“ ” “Clinico-pathologic correlation of capsulorhexis phimosis with anterior flexing of single-piece hydrophilic acrylic intraocular lens haptics” Liliana Werner, MD, PhD, 1,2 Brian Zaugg, BS, 1 Tobias Neuhann, MD, 3 Michael Burrow, 1 Don Davis, MD, 1 Nick Mamalis, MD, 1 Manfred Tetz, MD 2 1 John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA 2 Berlin Eye Research Institute, Berlin, Germany 3 Augenklinik am Marienplatz, Munich, Germany -The authors have no financial or proprietary interest in any product mentioned in this poster. -Supported in part by the Research to Prevent Blindness Olga Keith Weiss Scholar Award, and by a Research Grant from the European Society of Cataract and Refractive Surgeons (ESCRS) to L. Werner. -Some of the intraocular lenses mentioned in this poster are not FDA approved.

Background Cases of extreme capsular bag contraction after cataract surgery with intraocular lens (IOL) implantation are produced by an imbalance of forces on the capsular bag. Conditions with zonular weakness include pseudoexfoliation, myotonic muscular dystrophy, retinitis pigmentosa, advanced age, chronic intraocular inflammation, or trauma. 1 There are also cases of excessive capsular bag contraction for which no predisposing factor could be determined. 2,3 We describe the pathological findings of 2 cases of capsulorhexis phimosis, leading to anterior flexing of the haptics of single-piece hydrophilic acrylic lenses. These, and other similar cases raise concerns regarding postoperative behavior of highly flexible IOLs. 4,5

Patients and Methods: 1 Case 1: A 60-year-old female patient underwent phacoemulsification with implantation of a Raysoft 574R (Rayner, UK) hydrophilic acrylic IOL on 08/08/08. She presented with progressive glare, halo, and blurry vision. At presentation to one of us (TN), the pupil was small and could not be dilated, the IOL was decentered horizontally and tilted, with 2 adjacent closed loop haptics visible through the pupil, and there were fibrotic capsular folds (Figure 1). A hyperopic shift of 1.5 D was observed. During explantation surgery performed on 04/17/09, it was confirmed that 2 of the 4 closed loops of the lens were flexed anteriorly in the capsular bag. Capsular bag manipulation revealed very loose zonules. The patient did not have any history or signs of pseudoexfoliation syndrome. Figure 1: Clinical photographs

Patients and Methods: 2 Case 2: The only information available on this case is that in-the-bag implantation of a 4-looped, single-piece hydrophilic acrylic IOL (Bioacryl, Biotech, France) together with a poly(methyl methacrylate) (PMMA) capsular tension ring (CTR) was performed in 2002 due to capsular instability observed during phacoemulsification. The capsular bag/IOL/CTR complex was explanted on 02/26/09, because of postoperative luxation. Laboratory analyses: The specimens were immersed in 10% neutral buffered formalin and sent to the Berlin Eye Research Institute. Pathological evaluation was completed at the John A. Moran Eye Center. Gross photographs were taken using a camera (Model D1x with an ED mm AF lens, Nikon, Japan). After light microscopic examination, the specimens were prepared for histopathology. Sections were cut and stained with Masson’s trichrome. Light microscopy was performed using an Olympus light microscope (Model BX40, Japan), and photomicrographs were obtained via a microscope mounted camera (Model DP20, Olympus, Japan).

Results: 1 Gross and light microscopic examination of the first specimen revealed shrinkage of the capsular bag with the capsulorhexis measuring approximately 3.0 mm in diameter. The rhexis opening appeared to be fibrotic (whitish rim) and there were multiple capsular bag folds. Two of the closed loops appeared to be flexed anteriorly within the capsular bag, while the other 2 protruded through the bag and were in a normal configuration. Rhexis fibrosis was more prominent at the side of the 2 flexed loops (Figure 2). Figure 2: Gross and light microscopic photographs

Results: 2 The histopathological sections revealed a thick fibrocellular tissue attached to the inner surface of the anterior capsule, consistent with fibrous metaplasia of the anterior lens epithelial cells (LECs) corresponding to the anterior capsule opacification and folds. A mild amount of fibrocellular tissue was also seen attached to the inner surface of the posterior capsule (beginning of fibrotic posterior capsule opacification) (Figure 3). Figure 3: Light microscopic photographs; Masson’s trichrome stain Anterior capsule Posterior capsule

Results: 3 The lens model in the second case had an overall design similar to the lens in case 1. Gross examination also revealed a significant degree of shrinkage of the capsular bag with the capsulorhexis measuring approximately 2.0 mm in diameter. The entire anterior capsule appeared fibrotic with multiple folds. Half of the CTR was protruding out of the capsular bag, and its tips were overlapping each other. All closed loops exhibited some degree of anterior flexing, especially the loop closer to the tips of the CTR (Figure 4). Figure 4: Gross and light microscopic photographs

Results: 4 The histopathological sections revealed a thick fibrocellular tissue attached to the inner surface of the anterior capsule, consistent with fibrous metaplasia of anterior LECs corresponding to the anterior capsule opacification and folds. An amorphous substance was observed on the outer surface of the anterior capsule in an “iron-filing” pattern, suggesting pseudoexfoliation material (Figure 5). Figure 5: Light microscopic photographs; Masson’s trichrome stain Pseudoexfoliation material

Discussion / Conclusions: 1 Three cases of anterior haptic flexing of the Akreos Adapt IOL (Bausch & Lomb) with capsular bag contraction have been recently described. 4 In the first case, the patient was a high myope; in the second and third cases the patients had retinitis pigmentosa. Two of the cases had postoperative hyperopic shift. The Akreos is a hydrophilic acrylic lens with overall design similar to the lenses described in our study. Five cases of capsule contraction with haptic deformation and flexion of the Quatrix lens (Croma-Pharma), were described. 5 One patient had retinitis pigmentosa, and 2 other were over 80 years of age. In our first case the patient had no history of conditions with inherent zonular weakness and excessive capsular contraction, although the possibility of a somewhat traumatic implantation procedure cannot be discarded.

Ozturk et al. described 2 cases where the patients developed hyperopic shift due to posterior bowing of in-the-bag Collamer plate-haptic lenses (Staar Surgical), also a hydrophilic acrylic lens. 6 They hypothesized that prophylactic placement of a CTR might have changed the balance of forces acting on the equator of the capsular bag, although there was no known predisposing factor to indicate CTR in their cases. The CTR implanted in our second case could not prevent the occurrence of capsular bag contraction with capsulorhexis phimosis, as well as anterior haptic flexing. Histopathology suggested presence of pseudoexfoliation in this case, and the occurrence of capsulorhexis phimosis with any type of IOL even with a CTR in place has already been described in pseudoexfoliation syndrome. 7 Discussion / Conclusions: 2

These and other cases raise concerns regarding behavior of highly flexible lenses in excessive capsular fibrosis cases, 4 which may also occur in absence of known risk factors such as pseudoexfoliation. 2,3 Of particular concern are microincision cataract surgery IOLs, generally designed to be very thin and flexible allowing a tight roll of the material without fractures or other damages. 3,8,9 While occurrence of excessive capsular bag fibrosis can apparently not be predicted in some cases, one should be aware of the possible risks of implanting highly flexible IOLs, of overall quadrangular design, and no classic loops in the presence of known predisposing factors. 10 Discussion / Conclusions: 3

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