1) developmental (in general non progressive) -remnants of the tunica vasculosa lentis (ex:...

1) Developmental (in general non progressive)

-Remnants of the tunica vasculosa lentis (ex:

pupillary membrane remnants)

-Capsular

-Polar (anterior, posterior or bipolar)

-Anterior axial embryonic

-Anterior and posterior stellate

-Pulverulent

-Zonular

-Other rare forms (congenital diffuse nuclear

cataract of Vogt, axial fusiform cataract, etc…)

2) Pre age-related (in general involve the lens

periphery with slow progress)

-Dilacerated

-Coronary

3) Age-related (progressive)

-Nuclear

-Subcapsular

*Posterior subcapsular (very common)

*Anterior subcapsular (relatively rare,

unless caused by inflammation or injury)

-Cortical

-Mixed (in advanced stages)

Forms of CataractForms of Cataract

Phakic posterior chamber IOLs

1. Cells involved in crystalline lens and capsular bag opacification2. Evolution of designs of PPCIOLs3. Relevant aspects of fixation and sizing4. Sizing issue: New studies5. Surgical implantation6. Relationship between cataract and myopia7. 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?

PC-IOL model/ Age Female/ Date of Date of Explanting Reasons forManufacturer (Years) Male implantation Explantation Surgeon Explantation

Silicone/ 38 F 1995 07/97 Ralf Gerl CataractChiron-Adatomed

Collamer implantable contact

lens (ICL)/Staar Surgical

43 F 12/98 (OD) 01/00 Paul Koch Anterior cortical and posterior subcapsular

cataract

ICL 43 F 12/98 (OS) 01/00 Paul Koch Anterior cortical and posterior subcapsular

cataract

ICL 49 F 06/98 10/00 Martin Dörner Anterior subcapsularcataract

ICL 56 ? 06/99 06/01 W. Hütz Cataract

ICL 23 F 11/18/1997 10/4/2001 Jean-Luc Nguyen- Anterior subcapsularKhoa cataract

ICL 37 M 1999 08/01/01 Arturo Chayet Anterior subcapsularcataract

ICL 53 F 10/21/1998 (OD)

11/16/2001 Ralf Gerl Cataract

ICL 53 F 10/28/1998 (OS)

12/10/2001 Ralf Gerl Cataract

Third generation:Staar ICL

Courtesy: Paul Koch, MD, Koch Eye Surgicenter, Inc., Warwick, RI, USA

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

ICL – Pigment Deposition/Dispersion

Case of R. Gerl, MD, Germany


• 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%)

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


• Constant trauma

(contact phakic lens-anterior capsule)


central periphery

• Continuous disruption of theblood-aqueous barrier(subclinical inflammation)

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

Effects on the:-crystalline lens transmittance-corneal endothelium


• Crystalline lens metabolic

and nutritional disturbances

Caused by:

-subclinical inflammation

-blockage of normal circulation

of the aqueous humor


• Review of the literature (1996-2001)

-21 studies

-Fyodorov early lenses, Chiron-

Adatomed, ICL


• 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


• 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


• 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


• 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


• 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


• 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)


• 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


• 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


• 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…)


• 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


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

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)

1) developmental (in general non progressive) -remnants of the tunica vasculosa lentis (ex:...

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