Original article

Comparison of Nd:YAG capsulotomy

rates following phacoemulsification
with implantation of PMMA, silicone,
or acrylic intra-ocular lenses in four
European countries

Ophthalmic Epidemiology
0928-6586/04/US$ 22.00

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Ophthalmic Epidemiology
2004, Vol. 11, No. 4,
pp. 319329
DOI: 10.1080/09286580490515116
2004 Taylor & Francis Ltd.

Gerd U. Auffarth, MD, PhD1

Antoine Brezin, MD, PhD2
Aldo Caporossi, MD, PhD3
Antoine Lafuma, MD4
Javier Mendicute, MD, PhD5
Gilles Berdeaux, MD, PhD6
Andrew F. Smith, MSc, PhD7,8
European PCO Study Group*

Accepted 22 June 2004

Department of Ophthalmology, Ruprecht-Karls-University,

Heidelberg, Germany, 2Groupe Hospitalier Cochin, Paris, France,
3
Universit degli Studi di Siena, Siena, Italy, 4Cemka-Eval, Bourg
la Reine, France, 5Hospital Donostia, Donostia / San Sebastin,
Spain, 6Laboratories Alcon S.A., Rueil-Malmaison, France,
7
Nuffield Laboratory of Ophthalmology, University of Oxford,
England, UK and 8Health Economics Unit, Alcon Laboratories,
Hemel Hempstead, England, UK

Abstract
purpose The aim of this study was to compare the incidence of Nd :
YAG laser capsulotomy after cataract surgery according to the type
of intra-ocular lens material (PMMA, silicone, hydrophilic acrylic,
hydrophobic acrylic) implanted in four European countries (France,
Italy, Germany, Spain).
design A retrospective record review.
participants A review of 1525 patients (first operated eye), aged 50
to 80 years, operated on for cataract in 1996 or 1997 in 16 surgical
centers (4 per country).
methods The study employed a retrospective cohort design. Charts
were reviewed to collect information during at least a three-year period
Results of the European IOL study

Correspondence and
reprint requests to:
Andrew F. Smith, PhD
Health Economics Unit,
Alcon Laboratories Ltd.
Pentagon Park, Boundary Way
Hemel Hempstead
England HP2 7UD
U.K.
Tel.: +44-1442-341-186
Fax: +44-1442-341-299
E-mail: andrew.f.smith@alconlabs.com
Acknowledgements:
This paper was presented at the XX
Congress of the European Society of

319

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Cataract and Refractive Surgeons

(ESCRS), Nice, 711 September,
2002. The study was sponsored by
Alcon Laboratories Inc., Texas, USA.
Both Dr. Berdeaux and Dr. Smith
are employees of Alcon Laboratories
Ltd. None of the other authors had a
financial or proprietary interest in
this study other than grant support
for this specific project.
*For the membership of the European PCO Study Group, please
consult the appendix.

following cataract surgery to identify patients who underwent Nd :

YAG laser capsulotomy postoperatively.
main outcome measures Data on the type of intra-ocular lens
implanted was extracted from the patient notes, as was the date and
outcome of the Nd : YAG laser intervention. Kaplan-Meier survival
curve analysis with the time to Nd : YAG laser was performed on the
data.
results A total of 1525 patients (first operated eye) were available
for the study (n = 294 for hydrophilic acrylic, n = 384 for PMMA, n =
421 for hydrophobic acrylic, n = 426 for silicone). There was a highly
statistically significant difference between the IOL groups for the incidence of posterior capsule opacification (p < 0.001) and for Nd : YAG
laser treatment (p < 0.001). The mean delay of Nd : YAG laser treatment from the date of cataract operation was 2.48 years (1.70, ranging
from 0 to 5.88 years).The rate of Nd : YAG laser capsulotomy over the
follow-up period was lowest in the hydrophobic acrylic group (7.1%),
followed by silicone (16.2%), PMMA (19.3%) and hydrophilic acrylic
(31.1%), respectively.
conclusions A low incidence of posterior capsular opacification
(PCO) and Nd : YAG laser treatment was detected in hydrophobic
acrylic IOLs in comparison to three other types of IOLs implanted in
a large cohort of persons with age-related cataract. Choice of IOL type
may reduce the need for Nd : YAG laser treatment, although further
research on the reasons for this is needed.

