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Surgical prevention of posterior capsule opacification

Identifieur interne : 002531 ( Istex/Corpus ); précédent : 002530; suivant : 002532

Surgical prevention of posterior capsule opacification

Auteurs : Qun Peng ; Nithi Visessook ; David J. Apple ; Suresh K. Pandey ; Liliana Werner ; Marcela Escobar-Gomez ; Robert Schoderbek ; Kerry D. Solomon ; Alfred Guindi

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RBID : ISTEX:453A1C3A116D03AA81E0233483D823E7178257EB

Abstract

Purpose To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.Methods This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.Results Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.Conclusions The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.

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DOI: 10.1016/S0886-3350(99)00352-1

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ISTEX:453A1C3A116D03AA81E0233483D823E7178257EB

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<div type="abstract" xml:lang="en">Purpose To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.Methods This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.Results Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.Conclusions The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.</div>
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<abstract>Purpose To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.Methods This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.Results Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.Conclusions The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.</abstract>
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<note>Supported in part by an unrestricted grant from Research to Prevent Blindness Inc, New York, New York, USA.</note>
<note type="content">Section title: Articles</note>
<note type="content">Figure 1: (Peng) Gross photographs of 3 human eyes with PC IOLs obtained postmortem (Miyake–Apple posterior view). Each corresponding histologic view shows the profile of absence of Soemmering’s ring with total fusion of anterior and posterior capsules (Group 1-A, Table 1). With this scenario, the CCC diameter is larger than that of the IOL optic. A: An acrylic IOL. B: Photomicrograph of A (arrow = site of fusion of the anterior capsular flap edge [AC] and the posterior capsule [PC]; O = site of the IOL optic). C: A silicone IOL.D: Photomicrograph of C (H = haptic at lens equator; AC = anterior capsule; PC = posterior capsule; O = site of the IOL optic). E: An all-PMMA IOL. F: Photomicrograph of E (AC = anterior capsule; PC = posterior capsule; O = site of the IOL optic) (B, D, and F, PAS stain; original magnification ×20).</note>
<note type="content">Figure 2: (Peng) Gross photographs of 3 human eyes with PC IOLs obtained postmortem (Miyake–Apple posterior view). Each corresponding histologic view shows examples of absence of Soemmering’s ring but with a large, empty, open space between the anterior and posterior capsules (Group 1-B, Table 1). This profile exists because the CCC was smaller than the lens optic and the capsulorhexis edge was placed on the anterior surface of the optic. The cut edge of CCC in each histologic section is identified by an arrow. A: An acrylic IOL. B: Photomicrograph of A. C: A silicone IOL. D: Photomicrograph of C. E: A single-piece PMMA IOL; the opacity seen corresponds to anterior capsule fibrosis. F: Photomicrograph of E. (B, D, and F, PAS stain; original magnification ×20).</note>
<note type="content">Figure 3: (Peng) Gross photographs of 2 eyes with a PC IOL obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows an example of retained/regenerative cortex within a Soemmering’s ring. In this subset (Group 2-A, Table 1), cellular ingrowth toward the visual axis was blocked by fusion of the anterior capsular edge of the CCC (arrows in the histologic sections) and the posterior capsule. An IOL barrier effect is therefore not required in this subset. A: An acrylic IOL. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×100). C: A silicone IOL. D: Photomicrograph of C (PAS stain; original magnification ×100).</note>
<note type="content">Figure 4: (Peng) Gross photographs of 2 eyes with 2 PC IOLs obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows examples of retained Soemmering’s ring, in which the cellular ingrowth over the visual axis was blocked by a biconvex optic with a smooth, round, and tapered edge (Group 2-B-1, Table 1). This optic geometry may allow some cellular ingrowth for a short distance behind the optic’s periphery. A: A silicone IOL. B: Photomicrograph of A. Note the growth of a layer of cortex and cells extending behind the IOL optic. The cortex and cells in the Soemmering’s ring and within the ingrowing tissue (small arrows) stain red. The large arrow connotes the imprint of the edge of the rounded lens optic (Masson’s trichrome stain; original magnification ×20). C: A single-piece all-PMMA IOL. D: Photomicrograph of C. Note the layer of cortex and cells (lower right) extending behind the IOL optic (Masson’s trichrome stain; original magnification ×20).</note>
