# Presentation: 610748

## Slide 1

## Phakic posterior chamber IOLs

- Cells involved in crystalline lens and capsular bag opacification
- Evolution of designs of PPCIOLs
- Relevant aspects of fixation and sizing
- Sizing issue: New studies
- Surgical implantation
- Relationship between cataract and myopia
- Cataractogenesis
- Specimens analyzed in our Center (Center for Research on Ocular Therapeutics and Biodevices and Magill Research Center for Vision Correction, Storm Eye Institute, MUSC)
- Mechanisms
- Review of the literature
- Classification of cataracts after phakic IOL implantation?

## Slide 3

## Third generation:

**Third generation:**
**Staar ICL**

- _Courtesy:_ Paul Koch, MD, Koch Eye Surgicenter, Inc., Warwick, RI, USA

## Third generation:

**Staar ICL**

- _Courtesy:_ Paul Koch, MD, Koch Eye Surgicenter, Inc., Warwick, RI, USA

## Case of A. Chayet, MD, Mexico (ICL + capsulorhexis)

**Case of A. Chayet, MD, Mexico (ICL + capsulorhexis)**

## ICL – Pigment Deposition/Dispersion

**ICL – Pigment Deposition/Dispersion**

**Case of R. Gerl, MD, Germany**

## Phakic posterior chamber IOLs

- Cells involved in crystalline lens and capsular bag opacification
- Evolution of designs of PPCIOLs
- Relevant aspects of fixation and sizing
- Sizing issue: New studies
- Surgical implantation
- Relationship between cataract and myopia
- Cataractogenesis
- Specimens analyzed in our Center
- Mechanisms
- Review of the literature
- Classification of cataracts after phakic IOL implantation?

## Jimenez-Alfaro I, et al. Ophthalmology 2001; 108:90-99
(20 eyes; age 27-40 years; myopia –9.0 to -19.5 D; follow-up 16.5 ±
5.1 months):
Anterior chamber reduction (9-12%)
Central endothelial cell density decrease (not progressive)
Increase of the aqueous flare (50%); stabilization above preoperative values
Progressive decrease of crystalline lens transmittance
Contact ICL-iris in all eyes
Peripheral contact ICL-crystalline lens (60%)
Central contact ICL-crystalline lens (15%)
Changes in ICL axis (10%)

**(20 eyes; age 27-40 years; myopia –9.0 to -19.5 D; follow-up 16.5 ±**
**5.1 months):**
**Anterior chamber reduction (9-12%)**
**Central endothelial cell density decrease (not progressive)**
**Increase of the aqueous flare (50%); stabilization above preoperative values**
**Progressive decrease of crystalline lens transmittance**
**Contact ICL-iris in all eyes**
**Peripheral contact ICL-crystalline lens (60%)**
**Central contact ICL-crystalline lens (15%)**
**Changes in ICL axis (10%)**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Surgical trauma		-possible cataractogenetic effects of the 					Nd:YAG laser
					-accidental contact of the anterior capsule 				during different surgical steps

Intermitent microtraumas		-increased crystalline curvature 						during accommodation
						-rotation of the phakic lens 						postoperatively

Increase in the overall lens size throughout life

**	****	****	****	****	****-accidental contact of the anterior capsule ****	****	****	****	****during different surgical steps**
**Intermitent microtraumas****	****	****-increased crystalline curvature ****	****	****	****	****	****	****during accommodation**
**	****	****	****	****	****	****-rotation of the phakic lens ****	****	****	****	****	****	****postoperatively**
**Increase in the overall lens size throughout life**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Constant trauma
(contact phakic lens-anterior capsule)

**(contact phakic lens-anterior capsule)**
**	****	****	****	****	**
**	****	****	****	****	****	**
**	****	****	**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

**central**

**periphery**

## Continuous disruption of the
blood-aqueous barrier
(subclinical inflammation)

Caused by:
-friction iris/phakic lens
-ciliary sulcus fixation	

Effects on the:	
-crystalline lens transmittance
-corneal endothelium 						

**blood-aqueous barrier**
**(subclinical inflammation)**
**Caused by:**
**-friction iris/phakic lens**
**-ciliary sulcus fixation****	**
**Effects on the:****	**
**-crystalline lens transmittance**
**-corneal endothelium ****	****	****	****	****	****	**
**	****	**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Crystalline lens metabolic
and nutritional disturbances