Key words Cataract surgery; posterior capsular opacification;

capsulotomy; phacoemulsification; Nd : YAG laser; intra-ocular lens
implantation
Introduction The most frequent complication of cataract surgery
is posterior capsular opacification (PCO), which has been reported to
occur with a frequency as high as 18.2% by the end of the first year
after surgery.1 PCO develops gradually over time and usually appears
between three months and four years postoperatively. It may result in
glare and/or reduction in visual acuity.
PCO can be treated effectively and fairly with Nd : YAG laser capsulotomy. However, the latter incurs significant costs and accounts for
a sizable part of the total costs of cataract surgery.2 Nd : YAG capsulotomy can also result in significant morbidity due to postoperative complications, which include damage to the IOL, intra-ocular pressure
elevation, cystoid macular edema, retinal detachment, IOL subluxation
and exacerbation of localized endophthalmitis.36
Previous studies713 on the relationship between the material used to
make the IOL and the incidence of PCO after cataract surgery produced variable results. The differences in the rates were presumably
due, in part, to differences in the design of the studies. There are three
main materials used to make IOL: PMMA, silicone and acrylic, which
are further divided into two subtypes: hydrophilic and hydrophobic.
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The debate is still ongoing as to the factors other than material, such
as the optical design and shape, design and material of haptics, quality
of finishing, surface irregularities and other factors, which have been
associated with different PCO rates for different IOLs. The newer generation of lenses, however, tend to present better results than older
ones.14 It has also been shown that sharp-edge optical designs of different materials help to reduce PCO.15,16
Other surgical factors have also demonstrated their importance in
this discussion,17 including cortical clean-up, quality of fixation and continuous curvilinear capsulorhexis.
The purpose of this study, therefore, was to compare the incidence of
Nd : YAG laser capsulotomy after cataract surgery between the main
types of IOL material (PMMA, silicone, hydrophilic acrylic or
hydrophobic acrylic) implanted in a large population in four European
countries (France, Germany, Italy and Spain). To ensure the transparency of the results, it should again be noted that both Dr. Smith and
Dr. Berdeaux are employees of Alcon Laboratories.

Material and methods The study was designed as a retrospective cohort based on patient chart review. As the Nd : YAG rate after
cataract surgery has been shown to increase dramatically during the
third year after operation, the duration of follow-up was determined
to be a minimum of 3 years.15
The occurrence of Nd : YAG laser capsulotomy was selected as the
primary criterion to assess IOL implantation complications, even if the
underlying problem was PCO. This is mainly because no international
scale was available to quantify PCO and furthermore, it would have
been nearly impossible to retrieve this information retrospectively. The
International Advisory Board of the study (AB, GA, AC, JM) decided
that in a retrospective study, Nd : YAG laser treatment was the best and
only single criterion for a comparison of IOL implantation complications according to the material, if the numbers of different IOLs were
balanced across the four countries.
The members of the Scientific Committee selected the centers on the
basis of well-recognized centers, with high activity and facility for
follow-up of patients, with few local competitors and a strong network
of physicians who could be easily contacted.
The specific inclusion criteria consisted of patients, of either gender,
with an age above 50 in order to avoid non-age-related cataract and
below 80 at the time of surgery in order to prevent a high rate of loss
to follow up due to mortality, who underwent cataract surgery between
1/1/1996 and 31/12/1997 using the phacoemulsification technique with
IOL implantation in the capsular bag. Furthermore, the optical size of
the lens must have been between 5.5 and 6.5 mm in diameter; However,
other diameters were included due to particular local circumstances
(the silicone lenses in Spain were larger than 6.5 mm). The exclusion
criteria consisted of any of the following: age lower than 50 or greater
than 80 year at the time of surgery, previous enrolment in this study,
previous surgery for that eye, concomitant ocular pathologies (uveitis
or history of uveitis, high myopia (6 spherical equivalent), combined
surgery, previous trauma), complications during surgery (posterior
Results of the European IOL study

