Posterior Capsule Opacification: What's in the Bag?

Cataract, a clouding of the lens, is the most common cause of blindness in the world. It has a marked impact on the wellbeing and productivity of individuals and has a major economic impact on healthcare providers. The only means of treating cataract is by surgical intervention. A modern cataract operation generates a capsular bag, which comprises a proportion of the anterior capsule and the entire posterior capsule. The bag remains in situ, partitions the aqueous and vitreous humours, and in the majority of cases, houses an intraocular lens (IOL). The production of a capsular bag following surgery permits a free passage of light along the visual axis through the transparent intraocular lens and thin acellular posterior capsule. Lens epithelial cells, however, remain attached to the anterior capsule, and in response to surgical trauma initiate a wound-healing response that ultimately leads to light scatter and a reduction in visual quality known as posterior capsule opacification (PCO). There are two commonly-described forms of PCO: fibrotic and regenerative. Fibrotic PCO follows classically defined fibrotic processes, namely hyperproliferation, matrix contraction, matrix deposition and epithelial cell trans-differentiation to a myofibroblast phenotype. Regenerative PCO is defined by lens fibre cell differentiation events that give rise to Soemmerring's ring and Elschnig's pearls and becomes evident at a later stage than the fibrotic form. Both fibrotic and regenerative forms of PCO contribute to a reduction in visual quality in patients. This review will highlight the wealth of tools available for PCO research, provide insight into our current knowledge of PCO and discuss putative management of PCO from IOL design to pharmacological interventions.