IOL Opacification - EFCLIN...Khoramnia R, Salgado JP, Auffarth GU, Schmidt S, Wegner A, Kobuch KA, Winkler von Mohrenfels C. Ophthalmologe. 2012 May;109(5):483-6. University Eye Clinic

IOL OpacificationR. Khoramnia

[email protected] www.ivcrc.com www.djapplelab.com

International Vision Correction Research Centre (IVCRC)The David J. Apple International Laboratory for Ocular Pathology Department of OphthalmologyRuprecht-Karls-University of HeidelbergChairman: G. U. Auffarth, MD, PhD, FEBO

University Eye Clinic Heidelberg

IVCRC / DJ Apple Laboratory: Financial Disclosures 2018/2019

1 = Research Grants; 2 = Travel Expenses; 3 = Lecture Fees; 4 = Consulting

Acufocus1

Alcon/Novartis1,2,3,4

Alimera1,2

AMO/Johnson&Johnson1,2,3,4

Bausch+Lomb2,3

SIFI3Carl Zeiss Meditec1,2,3

Contamac1

Glaukos1

Hoya1,2,3

Kowa1,2,3

Oculentis1,2,3

Oculus1,2,3

Physiol1Presbia2,3,4

Rayner1,2,3

Santen1

SIFI1,2,3

Ursapharm1,2,3


David J. Apple Laboratory

Analysis of explanted IOLs, Biomaterial analysis of new IOLs,

Analysis of the optical quality of IOLs


Classification of Calcification: Neuhann et al. 1) Primary Calcification

• Calcification that is inherent in the IOL

• In otherwise normal eyes and not associated with

preexisting diseases

• Due to a material defect or problem during the

manufacturing process of the lens

2) Secondary Calcification

• Not related to any problem with the IOL itself

• Result of environmental circumstances (e.g., changes in the

aqueous milieu surrounding the implanted IOL associated

with preexisting or concurrent diseases or indeed any

condition that has disrupted the blood-aqueous barrier)

3) False-positive or Pseudocalcification

• Other pathology is mistaken for calcification or false-positive

staining for calcium occurs


Opcacification of hydrophilic acrylic IOLs


















Opacified hydrophilic IOL: Aquasense

*[Opacification of a hydrophilic intraocular lens 4 years after cataract surgery. A biomaterial analysis]. Khoramnia R, Salgado JP, Auffarth GU, Schmidt S, Wegner A, Kobuch KA, Winkler von Mohrenfels C. Ophthalmologe. 2012 May;109(5):483-6.


Opacified hydrophilic IOL: Euromaxx (Argonoptics)*

*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU. Optical and material analysis of opacified hydrophilicintraocular lenses after explantation: a laboratory study. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Opacified hydrophilic IOL: Euromaxx (Argonoptics)*

Light and scanning electron microscopy as well as X-ray spectroscopy in opacified Euromaxx ALI313Y and ALI313 IOLs

*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU.Optical and material analysis of opacified hydrophilicintraocular lenses after explantation: a laboratory study. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Material & Methods*− Explantation of 6 IOLs (Euromaxx ALI313Y and ALI313) that had opacified

− Light microscopy: Staining with Alizarin red and von Kossa

− Scanning electron microscopy

− X-ray spectroscopy (EDX): Chemical composition of the deposits

− Optical bench (OptiSpheric, Trioptics): Optical quality assessment

*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU.Optical and material analysis of opacified hydrophilic intraocular lenses after explantation: a laboratory study. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Results – Gross examination*

*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU.Optical and material analysis of opacified hydrophilic intraocular lenses after explantation: a laboratory study. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Results – Light microscopy*Staining with Alizarin red

*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU.Optical and material analysis of opacified hydrophilic intraocular lenses after explantation: a laboratorystudy. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Von Kossa Staining


Results – Light microscopy*


Results – Scanning electron microscopy*



Results – EDX*Energy dispersive X-ray spectroscopy (EDX)

Calcium phosphate*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU. Optical and material analysis of opacified hydrophilic intraocular lenses after explantation: a laboratorystudy. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Results – Element Mapping*



Results – Optical Bench*Modulation Transfer Function (MTF)

Severe reduction of optical quality*Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel M, Hugger P, Auffarth GU.Optical and material analysis of opacified hydrophilic intraocular lenses after explantation: a laboratorystudy. BMC Ophthalmol. 2015 Nov 25;15:170. doi: 10.1186/s12886-015-0149-1.


