ANNUAL REVIEW

Posterior Capsule Opacication After Phacoemulsication:

Annual Review
Abhay R. Vasavada, MS, FRCS (England) and Mamidipudi R. Praveen, DOMS

Purpose: The purpose of this article is to provide a clinical update on

posterior capsule opacication (PCO) after phacoemulsication by
reviewing the literature from the last 12 months.
Design: This article is a literature review.
Methods: The authors conducted a 1-year literature search in the
English language on PCO using PubMed. The period used to conduct
the literature search was from January 1, 2013, to January 1, 2014. The
following search terms were used during the PubMed search: phacoemulsication, microcoaxial incision, posterior capsule opacication, long-term
evaluation of intraocular lens (IOL) implantation, IOL edge design and
material, surgical technique, anterior capsule overlap on the IOL optic,
diabetes mellitus, myopia, pseudoexfoliation, retinitis pigmentosa, uveitis,
and neodymium: yttrium-aluminum-garnet laser capsulotomy.
Results: This review incorporates original articles that provided fresh
insights and updates on PCO. Particular attention was paid to observational, randomized, controlled clinical trials, as well as analyses of larger
cohorts with a prospective and retrospective study design. Letters to the
editor, unpublished works, experimental trials and abstracts were not
considered.
Conclusions: This annual review provides a brief update on PCO
that might be of interest to the practicing clinical ophthalmologist.
Key Words: phacoemulsication, posterior capsule opacication,
intraocular lens, neodymium:yttrium-aluminum-garnet laser
capsulotomy
(Asia Pac J Ophthalmol 2014;3: 235Y240)

ataract is the leading cause of blindness worldwide, despite

the availability of effective cataract surgery.1,2 In the developed world, cataract treatment and rehabilitation are managed satisfactorily, but in developing countries, up to 20 million
individuals are waiting to undergo cataract surgery and 14,000
new patients are added to the list every day.3,4 Manual smallincision cataract surgery and phacoemulsication are the most
frequently performed surgical procedures in the developed
countries. They provide quick restoration of vision. However,
they can lead to complications such as the development of
secondary cataract, which is also known as posterior capsular
opacication (PCO).5Y11 This is a major medical problem
impacting the patients well-being because it can lead to decreased visual acuity. In spite of improvements in basic research
on the development of cataract, surgical techniques, as well as
the material or the design of the intraocular lens (IOL), the incidence of PCO is still 8% to 34.3% in adults and nearly 100%

From the Iladevi Cataract and IOL Research Center, Raghudeep Eye Clinic,
Ahmedabad, India.
Received for publication March 25, 2014; accepted July 2, 2014.
Reprints: Abhay R. Vasavada, MS, FRCS, Iladevi Cataract and IOL
Research Center, Raghudeep Eye Clinic, Gurukul Rd, Memnagar,
Ahmedabad 380052, India. E-mail: icirc@abhayvasavada.com.
Copyright * 2014 by Asia Pacic Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000080

Asia-Pacic Journal of Ophthalmology

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in children.12Y17 Decreased visual acuity induced by PCO is

reported to occur in 20% to 40% of patients 2 to 5 years after
surgery.8,18 The most common and indeed successful method of
treatment of PCO is to photodisrupt a section of the posterior
capsule using a high-energy Nd:YAG laser to create a clear
region around the visual axis.19 This treatment is expensive,
costing the US Medicare program millions of dollars. It can also
lead to a host of medical complications such as an increase in
intraocular pressure, retinal detachment, cystoid macular edema, and, in the extreme cases, pitting of the surface and fracture
of the intraocular lens adjacent to the cleared region.20Y22 The
technology to perform YAG laser capsulotomy is frequently
unavailable in underdeveloped countries, adding considerably
to the problems of eradicating cataract-induced blindness in
these countries. The clinical and economic signicance of PCO
makes it an important public health problem. In order to prevent
it, a clear understanding of the pathogenesis is needed.23,24
Posterior capsular opacication is a wound-healing response
of the residual equatorial lens epithelial cells (LECs), which are
inevitably left in the bag and then undergo proliferation, migration,
and metaplasia. These residual LECs can be clinically differentiated into 2 types: brotic and regeneratory LECs. Transdifferentiation of residual LECs into myobroblasts causes brotic
PCO. Migration of LECs into the space between the capsule and
the IOL with subsequent proliferation causes regeneratory PCO.
Clinically, the anterior LECs surrounding the rhexis express alpha smooth muscle actin and become myobroblasts. The equatorial cells form Elschnigs pearls. However, a biological
understanding of the reason for this is lacking. Both brotic PCO
and regeneratory PCO can lead to visual loss once the visual axis
has been involved.
This review incorporates only a selected number of articles
involving clinical trials in the English-language literature. All
articles included in this review were listed in PubMed between
January 2013 and January 2014, including large retrospective
and prospective, comparative, observational, and randomized
trials on IOLs, surgical techniques, and ocular diseases after
phacoemulsication. Only clinically relevant, novel, and potentially important and original research has been included. The
goal is to provide a comprehensive and in-depth assessment of
ndings in the eld of PCO.

