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>�:	@A Review of Posterior Capsule Opacification.
ABSTRACT
Expectation of patients receiving modern day cataract surgery have become similar to refractive surgery. They expect almost perfect results, often emmetropia. Posterior capsule opacification (PCO) or after cataract refers to the opacity that develops in the posterior capsule after cataract surgery; a central PCO may affect forward light scatter, reduce contrast sensitivity, decreases visual acuity, thereby compromising working efficiency and productivity. PCO has therefore been the most common visually disabling sequel of cataract surgery and has important medical, social and economic implications. In recent years, better understanding of the mechanism of PCO formation, advent of phacoemusification, foldable and surface modified intraocular lenses (IOL�s), change in shape of IOL�s, recognition of the importance of thorough cortical clean-up, there has been a reduction in the incidence of PCO (to less than 10%). However, PCO has not yet been eradicated as it has not been possible to totally get rid of regenerative cells in the equatorial lens bow, by any interventional method currently known. The present article reviews literature related to incidence, aetio-pathogenesis, treatment and prevention, highlighting current concepts and developments in last four years and future endeavours to manage, prevent and eradicate PCO. 
Keywords: Posterior capsule, intraocular lens, Elschnig pearls, equatorial lens bow.






Introduction
Extracapsular cataract extraction (ECCE) entails leaving behind an intact posterior lens capsule and a part of anterior capsule, comprising the capsular bag, for intraocular lens (IOL) implantation.  Proliferation and differentiation of cells in the equatorial lens bow and their subsequent migration towards the posterior capsule leads posterior capsule opacification (PCO). The term PCO is actually a misnomer. The capsule itself does not opacify; an opaque membrane develops as a result of proliferation and migration of regenerative lens epithelial cells towards the posterior capsule. One of the earliest references of PCO or �after cataract� in literature was by Hirschberg, long before the invention of intraocular lenses. He described a subtype of after cataract, caused by proliferation of equatorial lens fibres, called Elschnig pearls [1]. Elschnig later characterized �pearls� as semi-globular and globular structures located on the posterior capsule [2]. Goulden described various types of opaque capsular membranes as capsular complications of cataract extraction [3]. However, the two clinically distinguishable fibrous and pearls subtypes of PCO and their pathogenesis was described by Apple et al [4].
Four review articles have been published in recent years. Pandey et al focused on factors leading to the reduction in the incidence of posterior capsule opacification with an insight into the pathogenesis of the disease [5]. Awasthi et al addressed the role of cytokines, growth factors, and extracellular matrix proteins in lens epithelial cell proliferation and migration, epithelial-mesenchymal transition, collagen deposition, and lens fibre generation;  describing advances and improvements in surgical techniques, intraocular lens materials, and the designs and use of therapeutic agents leading to safe, effective, and less expensive strategies to eradicate PCO [6]. Wormstone et al highlighted the role of growth factors, integrin�s and matrix metalloproteinases in development of PCO [7]. Bhargava et al laid emphasis on etiopathogenesis and prevention of posterior capsule opacification [8]. 
Since the last major review, advances have been made and our knowledge of the underlying mechanisms of PCO formation; however it still remains an important and prevalent complication of cataract surgery. Although this review article incorporates relevant data from the three earlier reviews, its main purpose is to describe recent advances in PCO quantification, prevention and management strategies. 
A PubMed search was conducted using the terms posterior capsule opacification, Elschnig pearls, and Nd: YAG laser capsulotomy. Of the articles retrieved by this method, we reviewed all publications in English and abstracts of non-English publications. We included articles that described the incidence, aetiopathogenesis, PCO prevention and PCO treatment. Emphasis was placed on articles published since the review by Awasthi et al [6] but we included earlier articles that provided a more comprehensive understanding of posterior capsule opacification. 

INCIDENCE 
There is a wide variation in the reported incidence of PCO ranging from 10-50%. Wilhelmus and Emery reported that duration of follow up after surgery was the crucial determinant in estimating the incidence of PCO following surgery. The authors found an incidence of 50% on follow up of more than three years [9].
