Back to Journals » Clinical Ophthalmology » Volume 16
Academy IRIS® Registry Analysis of Incidence of Laser Capsulotomy Due to Posterior Capsule Opacification After Intraocular Lens Implantation
Authors Horn JD, Fisher BL, Terveen D, Fevrier H, Merchea M, Gu X
Received 5 February 2022
Accepted for publication 10 May 2022
Published 1 June 2022 Volume 2022:16 Pages 1721—1730
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 2
Editor who approved publication: Dr Scott Fraser
Jeffrey D Horn,1 Bret L Fisher,2 Daniel Terveen,3 Helene Fevrier,4 Mohinder Merchea,5 Xiaolin Gu5
1Vision for Life, Nashville, TN, USA; 2Eye Center of North Florida, Panama City, FL, USA; 3Vance Thompson Vision, Sioux Falls, SD, USA; 4Verana Health, San Francisco, CA, USA; 5Alcon Vision LLC, Fort Worth, TX, USA
Correspondence: Jeffrey D Horn, Vision for Life, Nashville, TN, USA, Tel +1 615-588-2020, Email [email protected]
Purpose: Academy IRIS® (Intelligent Research in Sight) Registry was used to determine the incidence of postoperative neodymium-doped yttrium aluminum garnet laser capsulotomy (Nd:YAG) and time to posterior capsular opacification (PCO) diagnosis based on intraocular lens (IOL) type and brand.
Methods: This retrospective analysis included eyes implanted with 1 of 2 IOL brands, with ≥ 365 days of follow-up available in the IRIS Registry, and ≥ 2 visits within 180 days of surgery. Analyses included Nd:YAG incidence due to PCO within 1 year after surgery by IOL type and brand, mean time to PCO diagnosis, and mean time to Nd:YAG.
Results: Of 89,947 eyes after cataract surgery, 24,834 (28%) had PCO diagnosis within 365 days, and 9262 (10%) underwent Nd:YAG; 4.1% of 57,523 eyes with monofocal and 21.2% of 32,424 eyes with diffractive multifocal (MF) or diffractive extended depth of focus (EDOF) IOLs had Nd:YAG. Nd:YAG was 3.2 times more likely in eyes with diffractive MF or diffractive EDOF IOLs versus monofocal. For monofocal IOLs, 3.2% of eyes with AcrySof® and 8.1% of eyes with Tecnis® had Nd:YAG (P< 0.0001). For diffractive MF or diffractive EDOF IOLs, 13.0% of eyes with AcrySof and 21.7% of eyes with Tecnis had Nd:YAG (P< 0.0001). Nd:YAG risk was 2.4 times higher in eyes with Tecnis versus AcrySof IOLs. Overall, mean time to PCO diagnosis and Nd:YAG was 150.7 and 180.7 days. Mean time to PCO for monofocal versus diffractive MF or diffractive EDOF IOLs was 165.3 versus 139.7 days (P< 0.0001). Mean time to Nd:YAG for monofocal versus diffractive MF or diffractive EDOF IOLs was 196.4 versus 175.3 days (P< 0.05).
Conclusion: Real-world data for AcrySof and Tecnis IOLs revealed lower Nd:YAG rates and longer time to PCO diagnosis and Nd:YAG after monofocal versus diffractive multifocal or diffractive EDOF implantation. Nd:YAG rates were significantly lower with AcrySof versus Tecnis IOLs.