Posterior Capsule Opacication With Coexisting

Ocular Disease
There is a noticeable decline in the occurrence of PCO due
to improved surgical techniques and IOL technology. Despite
these improvements, the development of PCO in patients undergoing cataract surgery is inuenced by the presence of
systemic conditions such as diabetes, pseudoexfoliation
(PEX), uveitis, and retinitis pigmentosa (RP).

Posterior Capsule Opacication

and Pseudoexfoliation
stern et al25 carried out a long-term evaluation of patients
for the development of PCO. Patients with and without PEX

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were evaluated using retrospective records of patients with PEX,

who had undergone cataract surgery between June 2001 and
December 2002. The authors compared 44 patients with PEX
to 86 patients without PEX to assess the development of PCO
6 to 7 years after phacoemulsication. A standardized surgical
procedure was implemented. The images were analyzed using
a software program (POCOman) to determine the extent and
severity of PCO. Using the guidelines available for POCOman,
PCO was dened as any formation of pearls or brous opacication, visible on the retroilluminated JPEG-formatted images.
When the analyses were based on the (estimated) edge of
the IOL and capsulorhexis, there were statistically signicant
differences between the 2 groups concerning severity and percentage of PCO (Mann-Whitney U test, P = 0.01 and P = 0.02).
There was a lower level of PCO in eyes with PEX. Percentage
and severity of PCO within the central 4.0- and 1.3-mm optical
zones were compared between the 2 groups. The results were
not statistically signicant. An additional multivariate linear
regression analysis was conducted. The percentage and severity of PCO was not statistically signicant in both groups.
Neodymium:yttrium-aluminum-garnet capsulotomy was performed in 16% (n = 7) of eyes in both groups (chi-square test,
P = 0.96). In eyes with PEX undergoing phacoemulsication,
there was a reduced risk for incurring an inammatory response. The authors assumed that since the initial inammatory response was minimal, it acted as a weaker stimulus for
the development of PCO in eyes with PEX.
This study employed a semiobjective method to assess the
long-term development of PCO in eyes with PEX. Although PEX
is associated with a varied spectrum of complications, Ostern et al
provided objective evidence of a decreased incidence of PCO
after cataract surgery. Importantly, they implemented standardized
surgical techniques for in-the-bag AcrySof IOL xation and
postoperative medication. This standardization helped objectively evaluate whether the patients with PEX ran the risk of
developing PCO. In conclusion, this study showed that at the
end of 6 years, the presence of PEX did not increase the risk of
PCO development when compared with patients without PEX.
Patients with PEX did not need PCO treatment more frequently
than patients without PEX.

Posterior Capsule Opacication and

Retinitis Pigmentosa
Dikopf et al,26 in their retrospective observational case
series, evaluated surgical outcomes in patients with RP undergoing phacoemulsication. Generally, it is difcult to predict visual
outcomes when both lenticular and retinal pathologies coexist.
There is also a high risk for postoperative complications while
performing surgery on patients with RP. One of these complications is PCO.
In this study, the authors reviewed cataract extraction in a
large group of patients with RP. Special attention was drawn to
the outcomes and complications of surgical intervention. Between 2002 and 2012, 80 eyes of 47 consecutive patients with
RP underwent phacoemulsication with IOL implantation.
Postoperative records were analyzed for incidence of PCO,
ND:YAG capsulotomy, and surgical complications. The mean
follow-up time was 23.3 months. Sixty-six (82.5%) eyes developed some level of PCO and 42 (52.5%) eyes required a
YAG posterior capsulotomy at an average of 10.8 months after
surgery. Fifteen patients had less than 3 months of follow-up. A
Kaplan-Meier survival curve was created to better describe the
development of signicant PCO and the need for a YAG
capsulotomy. There was a high occurrence of YAG capsulotomy
in RP patients with RP after cataract extraction. A majority of the

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patients required YAG capsulotomy within a year after surgery.