<note type="content">Figure 5: (Peng) Gross photographs of eyes with acrylic PC IOLs obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows examples of retained/regenerative cortex (Soemmering’s ring), in which growth along the posterior capsule across the visual axis was abruptly blocked by the squared, truncated IOL optic edge (Group 2-B-2, Table 1). Two small arrows in each case demarcate the imprint of each square optic edge. The posterior capsule behind the optic is relatively cell free. The posterior capsules were artifactually ruptured during tissue processing. A: An acrylic IOL. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×20). C: An acrylic IOL. D: Photomicrograph of C (Masson’s trichrome stain; original magnification ×100).</note>
<note type="content">Figure 6: (Peng) A gross photograph of 1 eye with a single-piece all-PMMA PC IOL obtained postmortem (Miyake–Apple posterior view). The histologic correlate of this eye shows an example of retained/regenerative cortex (Soemmering’s ring) in which growth across the visual axis was abruptly blocked by the squared, truncated edge of the IOL optic (2-B-2, Table 1). The site of the square edge of the lens optic is connoted by 2 small arrows (B). A: Gross photograph. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×100).</note>
<note type="content">Figure 7: (Peng) Gross photographs of 2 human eyes with various types of early and recent model PC IOLs obtained postmortem (Miyake–Apple posterior view). Note the advanced Soemmering’s ring formation in each eye. The lens optic in each case is, in effect, called on to function to some extent as a barricade to inhibit cell ingrowth onto the visual axis. A: A 3-piece PMMA IOL. B: A single-piece silicone IOL.</note>
<note type="content">Figure 8: (Peng) The evolution of the IOL barrier effect shows the imperative of having both haptics in the capsular bag. Top: For the first 2 decades of PC IOLs, most IOL optics were plano-convex. They could initiate the barrier effect if both haptics were in the capsular bag. Middle: Placement of 1 or both haptics out of the capsular bag would diminish contact with the posterior IOL optic surface to the posterior capsule and therefore diminish the possibility of a barrier effect, allowing cell ingrowth. Bottom: Hoffer’s early attempt to enhance the IOL barrier with a 360 degrees barrier ridge (arrows). This functions as an effective barrier to ingrowth only if both haptics are securely fixated in the capsular bag.</note>
<note type="content">Figure 9: (Peng) The scenarios in the capsular bag without Soemmering’s ring (Groups 1-A and 1-B, Table 1). Top: There is fusion of the anterior and posterior lens capsules (Group 1-A). No IOL barrier effect is required. In this case, the capsulorhexis diameter is larger than the optic diameter. Bottom: In this scenario (Group 1-B), the CCC diameter is smaller than that of the optic and the cut edge of the anterior capsule rests on the optic. This leaves an empty space (aqueous filled in life) at the equatorial fornix.</note>
<note type="content">Figure 10: (Peng) The scenario when significant cortical retention/regeneration occurs (Groups 2-A and 2-B, Table 1). Top: Cell ingrowth is blocked by fusion of the posterior capsule and the anterior capsular flap (2-A). No IOL barrier effect is required. Middle: When the Soemmering’s ring is blocked by the tapered, round edge of a biconvex optic (Group 2-B-1), ingrowth behind the lens optic periphery may occur (horizontal arrow). Bottom: When the Soemmering’s ring cell ingrowth is blocked by a square, truncated optical edge (Group 2-B-2), ingrowth behind the optic is abruptly blocked at the outer edge of the optic.</note>
<note type="content">Figure 11: (Peng) Scanning electron microscopy of round-edge optic designs. Top: A PMMA IOL (original magnification ×150). Bottom: A silicone IOL (original magnification ×150).</note>
<note type="content">Figure 12: (Peng) Optic designs showing the barrier effect of a classic biconvex IOL with a round, tapered edge. Top: There is some potential of cell growth around the posterior peripheral edge of the optic into the area of posterior capsule behind the periphery of the optic (arrows). Bottom: A frontal view shows the pattern of ingrowth of cells and cortex (light green area) that may occur behind the outer periphery of the optic.</note>
<note type="content">Figure 13: (Peng) Scanning electron microscopy of 2 IOLs with square or truncated edges, each fabricated from a different biomaterial. Top: A PMMA IOL with a square-edge, unpolished design from the 1980s (original magnification ×150). Bottom: An acrylic IOL (original magnification ×150).</note>
<note type="content">Figure 14: (Peng) Optic designs demonstrating the barrier effect of a classic biconvex IOL with a thicker square or truncated edge. Top: With the square edge (seen here in sagittal section), abrupt blockage of cell growth at the optic edge is more likely. Bottom: A front view shows that ingrowth over the optic may be completely retarded as a result of the abrupt blockage of cells by the truncated, square edge.</note>
