1. Phakic cadaver eye (horizontal meridian)

2. Pseudophakic cadaver eye (horizontal meridian)

3. Patient of Dr. G. Baikoff, Marseille, France (Courtesy: S. Phillips, Ultralink) Phakic anterior chamber lens: Vivarte™

4. Patient of Dr. H. Matamoros, Madrid Spain (Courtesy: S. Phillips, Ultralink) Phakic posterior chamber lens: PRL

5. Phakic posterior chamber IOLs Cells involved in crystalline lens and capsular bag opacification Evolution of designs of PPCIOLs Relevant aspects of fixation and sizing Sizing issue: New studies Surgical implantation Relationship between cataract and myopia Cataractogenesis Specimens analyzed in our Center Mechanisms Review of the literature Classification of cataracts after phakic IOL implantation?

6. Surgical implantation Nd:YAG laser iridotomies: 2 superior iridotomies; placed 90 degrees apart (to avoid pupillary block); performed 1 or 2 weeks before surgery -Cataractogenetic effect? -Contribute to pigment deposition on the IOLs -1 single surgical iridectomy may be performed intraoperatively (risk of bleeding)

7. Surgical implantation 2) Incision (foldable lenses, thus, small incision; may be planned to correct pre-existing astigmatism) 3) Injection of viscoelastics (important to protect adjacent tissues and to allow the lens to unfold in a controlled manner) 4) Lens insertion: -ICLinjector/forceps -PRLspecial forceps/injector

8. Surgical implantation 5) Placement of the haptics behind the iris (spatula/hook) -No pressure should be placed on the crystalline lens 6) Pupil contriction with miotic agents 7) Viscoelastic removal (irrigation or irrigation/aspiration) 8) Wound closure Postoperative treatment: -Steroid/antibiotic (4 weeks) -Oral acetazolamide (48 hours)retained viscoelastics

9. Surgical implantation -The crystalline lens should ideally not be touched at all during the surgery -Many opportunities to have accidental contact with the anterior capsule of the crystalline lens -Anterior capsule trauma may lead to crystalline lens opacities months later

10. Phakic posterior chamber IOLs Cells involved in crystalline lens and capsular bag opacification Evolution of designs of PPCIOLs Relevant aspects of fixation and sizing Sizing issue: New studies Surgical implantation Relationship between cataract and myopia Cataractogenesis Specimens analyzed in our Center Mechanisms Review of the literature Classification of cataracts after phakic IOL implantation?

11. Cataract x Myopia Excess incidence of myopic refraction in cataract patients Age-related nuclear sclerosis causes refractive change towards myopia Brown NAP, Hill AR. Cataract: The relation between myopia and cataract morphology. Br J Ophthalmol 1987; 71:405-414

12. Cataract x Myopia Use of eyeglasses by age 20 years (indicator of myopia) increase the risk of cataract Leske MC, et al. The lens opacities case-control study. Risk factors for cataract. Arch Ophthalmol 1991; 109:244-251 Harding JJ, et al. Risk factors for cataract in Oxfordshire: diabetes, peripheral neuropathy, myopia, glaucoma and diarrhoea. Acta Ophthalmol 1989; 67:510-517.

13. Cataract x Myopia Moderate to high myopia has an association with age- related cataract For lower levels of myopia this relationship has been disputed Early-onset myopia: strong and independent risk factor for cataract Lim R, et al. Refractive associations with cataract: the Blue Mountains Eye Study. Invest Ophthalmol Vis Sci 1999; 40:3021-3026

14. Cataract x Myopia “High myopia is complicated by the frequent and early development of cataracts”. Metge P, Donnadieu M. Myopia and cataract. Revue du Praticien 1993; 43:1784-1786

15. Cataract x Myopia As a direct consequence of retinal damage lipid peroxidation is involved in the pathogenesis of cataract in diabetes and in severe myopia Simonelli F, et al. Lipid peroxidation and human cataractogenesis in diabetes and severe myopia. Exp Eye Res 1989; 49:181-187