In a series of 100 eyes that underwent conventional ECCE, Sakanishi et al found an incidence of PCO of 72%, with a mean follow up of 12�8 months [10]. 
Schaumberg et al conducted an important meta-analysis of all published articles on PCO. They generated pooled estimates of eyes developing PCO over three postoperative time points: 1, 3 and 5 years. They noted that rate of PCO remains unexpectedly and unacceptably high, still over 25% during 5 year follow up [11].
In a series of 55 eyes with myopia and cataract, Ignjatovi noted a higher incidence (40-60%) of posterior capsular opacification (secondary cataract) in myopia than in normal population [12].
In a review article, Spalton DJ reported that PCO is the commonest complication of cataract surgery occurring in about 50% of patients in 2-3 years. The author stated that PCO is caused by lens epithelial cells retained in the capsular bag following surgery which then proliferate, migrate and transform to myofibroblasts [13].
Birinci et al evaluated the effect of effect of intraocular lens (IOL) type and anterior capsulectomy technique on the incidence of posterior capsule opacification and demonstrated that demonstrated that the anterior capsulectomy technique and the IOL type significantly influenced the incidence of PCO [14].
In a review article, Pandey et al commented that PCO rates following paediatric cataract surgery are unexpectedly and inappreciably high approaching nearly 100% [15].
Ram et al compared the incidence of posterior capsule opacification (PCO) after extra-capsular cataract extraction (ECCE) and phacoemulsification and  evaluated the role of posterior chamber intraocular lens (PC IOL) haptic fixation and biomaterial/design in reducing the incidence the authors concluded that in-the-bag PC IOL fixation is required to consistently reduce the incidence of PCO [16].
In a prospective, observational, non-comparative study of 165 consecutive eyes undergoing phacoemulsification for age related cataract, Dholakia et al found that PCO rates were 4.84% at 6 months follow up [17].
Trivedi et al retrospectively reviewed 29 eyes with hydrophobic acrylic IOL and noted that when cataract and IOL surgery was undertaken within the first year of life, a secondary surgical procedure was required in 37.9% of eyes to maintain a clear visual axis [18].
Ebihara et al prospectively compared the degree of posterior capsule opacification (PCO) after cataract surgery in patients with and without diabetes mellitus and found that severity of PCO was more in diabetics than non-diabetics at 6 and 12 months postoperatively [19].
Vasavada et al conducted a � prospective masked trial in consecutive eyes with high axial myopia (myopia group) and age-matched eyes with a normal AL (21.00 to 23.99 mm) (control group) who had phacoemulsification and in-the-bag IOL implantation. The PCO area behind the IOL optic was scored (scale 0% to 100%) using the POCO software system. They found that axial myopia did not significantly increase the area or incidence of PCO at 4 years [20].
AETIOPATHOGENESIS
Duke elder stated that opacification of posterior capsule after ECCE is attributable to lens epithelium [21].
LEC�s proliferation has been implicated in the pathogenesis of anterior capsule opacification (ACO), PCO and interlenticalar opacification (ILO). LEC�s have been divided into two different biological zones [22]. 
A single layer of flat cuboidal epithelial cells (A cells) beneath the central part of anterior capsule have minimal mitotic activity but may undergo fibrous metaplasia termed �pseudofibrous metaplasia by Font and Brownstein [23]. Continuation of these cells in the equatorial region (E cells) form a zone of mitotically active cells known as the equatorial lens bow. These cells produce new lens fibres throughout life (Figure 1).
Apple et al commented that PCO is usually secondary to a proliferation and migration of residual lens epithelial cells (LEC�s) [24].
Jamal and Solomon in a retrospective analysis of 542 consecutive cases of ECCE with implantation of a plano-convex laser ridge posterior chamber intraocular lens found younger age to be a significant risk factor for PCO formation [25].