Caused by:
-subclinical inflammation
-blockage of normal circulation
of the aqueous humor					

**and nutritional disturbances**
**Caused by:**
**-subclinical inflammation**
**-blockage of normal circulation**
**of the aqueous humor****	****	****	****	****	**
**	****	**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Phakic posterior chamber IOLs

- Cells involved in crystalline lens and capsular bag opacification
- Evolution of designs of PPCIOLs
- Relevant aspects of fixation and sizing
- Sizing issue: New studies
- Surgical implantation
- Relationship between cataract and myopia
- Cataractogenesis
- Specimens analyzed in our Center
- Mechanisms
- Review of the literature
- Classification of cataracts after phakic IOL implantation?

## Review of the literature (1996-2001)
-21 studies
-Fyodorov early lenses, Chiron-
Adatomed, ICL					

**-21 studies**
**-Fyodorov early lenses, Chiron-**
**Adatomed, ICL****	****	****	****	****	**
**	****	**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Fechner PU et al. Posterior chamber myopia lenses in phakic eyes. J Cataract Refract Surg 1996; 22:178-182

-Chiron-Adatomed silicone lens
-69 eyes of 37 patients
-Anterior subcapsular opacities in 8/45 eyes (17.8%)
-1 to 2 years postoperatively
-No space between phakic lens and natural lens

**-Chiron-Adatomed silicone lens**
**-69 eyes of 37 patients**
**-Anterior subcapsular opacities in 8/45 eyes (17.8%)**
**-1 to 2 years postoperatively**
**-No space between phakic lens and natural lens**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Zaldivar R, et al. Posterior chamber phakic intraocular lens for myopia of -8 to -19 diopters. J Refract Surg 1998; 14:294-305

-Staar ICL
-124 myopic eyes
-2 eyes with opacities present preoperatively (no evolution)
- 1 eye with a peripheral anterior subcapsular opacity developed in the region of the peripheral laser iridotomy

**-Staar ICL**
**-124 myopic eyes**
**-2 eyes with opacities present preoperatively (no evolution)**
**- 1 eye with a peripheral anterior subcapsular opacity developed in the region of the peripheral laser iridotomy**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Trindade F, Pereira F. Cataract formation after posterior chamber phakic intraocular lens implantation. J Cataract Refract Surg 1998; 24:1661-1663

-Staar ICL
-1 case report
-Cataract 6 months postoperatively
-59-year-old woman
-Contact ICL-anterior capsule in the midperiphery (UBM)
-Anterior subcapsular opacity in the central, noncontact area

**-Staar ICL**
**-1 case report**
**-Cataract 6 months postoperatively**
**-59-year-old woman**
**-Contact ICL-anterior capsule in the midperiphery (UBM)**
**-Anterior subcapsular opacity in the central, noncontact area**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Pesando PM, et al. Posterior chamber collamer phakic intraocular lens for myopia and hyperopia. J Refract Surg 1999; 15:415-423

-Staar ICL
-19 myopic eyes
-15 hyperopic eyes
-Anterior subcapsular opacity developed 24 hours after surgery

**-****Staar ICL**
**-19 myopic eyes**
**-15 hyperopic eyes**
**-Anterior subcapsular opacity developed 24 hours after surgery**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Kaya V, et al. Phakic posterior chamber plate intraocular lenses for high myopia. J Refract Surg 1999; 15:580-585

-Fyodorov lens
-34 myopic eyes
-1 case of nuclear cataract
-52-year-old male, with +2 nuclear sclerosis preoperatively 

**-Fyodorov lens**
**-34 myopic eyes**
**-1 case of nuclear cataract**
**-52-year-old male, with +2 nuclear sclerosis preoperatively **

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Fink AM, et al. Cataract development after implantation of the Staar collamer posterior chamber phakic lens. J Cataract Refract Surg 1999; 25:278-282

-Staar ICL
-Case report (36 and 40-year-old patients)
-Anterior subcapsular opacities 10-14 months postoperatively in 3 of the 4 eyes
-Opacities appeared superiorly and progressed involving the optical zone
-Satisfactory central ICL vault in all of the cases (slit-lamp and UBM)

