Posterior capsule opacification

in eyes with a silicone or

poly(methyl methacrylate) intraocular lens
Min-Jeung Kim, MD, Hwa-eon Lee, MD, Choun-Ki Joo, MD

ABSTRACT
Purpose: To evaluate the effect of poly(methyl methacrylate) (PMMA) and silicone
intraocular lenses (IOLs) on posterior capsule opacification (PCO) after cataract
surgery.
Setting: Kangnam St. Mary's Hospital, Seoul, Korea.
Methods: This retrospective study comprised 48 patients (54 eyes) who had
neodymium:YAG (Nd:YAG) laser posterior capsulotomy from March 1995 to
December 1997. All operations were performed by 1 surgeon using the same
technique except for incision method.
Results: Mean interval from cataract surgery to Nd:YAG capsulotomy was 3t months
in the PMMA group and 15 months in the silicone group. The difference between
groups was statistically significant (P -- .0002). The ratio of Elschnig pearl to
fibrosis type PCO was 16:6 in the PMMA group and 14:18 in the silicone group.
Mean total Nd:YAG laser energy used was 256 mJ in the PMMA group and 309 mJ
in silicone group. However, the damage caused by the laser was more severe and
more common in the silicone group.
Conclusion: Silicone IOLs induced PCO faster than PMMA IOLs, with fibrosis the
most common type in the silicone group. Precautions should betaken to prevent
damage during Nd:YAG laser capsulotomy in eyes with a silicone IOL. J Cataract
Refract Surg 1999; 25;251-255

n most cataract surgeries, an intraocular lens (IOL) is

implanted, and many studies are attempting to
create better IOLs. In general, IOLs are divided into
2 categories: hard (e.g., poly[methyl methacrylate]
[PMMA]) and soft (e.g., silicone, polyHEMA, acrylic).
Although soft IOLs have advantages in terms of safety
and rapid visual rehabilitation, their effect on the

Acceptedfor publication August 7, 1998.

Reprint requeststo Choun-KiJoo, MD, Department of Ophthalmolog~
Catholic University Medical College, 505 Banpo-dong, Seocho-ku,
Seoul 1327-040, Korea.

formation of posterior capsule opacification (PCO) is

unclear; PCO is thought to develop when lens epithelial cells (LECs) multiply and migrate.
Many studies have sought methods to decrease
PCO development. However, a 5 year survey found
that PCO develops in about 20% to 50% of eyes after
cataract surgery.*'2
In this retrospective study, we compared silicone
and PMMA IOLs in terms of PCO based on time to
development, types of PCO, total laser energy required
for the capsulotomy, and damage caused to the IOL
surface by the laser.

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PCO IN PSEUDOPHAKIC EYES

Patients and Methods

This retrospective study included 54 eyes (48 patients) having cataract surgery and subsequent Nd:YAG
laser 'posterior capsulotomy from March 1995 to December 1997 at Kangnam St. Mary's Hospital. Exclusion criteria were ocular trauma, diabetes mellitus,
preoperative uveitis, and intraoperative complications
including posterior capsule rupture.
Patients were divided into 2 groups based on type
of IOL implanted: PMMA or silicone. The PMMA
group consisted of 22 eyes of 19 patients who received
a single-piece biconvex PMMA IOL with a 5 degree
angulation between optic and haptic, a 6.0 mm optic,
and a 12.0 overall length (811B, Pharmacia). The
silicone group consisted of 32 eyes of 29 patients who
received a 3-piece biconvex silicone IOL with polypropylene haptics, 5 degree angulation between optic and
haptic, 6.0 mm optic diameter, and overall 13.0 mm
length (SI-30NB, AMO).
The operations were performed by 1 surgeon
(C-K.T.) and comprised an anterior capsulotomy using
a continuous curvilinear capsulorhexis (CCC) technique. The size of the CCC was slightly smaller than
that of the IOL optic. Anterior subcapsular LECs
opposite the incision site were removed by irrigation/
aspiration (I/A). The phacoemulsification was done
using the phaco-drill technique3 and a Premier unit
(Storz). All IOLs were then implanted in the bag. In the
PMMA group, a corneoscleral incision and 2-bite
continuous suture were used and in the silicone group,
a clear corneal incision without a suture.
An Nd:YAG laser posterior capsulotomy was performed when best corrected visual acuity (BCVA)
decreased more than 3 lines because of PCO. Before the
capsulotomy, phenylephrine 2.5% and tropicamide 1%
were used for pupil dilation. A Coherent Nd:YAG laser
(model 7970) was used to perform the capsulotomies.
The laser was focused on the posterior capsule in the
PMMA group but below the posterior capsule in the
silicone group to prevent IOL damage. The energy
setting of the laser was 2 mJ and 1 pulse and then was
increilsed as needed. The size of the capsulotomy was
4.0 ram. After the capsulotomy, fluorometholone eyedrops 0.1% (FML Liquifilm) were instilled 4 times a
'day. The effect of the laser capsulotomy was estimated
by improvement in visual acuity 1 week later. The
252

