Posterior capsule opacification: Comparison of 3

intraocular lenses of different materials and design

Gisela Wejde, MD, Maria Kugelberg, MD, Charlotta Zetterstrom, MD, PhD
Purpose: To compare posterior capsule opacification (PCO) after cataract surgery
with implantation of 3 intraocular lenses (IOLs) of different materials and design.
Setting: St. Eriks Eye Hospital, Stockholm, Sweden.
Methods: In this prospective clinical study, 180 patients had standardized phacoemulsification performed by a single surgeon and were randomized to have implantation of a heparin-surface-modified (HSM) poly(methyl methacrylate) (PMMA)
IOL (809C, Pharmacia & Upjohn), a silicone IOL (SI-40NB, Allergan), or an acrylic
IOL (AcrySof MA60BM, Alcon). To morphologically evaluate PCO, retroillumination photographs were obtained and analyzed using Evaluation of Posterior Capsule Opacification computer software. The neodymium:YAG (Nd:YAG)
capsulotomy rate was recorded.
Results: After 2 years, the HSM PMMA IOL group had significantly more PCO
than the silicone and AcrySof IOL groups; the silicone group had significantly
more PCO than the AcrySof group (P.05). The Nd:YAG capsulotomy rate was
20% in the HSM PMMA group, 22% in the silicone group, and 8% in the AcrySof
group.
Conclusion: Patients with an AcrySof IOL developed significantly less PCO than
those with a silicone or HSM PMMA IOL with a round-edged design.
J Cataract Refract Surg 2003; 29:1556 1559 2003 ASCRS and ESCRS

ataract surgery is an increasingly safe procedure.

However, posterior capsule opacification (PCO) is
still the most common complication of phacoemulsification and intraocular lens (IOL) implantation, although its incidence is decreasing.1 Schaumberger and
coauthors2 and Schmidbauer et al.3 performed systematic overviews and analyses of published articles on
PCO. They conclude that no single causative mechanism has been recognized and that previous studies show
that several surgical and IOL-related factors appear to
play a major role in PCO formation.
Surgical-related factors such as hydrodissectionenhanced cortical cleanup, in-the-bag IOL fixation, and
a continuous curvilinear capsulorhexis (CCC) with the

Accepted for publication March 25, 2003.

Reprint requests to Gisela Wejde, MD, St. Eriks Eye Hospital, S-112
82, Stockholm, Sweden. E-mail: gisela.wejde@sankterik.se.
2003 ASCRS and ESCRS
Published by Elsevier Inc.

edge on the IOL surface are important in the prevention of PCO.4 6 Intraocular-lens-related factors such
as IOL material biocompatibility and design are major
determinants.7,8
In this study, we focused on IOL-related factors
and performed a prospective study with a 2-year
follow-up of 3 IOL types after modern, standardized
phacoemulsification.

Patients and Methods

This prospective study included 180 eyes of 180 patients
with senile cataract who had uneventful phacoemulsification
from May 1995 to March 1998 after approval from the local
ethical committee. Informed consent was obtained before surgery from all patients participating in the study. Patients were
between 61 and 86 years old (Table 1). They had no ocular
pathology except cataract, and they all had a potential visual
acuity of 20/40. Patients with glaucoma, exfoliation syndrome, corneal pathology, and a history of uveitis or intraocular surgery were excluded. Patients with mild macular
0886-3350/03/$see front matter
doi:10.1016/S0886-3350(03)00342-0

PCO: EFFECT OF IOL MATERIAL AND DESIGN

Table 1. Patients demographics.

IOL Group
Characteristic

HSM PMMA
809C

Silicone
SI-40NB

AcrySof
MA60BM

Number

61

60

59

Median

74

73

75

Range

6283

6284

6186

Male

20

32

21

Female

41

28

38

Age (y)