Keywords: monofocal intraocular lenses, diffractive multifocal intraocular lenses, diffractive extended depth of focus intraocular lenses
Posterior capsular opacification (PCO) is a common complication of cataract surgery and typically develops 1 to 3 years after surgery.1,2 PCO is caused by the migration of postoperative residual lens epithelial cells to the posterior capsule.2 The increased opacity impairs vision, with a reduction in visual acuity and contrast sensitivity, as well as glare disability.2,3
Clinically significant visual impairment induced by PCO such as a decrease in best corrected distance visual acuity, increased glare, or decreased contrast sensitivity, can be readily and effectively treated with neodymium-doped yttrium aluminum garnet laser capsulotomy (Nd:YAG).2,3 Nd:YAG capsulotomy is a simple and generally safe procedure that results in the immediate improvement of the subject’s vision.2,4 However, potential complications include damage to the optic portion of the intraocular lens (IOL), retinal detachment (eg, high myopes), cystoid macular edema, and a transient elevation in intraocular pressure.5,6 Moreover, surgical complications such as vitreous loss during lens exchange have been associated with prior Nd:YAG capsulotomy.7 A number of risk factors have been associated with PCO development, including younger age, dry eye disease, glaucoma, uveitis, age-related macular degenerations, surgery type, and experience of the surgeon.8–10 Several studies have shown that the rates of PCO and Nd:YAG as well as the time to Nd:YAG after cataract surgery are influenced by the IOL biomaterial and its optic edge design.3,4,11–14 A systemic review of the literature reported the incidence of PCO was from 5% to 32% for hydrophobic IOLs and from 18% to 65% for hydrophilic IOLs within 3 years of cataract surgery.14 During the same time period, Nd:YAG rates were 0% to 25% for hydrophobic IOLs and 3% to 51% for hydrophilic IOLs.14
The American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry was developed as a centralized data repository and reporting tool for patient data collected from physicians’ electronic health records (EHRs).15,16 It is the largest EHR-based comprehensive eye disease and condition registry in the world, with over 60 million unique patients and 349 million encounters.15 The IRIS Registry includes patient demographics, diagnosis codes, and visit rates that can be used to generate real-world clinical evidence and address clinical questions.15,16
In this report, we describe a real-world study using IRIS Registry data to compare the incidence of Nd:YAG due to PCO by optical design type (monofocal or multifocal) and brand type (AcrySof®, Alcon Research LLC, Fort Worth, TX, USA; or Tecnis®, Johnson & Johnson Surgical Vision, Santa Ana, CA, USA) of implanted hydrophobic acrylic IOLs. Additional analyses included the mean time to PCO diagnosis and Nd:YAG treatment within 365 days after IOL implantation.
Study Design and Study Population
This was a retrospective database analysis using data from the IRIS Registry. The analysis included the medical records from eyes implanted with IOLs from January 1, 2016, to March 31, 2018, and required the respective practices to have ≥365 days of follow-up available in the registry. Data extraction and analysis were independently performed by Verana Health (San Francisco, CA).
Patient records were eligible for inclusion if they were aged ≥45 years at the time of cataract surgery; had a Current Procedural Terminology (CPT) code of 66984 (extracapsular cataract removal with insertion of IOL prosthesis [1 stage procedure], manual or mechanical technique [eg, irrigation and aspiration or phacoemulsification]); had a diagnosis of age-related cataract as shown by an International Classification of Disease (ICD)-10 diagnosis code (Supplementary Table 1) 30 days before and including the day of the surgery and with ≥2 visits included in the IRIS Registry within 180 days of cataract procedure; had surgery at a practice that contributed data to the IRIS Registry for ≥365 days following the date of the procedure; and both the brand (AcrySof, Alcon Vision LLC, Fort Worth, TX; Tecnis, Johnson & Johnson, New Brunswick, NJ) and optical design type (toric/non-toric monofocal, diffractive multifocal, or diffractive extended depth of focus [EDOF]) of the implanted IOL could be identified (Supplementary Table 2).
Patient records were excluded if they showed an ICD-10 code indicating specific exclusion conditions indicative of pre-existing conditions that could potentially confound the outcomes (Supplementary Table 1); had unspecified laterality of the diagnosis code for mature cataract or the procedure code for cataract removal; or their records showed a CPT code for specific procedures indicative of surgical complications (Supplementary Table 2). Patient attrition is summarized in Supplementary Figure 1.
The primary analyses compared the incidence of Nd:YAG due to PCO, the mean time to first diagnosis of PCO, and mean time to Nd:YAG procedure after IOL implantation by brand and type of IOL within 365 days after implantation. Nd:YAG due to PCO was defined as the presence of a Nd:YAG procedure code (CPT 66821) with an accompanying PCO diagnosis code (ICD-10 code H26.491, H26.492, H26.493, or H26.499) for the same eye on the date of the Nd:YAG procedure or between the Nd:YAG procedure and the cataract procedure.
Statement of Ethics
Data were extracted automatically from the practice’s EHR system and placed in a clinical data repository, while maintaining compliance with the Health Insurance Portability and Accountability Act data protection, security, quality, and audits. This analysis of de-identified data did not qualify as human subjects research, and no ethics committee review or approval was required or undertaken. An Institutional Review Board waiver was not applicable to the Submission because (i) the research and analysis were conducted on anonymized data in accordance with de-identification standard promulgated under 45 CFR § 164.514 and (ii) no research was conducted on human subjects. To ensure consistent results during the data analysis, the incidence of Nd:YAG post-implantation was calculated for model type, brand, and both model type and brand.