An increased rate of PCO is quite normal in any population of
young patients undergoing cataract extraction. However, PCO
can be exacerbated by known disruptions of the blood-ocular
barrier in patients with RP, allowing for high aqueous levels of
interleukin 1 to accumulate after surgery.
There were high PCO rates in patients with RP due to
zonular laxity. It allowed posterior capsule wrinkling proir to
capsular phimosis, providing an effective network for migration
of lens epithelial cells (LEC). Aggressive capsule polishing by
simple or ultrasound aspiration, osmolysis, or even usage of a
capsular tension ring was often suboptimal in preventing PCO in
patients with RP. One of the strengths of this study is the use of a
large sample of patients with RP operated on by a single surgeon.
However, the study has its limitations. The most signicant
limitation is the use of a retrospective design. Another limitation
is the use of both eyes although the use of a single eye of each
patient would have been scientically more valid. The rates of
PCO and YAG capsulotomy (82.5% and 52.2%, respectively)
conrm this known complication of cataract surgery in patients
with RP.

Posterior Capsule Opacication and High Myopia

Zhao et al27 attempted to understand the mechanisms affecting the development of PCO in highly myopic eyes by using
ultra-long scan depth optical coherence tomography (UL-OCT).
They compared highly myopic eyes with emmetropic eyes
for capsule-IOL interactions, including anterior and posterior
capsule adhesion and conguration of the capsular bend. Various congurations of capsular bend with the IOL were observed
at the last follow-up. They were classied into complete and
incomplete capsular bends. Three different types of complete
capsular bends by UL-OCT were described postoperatively. The
rst was anterior adhesion in which the anterior posterior capsule was attached to the anterior side of the optic. The second was
middle adhesion in which the anterior posterior capsule was attached to the middle of the optic, and the third was posterior
adhesion in which the anterior posterior capsule was attached to
the posterior side of the optic. Three different types of incomplete capsular bends by UL-OCT were also described postoperatively. The rst was funnel adhesion in which the anterior
posterior capsule was attached to the middle of the optic at a
distance from the IOL. The second was parallel adhesion, in
which the anterior posterior capsule did not attach completely.
Finally, the third was furcate adhesion in which the anterior
posterior capsule was separated peripherally although the capsular bend was formed at the edge of the IOL.
This prospective study included 40 eyes of 40 patients with
cataract scheduled for phacoemulsication with a single-piece
AcrySof IOL implantation (Alcon Laboratories, Inc, Fort Worth,
TX, USA). Among the 40 eyes, 20 were highly myopic (axial length
926 mm; high myopia group) and the other 20 were emmetropic
with a normal axial length (22 mm G axial length G 24.5 mm; emmetropia group). Three types of capsular bends with complete
adhesion were found in highly myopic eyes. Anterior adhesion
was observed in most cases (70%). In highly myopic eyes, 4
capsular bends were observed with middle adhesion, while only
1 nasal capsular bend was found with posterior adhesion. Three
types of capsular bends with incomplete adhesion were found
at the last follow-up in highly myopic eyes. Six capsular bends
presented funnel adhesion, 8 capsular bends presented parallel
adhesion, and 1 capsular bend showed furcate adhesion. Three
types of capsular bends with complete adhesion were found in
highly myopic eyes. Anterior adhesion was observed in most
cases (70%). In highly myopic eyes, 4 capsular bends were
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observed with middle adhesion, whereas only 1 nasal capsular

