the 32 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | JANUARY 2019 MASTERING THE POSTERIOR CAPSULE s “THE POSTERIOR CAPSULE CAN run by the ESCRS. In to observe the Berger space, the that large multicenter anterior hyaloid, and the ligament study, CME was not of Wieger—structures that have not BE SAFELY REMOVED WITHOUT increased after PPCCC and BIL been visible until the advent of these implantation.5 new imaging technologies.9 We will RISK OF LEAKAGE. ... HOWEVER, Regarding Point No. 3, retinal have to wait for more studies and pub- detachment after PPCCC was stud- lications on this topic in the coming IN THE EVENT OF RUPTURE ied by Menapace after optic capture, years in order to know more about the and he did not find an increased risk incidence of anterior hyaloid detach- of postoperative retinal detachment.6 ment and the risk for retinal detach- OF THE ANTERIOR BIL We also studied retinal detachment ment. What we surely know is that in the after PPCCC and BIL implantation. the anterior hyaloid detaches with age HYALOID, LEAKAGE clinic.3 We found that the incidence of retinal and that the prevalence of its detach- This was detachment after BIL implantation was ment is highest after cataract surgery WAS EXTREMELY all good comparable to that after in-the-bag in patients 60 years of age or older news in favor of implantation, if not slightly lower.7 and in myopes. In the presence of a my approach, but Long-term postoperative follow-up detached ligament of Wieger, we can HIGH.” skeptics continued (not yet published) shows a small no longer use the term Berger space to question me about advantage for the BIL technique com- but rather retrolenticular interface. The the safety of systemati- pared with in-the-bag implantation. retrolenticular interface is still not fully cally performing PPCCC. Based on these findings, we con- unraveled. My response was three- cluded that there is no inferiority of By using the BIL in children and fold, and I committed myself the BIL technique compared with the infants, Van Looveren and colleagues to proving three points: traditional implantation technique were able to describe a new sub- regarding the postoperative incidence group of congenital cataract based s Point No. 1. The posterior capsule is of CME and retinal detachment. on the presence of anterior interface not the most important membrane dysgenesis.10 This is another amazing defining the anterior and posterior ANTERIOR VERSUS POSTERIOR new description made possible by segments of the eye; the anterior HYALOID intraoperative OCT. Not only can the hyaloid is; Why do we still have an increased anterior interface present a dysgenesis, risk of retinal detachment after cata- these authors concluded, but, due to s Point No. 2. The incidence of cystoid ract surgery? Although small, the risk the extremely bad condition of this macular edema (CME) is not is elevated in patients after cataract dysgenesis, the eye will not be able to increased after PPCCC; and surgery compared to the population fulfill the reflex of emmetropization as without surgery. What is the cause? Is programmed. s Point No. 3. The incidence of retinal it the anterior hyaloid or the posterior detachment is not increased after hyaloid that plays a role? MATERIAL NOT RESPONSIBLE FOR PCO PPCCC. In order to answer this question One thing we surely know is that the regarding the role of the posterior biomaterial of an IOL is not respon- To prove Point No. 1, we used an hyaloid, we have participated in the sible for the rate of PCO. We studied ocular flurophotometer to measure MYOPRED study, a multicenter study this by implanting lenses of two dif- the leakage of fluorescein, a very small run by the ESCRS that is enrolling high ferent designs made with the same molecule, into the anterior vitreous myopes (axial length >25 mm) with or biomaterial. We found that, when space after PPCCC and after inad- without posterior hyaloid detachment using the lens-in-the-bag technique, vertent vitreous loss during cataract prior to surgery.8 No results have been the incidence of PCO was much higher surgery. The results were absolutely posted from this study, so we cannot than using the BIL design.11 convincing. The posterior capsule can yet disclose details. PCO development is a result of be safely removed without risk of leak- However, we already know that the foreign body reaction of the eye age. Conversely, however, in the event anterior hyaloid detachment can against the IOL, which is initiated of rupture of the anterior hyaloid, leak- occur; it can be present preoperatively by lens epithelial cells. These cells, age was extremely high.4 or can occur after cataract surgery. We however, can have very little impact In an effort to prove Point No. 2, have used intraoperative OCT, incor- when the biomaterial is implanted we participated in the PREMED study porated into an operating microscope, using the BIL implantation technique. JANUARY 2019 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 33 s MASTERING THE POSTERIOR CAPSULE 6. Menapace R. Posterior capsulorhexis combined with optic buttonholing: an COMING SOON technologies of today have now alternative to standard in-the-bag implantation of sharp-edged intraocular In order to understand the anterior allowed us to visualize them and con- lenses? A critical analysis of 1000 consecutive cases. Graefes Arch Clin Exp Ophthalmol. 2008;246(6):787-801. interface, also called the retrolenticular firm their existence. 7. Tassignon MJ, Van den Heurck JJ, Boven KB, et al. Incidence of rhegmatog- enous retinal detachment after bag-in-the-lens intraocular lens implantation. J space or space of Berger (when the The coming years will be dedicated Cataract Refract Surg. 2015;41(11):2430-2437. Wieger ligament is still attached), I to learning why these structures are 8. Influence of posterior vitreous detachment on retinal detachment after lens surgery in myopic eyes (MYOPRED). clinicaltrials.gov. NCT03152747. https:// invite you all to read a book on the present and what their precise roles clinicaltrials.gov/ct2/show/NCT03152747. Accessed November 27, 2018. BIL that is soon to be published by are within the eye. They may also help 9. Tassignon MJ, Ní Dhubhghaill S. Real-time intraoperative optical coherence tomography imaging confirms older concepts about the Berger space. Springer Publishing. The editors of us to develop a better understanding Ophthalmic Res. 2016;56(4):222-226.