FROM THE EDITOR
Intraocular lens glistenings
All that glistens is not gold.
with apologies to William Shakespeare
Glistenings are fluid-filled microvacuoles that form
within an intraocular lens (IOL) optic when the IOL
is in an aqueous environment. The phenomenon of
glistenings has been reported most commonly in
hydrophobic acrylic IOLs. However, this phenomenon
has also been described in silicone and hydrophilic
acrylic IOLs, as well as in other materials such as poly-
(methyl methacrylate). The incidence of glistenings
varies widely and has been reported from approxi-
mately 11% to 100% in several series.1,2 The topic of
glistenings was thoroughly discussed in a review/
update article by Werner.3
Multiple studies have evaluated the possible mech-
anism of glistening formation within IOLs. The most
commonly described theory proposed for the forma-
tion of glistenings is that polymers absorb water
when immersed in an aqueous environment over an
extended period of time and that if the water vapor de-
taches from its surrounding matter and gathers into
a void within the polymer network of the IOL, a visible
water drop forms. As the light is reflected and
scattered at water–polymer interfaces, a sparkling or
glistening-like appearance of these fluid-filled vacu-
oles is noted because the refractive index of water is
different from that of the polymer. A more recent the-
ory has been proposed; ie, that glistenings are the re-
sult of relatively slow-moving hydrophilic impurities
within the IOL material that segregate out of the ma-
trix material into polymer voids, giving rise to osmotic
pressure differences between the cavity and the exter-
nal medium in which the IOL is immersed. Influx of
water into these cavities deforms the surrounding
polymer until it causes permanent deformation and
the cavities grow. Factors that have been consistently
associated with glistening formations are changes in
temperature, IOL manufacturing and packaging tech-
niques, as well as an association with breakdown of
the blood–aqueous barrier. The most significant factor
in the formation of glistenings is the time following
cataract surgery, as glistening formation as well as
the intensity of glistenings has been significantly asso-
ciated with a longer follow-up time.
In this issue, Colin et al. (pages 1140–1146) present
results of a study analyzing the incidence of glisten-
ings with the latest generation of a hydrophobic acrylic
posterior IOL that has a yellow tint. This retrospective
study evaluated 111 eyes of 74 patients who had cata-
ract surgery with implantation of a monofocal hydro-
phobic acrylic posterior chamber IOL with an aspheric
Q 2012 ASCRS and ESCRS
Published by Elsevier Inc.
optic and a blue light–filtering chromophore that ren-
ders the IOL yellow. The incidence and severity of
glistenings were evaluated with careful slitlamp
examination, and the authors looked at potential rela-
tionships with age, sex, length of follow-up, IOL
power, and corrected distance visual acuity (CDVA).
They used a subjective grading system with 0 Z the
absence of glistenings, 1 Z moderate glistenings,
and 2 Z dense glistenings.
Glistenings were found in 96 eyes (86.5%). They had
a severity grade of 1 in 45 eyes (40.5%) and 2 in 51 eyes
(45.9%). Significant differences between glistening se-
verities were found relative to the follow-up period.
Eyes with grade 2 severity had a statistically signifi-
cantly longer follow-up time after cataract surgery.
However, no significant difference in the follow-up pe-
riod was found between eyes with grade 0 and grade
1 glistenings. When analyzed in another way, a signi-
ficantly higher percentage of eyes with follow-up of
less than 24 months were present in the grade 0 glisten-
ing group than in the grade 2 group. Of interest, the
IOL power was significantly higher in eyes with glis-
tenings in the grade 2 group than in eyes in the grade
1 group. More important, there was no significant
difference between glistening severity groups when
evaluating CDVA despite a worse mean value in the
grade 2 group than in the other 2 groups. The authors
concluded that glistenings were a very common phe-
nomenon in eyes implanted with blue light–filtering
hydrophobic acrylic aspheric IOLs. Furthermore, the
severity of this glistening phenomenon increased
over time but did not have a clear effect on visual
acuity.
Also in this issue, Pagnoulle et al. (pages 1271–1277)
evaluated a new generation of “glistening free” hydro-
phobic acrylic material for use in the manufacture of
IOLs. Intraocular lenses made from this new hydro-
phobic acrylic material were compared with standard
hydrophobic acrylic materials in terms of glistenings,
surface hydrophobicity, and bioadhesiveness. The au-
thors found that when this material was equilibrated
in an aqueous medium, it had greater stability and
reached low water content at equilibrium that allowed
the material to be relatively glistening free. This testing
was done under the worst-case scenario in which
broad temperature fluctuations were chosen to cause
glistening formation within the material. This new
generation of material combining the advantages of
hydrophobic and hydrophilic acrylic materials was
not susceptible to postsurgical changes that promote
glistenings. The material performed much like a con-
ventional hydrophobic acrylic material in terms of
0886-3350/$ - see front matter 1119
doi:10.1016/j.jcrs.2012.05.023
1120 FROM THE EDITOR
hydrophobicity and bioadhesiveness, which allow the
potential advantages of a normal hydrophobic acrylic
material with a glistening-free optic.
The most important question to be answered about
IOLs with glistenings is whether the glistenings have
an effect on vision. There are many ways of evaluating
visual function, such as CDVA, contrast sensitivity,
and effects of light scattering. Most studies that have
looked at the CDVA have not found a statistically
significant difference in eyes with glistenings. When
contrast sensitivity is evaluated, some studies have
found no effect of glistenings whereas others have
found a difference in high contrast sensitivity when
looking at high spatial frequencies.4,5 The question
of light scattering in IOLs with glistenings and its ef-
fect on quality of vision and contrast sensitivity is still
unclear. Even significant glistenings and high-level
light scattering from the IOLs have not been shown
to have a detectable impact on CDVA or low contrast
visual acuity.
Glistenings are a relatively common phenomenon,
especially in patients with hydrophobic acrylic IOLs.
It has been shown that the severity of these glistenings
J CATARACT REFRACT SURG - VOL 38, JULY 2012
increases over time. However, it is unclear whether the
glistenings have a significant effect on visual acuity or
visual functioning. Further long-term studies are
necessary to assess potential effects of glistenings on
patients' visual function, especially in premium IOLs.
In the meantime, there are promising new generations
of hydrophobic acrylic IOL materials that may provide
a glistening-free IOL.
Nick Mamalis, MD
REFERENCES
1. Davison JA. Clinical performance of Alcon SA30Al and SA60AT
single-piece acrylic intraocular lenses. J Cataract Refract Surg
2002; 28:1112–1123
2. Waite A, Faulkner N, Olson RJ. Glistenings in the single-piece,
hydrophobic, acrylic intraocular lenses. Am J Ophthalmol 2007;
144:143–144
3. Werner L. Glistenings and surface light scattering in intraocular
lenses. J Cataract Refract Surg 2010; 36:1398–1420
4. Guneno U, Oner FH, Tongal S, Ferliel M. Effects on visual func-
tion of glistening and folding marks in AcrySof intraocular lenses.
J Cataract Refract Surg 2001; 27:1611–1614
5. Christiansen G, Durcan FJ, Olson RJ, Christiansen K. Glistenings
in the AcrySof intraocular lens: pilot study. J Cataract Refract
Surg 2001; 27:728–733