Sex

degeneration were accepted. Patients on preoperative oral steroid therapy or with diabetes mellitus were not included.
The patients were randomized to have implantation of 1
of 3 types of IOLs: single-piece heparin-surface-modified
(HSM) poly(methyl methacrylate) (PMMA) (809C, Pharmacia & Upjohn) with an optic diameter of 5.0 mm (n 61),
foldable 3-piece silicone (SI-40NB, Allergan) with an optic
diameter of 6.0 mm (n 60), or 3-piece foldable acrylic
(AcrySof MA60BM, Alcon) with an optic diameter of
6.0 mm (n 59) (Table 1). The MA60BM has a sharp-edged
optic, and the 809C and SI-40NB have round-edged optics.
Preoperatively, the pupil was dilated with a combination
of topical cyclopentolate 0.75% and phenylephrine 2.5%.
Cataract surgery was performed by the same surgeon (C.Z.)
using a standardized procedure. Anesthesia comprised topical
tetracaine chloride 0.5% and a subconjunctival injection of
lidocaine hydrochloride 1% (Xylocaine) and adrenaline
0.05%.
The surgery was performed through a 3.2 mm corneoscleral incision. Sodium hyaluronate 1% (Healon) was used
as a viscoelastic material. A CCC approximately 4.5 to
5.5 mm was created. Hydrodissection and hydrodelineation
were performed using balanced salt solution (BSS). Phacoemulsification was in the capsular bag using the divide-andconquer technique. Cortical lens material was aspirated
with an irrigation/aspiration tip using BSS with adrenaline
0.3 mg/500 mL for intraocular infusion. An IOL was implanted in the bag, and the incision was widened to 5.0 mm
for the HSM PMMA IOLs and to 3.4 to 3.6 mm for foldable
silicone or AcrySof IOLs. No-stitch wound closure was used
in all cases. Postoperatively, topical dexamethasone 0.1% was
prescribed 3 times a day for 1 week and 2 times a day for 2
weeks.
To evaluate PCO, a retroillumination photograph was
taken through a dilated pupil using a slitlamp and photographic setup. The images were digitized and imported into
the Evaluation of Posterior Capsule Opacification (EPCO)
computer-analysis system developed by Tetz et al.9 With
EPCO, the PCO density is interactively scored on a scale from

0 to 4 and then multiplied by the fractional area involved. The

EPCO classification is as follows: 0 none; 1 minimal
(mild capsule wrinkling, mild homogeneous layers or sheets of
lens epithelial cells [LECs]); 2 mild (honeycomb pattern of
PCO, thicker homogeneous layers, denser fibrosis); 3 moderate (classic Elschnig pearls, very thick homogeneous layer);
4 severe (very thick Elschnig pearls with a darkening effect and severe opacification).
The PCO density scores of each patient in the 3 IOL
groups were ranked from the lowest to the highest. The average of the ranks was then calculated and analyzed using the
Kruskal-Wallis 1-way analysis of variance by ranks with
additional multiple comparisons. The neodymium:YAG
(Nd:YAG) rate was also recorded and statistically analyzed
using the chi-square test.

Results
At 2 years, 17 of the 180 patients were lost to followup. Thirty patients were excluded from individual analysis because the images were of poor quality. After Nd:
YAG capsulotomy, patients were excluded from further
image analysis. Images from those patients were given
the highest rank in the statistical analysis.
The image analyses showed that the HSM PMMA
IOL group had significantly more PCO than the silicone and AcrySof IOL groups; the silicone group had
significantly more PCO than the AcrySof group
(P.05) (Table 2). After a 2-year follow-up, the Nd:
YAG capsulotomy rate was 20% (n 10) in the HSM
PMMA group, 22% (n 10) in the silicone group, and
8% (n 3) in the AcrySof group. The difference in the
Nd:YAG rate was not statistically significant among the
groups (P.05) (Table 2).
Ninety-five percent of all patients had a best corrected visual acuity (BCVA) of 20/40 or better at 2 years
(Table 3). Patients who had an Nd:YAG capsulotomy
before 2 years postoperatively were not included in the
Table 2. Average ranks of individual EPCO scores and Nd:YAG
frequency by IOL type.
IOL Group
HSM PMMA
809C

Parameter
Number of patients
Average of ranks*

Nd:YAG frequency (%)

Silicone AcrySof
SI-40NB MA60BM

49

46

38

87

67

43

20

22

*P.05, Kruskal-Wallis analysis by ranks

P.05, Chi-square test

J CATARACT REFRACT SURGVOL 29, AUGUST 2003

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PCO: EFFECT OF IOL MATERIAL AND DESIGN

Table 3. Best corrected visual acuity at 2 years excluding

patients who had an Nd:YAG capsulotomy before 2 years.