In a series of 90 eyes with in the bag implantation of lens, Hollick et al found that IOL biomaterials significantly influenced LEC�s migration on the posterior capsule [26].
 Oshika et al observed adhesion characteristics of several intraocular acrylic foldable IOL�s to rabbit�s lens capsule and found that acrylic IOL�s adhered to the lens capsule more than the PMMA  and the silicone IOL�s [27].
Marcantonio and Vrensen studied cell biology of PCO demonstrated that PCO results from the growth and trans-differentiation of lens epithelial cells left on the anterior capsule at the time of cataract surgery. These cells proliferate to form monolayers on the capsular surfaces. Some cells, however, differentiate or undergo a transition to another cell type, and these processes greatly contribute to PCO. Equatorial differentiation of cells to fibre-like structures leads to Soemmerring's ring formation and peripheral thickening of the capsular bag. Closer to the rhexis, cell swelling can result in globular Elschnig's pearls, which may occlude the visual axis. Cells at the rhexis edge and those in the space around the optic appear to undergo epithelial-mesenchymal transition. The resulting cells are fibroblastic in morphology, express the smooth muscle isoform of actin and secrete extracellular matrix containing proteins not normally present in the lens [28].
Wong et al evaluated the effect of Matrix metalloproteinases (MMPs) on human lens epithelial cell migration and contraction of the lens capsule. Human donor lens capsules were cultured and treated with a broad spectrum MMP inhibitor, Ilomastat (GM6001). Ilomastat significantly reduced lens epithelial cell migration onto the posterior capsule surface and inhibited capsule contraction. MMP inhibition [29].
According to Pandey et al, the single row of cuboidal lens epithelial cells in anterior capsule have two different biological zones; the anterior-central zone consists of flat cuboidal epithelial cells with minimal mitotic activity (�A� cells); these cells may undergo metaplastic changes in response to a variety of stimuli and are probably important in the pathogenesis of fibrous subtype of PCO. Continuation of these cells in the equatorial lens bow (�E� cells) have mitotic activity, produce lens fibres throughout life, and are important in the pathogenesis of �pearl� formation (Figure 2). However, �E� cells may also contribute in the pathogenesis of fibrous subtype of PCO, Soemmering�s ring and interlenticular opacification [5].
 Gotoh et al evaluated the importance of extra cellular matrix (ECM)-cell interaction in formation of PCO in in-vitro model. Matricellular protein SPARC (secreted protein, acidic and rich in cysteine) influenced the action of TGF-beta2 on LEC migration and proliferation [30]. 
Eldred et al evaluated the role of the ECM modulators matrix metalloproteinases (MMPs) in TGF�-mediated PCO formation. They used human lens epithelial cell-line FHL-124 and human capsular bag models. They found that MMP2 plays a critical role in TGF�2-mediated matrix contraction, which appears to be independent of MT1-MMP. MMP2 inhibition provides a novel strategy for the treatment of PCO and potentially other fibrotic disorders [31].
Chandler et al evaluated the role of hyaluronic acid (HA) in LEC migration and posterior capsule opacification. They found that exogenous HA can induce lenticular migration and CD44 expression. Use of viscoelastic that containing HA resulted in increased rates of ex vivo PCO. They suggested judicious   use of viscoelastic material during cataract surgery [32].�

PCO PREVENTION
Prevention of PCO has been a challenging task for researchers.  PCO may remain a nagging complication of cataract surgery for long as it seems virtually impossible to totally get rid of cells in the equatorial lens bow during cortical aspiration by any aspiration method currently known. However, clinical and experimental studies for over last three decades have identified a two stepped approach to prevent formation of PCO. First step involves a through cortical clean up during surgery to reduce the number of retained LEC�s. The second step is to prevent the inadvertently retained LEC�s from migrating towards the posterior capsule.
One of the early insights into the prevention of PCO were provided by animal studies by Juechter, who advocated capsular bag fixation of posterior chamber IOL [33].�
Santos et al provided laboratory evidence that direct physical contact between PMMA optic and posterior capsule inhibits migration of residual lens epithelial cells [34].