results were analyzed comparatively by the Student

paired t test.

Results
Mean patient age was 58.3 years for the entire population, 58.0 years in the PMMA group, and 60.0 years
in the silicone group. Mean follow-up was 28.4, 36.4,
and 23.0 months, respectively. The differences in age
and follow-up between groups were not significant.
There was no statistically significant difference
between groups in BCVA. In the PMMA group, mean
BCVA was 0.15 (range hand movement to 20/50)
before and 0.705 (range 20/100 to 20/20) after surgery.
In the silicone group, the respective values were 0.20
(range hand movement to 20/40) and 0.714 (range
20/50 to 20/20). In the PMMA group, mean BCVA
before the laser capsulotomy was 0.20 (range 20/1000
to 20/30) and after, 0.714 (20/50 to 20/20). In the
silicone group, the respective means were 0.30 (range
20/1000 to 20/30) and 0.75 (range 20/200 to 20/20)
(Figure 1). In some cases, poor visual acuity after the
cataract surgery was thought to be caused by such
factors as age-related macular degeneration and drusen,
but significant differences were not found between
groups.
Mean interval from cataract surgery to Nd:YAG
laser posterior capsulotomy was 31.82 months in the
PMMA group and 15.03 months in the silicone group.
The difference was statistically significant (P = .0002).
Regarding PCO, fibrous membrane progressed faster
than the Elschnig pearl type: 12 months faster in the
PMMA group and 6 months faster in the silicone

(8CVA)
20/15
20/20
20125
20/30
20/35
20140
20/50
20/70
201100
20200

- /
- ,~

0Preop

Figure 1.

Postop

PreYAG

PostYAG

(Kim) Change in BCVA by group over time (15;1PMMA;

silicone).

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PCO IN PSEUDOPHAKIC EYES

(%)

(month)

70
60

20
10

PMMA

silicone

Figure 2. (Kim) Interval between cataract surgery and Nd:YAG

posterior capsulotomy ([] Elschnig pearl; fibrosis).

group. However, the differences between groups were

not significant (P = .3 and P = .09, respectively)
(Figure 2). The ratio of Elschnig pearl to fibrous PCO
was greater in the PMMA (16 to 6 eyes) than in the
silicone group (14 to 18 eyes). Fibrous PCO was more
common in the silicone group (Figure 3).
In the PMMA group, mean laser power was
2.6318 mJ, total energy was 256 mJ, and mean pulses,
130.3. In the silicone group, the respective values were
2.6677 mJ, 309 mJ, and 114.2 pulses (Figure 4).
Although the power and total energy of the laser were
much higher in the silicone than in the PMMA group,
the between-group difference in the procedures was not
statistically significant (P = .84 and P = .8, respectively). Damage to the IOL surface was more common
in the silicone group.

PMMA

silicone

Figure 3. (Kim) Ratio of Elschnig pearl to fibrosis-type PCO by

group (1~ Elschnig pearl; fibrosis).

capsulotomy was 34.5 months in eyes with Elschnig

pearls and 24.7 months in those with fibrous membrane.
The intervals in the silicone groups were 18.2 months
and 12.4, respectively. Therefore, the Elschnig type of
PCO proceeded faster than the fibrous type, but the
differences between the 2 types were not statistically
significant (P = .3, PMMA; P = .09, silicone).
There have been many studies of the formation of
PCO. The frequency increases in eyes with cortical
remnants, 4'5 decreases with age5 and in eyes with a
biconvex IOL, 6'7 and is greater in eyes with a 3-piece
silicone than in those with a single plate-haptic silicone
IOL. 8,9
The CCC technique also has a tendency to increase
the frequency of PCO. It can also cause capsule contraction syndrome, resulting in fibrous metaplasia and
migration of the stimulated LECs to the anterior and

