Clinical Ophthalmology

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Epidemiological evaluation of YAG capsulotomy
incidence for posterior capsule opacification invarious intraocular lenses in Japanese eyes
This article was published in the following Dove Press journal:
Clinical Ophthalmology
1 September 2015
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Yutaro Nishi 1,2
Tomohiro Ikeda 1
Kayo Nishi 2
Osamu Mimura 1
Department of Ophthalmology,
Hyogo College of Medicine, Hyogo,
2
Nishi Eye Hospital, Osaka, Japan
1

Background and objective: We investigated the yttrium aluminum garnet (YAG) capsulotomy
rates in various intraocular lenses (IOLs).
Study design/patients and methods: We retrospectively analyzed 23,440 eyes implantedwith either MA60BM, MA60AC, VA-60BB, CeeOnEdge, Clariflex, Technis Z9002, SI-40NB,
or UV26T IOLs. We calculated the YAG capsulotomy rates at 1, 3, 5, and 10 years post lens
implantation.
Results: YAG capsulotomy rates at 3 years postimplantation for the eight groups of IOLs were,respectively, 3.7%, 3.9%, 23.7%, 3.4%, 4.5%, 4.7%, 10.4%, and 21.0%. YAG capsulotomy rates
at 10 years postimplantation for the MA60BM and SI-40NB IOLs were, respectively, 9.1% and
15% (P0.05). The average YAG rates for all sharp-edged and round-edged IOLs at 5 years
postimplantation were, respectively, 5.2%±0.7% and 25.6%±9.0% (P0.05).
Conclusion: In all studied IOLs, posterior capsule opacification prevention seemed to be
associated with the posterior optic sharp-edge design. Round-edged silicone IOLs may also
retard posterior capsule opacification formation, though not as much as sharp-edged IOLs. As
the follow-up period progressed, round-edged silicone IOLs showed significantly higher YAG
rates than sharp-edged IOLs.
Keywords: silicone, intraocular lenses, sharp optic edge, chi-square test, implantation surgery,posterior capsule opacification

Introduction

Correspondence: Yutaro Nishi
Department of Ophthalmology, Night
Graduate School, Hyogo Collegeof Medicine, 1-1, Mukogawa-chou,Nishinomiya, Hyogo 663-8501, Japan
Tel +81 798 456 270
Fax +81 798 456 937
Email y.nishi@nishi-ganka.or.jp

The rate of postoperative posterior capsule opacification (PCO) following cataract
surgery has been a subject of many reports. The rate of yttrium aluminum garnet(YAG) capsulotomy for PCO with respect to the design and material composition of
intraocular lenses (IOLs) has been investigated. Comparisons between IOLs, with andwithout a sharp-edged optic,1–4 1-piece IOLs, and 3-piece IOLs,5–7 have been made.
IOL materials have long been considered to be a factor in PCO formation.8–11 Especially, the silicone IOLs have been of interest in this regard.3,12,13 YAG capsulotomy totreat PCO14 has been a mainstay of therapy. At the same time, it has led investigators
assessing methods for the prevention of PCO formation to consider the design of andthe material used for IOLs, particularly in relation to capsular bending.15–17 PMMA
(poly(methyl methacrylate)) without a sharp-edged optics, for example, was foundto permit rapid proliferation of lens epithelial cells (LECs) with a resultant severe
PCO, whereas the posterior optic sharp-edge design was noted to prevent LECs fromproliferating, regardless of the material used in the IOL.15,17
However, interestingly, in a long-term follow-up, a sharp optic edge design that
did not result in diminution of PCO was reported with the use of hydrophobic acrylic
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Nishi et al

IOLs when compared with silicone IOLs without a sharpedged optic.12,18 Further studies of silicone IOLs in this regard
would be useful.
We retrospectively investigated Japanese eyes, at our
institution that underwent cataract surgery and YAG capsulotomy over a 17-year period. YAG rates in IOLs of different
designs and materials were determined at 1, 3, and 5 years and,in the case of the MA60BM and SI-40NB IOLs, at 10 years
postsurgery. Then, the average YAG rates of all sharp-edged
IOLs were compared with those of round-edged IOLs.