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capsular rupture, capsulorhexis tear, hyphema), infectious or severe

inflammatory postoperative reaction, endophthalmitis, and an IOP > 25
mmHg after cataract surgery as determined from the ophthalmologists
notes. In addition to data on the patients characteristics and comorbidities, data on Nd : YAG laser performance, PCO as reported by the
clinician from the patients notes, and visual acuity before and after
surgery and Nd : YAG laser were also collected.
Ethics Committee approvals were obtained as required by the
national regulations for retrospective studies at the time of the
study.
The selection of patients followed the following steps: each participating center provided a list of patients having had cataract surgery
between January 1st, 1996 and December 31st, 1997 with the type of IOL
implanted. Random selection was performed in each center and for
each type of IOL, searching for a balanced number of types of IOL in
each country.
The selected patient charts were reviewed to check whether the
patient met the inclusion or exclusion criteria. If the patient failed to
meet the inclusion criteria, he or she was replaced by the next patient
on the randomization list in the same stratum. The dedicated study
Case Report Forms were completed by the investigator or a trained
clinical research associate. In the event of a lack of follow-up data in
the hospital chart, information was collected from the referring ophthalmologist (letter and phone call) up to the end of 2000 in order to
collect information during a three-year period for the patients operated in December 1997.
A conservative estimate of the required sample size for the study was
calculated to be approximately 400 patients (first operated eyes) per
IOL type or a total sample size of 1600 in a balanced stratified random
design as described above. Previous randomized clinical trials with a
comparable period of follow-up have revealed differences in the Nd :
YAG rates between hydrophobic acrylic (conservatively estimated at
16%) and other lens types evaluated here to be higher than 10%. A
conservative alpha level of 0.01 was used to address the multiple comparisons problem (comparing hydrophobic acrylic with the three other
types) and keeping the overall type I error rate below 0.05. Using these
parameters: hydrophobic acrylic Nd : YAG rate: 0.16; other IOL Nd :
YAG rate: 0.26; alpha = 0.01 (two-sided); power = 0.8, the required
sample size per IOL group was estimated to be 406 patients or a total
sample size of about 1600 patients.
Statistical analysis was performed with SAS (V8, North Carolina,
USA) and all tests were interpreted two-sided, with an alpha value
fixed at 5%.
The main analysis compared the occurrence of Nd : YAG laser capsulotomy according to the IOL material, computing a survival analysis
with the Kaplan-Meier method. The log-rank test was used for testing
statistical significance of the observed differences. A Cox proportional
hazard model was performed to take into account differences observed
at inclusion between the groups according to type of IOL (i.e., age,
gender and country).

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Results A total of 14,146 patients were selected by the 16 centers

in the four countries and 1952 patients were randomized and screened.
Of the 1952 patients, 425 did not meet the inclusion criteria and were
omitted from the analysis. Therefore, 1,527 patients were included and
two patients were later excluded without replacement because their
operation for cataract was carried out in 2001. The final study population consisted of 1525 patients (first operated eye). In those cases where
both eyes were operated on, the selection of the eye for inclusion in
the study was always the eye that had received cataract surgery first.
characteristics of the study population at inclusion More
females (84755.5%) were included than males (67844.5%) and the
mean age of the population was 70.3 7.2 years.
A diagnosis of glaucoma was present in 117 patients (7.7%) and
raised intra-ocular pressure (IOP) was found in 122 (8.1%). Sixty-eight
patients (4.5%) had at least one other concomitant ocular pathology,
of which 46 had ARMD and 23 diabetic retinopathy.
The type of diabetes was type 2 in 122 patients, insulin-dependent
diabetes in 63 patients and non-specific diabetes in 22 patients.
The year of intervention ranged from 1995 to 1998, with five patients
in 1995 and two in 1998. Most patients were operated in 1997 (61.7%)
and 1996 (37.7%). Fifty-three different surgeons performed the operations.
The IOL material was hydrophilic acrylic in 294 (19.3%), PMMA in
384 (25.2%), hydrophobic acrylic in 421 (27.6%) and silicone in 426
patients (27.9%). Patients with hydrophilic IOLs were more difficult to
enrol, especially in countries (Spain and Italy) where this type of IOL
was not in regular use during the period 199697, and all eligible
patients were included.
Several statistically significant differences appeared between the IOL
groups at inclusion and these are presented in Table 1.
The change in distance visual acuity (DVA) with IOL implantation
was not statistically different between the types of IOL (p = 0.0622).