bend was found with posterior adhesion. Three types of capsular
bends with incomplete adhesion were found at the last follow-up
in highly myopic eyes. Six capsular bends presented funnel adhesion, 8 capsular bends presented parallel adhesion, and 1
capsular bend showed furcate adhesion. There was signicantly
less apposition of the posterior capsule against the IOL in
highly myopic eyes when compared to emmetropic eyes. Posterior capsular adhesions were delayed in highly myopic eyes
during the follow-up. At the 28-day follow-up, slight PCO was
found in 5 highly myopic eyes because the posterior capsule did
not adhere completely to the IOL. The rate of posterior capsule adhesion in eyes with a high degree of axial myopia
was signicantly lower than that observed in emmetropic eyes.
The authors speculated possible reasons for this. The IOLs were
implanted in relatively large capsular bags in the high myopia
group. The capsular bag diameter correlated positively with the
axial length, while IOL thickness correlated with IOL power.
Secondly, a lower IOL power resulted in reduced posterior convexity. A large-sized posterior capsule with steep convexity could
affect posterior capsular adhesion to the IOL. These two factors
may have weakened the ability of the capsule to stretch after IOL
insertion in highly myopic eyes. A noteworthy observation was
that the types of capsular bend were more heterogeneous in the
high myopia group and displayed incomplete apposition when
compared to the emmetropia group.
This was a prospective study exploring the dynamics of
PCO development in highly myopic eyes. The study objectively
documented the apposition of the posterior capsule to the IOL
using a custom-built, UL-OCT device. The development of PCO
could have been attributed to the incomplete formation of capsular bends in highly myopic eyes during the early postoperative
period, coupled with weak adhesion between the posterior capsule and the IOL. Capsular bend formation has long been considered crucial for PCO prevention. The authors further
speculated that highly myopic eyes with incomplete capsular
bend could have facilitated LEC migration. Delayed or incomplete capsule-IOL interaction is believed to increase LEC proliferation and migration due to weak adhesion. There are potential
limitations to this study. First, the authors evaluated the procedure
for only 28 days postoperatively. Secondly, the sample size was
too small. Thirdly, even though the authors observed the capsuleIOL interaction spatially, it was not possible to calculate the
space due to the technical limitations of OCT.

Posterior Capsule Opacication With Alternate

Surgical Techniques
Trypan Blue Injection and Posterior
Capsule Opacication
Today, the focus of combating PCO is on the lysis of LECs.
In a prospective, randomized, clinical trial of patients undergoing phacoemulsication with foldable IOL implantation,
Sharma et al coauthors studied the effect of injecting 0.1%
trypan blue into the capsular bag on the development of
PCO.28 Eyes were randomized into 2 groups, the trypan blue
group or the control group. The trypan blue group received
0.2 mL of 0.1% trypan blue (Visiblue; Shah & Shah) injected
subcapsularly at 2 sites that were 180 degrees apart after corticalcleaving hydrodissection. The control group received 0.2 mL
of a balanced salt solution injected in a similar fashion and a
second injection of balanced salt solution after cortical-cleaving
hydrodissection so that the total quantity of uid in the bag was
the same in both groups. A single surgeon performed all surgeries
using topical anesthesia and a standardized surgical technique.
* 2014 Asia Pacic Academy of Ophthalmology

PCO Annual Review (January 2013-January 2014)

A foldable hydrophilic acrylic square-edged IOL (CT ASPHINA

603P; Carl Zeiss Meditec) was implanted with a wound-assisted
delivery. An anterior segment photograph under full mydriasis
was taken at 6 and 12 months. Posterior capsular opacication
grading was done. The PCO score was signicantly lower in
the trypan blue group when compared to the control group at
6 and 12 months.
This study demonstrated the role played by trypan blue in
inhibiting PCO. However, a major limitation is the small sample
size used. Another limitation is that PCO had been evaluated for
over 1 year instead of the customary 3-year duration. A study
with a larger sample size carried out over a longer duration is
warranted to conclusively ascertain the long-term effects of
trypan blue on PCO formation.