<note type="content">Figure 15: (Peng) A slitlamp photograph of an eye 3 years after implantation of an Alcon AcrySof IOL, which has a square, truncated edge. There is total absence of cell growth in the area subtending the entire IOL optic. An extensive Soemmering’s ring with pearl formation is evident outside the region of the optic, but all ingrowth is blocked.</note>
<note type="content">Figure 16: (Peng) Photomicrographs of a human eye obtained after surgical enucleation. An acrylic IOL with a square, truncated optic edge had been implanted. This was a complicated case in which the patient had multiple intraocular and extraocular surgeries. An extensive amount of retained/regenerative cortex has overwhelmed the ability of the optic to adequately form a barrier to cell migration. A: Overview of the capsular bag showing Soemmering’s ring and posterior capsular ingrowth (PCO) on the left side (pairs of small arrows = imprint of each truncated optic against the central side of the Soemmering’s ring) (H&E stain; original magnification ×20). B: High-power photomicrograph of the left side of the capsular bag seen in A. Note the imprint of the truncated optic edge (arrows), which failed to obstruct cellular ingrowth (PCO) behind the lens optic (O) (H&E stain; original magnification ×40). C: High-power photomicrograph of the right side of the capsular bag seen in Ain which the square optic edge (arrows) successfully retarded ingrowth from the Soemmering’s ring. The posterior capsule has artifactually ruptured but remains clear behind the entire IOL optic (O) (PAS stain; original magnification ×100).</note>
<note type="content">Figure 17: (Peng) Slitlamp photographs of 2 patients with foldable IOLs with truncated, square-edge optics show clear capsules with no PCO. In each case, the CCC diameter (arrows) was smaller than that of the IOL optic. A: An AcrySof acrylic IOL. B: A Pharmacia 911™ silicone IOL.</note>
<note type="content">Figure 18: (Peng) A gross photograph of an eye with an acrylic IOL with a slightly off-center CCC obtained postmortem (Miyake–Apple posterior view). On one side (left) the edge of the capsulorhexis was placed over the anterior surface of the IOL optic (arrows). The capsular bag appears clear in this region. On the other side (right), the CCC edge was outside the optic. Note the more extensive accumulation of retained/regenerative cortex and cells in this latter region.</note>
<note type="content">Table 1: Classification of capsular bag status after cataract extraction.</note>
<note type="content">Table 2: Number of IOLs included in this study fitting in the different categories of capsular bag status after cataract extraction.</note>
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<forename type="first">Qun</forename>
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<forename type="first">Nithi</forename>
<surname>Visessook</surname>
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<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
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<forename type="first">David J</forename>
<surname>Apple</surname>
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<note type="biography">Reprint requests to David J. Apple, MD, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, 167 Ashley Avenue, PO Box 250676, Charleston, South Carolina 29425–2236, USA</note>
<affiliation>Reprint requests to David J. Apple, MD, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, 167 Ashley Avenue, PO Box 250676, Charleston, South Carolina 29425–2236, USA</affiliation>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Suresh K</forename>
<surname>Pandey</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Liliana</forename>
<surname>Werner</surname>
</persName>
<roleName type="degree">MD, PhD</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Marcela</forename>
<surname>Escobar-Gomez</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Robert</forename>
<surname>Schoderbek</surname>
</persName>
<roleName type="degree">BS</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Kerry D</forename>
<surname>Solomon</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
<author>
<persName>
<forename type="first">Alfred</forename>
<surname>Guindi</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</affiliation>
</author>
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<title level="j">Journal of Cataract & Refractive Surgery</title>
<title level="j" type="abbrev">JCRS</title>
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<p>Purpose To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.Methods This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.Results Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.Conclusions The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.</p>
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<ce:note-para>Supported in part by an unrestricted grant from Research to Prevent Blindness Inc, New York, New York, USA.</ce:note-para>