Variable

Hydrophilic
acrylic

PMMA

Hydrophobic
acrylic

Silicone

p
Value

Male (%)
Age (mean, years)
Patients with
glaucoma (%)
Other eye previously
operated (%)
DVA before surgery
(mean)
DVA after surgery
(mean)

43.2
71.9
10.2

51.6
69.5
5.7

42.8
69.8
10.5

40.6
70.3
5.2

0.011
<0.001
0.005

31.6

31.3

40.9

28.2

<0.01

0.32

0.23

0.25

0.29

<0.01

0.78

0.75

0.74

0.78

0.02

table 1. Statistical differences

between IOL groups at inclusion.

Note: DVA = distance visual acuity.

Results of the European IOL study

323

The proportions of IOL type also differed in different countries. This

was due to the reduced recruitment of patients with hydrophilic lenses
in Spain and Italy.

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general results at end of follow-up Patients were followed until the beginning of 2002. The mean duration of follow-up was
3.2 years and at the end of the follow-up period, 85 patients were dead
and 1,433 were alive. Of the patients (n = 1178) who did not die or did
not have Nd : YAG during the follow-up period, 16.7% were lost to
follow-up during the first year, 5.6% during the second year and 7.1%
during the third year. More than 70% of the patients were followed for
more than three years. Of the total population, more than 77% were
completely assessed.
PCO was noted in the medical records in 345 patients and 264
patients were treated with Nd : YAG laser.
The reasons for treatment by Nd : YAG laser were decreased visual
acuity in 90.2% of the patients, complaints from the patient in 20.2%
and to allow for fundus examination in 2.3%. No reason was provided
for five patients (1.9%).
Mean delay for Nd : YAG laser treatment from the date of operation
was 2.48 1.70 years, ranging from 0 to 5.88 years. The rate of occurrence of Nd : YAG laser treatment in the unscathed patients at the time
of measurement was low during the first two years (less than 1%),
increased to 2.4% at year three, doubled at year four to 5.8% and
reached 16.8% of the remaining patients at year 5.
Nd : YAG laser treatment rates were investigated according to different relevant variables. In the multivariate analysis, the Nd : YAG
laser rates were not affected by glaucoma, high intra-ocular pressure,
ARMD and diabetic retinopathy.
There was a statistically significant difference between patients with
other concomitant morbidities with the potential to impede vision
before surgery (n = 68) and those without (p = 0.0429); however, the
number of patients was too low to have any influence on the results of
the present study.
analysis according to type of IOL As shown in Table 2, there
were highly significant differences between the IOL groups for PCO
incidence (p < 0.001) and for Nd : YAG laser treatment occurrence
(p < 0.001).
The survival analysis that was performed is presented in Figure 1. Cox
model estimates between IOL types were performed and are presented
in Table 3. Variables included in the Cox model were age, gender and
country. Hydrophobic acrylic was the reference group.
The hazard ratio (HR) for females was 1.5 (p = 0.0012) and no difference was observed in the HR for age. The HR of the different countries as compared to France were all significant with 0.487 for Germany,
0.147 for Italy and 0.446 for Spain.
analysis by country An analysis of the operated population by the
country where the surgery was performed showed that there was a
similar distribution of IOL material across the countries except for
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G.U. Auffarth et al.