Nishi and Nishi compared PCO rates following ECCE and phacoemulsification in patients with lens epithelial cell removal and those without. PCO rates was higher in the control group [35].
Nishi et al evaluated the effect of enzymes dissolved in hyaluronic acid on lens epithelial cell dispersion. Cells were removed by irrigation and aspiration. There was negligible damage to zonules and endothelium [36].
Khalifa MA prospectively evaluated posterior capsular polishing in 412 patients with bilateral senile cataracts and found that polishing of the posterior capsule after lens cortex cleaning had no significant role in delaying or preventing capsular opacification [37].
Nagata and Watanabe evaluated Posterior capsular opacification in 46 eyes with an implanted sharp-edged biconvex (BC) lens, 108 eyes with the sharp-edged convex-plano (CP) lens, 160 eyes with the round-edged BC lens and 58 eyes with the round-edged CP lens respectively. They suggested that the most significant factor in prevention of posterior capsular opacification is the sharpness of the optic edge of IOL [38].
In a retrospective study of 106 eyes that had ECCE with in the bag implantation of IOL, Ravalico et al found that capsulorrhexis with a slightly smaller diameter than the IOL optic appears to be better than a large-size capsulorrhexis in reducing the incidence of PCO [39].
Gimbel HV evaluated the safety and efficacy of posterior continuous curvilinear capsulorrhexis with optic capture in preventing secondary opacification of the visual axis in paediatric eyes having cataract surgery and intraocular lens (IOL) implantation. Posterior continuous curvilinear capsulorrhexis with optic capture of the heparin-coated IOL appeared to successfully prevent secondary opacification of the visual axis in paediatric cataract cases [40].
Nishi O investigated the pathophysiology of LECs and found that a sharp bend in the lens capsule that induces contact inhibition of migrating LEC�s [41].
Birinci et al evaluated the effect of intraocular lens (IOL) type and anterior capsulectomy technique on the incidence of posterior capsule opacification. Posterior capsule opacification was significantly less in eyes with a capsular-bag-fixated plate-haptic silicone lens than in those with a PMMA or HSM PMMA IOL (P < .05). This study demonstrated that the anterior capsulectomy technique and the IOL type influence the incidence of PCO [42].
Peng et al analysed 150 consecutive eyes obtained post-mortem and found that the barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defence when cortical clean-up is incomplete. Analysis of PC IOLs obtained post-mortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic. [43].
Ram et al evaluated the role of posterior chamber intraocular lens (PC IOL) haptic fixation and biomaterial/design in reducing the incidence of PCO. In-the-bag PC IOL fixation is required to consistently reduce the incidence of PCO. Thorough removal of lens substance, including hydrodissection-assisted cortical clean-up, and in-the-bag PC IOL fixation seem to be the most important factors in reducing PCO, regardless of surgical procedure or IOL type used. Intraocular lens biomaterial and design also help prevent PCO [44].
Maloof et al described a technique of sealed capsule irrigation (SCI) to reduce PCO. This device consisted of a foldable suction ring with two separate lines, one for vacuum application and the other for irrigation. The device allowed the temporary seal of the capsulorrhexis after cataract removal and selective irrigation of the capsular bag with a pharmacological agent without damaging surrounding tissues [45]. 
Menapace et al evaluated the efficacy of posterior optic buttonholing (POBH) through a primary posterior capsulorrhexis (PPCCC) to preserve full capsular transparency, and its potential as a routine alternative to standard in-the-bag implantation of sharp-edged optic intraocular lenses (IOLs). They concluded that posterior optic buttonholing avoids after-cataract independent of optic edge design. Anterior capsule polishing adds to its efficacy by excluding any residual fibrosis [46].