</ce:article-footnote>
<ce:dochead>
<ce:textfn>Articles</ce:textfn>
</ce:dochead>
<ce:title>Surgical prevention of posterior capsule opacification</ce:title>
<ce:subtitle>Part 3: Intraocular lens optic barrier effect as a second line of defense
<ce:cross-ref refid="FN1">1</ce:cross-ref>
<ce:footnote id="FN1">
<ce:label>1</ce:label>
<ce:note-para>None of the authors has a financial or proprietary interest in any product mentioned.</ce:note-para>
</ce:footnote>
</ce:subtitle>
<ce:presented>Presented in part at the Chicago Ophthalmology Society Meeting, Chicago, Illinois, USA, October, 1997, and as a poster at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 1998.</ce:presented>
<ce:author-group>
<ce:author>
<ce:given-name>Qun</ce:given-name>
<ce:surname>Peng</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Nithi</ce:given-name>
<ce:surname>Visessook</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>David J</ce:given-name>
<ce:surname>Apple</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
<ce:cross-ref refid="CORR1">*</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Suresh K</ce:given-name>
<ce:surname>Pandey</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Liliana</ce:given-name>
<ce:surname>Werner</ce:surname>
<ce:degrees>MD, PhD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Marcela</ce:given-name>
<ce:surname>Escobar-Gomez</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Robert</ce:given-name>
<ce:surname>Schoderbek</ce:surname>
<ce:degrees>BS</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Kerry D</ce:given-name>
<ce:surname>Solomon</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author>
<ce:given-name>Alfred</ce:given-name>
<ce:surname>Guindi</ce:surname>
<ce:degrees>MD</ce:degrees>
<ce:cross-ref refid="AFF1">
<ce:sup>a</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:affiliation id="AFF1">
<ce:label>a</ce:label>
<ce:textfn>the Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA</ce:textfn>
</ce:affiliation>
<ce:correspondence id="CORR1">
<ce:label>*</ce:label>
<ce:text>Reprint requests to David J. Apple, MD, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, 167 Ashley Avenue, PO Box 250676, Charleston, South Carolina 29425–2236, USA</ce:text>
</ce:correspondence>
</ce:author-group>
<ce:date-accepted day="5" month="11" year="1999"></ce:date-accepted>
<ce:abstract>
<ce:section-title>Abstract</ce:section-title>
<ce:abstract-sec>
<ce:section-title>Purpose</ce:section-title>
<ce:simple-para>To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.</ce:simple-para>
</ce:abstract-sec>
<ce:abstract-sec>
<ce:section-title>Setting</ce:section-title>
<ce:simple-para>Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.</ce:simple-para>
</ce:abstract-sec>
<ce:abstract-sec>
<ce:section-title>Methods</ce:section-title>
<ce:simple-para>This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.</ce:simple-para>
</ce:abstract-sec>
<ce:abstract-sec>
<ce:section-title>Results</ce:section-title>
<ce:simple-para>Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.</ce:simple-para>
</ce:abstract-sec>
<ce:abstract-sec>
<ce:section-title>Conclusions</ce:section-title>
<ce:simple-para>The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.</ce:simple-para>
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<abstract lang="en">Purpose To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extracapsular cataract extraction, including phacoemulsification.Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.Methods This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake–Apple views) were taken and serial histologic sections prepared.Results Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering’s ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free.Conclusions The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.</abstract>
<note>Supported in part by an unrestricted grant from Research to Prevent Blindness Inc, New York, New York, USA.</note>
<note type="content">Section title: Articles</note>
<note type="content">Figure 1: (Peng) Gross photographs of 3 human eyes with PC IOLs obtained postmortem (Miyake–Apple posterior view). Each corresponding histologic view shows the profile of absence of Soemmering’s ring with total fusion of anterior and posterior capsules (Group 1-A, Table 1). With this scenario, the CCC diameter is larger than that of the IOL optic. A: An acrylic IOL. B: Photomicrograph of A (arrow = site of fusion of the anterior capsular flap edge [AC] and the posterior capsule [PC]; O = site of the IOL optic). C: A silicone IOL.D: Photomicrograph of C (H = haptic at lens equator; AC = anterior capsule; PC = posterior capsule; O = site of the IOL optic). E: An all-PMMA IOL. F: Photomicrograph of E (AC = anterior capsule; PC = posterior capsule; O = site of the IOL optic) (B, D, and F, PAS stain; original magnification ×20).</note>