Type of IOL

Hydrophilic
acrylic

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Number of patients 294

Patients with PCO
108
PCO rate
37.0%
Patients treated with 91
YAG
Nd : YAG rate
31.1%
Mean duration since
2.3
Nd : YAG (years)

PMMA

Hydrophobic
acrylic

Silicone

All
patients

384
108
28.3%
74

421
37
8.9%
30

426
69
21.6%
69

1525
345
22.8%
264

7.1%
2.3

16.2%
2.6

17.3%
2.5

19.3%
2.7

table 2. PCO and Nd : YAG rates

according to the type of IOL.

Note: PCO = posterior capsule opacification; Nd : YAG = Nd : YAG laser

capsulotomy.

Type of IOL

Number

P-value of
log-rank test

Hazard ratio of
Cox model

p value of
Cox model

Hydrophobic acrylic
Hydrophilic acrylic
PMMA
Silicone

419
292
384
426

<0.0001
<0.0001
< 0.001

1.00
4.50
2.58
2.69

< 0.001
< 0.001
< 0.001

Taking into account the confounding factors age, gender and country.

table 3. Comparison of
hydrophobic acrylic with the other
IOL types (log-rank test).

100%

90%

A
80%

70%

60%

A) Hydrophobic (n=419)
B) Silicone (n=426)
50%

C) PMMA (n=384)
D) Hydrophilic (n=292)

40%
0

n=1525

n=1304

n=1215

Year

n=1084

n=738

Fig. 1. Percent of living patients without Nd : Yag laser therapy over time according to the type of IOL (n = patients alive,
without Nd : Yag therapy, and followed at the beginning of the year).

Results of the European IOL study

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hydrophilic acrylic, which was less frequently used, particularly in

Spain.
No overall difference in age was observed between countries;
however, the distribution of patients in terms of the age at time of
surgery was slightly different (p = 0.0069). Greater numbers of younger
patients (below 60) were operated on in Spain (13.5%) than in
Germany (10.4%), Italy (9.0%) or France (5.6%). Older patients (75
years) were more numerous in Germany (39.4%) and Italy (37.6%)
than in Spain (33.8%) and France (28.4%). The results according to
country are presented in Table 4.

Discussion The objective of this European study was to compare

retrospectively the material used to make the IOL in relation to the
use of Nd : YAG laser therapy in current practice.
Several comparative studies in the literature have addressed this
topic and were mostly in favor of hydrophobic lenses. One study8
included 81 patients allocated at random to a PMMA, silicone or
hydrophobic acrylic IOL. At three years, the Nd : YAG laser rates were
0% with hydrophobic acrylic, 14% with silicone and 26% with PMMA
(p < 0.05). Another study randomly allocated 90 patients to PMMA,
silicone or hydrophobic acrylic.10 At three years, Nd : YAG laser therapy
rates were 4.6% in patients with hydrophobic acrylic, 40% with silicone
and 50% with PMMA IOLs. A controlled trial11,12 included 300 eyes
that were randomly allocated to receive PMMA, silicone or hydrophobic acrylic IOLs.Two years postoperatively, laser capsulotomy had been
performed in 4.2% of patients with hydrophobic acrylic, 14.4% with
silicone and 28.9% with PMMA IOLs. A retrospective analysis13 of a
US HMO database compared the incidence of Nd : YAG laser therapy
among 2,162 patients (including 2,672 eyes) followed-up postopera-

tab l e 4. Characteristics of enrolled

patients with significant differences
between countries.

Variable

Germany

Italy

France

Spain

p value

Number of patients
Male (%)
Presence of glaucoma (%)
DVA before surgery (mean)
DVA after surgery (mean)
Evolution of DVA (mean)
PCO (assessed by
physician)
Nd : YAG rate
PCO treated with
Nd : YAG
Reason for Nd : YAG: DVA
decreased
Patient complaints

416
38.9
15.1
0.30
0.66
0.36
23.2%

367
50.1
7.1
0.26
0.76
0.50
15.5%

363
43.8
3.1
0.30
0.80
0.49
28.4%

379
45.6
6.9
0.23
0.84
0.61
24.0%

0.011
<0.001
<0.001
<0.001
<0.001
<0.001

19.8%
85.4%

8.7%
56.0%

25.9%
93.0%

14.8%
61.5%

<0.001

80.5%

90.6%

95.7%

94.6%

0.006

15.9%

18.8%

33.3%

5.4%

<0.001

Note: DVA = distance visual acuity; PCO = posterior capsule opacification;

YAG = Nd : YAG laser capsulotomy.

