Snowflake degeneration of polymethyl methacrylate posterior chamber intraocular lens optic material: a newly described clinical condition caused by unexpected late opacification of polymethyl methacrylate.
OBJECTIVE
To report 25 cases of gradual, but sometimes progressive, late-postoperative degeneration of polymethyl methacrylate (PMMA) optics of posterior chamber (PC) intraocular lens (IOL) implants, often resulting in a clinically significant visual decrease long after the implantation, sometimes to a severity that required IOL explantation/exchange.


METHODS
Analysis of explanted PC IOLs, clinical histories, and photographs.


METHODS
We analyzed 25 case histories/photographs and/or explants from 18 patients implanted in the 1980s to mid-1990s with three-piece PC IOLs with PMMA optics and with polypropylene or PMMA haptics. The IOL optic from each case had characteristic snowflake or crystalline opacifications. This condition occurred with more than one manufacturer and in some cases was restricted to certain lot numbers.


METHODS
The explanted IOLs (n = 10) were studied by gross inspection and by light and scanning electron microscopy, as well as confocal and energy dispersive spectroscopy.


METHODS
The snowflake lesions were noted within the IOL optics. The nature of these lesions was investigated.


RESULTS
Assimilation of clinical information with pathologic and morphologic profiles of all cases suggested that the snowflake opacification was a small spherical lesion surrounded by an outer pseudocapsule composed of compressed, degenerated PMMA, with a central core containing convoluted fragments of PMMA. The lesions were classified into four clinical and pathologic grades according to their density and severity.


CONCLUSIONS
This is the first clinicopathologic correlative report on this complication. We postulate that manufacturing variations in some IOL models fabricated in the 1980s and early 1990s are responsible. The snowflake lesions seem to represent a destruction of the PMMA material. The cluster of lesions in implanted lenses manufactured by Surgidev was less progressive than some other models, including lenses made by IOPTEX Research Corporation. This identification of a condition previously unreported is important to alert clinicians regarding these perplexing lesions that may otherwise be considered idiopathic, with no obvious clinical hint as to their origin. The prevalence noted thus far is still too low to in any way suggest that this condition would occur in 100% of PMMA IOLs from these manufacturers. However, these late-occurring lesions, present in lens models that were implanted in hundreds of thousands of patients in the last decade or so, could have constituted a true epidemic, except that many of the patients are now deceased.
Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina 29425-2236, USA.
David J
DJ
Apple
Qun
Q
Peng
Stella N
SN
Arthur
Liliana
L
Werner
Jennifer H
JH
Merritt
Luis G
LG
Vargas
Daphne S M
DS
Hoddinott
Marcela
M
Escobar-Gomez
Josef M
JM
Schmidbauer
D020878:Device Removal; D006801:Humans; D019654:Lens Implantation, Intraocular; D007910:Lenses, Intraocular; D008855:Microscopy, Electron, Scanning; D019904:Polymethyl Methacrylate; D011183:Postoperative Complications; D011475:Prosthesis Failure; D014786:Vision Disorders / Q000209:etiology
D019904:Polymethyl Methacrylate