Phacovitrectomy and Posterior

Capsule Opacication
Iwase et al29 evaluated PCO development in eyes with idiopathic epiretinal membranes (ERMs) undergoing 20-gauge phacovitrectomy (n = 20 eyes), 23-gauge phacovitrectomy (n = 20
eyes), and phacoemulsication alone (n = 50 eyes). The duration
of follow-up was 24 months. After administration of retrobulbar
and peribulbar anesthesia, a half-round fornix-based conjunctival incision was created in the 20-gauge phacovitrectomy
group. A 3-mm self-sealing sclerocorneal tunnel was created at
12 oclock in eyes in all the groups. A standardized surgical
technique of phacoemulsication was implemented. The wound
was not enlarged and the SA60AT IOLs were inserted in the
capsular bag. Sutures were not used to close the sclerocorneal
tunnel incision. After making 3 scleral ports in the 23-gauge
phacovitrectomy group, vitrectomy and ERM peeling without
staining were performed. Each sclerotomy was then closed with
a 7.0 suture in the 20-gauge phacovitrectomy group. Finally, the
conjunctival wound was sutured in the 20-gauge phacovitrectomy group. Suturing was not required in the 23-gauge phacovitrectomy group. The PCO density value was measured using
Scheimpug video photography (EAS-1000; NIDEK, Gamagori,
Japan) at 1 week, 1 month, 3, 6, 12, 18, and 24 months after surgery.
The PCO value of the 20-gauge phacovitrectomy group
was signicantly higher than that of the 23-gauge phacovitrectomy group at 6, 12, 18, and 24 months after surgery. Similarly,
the PCO value in the 23-gauge phacovitrectomy group was significantly higher than that of the cataract surgery group at 24 months
after surgery. The same IOL, SA60AT, was implanted in all the
cases, indicating that the surgical procedure was the only difference among the groups. In this report, similar procedures
were performed for each ERM case, namely, cataract surgery,
core vitrectomy, and ERM peeling. The reduced incidence of
PCO could be attributed to the small size of the vitrectomy instruments used, which lowered postoperative intraocular inammation. As vitrectomy was less traumatic, the procedure did
not seem to cause strong inammation. There were no signicant
differences in postoperative intraocular inammation between the
23-gauge phacovitrectomy and the cataract surgery groups. Despite this, there was an incidence of PCO in the 23-gauge
phacovitrectomy group.
To the best of our knowledge, this is the rst report quantifying
PCO in phacovitrectomy using non-qualitative methods (EAS1000, Scheimpug camera). As selection bias had been minimized, the differences between the characteristics of patients
and the kinds of retinal diseases could not affect the resultant
outcomes. Minimization of selection bias is crucial to any study
of this kind. There are many variables that can be associated
with PCO development such as the occurrence of intraoperative
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and/or postoperative complications, usage of long-acting gas

tamponade, and postoperative posturing. We speculate that the
posterior pressure in eyes without a vitreous may have prevented
capsular bend formation that requires a sharp optic edge and
posterior pressure. It is, therefore, possible that the IOL edge has a
minimal effect in reducing PCO in phacovitrectomy. In addition, a
high level of postoperative inammation may probably lead to
LEC migration and extensive PCO in eyes undergoing phacovitrectomy. As this study included only cases with ERMs, these
results may only apply to similar cases that have not undergone
additional procedures, such as laser photocoagulation or gas tamponade. Further studies are warranted to examine the development
of PCO between patients undergoing 25-gauge phacovitrectomy
and cataract surgery.

Intraocular Lens and Posterior

Capsule Opacication
Posterior Capsule Opacication With the iMics1
NY-60 and AcrySof SN60WF: 3-Year Results of a
Randomized Trial
Leydolt et al30 conducted a prospective, randomized, and
controlled study comparing PCO development between two
hydrophobic acrylic single-piece, sharp-edged IOLs with a
follow-up period of 3 years. One hundred patients (200 eyes)
were included in this trial. Each patient randomly received an
iMics1 NY-60 IOL (Hoya Corp, Tokyo, Japan) in 1 eye and an
AcrySof SN60WF IOL (Alcon Laboratories, Inc, Fort Worth,
TX) in the contralateral eye to allow for intraindividual comparison. A single surgeon performed the surgeries using a standardized technique. Follow-up examinations were performed at 1
week and 3 years after surgery. At each follow-up visit, the amount
and type of regeneratory PCO were evaluated. Digital retroillumination images of the posterior capsule were captured. Posterior
capsular opacication levels were analyzed using automated
image analysis software (Automated Quantication of AfterCataract [AQUA]). At 3 years, the PCO score on a scale from
0 to 10 was 3.0 T 2.0 in the iMics1 NY-60 group and 1.9 T 1.4
in the AcrySof SN60WF group. The difference between the
2 groups was statistically signicant (P G 0.001). However,
46 eyes (82%) in the iMics1 NY-60 group and 9 eyes (16%) in the
AcrySof SN60WF group showed a high level of regeneratory
PCO. After the 3-year follow-up, the rates of Nd:YAG laser
capsulotomy in iMics1 NY-60 was signicantly higher when
compared against the AcrySof SN60WF eyes (P G 0.001). The
results demonstrated that 3 years after surgery, eyes with iMics1
NY-60 IOLs showed a statistically signicantly higher PCO score
(3.0 T 2.0) and Nd:YAG capsulotomy rate (35.6%) than those with
AcrySof SN60WF IOLs (PCO, 1.9 T 1.4; Nd:YAG, 13.7%). The
authors did not observe a lower incidence of PCO in the eyes
with the iMics1 NY-60 IOL compared to the eyes with the
AcrySof SN60WF IOL. On the contrary, the iMics1 NY-60 IOL
presented a statistically signicant higher Nd:YAG capsulotomy
rate (35.6%) 3 years after surgery. In conclusion, the present
study indicates statistically signicant differences in the rate
of PCO and Nd:YAG capsulotomy between 2 similarly designed
sharp-edged, single-piece IOL models. These disparities can be
attributed to differences in their material properties.
The results of this study have shown that IOL materials
play an important role in PCO formation. The various hydrophobic acrylic IOLs differ not only in the techniques used in their
manufacture, but also in the postprocessing modications of their
surface. It is evident that the properties of the materials used in
IOLs impact biological responses such as capsular biocompatibility and LEC migration. An analysis of the surface of AcrySof