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tively for at least one year; 1,592 eyes received an acrylic lens and 1,080
a silicone one. Cox proportional hazards ratios were calculated to
compare the risk of capsulotomy according to the type of lens. The risk
was found to be 3.6 times as high with silicone IOLs as compared with
acrylic IOLs (p < 0.0001). Two years postoperatively, the Nd : YAG laser
therapy rates were 4.15% and 14.04 % with acrylic and silicone lenses,
respectively.
In our study, it should be pointed out that since the Nd : YAG laser
rates did not decrease to very low levels over the study time period,
longer follow-up times would be required to establish whether there
would be any true difference in the Nd : YAG rates by IOL type over
the long term, although given the foreshortened time period of the
current study, this was not possible to detect.
In this multicenter European study, hydrophobic acrylic IOLs
showed a statistically significant lower rate of Nd : YAG laser treatment
than the other types of IOLs (p < 0.0001). These results, based on a
large population sample, were obtained taking into account differences
such as age, gender and country and clearly showed that the Nd : YAG
rates according to the type of IOL in current practice favored
hydrophobic acrylic IOLs.
Our results confirm previously published studies on a large number
of patients, using the current best practice management for cataract and
in different European health care systems. Apart from PCO, the timing
of when to perform Nd : YAG laser capsulotomy may depend on other
factors such as the level of visual acuity, patient satisfaction and other
characteristics such as financial incentives for professionals, etc.
In a retrospective study such as ours, the main problem is associated
with the difficulty to obtain relevant information. The relatively low
number of patients lost to follow-up is due to the proper selection of
the centers. The study highlighted several interesting results on the differences between countries. With a retrospective design and random
selection, investigators were not influenced by the study protocol. Sex
ratios were different in the four countries and that needs to be analysed
in relation to the current sex-ratios of the populations. Patients were
treated at a more advanced stage, as assessed by a lower DVA before
surgery, in Italy and Spain, but surprisingly, the benefit in DVA was
better in Spain than in the other countries. PCO was more commonly
assessed in France and Germany, and French ophthalmologists were
more likely to treat patients with PCO with Nd : YAG laser. French
patients were also more affected by their decrease in DVA. In Italy,
PCO was less frequently assessed by ophthalmologists and they were
less likely to perform Nd : YAG laser capsulotomy. These inter-country
variations owe their origin to factors in health care organization and
funding.
In summary, this European multi-center study showed that in a
large series of patients covering different national and demographic
factors, implantation of a hydrophobic acrylic intra-ocular lens with
sharp optical edges after cataract surgery resulted in a significantly
lower incidence of Nd : YAG laser treatment for posterior capsular
opacification.

Results of the European IOL study

327

References

Ophthalmic Epidemiol Downloaded from informahealthcare.com by The University of Manchester on 11/02/14

For personal use only.