All statistical analyses were performed by Verana Health (San Francisco, CA), the vendor retained by the American Academy of Ophthalmology for the curation and analysis of the IRIS Registry data. Verana Health applied a set of policies and procedures to ensure data equality, integrity, security, and traceability. Data quality at Verana Health was assessed based on a matrix of 6 data quality dimensions (completeness, accuracy, traceability, consistency, generalizability, timeliness) across 3 data quality classifications (technical, clinical, scientific). Categorical and continuous variables were summarized using chi-square and analysis of variance, respectively. Odds ratios were calculated using logistic regression to determine the risk of Nd:YAG due to PCO. Descriptive analysis included mean ± SD.
A total of 89,947 eyes were identified from the IRIS Registry as meeting all the inclusion and exclusion criteria and comprised the master cohort (Table 1). In the master cohort, the most frequently implanted IOL types were monofocal (55%) and diffractive EDOF (44%). Demographics and baseline characteristics were generally balanced between patients receiving AcrySof or Tecnis IOLs. Of the 89,947 eyes in the master cohort, 24,834 eyes (28%) received a diagnosis of PCO within 365 days of cataract surgery (Table 2). Most patients were female (64%) and white (85%). Overall, 71% of surgeries were conducted in the South and Midwest regions of the United States.
Table 1 Demographics and Baseline Characteristics of Master Cohort
Table 2 Demographics and Baseline Characteristics of Patients with a Diagnosis of PCOa After Cataract Surgery
Overall, 9262 of 89,947 enrolled eyes (10.3%) had a Nd:YAG procedure. Across all eyes, the rates of Nd:YAG were significantly lower in eyes with monofocal IOLs versus those with diffractive multifocal or diffractive EDOF IOLs (P<0.0001, Figure 1A). Across brands, the rates of Nd:YAG were significantly lower in eyes implanted with AcrySof monofocal versus Tecnis monofocal (P<0.0001) or AcrySof multifocal versus Tecnis multifocal or diffractive EDOF IOLs (P<0.0001, Figure 1B). The risk of Nd:YAG treatment was 3 times higher in eyes with diffractive multifocal or diffractive EDOF lenses compared with monofocal lenses, and 2 times higher in eyes with Tecnis compared with AcrySof lenses (Figure 2).
Among all eyes diagnosed with PCO that completed at least 1-year follow-up (n=24,834), the mean time ± SD to PCO was 150.7±96.0 days. The time to PCO was significantly greater for eyes implanted with monofocal IOLs compared with diffractive multifocal and diffractive EDOF IOLs (P<0.0001; Figure 3A). Similarly, the time to PCO was greater for AcrySof monofocal IOLs compared with Tecnis monofocal IOLs (P<0.0001; Figure 3B). Mean ± SD time to Nd:YAG (defined as the presence of Nd:YAG procedure code within 1 year of the cataract surgery) for all eyes was 180.7±86.8 days. The time to Nd:YAG was significantly greater for eyes implanted with monofocal compared with diffractive multifocal or diffractive EDOF IOLs (P<0.05; Figure 4A). The time to Nd:YAG was significantly greater for AcrySof diffractive multifocal IOLs compared with Tecnis diffractive multifocal and diffractive EDOF IOLs (P<0.05 for both; Figure 4B).
This real-world study analyzed data from 89,947 eyes in the IRIS Registry that underwent cataract surgery and found the overall rate of Nd:YAG was 10.3% at 1 year after surgery. Significantly lower rates of Nd:YAG were reported for patients implanted with monofocal (4.1%) versus those implanted with diffractive multifocal or diffractive EDOF IOLs (21.2%). This difference held whether comparing AcrySof monofocal lenses (3.2%) to AcrySof multifocal (ReSTOR®) lenses (13.0%) or Tecnis monofocal lenses (8.1%) to Tecnis multifocal (22.5%) or Tecnis EDOF (21.5%) lenses. The rates of Nd:YAG in patients receiving AcrySof IOLs were significantly lower compared with those receiving Tecnis IOLs. A greater risk of Nd:YAG treatment was associated with implanting diffractive multifocal or diffractive EDOF lenses as well as Tecnis lenses.