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IOLs revealed a signicantly higher magnitude of surface roughness or morphological changes. Another important factor is adhesion of the IOL surface to the capsular bag mediated by
extracellular matrix proteins. Better adhesion is assumed to result in less LEC growth between the IOL surface and the capsular bag, causing a lower level of PCO. In vitro studies have
shown that hydrophobic acrylic IOLs bind bronectin to a statistically signicantly greater degree than other IOL materials.
Thus, bronectin seems to act as a biological glue with these
IOLs resulting in a lower level of PCO. A limitation of the present
study is that no additional follow-up visits scheduled between 1
week and 3 years after surgery. An in-between follow-up visit
would have allowed a PCO value to be estimated for those eyes
so as to demonstrate viability of laser capsulotomy at the 3-year
follow-up.

Posterior Capsule Opacication With 3

Intraocular Lenses: 12-year Prospective Study
Most PCO studies have a follow-up duration ranging from
1 to 3 years, and there are a few studies with a 5-year follow-up.
There are very few data available in the literature on PCO development on a long-term basis.
This study was an extended follow-up of a randomized
trial whose earlier outcomes at 2, 3, and 5 years have already
been reported. Rnbeck et al31 in this prospective study compared PCO formation after implantation of 3 IOL models
12 years after surgery. Using a randomization protocol, the
surgeon implanted 1 of the following 3 IOLs: a heparin-surfacemodied poly (methyl methacrylate) (HSM PMMA) IOL (809C;
Pharmacia & Upjohn, Inc.), a foldable silicone IOL (SI-40NB,
Allergan, Inc.), or a foldable hydrophobic acrylic IOL (AcrySof
MA60BM; Alcon Laboratories, Inc.). At the follow-up examinations, 11.3 to 13.4 years postoperatively, POCOman system
was used to analyze PCO in retroillumination images of the
posterior capsule. The percentage of PCO in the total area of the
posterior capsule inside the capsulorhexis was the PCO fraction.
The number of patients undergoing Nd:YAG capsulotomy during the extended follow-up period and the timing of this treatment after surgery were recorded. After 12 years, there was no
signicant difference in the fraction or severity of PCO between
the silicone and acrylic IOLs. The HSM PMMA IOL had a
signicantly higher PCO fraction than the silicone IOL (P G
0.05) but not higher that of the acrylic IOL. There was no difference in the severity of PCO between the HSM PMMA IOL
and the other 2 IOLs. The silicone IOL had a higher median
capsulotomy-free survival (9150 months) than the acrylic IOL
(108 months) and the HSM PMMA IOL (53 months). Survival
without Nd:YAG capsulotomy did not differ between the acrylic
and the silicone IOLs or between the silicone and the HSM
PMMA IOLs; however, overall survival was signicantly better
with the acrylic IOL than with the HSM PMMA IOL (P G 0.001).
The PCO evaluation using the retroillumination photographs
showed that over time, the differences between the IOLs became
increasingly lower. Regarding the overall survival without
Nd:YAG capsulotomy over the entire 12-year postoperative period, the sharp-edged hydrophobic acrylic IOL and the roundedged silicone IOL seemed to induce less PCO than the roundedged HSM PMMA IOL. After approximately 6 to 7 years, the
survival curve of the silicone IOL crossed that of the hydrophobic
acrylic IOL. Subsequently, it had better survival without Nd:YAG
capsulotomy than the hydrophobic acrylic IOL despite its round
edge.
The authors observed that these results were in line with
those in their 5-year follow-up study. They attributed the
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efciency of the silicone IOL in inhibiting PCO in the long run

