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Purpose: To assess the clinical outcomes of bag-in-the-lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979-7:2006 in pediatric eyes and eyes with ocular comorbidities., Setting: Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium., Design: Cohort study., Methods: This cohort included the first series of patients having IOL implantation using the bag-in-the-lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis., Results: The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (-0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, -0.24 ± 0.71 D. The A-constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow-up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient., Conclusion: The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow-up of 26.1 ± 21.3 months., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine surgically induced astigmatism (SIA) after monofocal spherical intraocular lens (IOL) implantation using the bag-in-the-lens (BIL) technique., Setting: Department of Ophthalmology, Antwerp University Hospital, Antwerp, Belgium., Design: Case series., Methods: Adult patients had routine phacoemulsification followed by BIL IOL implantation, which requires a double capsulorhexis for IOL fixation. The 2.8 mm limbo-corneal self-sealing incision was temporally located. Preoperative and 3-month postoperative keratometries were measured by Scheimpflug imaging (Pentacam). The patients were divided into 2 groups based on corneal astigmatism. Group A0 consisted of eyes with physiological corneal astigmatism less than 1.00 diopter (D). Group A1 consisted of eyes with corneal astigmatism of 1.00 D or higher. Vector analysis of the corneal power was used to determine the SIA., Results: The study comprised 100 eyes (58 patients). There was no difference in SIA between Group A0 and Group A1. The mean preoperative and postoperative keratometries were highly correlated in both groups (A0: r(2) = 0.95; A1: r(2) = 0.83). The correlation between preoperative and postoperative vectorial astigmatism was low in Group A0 (J0: r(2) = 0.24; J45: r(2) = 0.10). The mean postoperative SIA was 0.06 D @ -24 degrees in Group A0 and 0.09 D @ 6 degrees in Group A1, with an uncertainty of ± 1.00 D., Conclusions: After BIL IOL implantation, the SIA was not statistically significant. Based on these findings, the technique can be considered an option for spherocylindrical correction of corneal astigmatism of 1.00 D or more., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the clinical and histopathologic features of eyes implanted with the bag-in-the-lens (BIL), which involves the use of a twin capsulorhexis lens design, and performance of anterior and posterior capsulorhexes., Design: Case series with clinicopathologic correlation., Participants: Six eyes implanted with the foldable, hydrophilic acrylic BIL, obtained postmortem at different postoperative times, from 4 patients were studied., Methods: On the patients' death, the eyes were enucleated, immersed in fixative, and submitted for analyses under a high-frequency ultrasound unit (Artemis, Ultralink, St. Petersburg, FL; 50 MHz), gross analyses, and histopathologic analyses. Clinical data in each case were obtained by chart review., Main Outcome Measures: Clinical data obtained included patient demographics, preoperative evaluation, description of surgical implantation procedure, and postoperative outcomes. The postmortem evaluation included analyses of lens fixation and centration, as well as gross and histopathologic analyses of postoperative capsular bag opacification., Results: The patients were aged 74.6+/-12.6 years at implantation. The postoperative time in this series ranged from 4 to 39 months. In all eyes for which the surgical implantation was uneventful (N = 5), postoperative BIL decentration was insignificant. In 1 eye, the anterior capsulorhexis was torn off, and although BIL implantation was still possible, a relative lens decentration was observed postoperatively, but without clinical significance. Although progressively larger amounts of Soemmering's ring formation were observed in the specimens with larger follow-up, the central area delimitated by the rhexis openings remained perfectly clear in all 6 eyes., Conclusions: This is the first series of human eyes implanted with the BIL, obtained postmortem at different postoperative times. BIL centration depends on the performance of centered capsulorhexes of appropriate size. The results confirm the concept of the lens design in that any proliferative/regenerative material remains confined to the intercapsular space of the capsular bag remnant outside the optic rim., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine the centration and visual outcomes after cataract surgery using the bag-in-the-lens (BIL) implantation technique., Setting: University Hospital Antwerp, Department of Ophthalmology, Edegem, Belgium., Methods: This study comprised 180 eyes of 125 patients who had cataract surgery with implantation of the BIL intraocular lens (IOL) between March 2002 and September 2005. Postoperative data at 5 weeks, 6 months, and 1 year were evaluated. The geometric center of the IOL, measured on a red reflex slitlamp photograph, was compared with the geometric center of the pupil and the limbus., Results: The mean decentration compared with the limbus was 0.304 mm+/-0.17 (SD) at a mean angle of -24.9+/-113.3 degrees. Compared with the dilated pupil, the mean deviation was 0.256+/-0.15 mm at a mean angle of -5.2+/-119.0 degrees. The amount of decentration was stable during the postoperative follow-up period. There was no correlation between the amount of decentration and the visual outcomes (pupil: r=-0.07, P=.494; limbus: r=0.11, P=.304)., Conclusions: Surgeon-controlled BIL centration was predictable 5 weeks and unchanged 6 months and 1 year postoperatively. It can therefore be concluded that capsular bag healing has no influence on BIL IOL centration over time.