The mean time to PCO diagnosis was significantly greater for patients implanted with monofocal IOLs (toric and non-toric) versus patients implanted with diffractive multifocal or diffractive EDOF IOLs. Time to PCO diagnosis was also longer in patients implanted with monofocal AcrySof compared with those implanted with monofocal Tecnis IOLs. Mean time to PCO diagnosis data were consistent with mean time to Nd:YAG procedure. There was a significantly longer time to Nd:YAG procedure for patients with AcrySof multifocal IOLs compared with Tecnis multifocal or Tecnis EDOF IOLs.
Differences in PCO development and Nd:YAG rates have been attributed to the biocompatibility of the lens material and its design (eg, optic edge).1,9,12,17 Several studies indicate that hydrophobic lenses,11,17,18 especially lenses made of acrylic material,12 are more effective in preventing PCO and lowering Nd:YAG rates. A meta-analysis showed that hydrophobic lenses generally result in lower subjective and estimated PCO scores, as well as Nd:YAG rates, compared with hydrophilic lenses.18 A review of EHRs from ophthalmology clinics in the United Kingdom found that 2 hydrophobic acrylic IOLs (AcrySof, Tecnis) had the lowest 3- and 5-year incidence of Nd:YAG compared with their hydrophilic counterparts.4 Patients with hydrophilic lenses showed a significantly greater severity and area of PCO (P<0.001) 1 year after cataract surgery than patients with hydrophobic lenses.17 Systematic reviews have shown that in addition to lens material, sharp-edged IOLs have a mitigating effect on PCO development.3,12
Both the longer time to PCO diagnosis and the lower Nd:YAG rate and risk of Nd:YAG treatment observed with monofocal IOLs compared with diffractive multifocal and diffractive EDOF IOLs were consistent with the findings of several studies.19–22 In a retrospective chart review, the Nd:YAG rates for 2 monofocal groups were 17% and 4% versus 25% for a multifocal group.19 In a case-controlled study, patients with multifocal IOLs needed to undergo treatment with Nd:YAG earlier compared with patients implanted with a monofocal IOL (8.8 vs 10.4 months, respectively).20
The AcrySof and Tecnis diffractive multifocal and diffractive EDOF IOLs were based on the AcrySof and Tecnis platforms, respectively, sharing the edge and haptic designs and using the same biomaterials as their monofocal counterparts, but with the addition of diffractive optics.23–28 The observed differences in PCO and Nd:YAG rates between monofocal and diffractive multifocal/EDOF IOLs were consistent regardless of the brand of the lens, suggesting that the diffractive multifocal and diffractive EDOF IOL optical design and the related visual outcomes play an important role in post-surgical complications.
Reduced contrast sensitivity and photic phenomena are typically experienced more often by patients receiving diffractive multifocal and diffractive EDOF IOLs because light is distributed among multiple focal points to provide an extended range of vision.20,29–32 Mild PCO in such patients may lead to greater intolerance or greater sensitivity to early functional vision loss and worse quality of vision than in patients implanted with monofocal IOLs with the same level of PCO, consequently decreasing the time to Nd:YAG treatment.20,21,33 Moreover, the higher expectations of patients receiving diffractive multifocal/EDOF IOLs may be associated with the higher out-of-pocket costs related to multifocal/EDOF IOLs.34,35
Photic phenomena, such as glare and halos, occurring after implantation with a multifocal IOL may not be caused by PCO, but rather by the properties inherent to the optic design. An Nd:YAG procedure will not resolve photic phenomena caused by optic design and could lead to complications if a subsequent IOL exchange is needed.36 Therefore, it is important to differentiate the cause of glare and halos before Nd:YAG treatment.
