Forms of Cataract 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 Cataract

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?

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)

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?

Cataractogenesis after phakic posterior chamber intraocular lens 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

Cataractogenesis after phakic posterior chamber intraocular lens implantation Constant trauma (contact phakic lens-anterior capsule) central periphery

Cataractogenesis after phakic posterior chamber intraocular lens implantation 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

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

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?

Cataractogenesis after phakic posterior chamber intraocular lens implantation Review of the literature (1996-2001) -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

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

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

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

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

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)

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

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

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…)

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

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

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)

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