Patients, materials and methods
Types of IOLs
A retrospective review of all patient eyes was undertaken, which
underwent uneventful phacoemulsification and aspiration with
an implantation of IOLs between January 1, 1997 and June 30,
2014 at Nishi Eye Hospital, Osaka, Japan, utilizing an electronic
chart system (Topcon, Tokyo, Japan). Various IOLs implanted
in minimum of 400 eyes during this period were screened. As
a result, eight groups of IOLs were selected. The Nishi Eye
Hospital Ethics Review Committee approved the study.
The eight groups of IOLs investigated in this study wereas follows: MA60BM (3-piece hydrophobic IOL with a sharp
optic edge), MA60AC (3-piece hydrophobic IOL with a sharp
optic edge), VA-60BB (1-piece hydrophobic IOL with anincomplete sharp optic edge), CeeOnEdge (3-piece silicone
IOL with a sharp optic edge), Clariflex (3-piece silicone IOL
with a sharp optic edge), Technis Z9002 (3-piece silicone
IOL with a sharp optic edge), SI-40NB (3-piece silicone IOL
without a sharp optic edge), and UV26T (3-piece PMMA
IOL without a sharp optic edge). The posterior optic edge
of VA-60BB is described here as “incomplete sharp opticedge”, meaning the edge is not sharp enough. When theposterior optic edge is sharp but not clinically sharp enoughat a micro level for PCO prevention,19,20 it may be describedas “incomplete sharp optic edge”.

The details for each IOL in the eight groups are foundin Table 1.

Surgery and YAG capsulotomy
The standard phacoemulsification and aspiration with an
implantation of an IOL were performed in all cases.
Several surgeons were involved, and all surgeries were
performed at Nishi Eye Hospital under the supervision of
one experienced surgeon (ON).
YAG capsulotomy was also performed at the same
hospital when clinical PCO was noted in the 3 mm central
area of the IOL optic and when the patient subjectively
presented with decreased vision with best-corrected visualacuity of 20/40 or worse. The morphological evaluationof PCO was not possible. The study adhered to Helsinki
Accords.

Exclusion criteria
Exclusion criteria included ocular diseases such as active
keratitis, uncontrolled glaucoma, uveitis, and conditions
that would complicate a surgical intervention, such as an
opacified cornea or severe pterygium. Cases of posterior
capsule rupture during surgery were also excluded, thougheyes with pseudoexfoliation syndrome and diabetics were
not. Dropping out of the assessment during the follow-up
was unclear and not excluded.

Statistical analysis
Statistical analysis of YAG rates using Pearson’s chi-square
test was done, and P0.05 was considered to be statisticallysignificant.
The average YAG rates for all sharp-edged (MA60BM,
MA60AC, CeeOnEdge, Clariflex, and Technis Z9002) andround-edged (VA-60BB, SI-40NB, and UV26T) IOLs werealso analyzed using Welch’s t-test, and P0.05 was considered to be statistically significant.

Table 1 The manufacturer, material, optic diameter (mm), IOL design, and haptic angulation (°) of each IOL
IOL

Manufacturer

Material

Optic diameter(mm)

Posterior optic edge
characteristic

1- or
3-piece

Hapticangulation (°)

MA60BM
MA60AC
VA-60BB
CeeOnEdge
Clariflex
Technis Z9002
SI-40NBUV26T

Alcon (Fort Worth, TX, USA)
Alcon (Fort Worth, TX, USA)
Hoya (Tokyo, Japan)
Pharmacia (Uppsala, Sweden)
AMO (Santa Ana, CA, USA)AMO (Santa Ana, CA, USA)AMO (Santa Ana, CA, USA)
Menicon (Nagoya, Japan)

Hydrophobic acrylic
Hydrophobic acrylic
Hydrophobic acrylic
Silicone
Silicone
Silicone
Silicone
PMMA

6.0
6.0
6.0
6.0
6.0
6.0
6.0
6.0

Sharp
Sharp
Incomplete
Sharp
Sharp
Sharp
Round
Round

3-piece
3-piece1-piece
3-piece
3-piece
3-piece
3-piece
3-piece

10
10
5
6
10
10
10
10

Abbreviations: IOL, intraocular lens; PMMA, poly(methyl methacrylate).