The AcrySof and Tecnis IOLs, regardless of type (ie, monofocal vs diffractive multifocal/EDOF), have similar characteristics that include hydrophobic acrylic material and a posterior square-edged design.25,26,28 However, there were significantly lower rates of Nd:YAG and risk of Nd:YAG treatment in eyes implanted with the AcrySof lens compared with the Tecnis lens. The mean time to PCO diagnosis was longer in patients implanted with either brand of monofocal IOL, but there was also a significantly longer time to PCO for patients receiving monofocal AcrySof compared with those receiving monofocal Tecnis. The resulting differences may be attributed to slight distinctions between the lenses. AcrySof is composed of an acrylate and methacrylate copolymer, and its posterior square edge is interrupted at the haptic-optic junction.23,24,28 Tecnis is composed of an acrylic material and has a continuous 360° edge.25,26 Previous studies have indicated that the material of a lens and its surface properties contribute to PCO formation. In a comparison of monofocal hydrophobic and hydrophilic acrylic IOLs, including the hydrophobic AcrySof lens, the incidence of Nd:YAG for eyes implanted with AcrySof was 2–4 times lower than the non-AcrySof hydrophobic and hydrophilic IOLs, respectively, 3 years after cataract surgery.37 A retrospective study comparing 3 hydrophobic IOLs (Hoya FY60AD, Hoya PY60AD, AcrySof SN60WF), reported that the sharper-edged Hoya PY60AD had a significantly lower Nd:YAG rate than its predecessor (4.3% vs 8.9%).28 The AcrySof lens had a still lower Nd:YAG rate (1.4%) than either Hoya IOL, although it had a slightly rounder edge than the Hoya PY60AD.28 Similarly, a prospective randomized contralateral eye study comparing 2 single-piece, sharp-edged hydrophobic acrylic IOLs (iMiCs NY-60, AcrySof SN60WF) 3 years after cataract surgery, reported a significantly lower PCO score and Nd:YAG rate in eyes implanted with AcrySof (36% vs 14%).38 These data suggest that modern IOL materials and edge design may each play a role in the incidence of PCO and Nd:YAG after cataract surgery.17,28,37
The low PCO incidence observed with AcrySof lenses may result from its posterior edge design.39 However, comparisons against sharper-edged IOLs suggest that the biocompatibility of its acrylic polymer strengthens its binding to the capsule and minimizes PCO formation.14,28,38 Successful mitigation of PCO development has been attributed to the formation of a physical barrier caused by the IOL adhering tightly to the capsular bag, which deters the migration of residual lens epithelial cells.2,14 This resulting barrier may be formed by either the edge of the IOL causing the capsule to bend and wrap more tightly around the IOL,40,41 or by the binding of a sandwich-like structure (fibronectin-lens, epithelial cell, monolayer-fibronectin) to the bioactive material of the IOL and to the posterior capsule, thus creating a blockade to migrating cells.42 Results from assays testing the bioadhesive properties of different IOLs have demonstrated that the AcrySof IOL’s material adhered strongly to collagen film,43 and when compared with Tecnis, fibronectin bonded better to the AcrySof lens.44 Consequently, the AcrySof biomaterial attaches to the capsule through fibronectin, creating an effective barrier to migrating cells and minimizing PCO formation.14,44
Limitations of these analyses included reliance on EHR and physician’s documentation in the EHR. There could be potential errors in documentation or variations among the EHR systems. The pre-collected data in the EHR were fixed and were not collected by the investigators; therefore, not all relevant information was available or provided at the level of detail comparable to clinical studies.45 For example, Nd:YAG due to PCO may not be captured in patients who changed their physician to one not participating in the IRIS Registry. Moreover, other factors that could contribute to the observed differences in the Nd:YAG rates or the elapsed time to PCO or Nd:YAG, such as the differences in surgical technique, criteria used for PCO diagnosis and Nd:YAG, or patient history (eg, uveitis, glaucoma, or diabetes), may not have been captured in the EHR.9,13,46 The follow-up period of 365 days may have been insufficient to capture PCO development. Future analyses should consider extending to 2, 5, or 10 years as PCO development has been observed up to 10 years after cataract surgery,14 and the risk of PCO development that requires treatment with Nd:YAG is associated with follow-up time.47
Outcomes of this analysis suggest that retrospective studies using comprehensive clinical databases, such as the IRIS Registry, can generate real-world evidence to answer clinically important questions. Additional analytic applications and user interfaces can be designed to further enhance the value of the IRIS Registry. The IRIS Registry data revealed that overall Nd:YAG rates were lower, and the time to PCO diagnosis and Nd:YAG was longer after monofocal implantation than diffractive multifocal or diffractive EDOF implantation when using AcrySof and Tecnis IOLs. AcrySof Nd:YAG rates were significantly lower than Tecnis Nd:YAG rates.
Data Sharing Statement
Study level data for this study can be provided by Dr. Xiaolin Gu ([email protected]) upon reasonable request.