Hara et al evaluated results of a specially designed closed ring with a square edge (endocapsular equator ring) in a young patient to prevent posterior capsular opacification. This endocapsular equator ring effectively prevents posterior capsular opacification in a young patient with atopic cataracts [47].
Huang and Xie evaluated the safety and efficacy of dry pars plana posterior capsulotomy and anterior vitrectomy in paediatric cataract surgery using 25-gauge instruments. They found this to be safe and effective for the management of posterior lens capsule and anterior vitreous in surgery for paediatric cataract [48].
Liu et al evaluated the role of anterior capsule polishing in residual lens epithelial cell (LEC) proliferation. They found that anterior capsule polishing, although it removed many LECs, did not decrease residual cell growth and, conversely, enhanced cell proliferation in capsular bag cultures. This might explain why polishing does not reduce PCO in clinical studies [49].
Yazici et al evaluated the 2-year outcomes of phacoemulsification combined with primary posterior curvilinear capsulorrhexis (PPCC) in adults. Cataract surgery combined with PPCC is a safe procedure with a low rate of complications over the long term. This procedure reduced the necessity of Nd: YAG laser capsulotomy in adults with postoperative residual posterior capsule opacification despite careful polishing [50].
Rekas et al evaluated the efficacy and safety of sealed-capsule irrigation (SCI) using distilled water (DW) to prevent posterior capsule opacification (PCO). They found that SCI is a safe procedure and the endothelial cells loss can be associated with the Perfect Capsule� device (Milvella) in the anterior chamber insertion. Distilled water irrigated for 3' reduces PCO in long-term follow-up [51].
Wertheimer et al evaluated the role of erlotinib on cell proliferation, migration, 3D matrix contraction and spreading of human lens epithelial cells in an in-vitro study. The found that the drug displayed good biocompatibility on ocular cells and mitigated human lens epithelial cell proliferation, migration, contraction, and spreading [52].
Alon et al investigated the ability of an open capsule device to prevent posterior capsule opacification in rabbits. They found that the tested devices were effective in reducing posterior capsule opacification and Soemmering's ring formation [53].
Dick and Schultz described a new techniques for performing primary posterior laser-assisted capsulotomy (PLC) to prevent posterior capsule opacification after cataract surgery. After lens and cortex removal, three different techniques were used to cut the posterior capsule with an image-guided (optical coherence tomography [OCT]) femtosecond laser. They stated that techniques for PLC have the potential to prevent and solve posterior capsule opacification in routine cases [54].
PCO QUANTIFICATION
Lasa et al documented PCO using Zeiss Scheimpflug photography and computerized image analysis. They examined 42 eyes with clear capsules (group A) and 27 with posterior capsule opacities (group B). Group �A� eyes had significantly better visual acuity (P < .05), lower mean capsular densitometry readings (0.03 +/- 0.03 optical density units versus 0.15 +/- 0.11 optical density units; P < .0001), and thinner capsules (0.03 +/- 0.4 mm versus 0.10 +/- 0.05 mm) than the group �B� eyes. This new objective method of documenting postoperative capsular haze may be useful for clinical studies such as clinical trials of drugs or surgical techniques being developed to prevent or minimize capsule opacification [55].
Tetz et al described a morphological scoring system of PCO not based on visual acuity testing, in which standardized photographs of the pseudophakic anterior segments were obtained using a photo slit lamp and scoring was done by evaluating retro-illumination photographs. The individual PCO score was calculated by multiplying the density of the opacification (graded from 0 to 4) by the fraction of capsule area involved behind the IOL optic [56].
Camparini et al investigated the relative merit of retro illumination and reflected light slit lamp-derived photographs in the assessment of opacification of the posterior lens capsule in 23 consecutive eyes with PCO in uncomplicated pseudophakia. Their results indicated that, with respect to retro illumination images, reflected-light photography has an increased ability to adequately capture the presence and severity of PCO and that the use of only retro illumination images may lead to its underestimation [57].