**-Staar ICL**
**-Case report (36 and 40-year-old patients)**
**-Anterior subcapsular opacities 10-14 months postoperatively in 3 of the 4 eyes**
**-Opacities appeared superiorly and progressed involving the optical zone**
**-Satisfactory central ICL vault in all of the cases (slit-lamp and UBM)**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Menezo JL, et al. Posterior chamber phakic intraocular lenses to correct high myopia: A comparative study between Staar and Adatomed models. J Refract Surg 2001; 17:32-42

-12 myopic patients
-ICL in one eye and Chiron-Adatomed in the other
-Anterior subcapsular cataract: 25% with ICL after 19-21 months; 33.3% with silicone lens after 9-16 months
-No space between phakic lens and natural lens

**-12 myopic patients**
**-ICL in one eye and Chiron-Adatomed in the other**
**-Anterior subcapsular cataract: 25% with ICL after 19-21 months; 33.3% with silicone lens after 9-16 months**
**-No space between phakic lens and natural lens**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Incidence of cataract varies considerably
	Chiron-Adatomed: 0-52.9%
	ICL: 0-25%
	-Definition: cataract x opacity
	-Variation of age and follow up period
	-Implantation of different (successive) models in the same study 

**	****Chiron-Adatomed: 0-52.9%**
**	****ICL: 0-25%**
**	****-Definition: cataract x opacity**
**	****-Variation of age and follow up period**
**	****-Implantation of different (successive) models in the same study **

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Standardization of the studies:

	-Describe parameters of Nd:YAG laser iridotomies
	-Note any intraoperative trauma to the anterior capsule
	-Follow up period of at least 1 year
	-Evaluation of the relationship of the phakic lens with anatomic structures (slit-lamp, UBM, Scheimpflug camera...)

**	****-Describe parameters of Nd:YAG laser iridotomies**
**	****-Note any intraoperative trauma to the anterior capsule**
**	****-Follow up period of at least 1 year**
**	****-Evaluation of the relationship of the phakic lens with anatomic structures (slit-lamp, UBM, Scheimpflug camera...)**
**	**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Standardization of the studies (cont.):

	-Development of an accurate method to choose the IOL size
	-Evaluation of subclinical inflammation with laser flare meters
	-Evaluation of explanted phakic lenses and histopathological analysis of adjacent tissues
	-Description of the evolution of the anterior subcapsular opacity

**	****-Development of an accurate method to choose the IOL size**
**	****-Evaluation of subclinical inflammation with laser flare meters**
**	****-Evaluation of explanted phakic lenses and histopathological analysis of adjacent tissues**
**	****-Description of the evolution of the anterior subcapsular opacity**

**Cataractogenesis after phakic posterior chamber intraocular lens implantation**

## Phakic posterior chamber IOLs

- Cells involved in crystalline lens and capsular bag opacification
- Evolution of designs of PPCIOLs
- Relevant aspects of fixation and sizing
- Sizing issue: New studies
- Surgical implantation
- Relationship between cataract and myopia
- Cataractogenesis
- Specimens analyzed in our Center
- Mechanisms
- Review of the literature
- Classification of cataracts after phakic IOL implantation?

## Progression of the cataracts

- “Peripheral opacities, non progressive” (personal communications)
- “Superior opacity, with progression involving the optical zone” (**Fink AM, et al. Cataract development after implantation of the Staar collamer posterior chamber phakic lens. *****J Cataract Refract Surg***** 1999; 25:278-282)**

## Classification systems

- Based on standard retroillumination photographs and the total area of the opacities
- 	-Lens Opacities Classification System (LOCS III)
- 	-Wilmer system
- 	-Oxford system

## Slide 29

## Slide 30

## Slide 31

## Classification systems

- Sophisticated systems combining high-resolution digital retroillumination imaging with image analysis systems, allowing objective documentation and quantitative measurement (as for PCO)
- 	-Pande MV, Ursell PG, Spalton DJ, et al. High-resolution digital retroillumination imaging of the posterior lens capsule after cataract surgery. *J Cataract Refract Surg* 1997; 23:1521-1527
- 	-Tetz MR, Auffarth GU, Sperker M, et al. Photographic image analysis system of posterior capsule opacification. *J Cataract Refract Surg* 1997; 23:1515-1520

## Classification of cataracts after phakic IOL implantation?

**-Peripheral (area)**
**-Paracentral (area)**

**-Central (area)**

## Thank you!