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Clinical Ophthalmology 2015:9

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Epidemiological evaluation of YAG capsulotomy rates in IOLs in Japanese eyes

Results
Overall YAG rates
Between January 1, 1997 and June 30, 2014, a total of 23,440
eyes were implanted, and these were divided into the eight groupsof IOLs for analysis as follows: group 1: MA60BM (5,007 eyes),group 2: MA60AC (421 eyes), group 3: VA-60BB (1,606 eyes),group 4: CeeOnEdge (1,601 eyes), group 5: Clariflex (2,861
eyes), group 6: Technis Z9002 (6,495 eyes), group 7: SI-40NB(3,184 eyes), and group 8: UV26T (2,265 eyes).
The overall YAG rates, the mean, the maximum, and theminimum period from IOL implantation to YAG capsulotomy
in each IOL group, and the mean patient age at time of surgery
are found in Table 2.

YAG rates at each visit
Table 3 describes the YAG rates for each IOL group at 1, 3,
5, and 10 years post implantation surgery (for P-values, see“Notes:”). The 5-year YAG rates of Technis Z9002 were
not available. The 10-year YAG rates were available for twogroups of IOLs, MA60BM and SI-40NB.
VA-60BB (1-piece hydrophobic IOL with an incomplete
sharp edge) and UV26T (3-piece PMMA IOL without asharp edge) showed the highest YAG rates throughout thefollow-up period.
At 1, 3, and 5 years postimplantation, all sharp-edged(MA60BM, MA60AC, CeeOnEdge, Clariflex, and Technis
Z9002) IOLs showed a similar performance in general.
SI-40NB with a round edge had higher YAG rates compared to the sharp-edged (MA60BM, MA60AC, CeeOnEdge,
Clariflex, and Technis Z9002) IOLs, but lower YAG rates
than VA60BB and UV26T.

Statistical analysis of average YAG rates
Table 4 describes the average YAG rates for the sharp-edgedgroup (MA60BM, MA60AC, CeeOnEdge, Clariflex, andTechnis Z9002) and the round-edged group (VA-60BB,
SI-40NB, and UV26T) at 1, 3, and 5 years post lens implantation surgery.

Discussion
The design and material used for IOLs influenced clinical
PCO formation and the need for YAG capsulotomy. During
the early postoperative period, only a few cases in each
IOL group, each meeting the criteria of YAG capsulotomy,
underwent YAG capsulotomy, and this early postoperative
data were included in the analysis.
This large sample retrospective study showed that silicone
IOLs with a sharp edge compared to hydrophobic acrylic
IOLs with a sharp edge had a similar or slightly better capability to prevent PCO1,2,8,13 when the YAG rates are taken
into consideration. The sharp-edged (MA60BM, MA60AC,
CeeOnEdge, Clariflex, and Technis Z9002) IOLs showedsignificantly lower YAG rates on average than the roundedged (VA-60BB, SI-40NB, and UV26T) IOLs (P0.05),
emphasizing the importance of the role of posterior optic
sharp-edge design for PCO prevention.1,3,7,15,17
The hydrophobic IOL with an incomplete sharp-edged
optic (VA-60BB) and the PMMA IOL without a sharp-edged
optic (UV26T) had the highest YAG rates. The silicone IOL
without a sharp-edged optic (SI-40NB) had lower YAG
rates than did the latter two IOLs, and the difference wasstatistically significant (P0.05). The reason for this finding
deserves future investigation.
Silicone IOLs may have the tendency to induce morestable capsular bending formation that, together with anterior fibrosis formation, may play a role in the prevention of
PCO. The posterior optic edge design can vary with eachmanufacture. A sharp-edged optic with one design may havecharacteristics more in keeping with a round-edged optic
design.19 Even among the same type of IOLs, if the IOL