Discussion
"The frequency of PCO after cataract surgery is
reported to be between 20% and 50%. 1'2 Although the
mechanism of PCO is not clear, it can be divided into
2 types: LEC migration and LEC fibrous metaplasia.
The morphological types of PCO are fibrous membrane and Elschnig pearl. Clinically, the Elschnig pearls
develop several months to several years after surgery
and are caused by LEC migration at the equatorial
zone. In contrast, fibrous opacity develops 2 to 6 months
postoperatively and is caused by fibrous metaplasia of
LECs beneath the anterior capsule.
Our study confirms these time frames. In the
PMMA group, the interval from surgery to Nd:YAG

(mJ)

PMMA

silicone

Figure 4. (Kim) Total laser energy required for posterior

capsulotomy by group (P'A Elschnig pearl; fibrosis).

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PCO IN PSEUDOPHAKIC EYES

posterior capsules. 10,11However, the advantages of CCC

far outweigh its disadvantages.
There have also been many attempts to decrease
the number of LECs remaining after cataract surgery.
Nish112 reported using ultrasound and I/A to decrease
the fibrous development earlier after the removal of
LECs. Meucci and coauthors 13 reported using an ultrasound irrigating scratcher and Caldwell, 14 cryotherapy.
However, these physical methods are less effective
because it is difficult to remove the LECs remaining at
360 degrees of the anterior capsule and the equator. An
irrigating solution containing heparin easily removes
LECS, 15 however; chemicals, as well as other antimetabolites, have limitations in clinical application because of the probability that they will damage the iris
and corneal endothelial cells during surgery.
Although the effect of IOL type on PCO has been
studied, no clear conclusions have been reached. In a
3 year survey of 1170 eyes, Setty and Percival 16reported
that type of IOL did not make a difference in suppressing LEC growth. Sorensen and Jensen, J7 in a 1 year
study of 59 eyes, reported that PCO progressed faster in
a PMMA than a silicone group. In a 3 year survey of
111 eyes, Milazzo and coauthors Is reported no difference between eyes with PMMA and those with silicone
IOLs.
Mean interval from cataract surgery to Nd:YAG
laser capsulotomy in our study was 31.82 months in
the PMMA group and 15.03 months in the silicone
group; the difference between groups in time to onset
was significant. Hschnig-type PCO was more common
in the PMMA group and the fibrous type, in the
silicone group. Further studies are needed to determine
whether the greater occurrence of fibrous PCO in the
silicone group is caused by the IOL type or other
factors.
In our study, we regarded the differences between
PMMA and silicone IOLs as being limited to the lenses'
optic quality. However, the angle between the IO12s
optic and haptic, quality of haptic, and design of optic
also affect LEC stimulation and migration. Thus, studies must be done to assess the effects of these factors on
PCO' formation.
Joo and Kim 19reported that in a test tube, Nd:YAG
laser damage to the surface of silicone and polyHEMA
IOLs was less than to PMMA IOLs. In our study, the
damage was greater to the surface of the silicone than to
254

PMMA IOLs. We believe the reason is that Joo and

Kim focused the laser on IOLs in balanced salt solution
using higher energy (4, 6, and 8 mJ) to study shock
absorption. We focused the energy on the posterior
capsule at the posterior IOL surface in the human eye
using the lowest possible energy and studied the damage to the surface of the IOL caused by the shock effect
and focusing error. Our results show that higher energy
makes radiating cracks in the PMMA IOLs and less
damage in the silicone IOLs and that lower energy has
less effect on the PMMA IOLs but damages silicone
IOLs more easily. Although more damage to silicone
IOLs was observed by slitlamp examination, it did not
affect the visual acuity clinically.
In our study, total mean laser energy used was higher
in the silicone than in the PMMA group (256 versus
309 mJ). This can be explained by the fact that the
fibrotic change was more common and that the laser
beam was focused as posteriorly as possible in the
silicone group.

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From the Departments of Ophthalmology, Catholic UniversityMedical

College (Kim, Joo), and Dae Rim St. Mary's Hospital (Lee), Seou~
Korea.
Supported in part by the Catholic Foundationfor Eye Researchand the
Ministry of Heahh and Welfare, Korea.
Drs. Mike Kim and Daniel Y. Kim provided comments on the
manuscript and Miss H.S. Kim, editorial help.

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255