Bender et al described a new interactive software program, POCOman, for the semi-objective assessment of PCO. Digital images of the posterior capsule, acquired by any technique, were analyzed by the observer to determine the percentage area of PCO and assign a severity score. The system was validated by comparing it to clinical slit lamp evaluation of PCO and automated POCO system analysis using a library of 100 images taken from archives. They found that an image could be analyzed in approximately 2 minutes and the results of the POCOman system correlated well with the results of the automated POCO system and clinical evaluation [58].
Moreno-Montanes�et al measured PCO thickness using optical coherence tomography (OCT) and found a significant relationship between CDVA and PCO thickness, with thick subtype having worse vision [59].  
Kaluzny et al evaluated�in vivo�imaging of PCO using Spectral OCT (SOCT) in a case 3 years after uneventful extracapsular cataract extraction (ECCE) with implantation of a poly methyl methacrylate (PMMA) IOL. The quality of the SOCT images was adequate for detailed cross-sectional evaluation of the IOL, PCO, and morphological changes after laser capsulotomy [60].
Grewal et al quantified PCO using Scheimpflug Pentacam tomograms and compared its validity with slit lamp retro illumination image analysis. In a study of 124 pseudophakic eyes of 124 patients, they found good correlation between the two methods and Pentacam tomograms were easier to obtain, free of flash reflections, and they allowed more objective analysis in comparison with the retro illumination method [61].
Bhargava et al estimated mean energy levels for subtypes of PCO and found that the mean energy required to create capsulotomy in fibrous and pearl form of PCO was significantly different. Being thicker, fibrous PCO (Figure 3) required more laser energy as compared to pearl subtype. The authors suggested that subtypes exist amongst fibrous and pearl forms [62].

PCO MANAGEMENT
Posterior capsule opacification, caused by pearl formation or fibrosis, occurs commonly following cataract surgery. Management of posterior capsule opacification has undergone a paradigm shift in strategy and technique. Prior to advent of lasers, PCO was managed by a dissection procedure, in which a cut was made on the posterior capsule with a Ziegler knife or a bent needle [63]. A secondary posterior capsulotomy was done for PCO following ECCE, and may still be done in extremely thick PCO [64-65].
Riebsamen et al described a peeling technique in which epithelial pearls were peeled with a hand held device advanced behind the IOL from the limbus, connected to a suction system.  The technique was not effective against capsular fibrosis and occasionally caused posterior capsular tears [66]. Some authors also proposed cryotherapy for prevention of PCO [67].
Now, Neodymium-Yttrium-Aluminium-Garnet laser (Nd: YAG) capsulotomy has replaced invasive surgery as the most common treatment modality for PCO management. [68-71].
Mitra et al suggested pars plana capsulovitrectomy in cases with PCO in which the Nd: YAG laser was ineffective in clearing the visual axis, and they found success in penetrating the thick pupillary membranes [72].
Guo and co-authors reviewed literature related to paediatric cataract surgery and found that there was a consensus to perform posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy in children under 6-7 years. PCCC alone may delay the onset of PCO but cannot eliminate it [73].
Lee at al reported a case of dense PCO and anterior hyaloid opacity after congenital cataract extraction that was successfully and easily removed using the trans-conjunctival suture less vitrectomy system with maintenance of clear visual axes [74].
Lam et al evaluated the safety and efficacy of pars plana membranectomy using 25-gauge TSV system in the surgical management of PCO in 10 pseudophakic eyes of 6 (mean age: 35.1 � 37.8 months; age range: 6�93 months) children. All eyes showed improvement of VA from a mean of 6/67 before to 6/29 after surgery (P�= 0.001). One eye in a patient with uveitis developed recurrent PCO and a second capsulotomy was performed using the 25-gauge TSV system. Posterior capsulotomy using the 25-gauge TSV system appears to be a safe and effective approach in the management of PCO in pseudophakic children. Advantages include easier manipulation with the smaller instruments in these small eyes, and it can be considered in appropriate cases. [75].