<note type="content">Figure 2: (Peng) Gross photographs of 3 human eyes with PC IOLs obtained postmortem (Miyake–Apple posterior view). Each corresponding histologic view shows examples of absence of Soemmering’s ring but with a large, empty, open space between the anterior and posterior capsules (Group 1-B, Table 1). This profile exists because the CCC was smaller than the lens optic and the capsulorhexis edge was placed on the anterior surface of the optic. The cut edge of CCC in each histologic section is identified by an arrow. A: An acrylic IOL. B: Photomicrograph of A. C: A silicone IOL. D: Photomicrograph of C. E: A single-piece PMMA IOL; the opacity seen corresponds to anterior capsule fibrosis. F: Photomicrograph of E. (B, D, and F, PAS stain; original magnification ×20).</note>
<note type="content">Figure 3: (Peng) Gross photographs of 2 eyes with a PC IOL obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows an example of retained/regenerative cortex within a Soemmering’s ring. In this subset (Group 2-A, Table 1), cellular ingrowth toward the visual axis was blocked by fusion of the anterior capsular edge of the CCC (arrows in the histologic sections) and the posterior capsule. An IOL barrier effect is therefore not required in this subset. A: An acrylic IOL. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×100). C: A silicone IOL. D: Photomicrograph of C (PAS stain; original magnification ×100).</note>
<note type="content">Figure 4: (Peng) Gross photographs of 2 eyes with 2 PC IOLs obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows examples of retained Soemmering’s ring, in which the cellular ingrowth over the visual axis was blocked by a biconvex optic with a smooth, round, and tapered edge (Group 2-B-1, Table 1). This optic geometry may allow some cellular ingrowth for a short distance behind the optic’s periphery. A: A silicone IOL. B: Photomicrograph of A. Note the growth of a layer of cortex and cells extending behind the IOL optic. The cortex and cells in the Soemmering’s ring and within the ingrowing tissue (small arrows) stain red. The large arrow connotes the imprint of the edge of the rounded lens optic (Masson’s trichrome stain; original magnification ×20). C: A single-piece all-PMMA IOL. D: Photomicrograph of C. Note the layer of cortex and cells (lower right) extending behind the IOL optic (Masson’s trichrome stain; original magnification ×20).</note>
<note type="content">Figure 5: (Peng) Gross photographs of eyes with acrylic PC IOLs obtained postmortem (Miyake–Apple posterior view). Each histologic correlate shows examples of retained/regenerative cortex (Soemmering’s ring), in which growth along the posterior capsule across the visual axis was abruptly blocked by the squared, truncated IOL optic edge (Group 2-B-2, Table 1). Two small arrows in each case demarcate the imprint of each square optic edge. The posterior capsule behind the optic is relatively cell free. The posterior capsules were artifactually ruptured during tissue processing. A: An acrylic IOL. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×20). C: An acrylic IOL. D: Photomicrograph of C (Masson’s trichrome stain; original magnification ×100).</note>
<note type="content">Figure 6: (Peng) A gross photograph of 1 eye with a single-piece all-PMMA PC IOL obtained postmortem (Miyake–Apple posterior view). The histologic correlate of this eye shows an example of retained/regenerative cortex (Soemmering’s ring) in which growth across the visual axis was abruptly blocked by the squared, truncated edge of the IOL optic (2-B-2, Table 1). The site of the square edge of the lens optic is connoted by 2 small arrows (B). A: Gross photograph. B: Photomicrograph of A (Masson’s trichrome stain; original magnification ×100).</note>
<note type="content">Figure 7: (Peng) Gross photographs of 2 human eyes with various types of early and recent model PC IOLs obtained postmortem (Miyake–Apple posterior view). Note the advanced Soemmering’s ring formation in each eye. The lens optic in each case is, in effect, called on to function to some extent as a barricade to inhibit cell ingrowth onto the visual axis. A: A 3-piece PMMA IOL. B: A single-piece silicone IOL.</note>
<note type="content">Figure 8: (Peng) The evolution of the IOL barrier effect shows the imperative of having both haptics in the capsular bag. Top: For the first 2 decades of PC IOLs, most IOL optics were plano-convex. They could initiate the barrier effect if both haptics were in the capsular bag. Middle: Placement of 1 or both haptics out of the capsular bag would diminish contact with the posterior IOL optic surface to the posterior capsule and therefore diminish the possibility of a barrier effect, allowing cell ingrowth. Bottom: Hoffer’s early attempt to enhance the IOL barrier with a 360 degrees barrier ridge (arrows). This functions as an effective barrier to ingrowth only if both haptics are securely fixated in the capsular bag.</note>
<note type="content">Figure 9: (Peng) The scenarios in the capsular bag without Soemmering’s ring (Groups 1-A and 1-B, Table 1). Top: There is fusion of the anterior and posterior lens capsules (Group 1-A). No IOL barrier effect is required. In this case, the capsulorhexis diameter is larger than the optic diameter. Bottom: In this scenario (Group 1-B), the CCC diameter is smaller than that of the optic and the cut edge of the anterior capsule rests on the optic. This leaves an empty space (aqueous filled in life) at the equatorial fornix.</note>