Medical writing assistance was provided by Lauriaselle Afanador, PhD, of ICON plc (Blue Bell, PA), and was funded by Alcon Vision LLC (Fort Worth, TX). Data contained in this manuscript were presented at the American Academy of Ophthalmology annual meeting; October 12–15, 2019; San Francisco, CA:
- Fisher BL, Gu X, Relucio A. Comparison of time to PCO in two hydrophobic intraocular lens materials: An analysis of the AAO clinical registry.
- Horn J, Relucio A, Gu X. Incidence of YAG due to PCO following intraocular lens implantation: an analysis of Academy IRIS Registry.
- Terveen D, Relucio A, Gu X. Description of a retrospective study using EHR-based registry to correlate IOL biocompatibility with YAG.
This study was funded by Alcon Vision LLC (Fort Worth, TX). Alcon participated in the design, interpretation of the data; and preparation, review, and approval of the manuscript.
JDH is a consultant and clinical investigator for Alcon Vision LLC, has received speaker fees from Alcon, and is a clinical investigator for Bausch & Lomb. BLF is a consultant for Alcon, AcuFocus, CorneaGen, and Imprimis Pharmaceuticals and a Medical Monitor for Ziemer NA. DT reports personal fees for medical monitor from Rayner; grants from Glaukos, Sight Sciences, and Alcon, outside the submitted work. HF is an employee of Verana Health, which was contracted by Alcon Vision LLC to conduct this study. MM and XG are employees of Alcon Vision LLC. The authors report no other conflicts of interest in this work.
1. Sinha R, Shekhar H, Sharma S, Titiyal JS, Vajpayee RB. Posterior capsular opacification: a review. Indian J Ophthalmol. 2013;61(7):371–376. doi:10.4103/0301-4738.115787
2. Chan E, Mahroo OA, Spalton DJ. Complications of cataract surgery. Clin Exp Optom. 2010;93(6):379–389. doi:10.1111/j.1444-0938.2010.00516.x
3. Buehl W, Findl O. Effect of intraocular lens design on posterior capsule opacification. J Cataract Refract Surg. 2008;34(11):1976–1985. doi:10.1016/j.jcrs.2008.07.029
4. Ursell PG, Dhariwal M, O’Boyle D, Khan J, Venerus A. 5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a real-world evidence study of 20,763 eyes. Eye (Lond). 2020;34(5):960–968. doi:10.1038/s41433-019-0630-9
5. Grzybowski A, Kanclerz P. Does Nd:YAG capsulotomy increase the risk of retinal detachment? Asia Pac J Ophthalmol. 2018;7(5):339–344.
6. Karahan E, Er D, Kaynak S. An overview of Nd: YAG laser capsulotomy. Med Hypothesis Discov Innov Ophthalmol. 2014;3(2):45–50.
7. Leysen I, Bartholomeeusen E, Coeckelbergh T, Tassignon MJ. Surgical outcomes of intraocular lens exchange: five-year study. J Cataract Refract Surg. 2009;35(6):1013–1018. doi:10.1016/j.jcrs.2009.01.024
8. Chen HC, Lee CY, Sun CC, et al. Risk factors for the occurrence of visual-threatening posterior capsule opacification. J Transl Med. 2019;17(1):209. doi:10.1186/s12967-019-1956-6
9. Fong CS, Mitchell P, Rochtchina E, et al. Three-year incidence and factors associated with posterior capsule opacification after cataract surgery: the Australian Prospective Cataract Surgery and Age-related Macular Degeneration study. Am J Ophthalmol. 2014;157(1):171–179.e1. doi:10.1016/j.ajo.2013.08.016
10. Wu S, Tong N, Pan L, et al. Retrospective analyses of potential risk factors for posterior capsule opacification after cataract surgery. J Ophthalmol. 2018;2018:9089285. doi:10.1155/2018/9089285
11. Li Y, Wang J, Chen Z, Tang X. Effect of hydrophobic acrylic versus hydrophilic acrylic intraocular lens on posterior capsule opacification: meta-analysis. PLoS One. 2013;8(11):e77864. doi:10.1371/journal.pone.0077864
12. Cheng JW, Wei RL, Cai JP, et al. Efficacy of different intraocular lens materials and optic edge designs in preventing posterior capsular opacification: a meta-analysis. Am J Ophthalmol. 2007;143(3):428–436. doi:10.1016/j.ajo.2006.11.045
13. Tokko HA, Hussain F, Al-Awadi A, et al. Factors associated with the development of posterior capsule opacification requiring yttrium aluminum garnet capsulotomy. Optom Vis Sci. 2019;96(7):492–499. doi:10.1097/OPX.0000000000001396
14. Perez-Vives C. Biomaterial influence on intraocular lens performance: an overview. J Ophthalmol. 2018;2018:2687385. doi:10.1155/2018/2687385
15. American Academy of Ophthalmology. IRIS registry data analysis. Available from: https://www.aao.org/iris-registry/data-analysis/requirements.