Report to the authorities


Recall of IOL










• Result of environmental circumstances (e.g., changes in

the aqueous milieu surrounding the implanted IOL

associated with preexisting or concurrent diseases or

indeed any condition that has disrupted the blood-

aqueous barrier)





IOL Opacification following Intracameral Injection of rtPA to Treat Inflammatory Membranes after Cataract Surgery

*Intraocular Lens Opacification following Intracameral Injection of Recombinant Tissue Plasminogen Activator to Treat Inflammatory Membranes after Cataract Surgery. Fung SS, Sykakis E, Islam NM, Zambarakji HJ, Khoramnia R, Auffarth GU, Parmar DN. J Ophthalmol. 2015;2015:975075. doi: 10.1155/2015/975075.


*Intraocular Lens Opacification following Intracameral Injection of Recombinant Tissue Plasminogen Activator to Treat Inflammatory Membranes after Cataract Surgery. Fung SS, Sykakis E, Islam NM, Zambarakji HJ, Khoramnia R, Auffarth GU, Parmar DN. J Ophthalmol. 2015;2015:975075. doi: 10.1155/2015/975075.

IOL Opacification following Intracameral Injection of rtPA to Treat Inflammatory Membranes after Cataract Surgery


Hydrophilic intraocular lens opacificationafter posterior lamellar keratoplasty*

*Giers BC, Tandogan T, Auffarth GU, Choi CY, Auerbach FN, Sel S, Mayer C, Khoramnia R. Hydrophilic intraocular lens opacification after posterior lamellar keratoplasty - a material analysiswith special reference to optical quality assessment. BMC Ophthalmol. 2017 Aug 22;17(1):150. doi: 10.1186/s12886-017-0546-8.



Hydrophilic IOL opacification after posterior lamellar keratoplasty*


Light microscopy*




Light microscopy*


Scanning electron microscopy*



Element Mapping*



EDX*



Optical quality*



Hydrophilic IOL opacification after posterior lamellar keratoplasty: Straylight*

*Assessment of straylight and the modulation transfer function of intraocular lenses with centrally localized opacification associated with the intraocular injection of gas. Łabuz G, Yildirim TM, van den Berg TJTP, Khoramnia R, Auffarth GU. J Cataract Refract Surg. 2018 May;44(5):615-622.

Severeincrease of straylight


Hydrophilic IOL opacification after PpV*

*Material Analysis and Optical Quality Assessment of Opacified Hydrophilic Acrylic Intraocular Lenses after Pars Plana Vitrectomy. Yildirim TM, Auffarth GU, Łabuz G, Bopp S, Son HS, Khoramnia R. Am J Ophthalmol. 2018 Sep;193:10-19.



*Material Analysis and Optical Quality Assessment of Opacified Hydrophilic Acrylic Intraocular Lenses after Pars Plana Vitrectomy. Yildirim TM, Auffarth GU, Łabuz G, Bopp S, Son HS, Khoramnia R. Am J Ophthalmol. 2018 Sep;193:10-19.


*Opacification of hydrophilic intraocular lenses associated with vitrectomy and injection of intraocular gas. Marcovich AL, Tandogan T, Bareket M, Etting E, Kaplan-Ashiri I, Bukelman A, Auffarth GU, Khoramnia R. BMJ Open Ophthalmol. 2018 Dec 15;3(1):e000157.









Opacification of hydrophilic intraocular lens after multiple injections of bevacizumab*

*Opacification of hydrophilic intraocular lens after multiple injections of bevacizumab. Roland S., Khoramnia R., Auffarth G.U., Son H.-S., Yildirim T.M., Schoenherr U. In press















• Other pathology is mistaken for calcification or false-

positive staining for calcium occurs


Liquefied Aftercataract*

*Giers BC, Khoramnia R, Tandogan T, Auffarth GU. Liquefied Aftercataract Mimicking IOL-Opacification. Klin Monbl Augenheilkd. 2017 Aug;234(8):988-990.


Summary• In addition to good optical quality, material properties are important in IOLs.

• In contrast to IOLs from hydrophobic acrylic, IOLs made of hydrophilic material can calcify.

• Primary Calcification: Production errors may be responsible for IOL calcification (e.g. Aquasense and Euromaxx).

• Secondary Calcification: IOLs made of hydrophilic acrylic can opacify irrespective of themanufacturer during various interventions (e.g. posterior lamellar keratoplasty, rtPAinjection, PpV).

• IOL exchange in symptomatic patients is the only treatment option available. Since IOL exchange is associated with a high intraoperative complication rate, our results suggest to consider the risk of IOL calcification when implanting hydrophilic acrylic IOLs.

Thank you!

Documents

IOL Opacification - EFCLIN...Khoramnia R, Salgado JP, Auffarth GU, Schmidt S, Wegner A, Kobuch KA, Winkler von Mohrenfels C. Ophthalmologe. 2012 May;109(5):483-6. University Eye Clinic