Table 2 The overall YAG rates (%), age at the time of surgery (years), mean, maximum, and minimum period (months) from IOL
implantation to YAG capsulotomy in each IOL groupAge (years)

IOL

Total (eyes)

YAG (eyes)

YAG rates (%)

Period (months)

Period (min/max)

65±11.9

MA60BM

5,007

501

10.0

56±41

1/176

66±9.4

MA60AC

421

28

6.7

38±34

1/122

66±9.2

VA-60BB

1,606

429

26.7

25±16

1/88

71±9.6

CeeOnEdge

1,601

86

5.4

34±22

1/98

71±9.1Clariflex

2,861

164

5.7

22±19

1/100

72±9.0Technis Z9002

6,495

303

4.7

10±10

1/50

68±10.7

SI-40NB

3,184

500

15.7

32±28

1/146

71±10.1

UV26T

2,265

642

28.3

27±20

1/127

Abbreviations: IOL, intraocular lens; YAG, yttrium aluminum garnet; min, minimum; max, maximum.

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Nishi et al

Table 3 The YAG rates (%) in each IOL group during the early(1 year), middle (3 years), long-term (5 and 10 years) postoperative
periodIOL

1 year

3 years

5 years

10 years

MA60BM
MA60AC
VA-60BB
CeeOnEdge
Clariflex
Technis Z9002
SI-40NB
UV26T

1.3
1.7
5.7
0.9
1.8
3.1
3.5
5.2

3.7
3.9
23.7
3.4
4.5
4.7
10.4
21.0

6.1
5.1
31.2
4.4
5.3
–
13.6
25.9

9.1
–
–
–
–
–
14.9
–

Notes: The difference of the YAG rates between VA-60BB and UV26T and theother IOLs with a sharp edge (MA60BM, MA60AC, CeeOnEdge, Clariflex, andTechnis Z9002) was statistically significant throughout the follow-up period (P0.05).
At 1, 3, and 5 years postimplantation, there was no statistically significant difference
between the two IOLs (MA60BM and MA60AC) and silicone IOLs with a sharp edge
(CeeOnEdge, Clariflex, and Technis Z9002), with exceptions at the 1- and 3-year
follow-up period between MA60BM and Technis Z9002 (P0.05) as well as at the
5-year follow-up period between MA60BM and CeeOnEdge (P0.05). SI-40NB had
higher YAG rates compared to the sharp-edged IOLs, but lower rates than VA-60BB
and UV26T. At 1, 3, and 5 years follow-up, the difference between SI-40NB andthe sharp-edged IOLs (MA60BM, MA60AC, CeeOnEdge, Clariflex, and Technis
Z9002) as well as between SI-40NB, VA-60BB, and UV26T was statistically significant(P0.05), with the only exception that the difference between SI-40NB and Technis
Z9002 at the 1-year follow-up was not statistically significant (P=0.31). At the 10-year
follow-up, the YAG rates of SI-40NB were significantly higher than those of MA60BB(P0.05).
Abbreviations: IOL, intraocular lens; YAG, yttrium aluminum garnet.

power is different, the sharpness index reported is different.20
The potential importance of the sharpness and thickness ofthe posterior optic edge was emphasized while investigating commercially available IOLs.19 Since capsular bending
formation is a key factor in PCO prevention, the sharpness ofthe posterior optic edge and the characteristics of materials
upon which this bending is dependent are important.
Should the formation of capsular bending at an early stage
be inhibited in any model of IOL, PCO development would
occur.15,17 LECs stop proliferating, when their contact is inhibited at capsular bending and when they are in G0 phase of thecell cycle.17 Whether the LECs which once stopped proliferating
can be reactivated or not is a subject for further investigation.
A previous morphological study in Europe reported thatsilicone IOLs with a round edge had less PCO in the long run
than hydrophobic acrylic IOLs with a sharp edge.12 In thisTable 4 The average YAG rates (%) for the sharp-edged group andthe round-edged group at 1, 3, and 5 years post lens implantation
surgeryGroup

1 year

3 years

5 years

Sharp edged
Round edged

1.7±0.8
4.8±1.2

4.0±0.5
18.4±7.0

5.2±0.725.6±9.0

Notes: The sharp-edged group showed significantly lower YAG rates on averagethan the round-edged group at 1, 3, and 5 years post lens implantation surgery(P0.05).
Abbreviation: YAG, yttrium aluminum garnet.