16. Chiang MF, Sommer A, Rich WL, Lum F, Parke DW, 2nd. The 2016 American Academy of Ophthalmology IRIS® registry (Intelligent Research in Sight) database: characteristics and methods. Ophthalmology. 2018;125(8):1143–1148. doi:10.1016/j.ophtha.2017.12.001
17. Kugelberg M, Wejde G, Jayaram H, Zetterstrom C. Posterior capsule opacification after implantation of a hydrophilic or a hydrophobic acrylic intraocular lens: one-year follow-up. J Cataract Refract Surg. 2006;32(10):1627–1631. doi:10.1016/j.jcrs.2006.05.011
18. Zhao Y, Yang K, Li J, Huang Y, Zhu S. Comparison of hydrophobic and hydrophilic intraocular lens in preventing posterior capsule opacification after cataract surgery: an updated meta-analysis. Medicine (Baltimore). 2017;96(44):e8301. doi:10.1097/MD.0000000000008301
19. Biber JM, Sandoval HP, Trivedi RH, et al. Comparison of the incidence and visual significance of posterior capsule opacification between multifocal spherical, monofocal spherical, and monofocal aspheric intraocular lenses. J Cataract Refract Surg. 2009;35(7):1234–1238. doi:10.1016/j.jcrs.2009.03.013
20. Shah VC, Russo C, Cannon R, Davidson R, Taravella MJ. Incidence of Nd: YAG capsulotomy after implantation of AcrySof multifocal and monofocal intraocular lenses: a case controlled study. J Refract Surg. 2010;26(8):565–568. doi:10.3928/1081597X-20100303-01
21. Elgohary MA, Beckingsale AB. Effect of posterior capsular opacification on visual function in patients with monofocal and multifocal intraocular lenses. Eye (Lond). 2008;22(5):613–619. doi:10.1038/sj.eye.6702661
22. Vingolo EM, Grenga P, Iacobelli L, Grenga R. Visual acuity and contrast sensitivity: AcrySof ReSTOR apodized diffractive versus AcrySof SA60AT monofocal intraocular lenses. J Cataract Refract Surg. 2007;33(7):1244–1247. doi:10.1016/j.jcrs.2007.03.052
23. AcrySof IQ Aspheric Natural IOL. Full Prescribing Information. Frimley, Camberley, Surrey, UK: Alcon Laboratories (UK) Ltd; 2014.
24. AcrySof IQ ReStor Multifocal IOL. Full Prescribing Information. Fort Worth, TX: Alcon Laboratories, Inc; 2015.
25. Tecnis 1-Piece IOL. Full Prescribing Information. Santa Ana, CA: Johnson & Johnson Surgical Vision, Inc; 2017.
26. Tecnis Multifocal 1-Piece Intraocular Lens (IOL) - Models ZKB00 (+2.75 D) and ZLB00 (+3.25 D). Full Prescribing Information. Santa Ana, CA: Johnson & Johnson Surgical Vision, Inc; 2017.
27. TECNIS Symfony® Extended Range of Vision IOL. Full Prescribing Information. Santa Ana, CA: Johnson & Johnson Surgical Vision, Inc; 2017.
