Glistenings worsen over time but have
Cataract
Randall J Olson
Dermot McGrath
in London
ALTHOUGH glistenings are commonly
found in single-piece acrylic IOLs, their
incidence does not seem to have any
major adverse impact on visual acuity or
quality of vision except in the more severe
cases, according to Randall J Olson MD.
Reporting data from a three-year study
of single-piece acrylic IOLs with and
without blue-blockers, Dr Olson, professor
and chairman, department of
ophthalmology, University of Utah, Salt
Lake City, said that in this series the
glistenings did increase in severity over the
three-year follow-up period.
“The real issue that we
wanted to address was to
discover if glistenings are
just a curiosity or is there
a genuine concern about
them from a clinical
standpoint”
“We concluded that the glistenings did
get worse in the single-piece acrylic IOLs
over the study period. Do they reach a
certain point where they are no longer
getting worse? I think that this has still not
been answered satisfactorily. I think it is
likely, however, that it reaches a certain
plateau and this is borne out by the lack of
long-term complaints. Other published
papers have also shown a worsening over
time,” he said.
Describing the motivation for his study,
Dr Olson explained that glistenings are
formations of tiny water vacuoles that
present as clear to white sparkling areas
within the IOL. They are believed to occur
when water fills microscopic openings in
the material, becoming visible at the slit
lamp or with the naked eye. While their
incidence has been more closely
associated with acrylic material, Dr Olson
emphasised that other materials such as
silicone and PMMA have also had
glistenings reported in the literature.
“The real issue that we wanted to
address was to discover if glistenings are
just a curiosity or is there a genuine
concern about them from a clinical
standpoint,” he asked.
Previous studies carried out by Dr
Olson and his fellow researchers showed
that there was a contrast sensitivity loss
associated with severe glistenings in early
AcrySof lenses although visual acuity was
20
limited impact on visual acuity, study finds
Severe glistenings in a PMMA IOL
not affected. “These acute glistenings were
associated with problems with the
AcryPak packaging and they did actually
get better with time,” he added.
Once the packaging was changed, the
severe glistenings became a rarer
phenomenon, occurring in about 10 per
cent of cases, estimated Dr Olson.
Another study carried out by Dr Shiba
and colleagues at Jikei University in Tokyo
examined the phenomenon of glistening
formation in AcrySof acrylic lenses and
concluded that the temperature at which
AcrySof lenses are stored can affect their
characteristics, including the formation of
glistenings.
In a 2003 study, Daniele Tognetto MD
and colleagues in Trieste, Italy, found that
patients implanted with the AcrySof IOL
had a higher percentage and a greater
density of glistenings. However, all
glistenings seen in the study were
described as ‘trace to moderate’, and the
density was not severe enough to impair
visual acuity in any of the seven types of
IOL implanted.
Dr Olson’s current study randomly
selected a series of post-cataract patients
implanted with acrylic IOLs (AcrySof SA60
and SN60) one, two and three years ago.
Parameters assessed included best-
corrected visual acuity (BCVA), contrast
sensitivity, slit lamp exam, fundus
examination and wavefront analysis. The
number and size of glistenings accumulated
over time by both acrylic IOLs were
compared using computer analysis. The
glistening density and size and their impact
on parameters of visual function were also
analysed.
Of the 53 eyes that were included in the
final analysis, all experienced some degree
of glistenings, noted Dr Olson. Some of
these are so slight as not to be visible on
the slit lamp, but the average was about 43
glistenings per square millimetre slice. The
average size of the glistenings was about
10 microns, which Dr Olson said accorded
well with a previous in vitro study that
recorded an average 9.9 microns diameter.
The severity index, derived from a
combination of the size of the glistenings
and their density, was used to determine
Glistenings in a single-piece AcrySof IOL
the impact, if any, on visual function.
“We found no statistically significant
correlation between the severity index of
the glistenings and visual acuity, glare or
wavefront analysis. However, there was a
borderline correlation with high spatial
contrast sensitivity (p=0.06), which has
also been suggested in some previously
published reports,” he said. The severity
index also showed a statistically significant
increase over the period of three years,
added Dr Olson.
Dr Olson concluded that the usual
glistenings found on most IOLs are
unlikely to pose a problem for patients’
quantity or quality of vision. However, he
suggested that further study was needed
to establish the true impact of more
severe glistenings in certain cases.
“It’s hard to assess because anecdotal
cases can’t provide us with the
information that we need. Looking at one
of the worst cases in my series, a patient
with 223 glistenings per 1mm squared
slice, with no observed pathology,
substantially decreased contrast sensitivity
and 20/25 best spectacle corrected visual
acuity was documented. However there
were other patients with more than 100
glistenings per 1mm squared slice in which
there was no impact at all,” he said.
Looking to the future, Dr Olson
suggested that further large-scale
controlled studies were needed to shed
further light on the issue.
“Based on what we have learned in
previous studies, it is the unusual
glistenings, in other words, the dense and
large glistenings, which I think need further
analysis. It would probably need about 500
patients or more to get a proper handle
on that and also to tell us which IOLs in
terms of design and material might be
more susceptible to the phenomenon,” he
said.
randall.olson@hsc.utah.edu.