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study, in Japanese eyes, silicone IOLs with a round edge
had higher YAG rates than hydrophobic acrylic IOLs witha sharp edge, and the difference was statistically significant(P0.05). Silicone IOLs appeared to have a quite similarcapability1,2,8 to prevent PCO formation when comparedwith hydrophobic acrylic IOLs, as long as the posterior optic
edge was sharp. A round-edged silicone IOL likewise had
the effect of PCO prevention,2 though less than all categoriesof sharp-edged IOLs (P0.05).
Though statistical significance was achieved between
SI-40NB and MA60BM, clinically the difference of YAG
rates was not very apparent. This may have to do with theduration of the follow-up period, the sample size, the sharpness index of each IOL, the overlapping area between an IOL
and anterior capsule, the haptic design,21 and the study design.
A recent report showed that indeed the silicone IOL with around edge was as good as the acrylic IOL with a sharp edgein the prevention of PCO during the long-term follow-up.18
The limitations of our study include the surgical techniqueof several surgeons, the ocular axial length, the sharpness
index of the optic edge, and haptic angulation,21 all of which
can influence PCO development and affect the final results.
Absence of data for the overlapping area between the anterior
capsule and IOL may be another limitation. Also, the severityof PCO was not objectively quantified when YAG capsulotomy was performed. We could not accurately assess thenumber of cases in each of the eight IOL groups that dropped
out of the study. Consequently, Kaplan–Meier survival curves
for each IOL were not available. Instead, Welch’s t-test wasused for the statistical analysis of the average YAG rates of all
sharp-edged (MA60BM, MA60AC, CeeOnEdge, Clariflex,
and Technis Z9002) and round-edged (VA-60BB, SI-40NB,
and UV26T) IOLs. Since the YAG rates in this study were
low, they may be underestimated due to undercounted casesthat dropped out in the course of the later examinations.
The large sample size of this intrainstitutional epidemiological study, however, militates against these restrictions,though a multicenter prospective morphological study with alarge sample size would add to the validity of the findings.
While randomized prospective clinical trials may provide
more accurate data, they may also be biased, particularly
because of their limited sample size. Retrospective studies
may be useful for epidemiological screening of data based on
the large sample size, although the data obtained may be lessaccurate. Nevertheless, the retrospective nature of this studyof comparative YAG rates in IOLs would provide a certain
epidemiological evidence for the clinical PCO development
in various IOLs in Japanese eyes.

Clinical Ophthalmology 2015:9

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Epidemiological evaluation of YAG capsulotomy rates in IOLs in Japanese eyes

In conclusion, PCO formation and the timing for YAG capsulotomy varied with the IOLs employed. In IOL groups madeof silicone, hydrophobic acrylic, and PMMA, the role of a posterior optic sharp-edge design seemed to be critical for clinical
PCO prevention, judging from the YAG rates. A silicone IOL
showed a similar performance in clinical PCO prevention whencompared to a hydrophobic acrylic IOL, as long as the optic
edge was sharp. A round-edged silicone IOL may also retard
clinical PCO formation, though not to the same degree as a
sharp-edged IOL. As the follow-up period progressed, silicone
IOLs with a round-edged optic showed significantly higher
YAG rates than did sharp-edged IOLs, although clinically thedisparity was slight. More clinical and laboratory studies ofthe performance of silicone IOLs are desired.
Last but not least, longer term follow-up with IOLs ofdifferent designs and materials with a large sample size,
preferably, a multicenter prospective morphological study,
is definitely required for further investigation.

Disclosure
The authors report no conflicts of interest in this work.

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