IOL

BCVA
(Range)

HSM PMMA* (n 43)

20/40

Silicone* (n 40)

AcrySof (n 36)

Number
of
Patients EPCO Score
(%)
(Median)
3 (7)

0.741

20/4020/25

8 (19)

0.456

20/25

32 (74)

0.649

20/40

2 (5)

1.807

20/4020/25

8 (20)

0.167

20/25

30 (75)

0.145

20/40

1 (3)

0.411

20/4020/25

6 (17)

0.200

20/25

29 (80)

0.020

BCVA best corrected visual acuity; EPCO Evaluation of Posterior

Capsule Opacification system
*Four patients treated by Nd:YAG laser at 2 years

One patient treated by Nd:YAG laser at 2 years

2-year BCVA analysis. Some of these patients were lost

to treatment at other clinics. Before 2 years postoperatively, 6 patients in the HSM PMMA group, 6 in the
silicone group, and 2 in the AcrySof group had an Nd:
YAG capsulotomy. The median EPCO score in all 3
groups was highest in patients with a BCVA worse than
20/40. The AcrySof group had the lowest median
EPCO score.

Discussion
This prospective study shows that there are differences in PCO formation depending on which IOL is
used. There was significantly less PCO 2 years postoperatively in eyes with an AcrySof IOL. These results
agree with those in previous studies.10 12 The BCVA
was good in most patients at the 2-year follow-up. When
patients notice impaired visual function, they often
want to be treated as soon as possible. Therefore, the
Nd:YAG capsulotomy treatments in our study were
spread over time and not performed when patients came
for a regular examination. The patients who had an
Nd:YAG capsulotomy before 2 years were excluded
from the BCVA analysis at 2 years because we could not
obtain EPCO scores from them to evaluate PCO. However, the higher median EPCO scores in patients with
1558

worse vision suggests that the visual acuity loss was, at

least in part, a result of PCO.
Many factors can predispose to PCO formation,
including ocular, systemic, and surgical. The prospective randomized single-surgeon design of this study of
normal eyes largely excludes the effect of host factors and
surgical technique on the study observations. Therefore,
the differences in PCO among the study groups can
probably be ascribed to IOL material and design. Many
studies use different criteria to quantify PCO. We
believe that morphological evaluation of PCO is crucial to an objective comparison of IOLs and surgical
techniques.
Studies have shown that the degree of PCO is more
extensive in eyes with PMMA IOLs than in eyes with
silicone or acrylic IOLs. However, the differences between silicone and acrylic IOLs have not always been
conclusive.13 In our study, the silicone group had less
PCO than the HSM PMMA group but significantly
more than the AcrySof group.
The influence of IOL material on PCO is not entirely understood. Oshika and coauthors14 found different capsule-adhesion properties among PMMA,
silicone, and acrylic IOLs. Nagata and coauthors15
showed that AcrySof has a strong tendency to adhere to
the lens capsule, contributing to posterior capsule and
anterior capsule clarity.
Furthermore, the barrier effects and inhibition of
PCO have been under study for several years. The ingrowth of LECs migrating from the equator along the
posterior capsule can be retarded by an IOL.1,3,8 The
best barrier effect appears to be created by an IOL with a
square edge.3,8 Nishi and coauthors16,17 suggest that the
square-edged optic of the AcrySof lens creates a sharp
bend in the posterior lens capsule, preventing LEC migration. The preventive effect of a sharp optic edge can
be obtained regardless of IOL material, as suggested in
comparative studies of PMMA IOLs with a sharp edge
and AcrySof, silicone CeeOn 911 IOLs with a sharp
edge and AcrySof, and acrylic IOLs with a round edge
and AcrySof.18 20 Studies also show that silicone IOLs
with a sharp edge lead to less PCO than silicone IOLs
with round edge.21
In our study, eyes with sharp-edged acrylic AcrySof
IOL developed less PCO. A limitation of the study is
that the 3 IOL types differ in both material and design.
However, when the study was designed and started in

J CATARACT REFRACT SURGVOL 29, AUGUST 2003

PCO: EFFECT OF IOL MATERIAL AND DESIGN

1995, the AcrySof was the only IOL with a sharp edge
that was commercially available to us.
In conclusion, this study demonstrates that patients
with an AcrySof IOL developed significantly less PCO
than those with a silicone or HSM PMMA IOL with a
round-edged design. The AcrySof IOL also leads to a
lower Nd:YAG capsulotomy rate. With modern IOLs,
PCO formation is reduced; however, the duration of the
IOL in the eye plays an important role. Therefore, longterm studies are required to understand how various
IOLs perform in relation to PCO.

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From St. Eriks Eye Hospital, Stockholm, Sweden.
Presented at the ASCRS Symposium on Cataract, IOL and Refractive
Surgery, San Diego, California, USA, April 2001, and the XIXth Congress of the European Society of Cataract & Refractive Surgeons, Amsterdam, The Netherlands, September 2001.
None of the authors has a proprietary or financial interest in any material, method, or product mentioned.

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