to its material property. The adhesiveness of silicone to
vitronectin and collagen type IV was signicantly higher than
the adhesiveness of acrylate to these proteins, 1 week after incubation. Silicone is believed to catalyze the process of
myobroblastic transdifferentiation and collagenous sealing of the
capsular leaves at the optic edge. This might have resulted in
more permanent sealing at the optic edge so that it could better
withstand mechanical pressure from proliferating LECs. In
conclusion, after 12 years, there was no difference in PCO or
overall survival without capsulotomy between the acrylic and the
silicone IOLs. The HSM PMMA IOL had a signicantly higher
PCO fraction than the silicone IOL and a lower overall survival
than the acrylic IOL.
The PCO inhibitory property of the 3 IOL groups with a
shorter follow-up of 2 to 3 years does not apply after 12 years.
The PCO scores were not signicantly higher with the hydrophobic acrylic IOL than with the silicone IOL. The reduced or
lost efciency of the sharp edge of the hydrophobic acrylic IOL
is believed to result from late proliferation of LECs leading to
an emerging Soemmerring ring in the peripheral capsular bag.
This causes mechanical pressure, breaking the seal between the
fused anterior and posterior capsule leaves. The capsular bend
at the sharp posterior edge is reversed. This results in a delayed
barrier failure. The LECs can migrate behind the posterior optic. There was a slope in the Nd:YAG-free survival curve of the
hydrophobic acrylic IOL at 4 to 5 years, indicating that the
Soemmerring ring was present from approximately 4 years
onward as it took weeks to months for the LECs to proliferate
and migrate to the visual axis. The current study has a few
limitations. Due to the lengthy duration of the study, many patients were lost to follow-up. The 3 IOLs differed in material,
design, and size. However, despite this, the results are interesting and worth reporting.

Posterior Capsule Opacication Between 2 Aspheric

Microincision Intraocular Lenses
The use of microincision cataract surgery (MICS) has necessitated the development of a generation of microincision
IOLs that can be implanted through subY2.0-mm incisions. It is
important that these IOLs perform as well as IOLs designed for
conventional incisions. Until recently, available microincision
IOLs did not match the standards of conventional IOLs.
Keeping these factors in view, Nanavaty et al32 designed
this study to evaluate differences in the incidence of PCO between 2 aspheric microincision hydrophilic IOLs (Acri.Smart
36A and Akreos MI-60) with a conventional single-piece hydrophobic acrylic spherical IOL (AcrySof SN60AT; Alcon Laboratories, Inc.). All eyes underwent standardized phacoemulsication
for bilateral cataract performed by a single surgeon. The
capsulorhexis was fashioned to overlap the IOL optic edge by
360 degrees. Either the Acri.Smart 36A (negatively aspherical
IOL) or the Akreos MI-60 (aspherically neutral IOL) was injected
through a 2.4-mm temporal clear corneal incision in the rst
eye. The AcrySof SN60AT IOL was implanted in the fellow eye
within 3 weeks. All patients were examined postoperatively at 1,
3, 6, 12, and 24 months. The digital retroillumination images of
each of the eyes were analyzed to measure the percentage area of
PCO in the capsulorhexis area. The mean percentage PCO score
was signicantly less with the Acri.Smart 36A IOL when compared with the Akreos MI-60 IOL at 1, 3, and 12 months (P =
0.03, P = 0.02, and P = 0.05, respectively). Further, there was a
signicant difference in the percentage of PCO scores at 1 month
and 12 months among all 3 IOLs (P = 0.01 and P = 0.04). At
* 2014 Asia Pacic Academy of Ophthalmology

PCO Annual Review (January 2013-January 2014)