28. Morgan-Warren PJ, Smith JA. Intraocular lens-edge design and material factors contributing to posterior-capsulotomy rates: comparing Hoya FY60aD, PY60aD, and AcrySof SN60WF. Clin Ophthalmol. 2013;7:1661–1667. doi:10.2147/OPTH.S48824
29. Haring G, Dick HB, Krummenauer F, Weissmantel U, Kroncke W. Subjective photic phenomena with refractive multifocal and monofocal intraocular lenses. Results of a multicenter questionnaire. J Cataract Refract Surg. 2001;27(2):245–249. doi:10.1016/S0886-3350(00)00540-X
30. Liu J, Dong Y, Wang Y. Efficacy and safety of extended depth of focus intraocular lenses in cataract surgery: a systematic review and meta-analysis. BMC Ophthalmol. 2019;19(1):198. doi:10.1186/s12886-019-1204-0
31. Rosen E, Alio JL, Dick HB, Dell S, Slade S. Efficacy and safety of multifocal intraocular lenses following cataract and refractive lens exchange: metaanalysis of peer-reviewed publications. J Cataract Refract Surg. 2016;42(2):310–328. doi:10.1016/j.jcrs.2016.01.014
32. Voigt U, Strobel J. [YAG laser capsulotomy in multifocal intraocular lenses]. Ophthalmologe. 1999;96(9):578–582. German. doi:10.1007/s003470050455
33. Ouchi M. Primary posterior continuous curvilinear capsulorhexis combined with diffractive multifocal intraocular lens implantation. Eye (Lond). 2016;30(1):95–101. doi:10.1038/eye.2015.201
34. Wei CK, Wang SM, Lin JC. A study of patient satisfaction after cataract surgery with implantation of different types of intraocular lenses. BMC Res Notes. 2012;5:592. doi:10.1186/1756-0500-5-592
35. Zhang F, Sugar A, Jacobsen G, Collins M. Visual function and patient satisfaction: comparison between bilateral diffractive multifocal intraocular lenses and monovision pseudophakia. J Cataract Refract Surg. 2011;37(3):446–453. doi:10.1016/j.jcrs.2010.10.045
36. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009;35(6):992–997. doi:10.1016/j.jcrs.2009.01.031
37. Ursell PG, Dhariwal M, Majirska K, et al. Three-year incidence of Nd: YAG capsulotomy and posterior capsule opacification and its relationship to monofocal acrylic IOL biomaterial: a UK Real World Evidence study. Eye (Lond). 2018;32(10):1579–1589. doi:10.1038/s41433-018-0131-2
38. Leydolt C, Schriefl S, Stifter E, Haszcz A, Menapace R. Posterior capsule opacification with the iMics1 NY-60 and AcrySof SN60WF 1-piece hydrophobic acrylic intraocular lenses: 3-year results of a randomized trial. Am J Ophthalmol. 2013;156(2):375–381.e2. doi:10.1016/j.ajo.2013.04.007
39. Hancox J, Spalton D, Cleary G, et al. Fellow-eye comparison of posterior capsule opacification with AcrySof SN60AT and AF-1 YA-60BB blue-blocking intraocular lenses. J Cataract Refract Surg. 2008;34(9):1489–1494. doi:10.1016/j.jcrs.2008.05.024
40. Nishi O, Nishi K. Preventing posterior capsule opacification by creating a discontinuous sharp bend in the capsule. J Cataract Refract Surg. 1999;25(4):521–526. doi:10.1016/S0886-3350(99)80049-2
41. Nishi O, Nishi K, Wickstrom K. Preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edges. J Cataract Refract Surg. 2000;26(10):1543–1549. doi:10.1016/S0886-3350(00)00426-0
42. Linnola RJ, Werner L, Pandey SK, et al. Adhesion of fibronectin, vitronectin, laminin, and collagen type IV to intraocular lens materials in pseudophakic human autopsy eyes. J Cataract Refract Surg. 2000;26(12):1807–1818. doi:10.1016/S0886-3350(00)00747-1
43. Nagata T, Minakata A, Watanabe I. Adhesiveness of AcrySof to a collagen film. J Cataract Refract Surg. 1998;24(3):367–370. doi:10.1016/S0886-3350(98)80325-8
44. Ong M, Wang L, Karakelle M. Fibronectin adhesive properties of various intraocular lens materials. Invest Ophthalmol Vis Sci. 2013;54:819.
45. Thygesen LC, Ersboll AK. When the entire population is the sample: strengths and limitations in register-based epidemiology. Eur J Epidemiol. 2014;29(8):551–558. doi:10.1007/s10654-013-9873-0
46. Tran DB, Vargas V, Potvin R. Neodymium:YAG capsulotomy rates associated with femtosecond laser-assisted versus manual cataract surgery. J Cataract Refract Surg. 2016;42(10):1470–1476. doi:10.1016/j.jcrs.2016.08.019
47. Sundelin K, Almarzouki N, Soltanpour Y, Petersen A, Zetterberg M. Five-year incidence of Nd:YAG laser capsulotomy and association with in vitro proliferation of lens epithelial cells from individual specimens: a case control study. BMC Ophthalmol. 2014;14:116. doi:10.1186/1471-2415-14-116
© 2022 The Author(s). This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.