1. Authors: Lawrence Strenk, PhD, 1 Liliana Werner, MD, PhD, 2 Nick Mamalis, MD, 2 Susan Strenk, PhD 1 From: 1) MRI Research, Inc., Cleveland, OH; 2) Moran Eye Center, University of Utah, Salt Lake City, UT -The authors have no financial or proprietary interest in any product mentioned in this poster. -Supported by NEI EY018518 to MRI Research. -The authors have received research materials from Alcon. Magnetic Resonance Imaging, Gross, and Pathological Analysis of Long- Term Soemmering Ring in Aphakic Human Eye

2.  Complications of new intraocular lens (IOL) designs are often not discovered until years after their introduction (1). Many complications can be directly or indirectly linked to Soemmering’s ring (SR) formation, which is believed to develop to some extent after most cataract surgeries. A SR is a doughnut-shaped lesion composed of retained/regenerated cortex material and lens epithelial cells that may form following any type of disruption of the anterior lens capsule. It is a precursor to posterior capsule opacification and, if abundant, can result in IOL tilt and displacement, iris contact, and possibly angle closure and glaucoma. Its abundance is inversely related to the age of patient at the time of surgery/trauma and the care taken in cortical clean-up and directly proportional to the amount of time the IOL has been in place (2). IOL design is also known to play a significant role.

3.  We had the opportunity to receive in our laboratories a human eye obtained postmortem, with 65 years of SR development.  The aim of our study was to provide clinicians with the MRI appearance and pathological features of this specimen.  To the best of our knowledge, this is the only report available on such long-term SR.

4.  Patient: 79-year-old Caucasian woman, deceased in 2009.  Aphakic: Suffered traumatic scissors injury at age 14, resulting in blindness in this eye.  Interval between trauma/death of donor: 65 years.  Laboratory analyses: High-resolution anterior segment magnetic resonance imaging (MRI) of the enucleated eye; gross analyses of the anterior segment of the eye from the posterior and anterior views; and histopathologic analysis of the donor eye (3,4).

5.  Non-invasive MRI imaging showed a large area within the anterior segment containing three distinct levels of image contrast in the coronal plane (Figure 1) and multi-lamellar structure in the cross-sectional plane (Figure 2). Figure 2Figure 1

6.  Gross examination of the anterior segment from posterior view (Figure 4) view indicates that the structure seen with MRI is SR Figure 3Figure 4 SR

7.  Gross anterior view (Figure 5) indicates a corneal scar, presumably the site of then scissor entry (arrow)  Gross (Figures 6) shows posterior segment with peripheral scar (arrow). Figure 5 Figure 6

8.  Histopathological examination revealed a large SR with a tri-lamellar configuration: the center-most area had intense calcification; (Figures 7, and 8; Masson’s trichrome stain). Figure 7 Figure 8 Iris Cornea Iris Area of calcification Soemmering’s ring

9.  Concentric and external to the central calcified area, was a middle layer of dense, irregular cortical material evidencing fibrous-like changes; and the concentric outmost layer contained normal cortical material (Figure 9; H & E stain). Figure 9 Iris External layer of cortical material Irregular cortical material

10.  Because long-term SR may develop with new accommodating IOLs (A-IOLs) and other designs, this report sought to present its MRI and pathological features. This case suggests that even long term SR is limited to a tri- lamellar structure.  This study cross-validates in-vivo MRI SR in a donor eye with both gross and histopathological analyses.

11.  These findings are relevant to emerging IOL designs such as A-IOLs, as they may be implanted in younger people with whom SR is likely to develop more abundantly and thus potentially lead to more complications. Additionally, A-IOLs are likely to be in place for longer periods of time, thus allowing multi- lamellar SR to develop; the resulting calcifications may limit haptic movement. Longitudinal in vivo MRI studies of cataract patients potentially provide an opportunity to obtain feedback on SR development in newly introduced IOL designs earlier.  In conclusion, this case of a 65-year-old SR revealed tri-lamellar structure, with the innermost layer calcified.

12.  1. Apple DJ, Werner L. Complications of cataract and refractive surgery: A clinicopathological documentation. Trans Am Ophthalmol Soc 2001; 99:95-109.  2. Chew J, Werner L, Stevens S, Hunter B, Mamalis N. Evaluation of the effects of hydrodissection with antimitotics using a rabbit model of Soemmering’s ring formation. Clin Experiment Ophthalmol 2006; 34:449-56.  3. Strenk SA, Strenk LM, Guo S. Magnetic resonance imaging of the anteroposterior position and thickness of the aging, accommodating, phakic, and pseudophakic ciliary muscle. J Cataract Refract Surg 2010; 36:235-41.  4. Davis D, Werner L, Strenk S, Strenk L, Yeh O, Mamalis N. Long-term pathological follow-up of obsolete design: Pannu universal intraocular lens. J Cataract Refract Surg 2010; 36:512-6.