Purpose: To study the cumulative neodymium:YAG (Nd:YAG) laser rate after bag-in-the-lens implantation (Morcher 89A) and lens-in-the-bag implantation (Morcher 92S) of 2 intraocular lenses (IOLs) of the same biomaterial., Setting: Department of Ophthalmology, University Hospital of Antwerp, Edegem, Belgium., Methods: This study comprised 100 eyes of 87 patients who had the bag-in-the-lens IOL implantation between January 2000 and August 2004. The postoperative follow-up ranged between 17 and 72 months. One hundred eyes of 94 patients of the same age and with the same follow-up period received the lens-in-the-bag IOL. The cumulative Nd:YAG laser frequency rates in both groups were calculated, and the cumulative incidence rates were defined by Kaplan-Meier survival analysis., Results: No Nd:YAG laser capsulotomy was performed in eyes having bag-in-the-lens IOL implantation. A laser capsulotomy was performed in 20 eyes having lens-in-the-bag IOL implantation; the cumulative frequency in this group was 2% at 1 year and 20% at 71 months, with a plateau beginning at 42 months. The cumulative incidence rate of Nd:YAG posterior capsulotomy was approximately 2% at 1 year, increasing to approximately 28% at 42 months., Conclusions: The cumulative Nd:YAG laser rate after bag-in-the-lens implantation was zero. A zero rate has not been reported with lens-in-the-bag implantation of an IOL of the same biomaterial or of other biomaterials, as published in the literature. Thus, it can be concluded that the bag-in-the-lens implantation technique has 100% effectiveness against posterior capsule opacification.

Purpose: To report the feasibility and clinical results of implanting a bag-in-the-lens intraocular lens (IOL) designed to prevent posterior capsule opacification after cataract surgery., Setting: Departments of Ophthalmology, University of Antwerp, Antwerp, Belgium, and University of Munich, Munich, Germany., Methods: This prospective study comprised 63 eyes (55 patients; 7 children, 48 adults) scheduled for cataract surgery and bag-in-the-lens IOL implantation. A posterior curvilinear capsulorhexis the same size as the anterior capsulorhexis was created for IOL insertion. After surgery, lens epithelial cell (LEC) proliferation was documented every 6 months with a minimum follow-up of 12 months., Results: Sixty of 63 eyes (95%) had implantation of the bag-in-the-lens IOL. Conversion to a conventional IOL was necessary in 2 cases. In 1 eye, postoperative luxation of the IOL into the vitreous occurred as a result of an oversized anterior and posterior capsulorhexis. Three eyes had early postoperative iris incarceration in the lens groove that required surgery. No LEC proliferation on the optic occurred during a mean follow-up of 22.7 months (range 12 to 64 months); LEC proliferation was confined to the peripheral capsular bag., Conclusion: Lens epithelial cell proliferation was mild and confined to the periphery of the capsular bag during follow-up, and the bag-in-the-lens IOL optic remained clear.

Purpose: To evaluate bag-in-the-lens implantation by studying the feasibility of implanting a new type of intraocular lens (IOL) and the occurrence of posterior capsule opacification (PCO) in human postmortem eyes and in eyes of living rabbits., Setting: Department of Ophthalmology, University of Antwerp, Belgium, and Netherlands Research Institute of Amsterdam, Amsterdam, The Netherlands., Methods: The IOL was implanted in 10 postmortem human donor eyes (in vitro study) and in 17 eyes of 10 rabbits (in vivo study). The postmortem capsular bags were cultured for 4 to 6 weeks, and the rabbits were killed 1 to 5 months after implantation. All capsular bags with the bag-in-the-lens were examined by light microscopy and scanning electron microscopy., Results: The IOL design was highly effective in restricting lens epithelial cell (LEC) proliferation in the remaining lens bag in human donor eyes and in rabbit eyes. In eyes in which the capsules were not positioned well within the groove of the IOL, LEC proliferation and PCO occurred., Conclusion: Bag-in-the-lens implantation was highly effective in preventing PCO in vitro and in vivo provided the anterior and posterior capsules were secured properly in the peripheral groove of the IOL.

Purpose: To report a new intraocular lens (IOL) and an IOL implantation concept, the bag-in-the-lens implantation technique, designed to prevent posterior capsule opacification (PCO)., Setting: The University of Antwerp, Department of Ophthalmology, Edegem, Belgium, and the Netherlands Ophthalmic Research Institute, Department of Morphology, Amsterdam, The Netherlands., Methods: After identical curvilinear capsulorhexes are created in both the anterior and posterior capsules, the capsules are inserted in a flange of the IOL, thus the term bag-in-the-lensas opposed to the currently used lens-in-the-bagtechnique. The IOL was implanted in an in vitro human capsular bag model and in 10 eyes of 9 patients with cataract. Lens epithelial cell (LEC) outgrowth and PCO formation were observed., Results: When both capsular blades were well stretched around the IOL optic, the in vitro capsular bag model showed LEC proliferation only within the space of the remaining lens bag. The LEC proliferation was limited, and there was no tendency toward proliferation approaching the visual axis. In all 10 eyes, the optical axis remained clear during a follow-up between 4 and 15 months., Conclusions: This new IOL prevented LEC proliferation in vitro and seems promising in vivo. Target patients are those at risk of PCO including those with congenital cataract, uveitis, diabetes, or cataract extraction combined with vitrectomy.