1 Powe NR, Schein OD, Gieser SC,

et al. Synthesis of the literature on
visual acuity and complications
following cataract extractions with
intra-ocular lens implantation. Arch
Ophthalmol. 1994;112:239252.
2 Steinberg EP, Javitt JC, Zuckerman
A, et al. The content and cost of
cataract surgery. Arch Ophthalmol.
1993;111:10411049.
3 Tielsch JM, Legro MW, Cassard SD,
et al. Risk factors for retinal
detachment after cataract surgery. A
population-based case-control study.
Ophthalmology. 1996;10:15371545.
4 Fourman S, Apisson J. Late-onset
elevation in intra-ocular pressure
after neodymium-Yag posterior
capsulotomy. Arch Ophthalmol.
1991;109:511513.
5 Steinert RF, Puliafito CA, Kumar
SR, et al. Cystoid macular edema,
retinal detachment, and glaucoma
after Nd-Yag laser posterior
capsulotomy. Am J Ophthalmol.
1991;112:373380.
6 Bath PE, Frankhauser F. Long-term
results of Nd : Yag laser posterior
capsulotomy with the Swiss laser.
J Cataract Refract Surg. 1986;12:
150153.
7 Zhang Z, Yin H, Zeng J, et al.
Clinical results of acrylic
hydrophobic foldable intra-ocular
lens implantation in China. AsiaPacific J Ophthalmol. 1999;11(2):
26.
8 Hollick EJ, Spalton DJ, Ursell
PG, et al. The effect of
polymethylmethacrylate, silicone
and polyacrylic intra-ocular lenses
on posterior capsular opacification 3
years after cataract surgery.
Ophthalmology. 1999;106:4955.
9 Tetz MR, Auffarth GU, Wersching
CH, et al. Vergleichende
Untersuchungen zur
Nachstarausprgung bei Faltlinsen
und PMMA Linsen. [Comparison of
posterior and anterior opacification
in eyes with foldable and PMMAIOLs] In: Dunker G, Ohrloff Ch,
Wilhelm F, eds. Trans 12th. Congress
of the German Society for

328

G.U. Auffarth et al.

10

11

12

13

14

15

16

17

Intraocular Lens Implantation and

Refractive Surgery. Berlin: Springer
Verlag, 1998; 182186.
Maxwell AW. Posterior capsule
opacification, Nd : Yag laser
capsulotomy rates, and visual acuity
outcome: a prospective masked
comparisons of Acrylic, Silicone
and PMMA IOL materials
[presentation]. American Society of
Cataract and Refractive Surgery.
Seattle, June 1996.
Hayashi H, Hayashi K, Nakao F,
et al. Quantitative comparison of
posterior capsule opacification after
polymethylmethacrylate, silicone
and polyacrylic intra-ocular lenses
on posterior capsular opacification
3 years after cataract surgery.
Ophthalmology. 1999;106:4955.
Hayashi K, Hayashi H, Nakao F,
et al. Changes in posterior
capsule opacification after
polymethylmethacrylate, silicone
and acrylic intra-ocular lenses.
J Cataract Refract Surg. 2001;27:
817824.
Halpern MT, Covert D, Battista C,
et al. Relationship of Acrysof acrylic
and PhacoFlex silicone intraocular
lenses to visual acuity and posterior
capsule opacification. J Cataract
Refract Surg. 2002;28:662669.
Apple J, Peng Q, Visesook N, et al.
Eradication of posterior capsule
opacification. Ophthalmology. 2001;
108:505518.
Auffarth GU, Golescu A, Becker
KA, et al. Quantification of
posterior capsule opacification with
round and sharp edge intraocular
lenses. Ophthalmology. 2003;110:
772780.
Auffarth GU, Peng Q. Posterior
capsule opacification: Pathology,
clinical evaluation and current
means of prevention. Ophthalmic
Practice. 2000;18(4):172182.
Schmidbauer JM, Vargas L,
Apple D, et al. Evaluation of
Neodymium:yttrium-aluminumgarnet capsulotomies in eyes
implanted with Acrysof intraocular
lenses. Ophthalmology. 2002;109:
14211426.

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Appendix
The European PCO study group comprised:
A. Brezin, Paris, F. Blondeau, Saumur, T. Amzallag, Somain, E.
Ribaute, Quimper, C. Billotte, Caen, A. Lafuma, Bourg la Reine, G.
Berdeaux (Alcon Laboratories), Rueil Malmaison, France;
A. Caporossi, Siena, M. Nardi, Pisa, A. Scialdone, Milan, A. Rapisarda, Siracusa, Italy;
G. Auffarth, Heidelberg, E. Mehdorn, Aachen, K. Gerstmeyer,
Minden, H. B. Dick, Mainz, Germany;
X. Mendicute, San Sebastin, L. Cadarso, Vigo, J. A. Cristbal,
Zaragoza, J. Ferro, Gasteiz-Vitoria, Spain; and
A. F. Smith, Nuffield Laboratory of Ophthalmology, University of
Oxford, Oxford and Alcon Laboratories, United Kingdom.

Results of the European IOL study

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