<note type="content">Figure 10: (Peng) The scenario when significant cortical retention/regeneration occurs (Groups 2-A and 2-B, Table 1). Top: Cell ingrowth is blocked by fusion of the posterior capsule and the anterior capsular flap (2-A). No IOL barrier effect is required. Middle: When the Soemmering’s ring is blocked by the tapered, round edge of a biconvex optic (Group 2-B-1), ingrowth behind the lens optic periphery may occur (horizontal arrow). Bottom: When the Soemmering’s ring cell ingrowth is blocked by a square, truncated optical edge (Group 2-B-2), ingrowth behind the optic is abruptly blocked at the outer edge of the optic.</note>
<note type="content">Figure 11: (Peng) Scanning electron microscopy of round-edge optic designs. Top: A PMMA IOL (original magnification ×150). Bottom: A silicone IOL (original magnification ×150).</note>
<note type="content">Figure 12: (Peng) Optic designs showing the barrier effect of a classic biconvex IOL with a round, tapered edge. Top: There is some potential of cell growth around the posterior peripheral edge of the optic into the area of posterior capsule behind the periphery of the optic (arrows). Bottom: A frontal view shows the pattern of ingrowth of cells and cortex (light green area) that may occur behind the outer periphery of the optic.</note>
<note type="content">Figure 13: (Peng) Scanning electron microscopy of 2 IOLs with square or truncated edges, each fabricated from a different biomaterial. Top: A PMMA IOL with a square-edge, unpolished design from the 1980s (original magnification ×150). Bottom: An acrylic IOL (original magnification ×150).</note>
<note type="content">Figure 14: (Peng) Optic designs demonstrating the barrier effect of a classic biconvex IOL with a thicker square or truncated edge. Top: With the square edge (seen here in sagittal section), abrupt blockage of cell growth at the optic edge is more likely. Bottom: A front view shows that ingrowth over the optic may be completely retarded as a result of the abrupt blockage of cells by the truncated, square edge.</note>
<note type="content">Figure 15: (Peng) A slitlamp photograph of an eye 3 years after implantation of an Alcon AcrySof IOL, which has a square, truncated edge. There is total absence of cell growth in the area subtending the entire IOL optic. An extensive Soemmering’s ring with pearl formation is evident outside the region of the optic, but all ingrowth is blocked.</note>
<note type="content">Figure 16: (Peng) Photomicrographs of a human eye obtained after surgical enucleation. An acrylic IOL with a square, truncated optic edge had been implanted. This was a complicated case in which the patient had multiple intraocular and extraocular surgeries. An extensive amount of retained/regenerative cortex has overwhelmed the ability of the optic to adequately form a barrier to cell migration. A: Overview of the capsular bag showing Soemmering’s ring and posterior capsular ingrowth (PCO) on the left side (pairs of small arrows = imprint of each truncated optic against the central side of the Soemmering’s ring) (H&E stain; original magnification ×20). B: High-power photomicrograph of the left side of the capsular bag seen in A. Note the imprint of the truncated optic edge (arrows), which failed to obstruct cellular ingrowth (PCO) behind the lens optic (O) (H&E stain; original magnification ×40). C: High-power photomicrograph of the right side of the capsular bag seen in Ain which the square optic edge (arrows) successfully retarded ingrowth from the Soemmering’s ring. The posterior capsule has artifactually ruptured but remains clear behind the entire IOL optic (O) (PAS stain; original magnification ×100).</note>
<note type="content">Figure 17: (Peng) Slitlamp photographs of 2 patients with foldable IOLs with truncated, square-edge optics show clear capsules with no PCO. In each case, the CCC diameter (arrows) was smaller than that of the IOL optic. A: An AcrySof acrylic IOL. B: A Pharmacia 911™ silicone IOL.</note>
<note type="content">Figure 18: (Peng) A gross photograph of an eye with an acrylic IOL with a slightly off-center CCC obtained postmortem (Miyake–Apple posterior view). On one side (left) the edge of the capsulorhexis was placed over the anterior surface of the IOL optic (arrows). The capsular bag appears clear in this region. On the other side (right), the CCC edge was outside the optic. Note the more extensive accumulation of retained/regenerative cortex and cells in this latter region.</note>
<note type="content">Table 1: Classification of capsular bag status after cataract extraction.</note>
<note type="content">Table 2: Number of IOLs included in this study fitting in the different categories of capsular bag status after cataract extraction.</note>
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