Xie et al evaluated the outcome of pars plana capsulotomy and vitrectomy with infusion through the limbus to remove PCO in 51 children (57 pseudophakic eyes) in which it was not possible to remove it through Nd: YAG capsulotomy. The central opaque posterior capsule and anterior vitreous were successfully removed in all patients without complication. A round hole with 3 4 mm diameter was obtained at the central part of the posterior capsule with VA e"0.3 in 51.9% eyes at 3 months and a clear visual axis maintained over a follow-up period of 30 months [76].
Stager et al evaluated the effectiveness of Nd: YAG laser capsulotomy for the treatment of PCO in children with acrylic IOLs. A total of 51 eyes (70%) maintained a clear visual axis after a single Nd: YAG procedure, ten eyes (84% cumulative) after two procedures, and another three eyes (88% cumulative) after three procedures (follow-up period range: 3�92 months; median: 25 months). They concluded that Nd: YAG laser capsulotomy is an acceptable option for the management of PCO after acrylic IOL implantation in children [77]. 
Bhargava et al evaluated the efficacy of surgical peeling and aspiration for pearl form of PCO (Figure 4) and found that peeling and aspiration of pearls to be a viable alternative to Neodymium yttrium garner aluminium (Nd: YAG) laser capsulotomy for membranous PCO. Recurrence of pearls, uveitis and cystoid macular edema were the most common causes of reduced vision [78].
In a prospective study on 474 patients with PCO who had Nd: YAG laser capsulotomy, Bhargava et al found a significant relation between mean total laser energy and complications like IOL pitting, IOP rise, CME and retinal detachment. The authors concluded that subtype of PCO and IOL fixation significantly influence laser energy required for capsulotomy, whereas IOL biomaterials do not. Rate complications like pitting, uveitis, IOP elevation, RD and CME was significantly more when total laser energy delivered to treatment site was higher [79].
Conclusion: Despite advances in our understanding of the mechanism of PCO formation, it remains a significant problem, although there has been a reduction in its incidence. Biological mechanisms leading to PCO formation have now been revealed and agents to inhibit these signalling systems are currently under evaluation. 



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Chambless WS (1985). Neodymium: YAG laser posterior capsulotomy results and complications. J Am Intraocul Implant Soc; 11(1):31-2.
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Lee HK, Kim CY, Kwon OW, Kim EK, Lee SC et al (2004). Removal of dense posterior capsule opacification after congenital cataract extraction using the transconjunctival suture less vitrectomy system. J Cataract Refract Surg; 30(8):1626-8.
Lam DS, Fan DS, Mohamed S, Yu CB, Zhang SB et al (2005). 25-gauge transconjunctival suture less vitrectomy system in the surgical management of children with posterior capsular opacification. Clin Experiment Ophthalmol; 33(5):495-8.
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Bhargava R, Kumar P, Sharma SK, Sharma S, Mehra N et al (2013). Peeling and aspiration of elschnig pearls! An effective alternative to Nd: YAG laser capsulotomy! Indian J Ophthalmol; 61(9):518-20.
Bhargava R, Kumar P, Phogat H, Chaudhary KP (2014). Analysis of Neodymium-Yttrium Aluminium Garnet Laser Capsulotomy Energy Levels for Posterior Capsule Opacification. J Ophthalmic Vision and Research 2014; (In press).
 Acknowledgements: None
Conflict of Interest: None
Financial interest: None



Legend for figures:
Figure 1:  Diagram illustrating the anterior lens capsule, �A� cells of anterior epithelium, and the equatorial lens bow. The germinal cells of the lens bow (E) cells have mitotic activity. These cells produce lens fibres throughout life and may migrate towards the posterior capsule after cataract surgery and led to opacification of capsule.
Figure 2: Opacification of both anterior and posterior lens capsule.
Figure 3:  Nd: YAG laser capsulotomy in fibrous subtype of posterior capsule opacification.
Figure 4: Pearl form of posterior capsule opacification.















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