1 month, the AcrySof SN60AT IOL showed a higher level of

PCO, whereas at 12 months, the Akreos MI-60 IOL showed a
higher level of PCO. It increased linearly with time for the
Acri.Smart 36A IOL and the Akreos MI-60 IOL, with a maximum of up to 16% and 23%, respectively. Further, the
capsulotomy rate was 4.8% (2 out of 42 eyes) with the
Acri.Smart 36A IOL 24 months postoperatively. With the
Akreos MI-60 IOL, the authors found a mean PCO score
of 22.57% T 25.56% at 2 years and 8 eyes (19%) required Nd:
YAG capsulotomy for a visually signicant PCO. At 2 years,
the mean PCO score was lower than 11% for the conventional
AcrySof IOL and 23% for the Akreos MI-60 IOL. With the
hydrophilic acrylic microincision IOLs, PCO showed a trend
toward progression over the 2-year follow-up.
Hydrophilic acrylic material and the posterior optic edge
design of the IOL inuence PCO performance. The Acri.Smart
36A IOL is a hydrophilic IOL with a hydrophobic surface and
is used as a platform for toric, multifocal, and multifocal toric
IOLs. It is likely that these variations will have a similar incidence of PCO. The Akreos MI-60 IOL has 4 haptics with a
10-degree angulation and a 360-degree square-edged design.
These features are intended to prevent PCO. In the present
study, high rates of YAG capsulotomy with the Akreos MI-60
IOL were found. This could have been due to the difference
in material characteristics and design or the posterior optic
edge prole. Sharpness of the square edges of the IOL varies
with different IOLs and is dependent on the manufacturing techniques. The absence of a square-edged barrier at the optic-haptic
junction of some IOLs may contribute to the migration of LECs
through the optic-haptic junction. In summary, in this study, the
authors found that the Acri.Smart 36A IOL had better PCO performance than the Akreos MI-60 IOL. However, at the two-year
follow-up, a conventional hydrophobic acrylic IOL had better
PCO performance than both microincision IOLs.

CONCLUSIONS
At present, PCO remains the most common complication
of modern cataract surgery. Posterior capsular opacication is
caused by residual LECs, which are inevitably left in the bag
and undergo proliferation and metaplasia. PCO is believed to be
multifactorial and inuenced by factors such as age or concomitant intraocular or systemic diseases, surgical technique,
and IOL design. There is considerable interest in the impact of
the IOL on the development of PCO since the characteristics and
the designs of the IOLs play a crucial role in preventing PCO.
Furthermore, differences in PCO performance between IOLs are
likely to reect their distinction in biomaterials and designs.
Current strategies to prevent PCO focus on IOL design. Clinical
studies have now clearly dened important parameters. The
sharpness or squareness of the edge prole is of paramount
importance. The square edge seems to prevent LEC migration
into the central posterior capsule. It forms a pressure barrier as it
is pushed against the posterior capsule, thereby increasing brosis of the bag in the rst few weeks after surgery. This helps
prevent PCO no matter which type of IOL is used. Most surgeons now aim to make the rhexis smaller than the IOL diameter.
Another important design feature is that the square edge barrier
should be of 360 degrees. A break in the barrier is the Achilles
heel, where LECs can penetrate into the posterior capsule
through the optic-haptic junction. The no space, no cell theory
is known as the main mechanism preventing PCO. Although the
cortex is completely removed, the LECs at the equator could
proliferate and migrate toward the posterior capsule when a potential space exists between the capsular bag and the IOL. It is
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Vasavada et al

generally believed that delayed or incomplete capsule-IOL interaction might increase LEC proliferation and migration due to
weak adhesion. Two key factors should be considered: capsular
bend formation and posterior capsule apposition with the IOL.
Early and rapid formation of the capsular bend could block LEC
migration and proliferation. Tight adhesion between the posterior capsular bag and the IOL could create a second defensive
barrier to inhibit LEC migration and proliferation. Many clinical
studies have also shown that PCO rates seem to be higher with
hydrophilic IOLs in comparison with hydrophobic IOL materials. This is related to an intrinsic property of the hydrophilic
material. There is a large amount of experimental works on
destroying LECs at the time of surgery by drug delivery, surgical
technique, or physical LEC destruction, but none of these has
been applied in clinical practice lest there be of pharmacological
bystander damage elsewhere in the eye or the risk of increased
surgical complications, time or cost. Present research now focuses on modulating LECs rather than destroying them. Last but
not least implantation of IOLs with improved designs and enhanced surgical techniques have reduced the incidence of PCO.
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