Autologous incubated macrophage therapy in acute, complete spinal cord injury: results of the phase 2 randomized controlled multicenter trial.

STUDY DESIGN: Randomized controlled trial with single-blinded primary outcome assessment. OBJECTIVES: To determine the efficacy and safety of autologous incubated macrophage treatment for improving neurological outcome in patients with acute, complete spinal cord injury (SCI). SETTING: Six SCI treatment centers in the United States and Israel. METHODS: Participants with traumatic complete SCI between C5 motor and T11 neurological levels who could receive macrophage therapy within 14 days of injury were randomly assigned in a 2:1 ratio to the treatment (autologous incubated macrophages) or control (standard of care) groups. Treatment group participants underwent macrophage injection into the caudal boundary of the SCI. The primary outcome measure was American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-B or better at ≥6 months. Safety was assessed by analysis of adverse events (AEs). RESULTS: Of 43 participants (26 treatment, 17 control) having sufficient data for efficacy analysis, AIS A to B or better conversion was experienced by 7 treatment and 10 control participants; AIS A to C conversion was experienced by 2 treatment and 2 control participants. The primary outcome analysis for subjects with at least 6 months follow-up showed a trend favoring the control group that did not achieve statistical significance (P=0.053). The mean number of AEs reported per participant was not significantly different between the groups (P=0.942). CONCLUSION: The analysis failed to show a significant difference in primary outcome between the two groups. The study results do not support treatment of acute complete SCI with autologous incubated macrophage therapy as specified in this protocol.

A phase 2 autologous cellular therapy trial in patients with acute, complete spinal cord injury: pragmatics, recruitment, and demographics.

STUDY DESIGN: Post hoc analysis from a randomized controlled cellular therapy trial in acute, complete spinal cord injury (SCI). OBJECTIVES: Description and quantitative review of study logistics, referral patterns, current practice patterns and subject demographics. SETTING: Subjects were recruited to one of six international study centers. METHODS: Data are presented from 1816 patients pre-screened, 75 participants screened and 50 randomized. RESULTS: Of the 1816 patients pre-screened, 53.7% did not meet initial study criteria, primarily due to an injury outside the time window (14 days) or failure to meet neurological criteria (complete SCI between C5 motor/C4 sensory and T11). MRIs were obtained on 339 patients; 51.0% were ineligible based on imaging criteria. Of the 75 participants enrolled, 25 failed screening (SF), leaving 50 randomized. The primary reason for SF was based on the neurological exam (51.9%), followed by failure to meet MRI criteria (22.2%). Of the 50 randomized subjects, there were no significant differences in demographics in the active versus control arms. In those participants for whom data was available, 93.8% (45 of 48) of randomized participants received steroids before study entry, whereas 94.0% (47 of 50) had spine surgery before study enrollment. CONCLUSION: The 'funnel effect' (large numbers of potentially eligible participants with a small number enrolled) impacts all trials, but was particularly challenging in this trial due to eligibility criteria and logistics. Data collected may provide information on current practice patterns and the issues encountered and addressed may facilitate design of future trials.

Hydroview lens implant calcification: 186 exchanges at a district general hospital.

AIM: This paper describes the experience at a district general hospital of coping with an abrupt onset of calcification of Hydroview intraocular lens (IOL) implants requiring exchange surgery mostly for symptoms of glare, even though the visual acuities were relatively good. METHODS: In this retrospective study, the operative details of 174 consecutive lens exchanges by one surgeon were retrieved from the surgeon's notes. Of these, pre and post-operative details of 106 consecutive patients were obtained from the hospital notes. RESULTS: Of the 174 lens exchanges, all were sutureless except one and 31 eyes (18%) had had previous capsulotomies. Of 143 eyes with intact posterior capsules, eight (5.6%) needed anterior vitrectomy. Lens replacements were in the bag in 136 (95%), in the sulcus in five (3.5%), and in the anterior chamber in two (1.5%). Of the 31 eyes with previous capsulotomies, 10 (32%) needed anterior vitrectomy. Lens replacements were in the bag in 22 (71%) and in the sulcus in the remaining nine cases (29%). Postoperatively the best-corrected visual acuity was improved in 53%, remained the same in 35%, and deteriorated in 12%. CONCLUSION: The lens exchange procedure was mostly predictable with satisfactory visual results allowing preoperative counselling of risks to be similar to that for cataract surgery. The onset and resolution of the period of implantation of lenses requiring exchange has not been explained.

The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial.

BACKGROUND: The Spinal Cord Injury Locomotor Trial (SCILT) compared 12 weeks of step training with body weight support on a treadmill (BWSTT) that included overground practice to a defined but more conventional overground mobility intervention (CONT) in patients with incomplete traumatic SCI within 8 weeks of onset. No previous studies have reported walking-related outcomes during rehabilitation. METHODS: This single-blinded, randomized trial entered 107 American Spinal Injury Association (ASIA) C and D patients and 38 ASIA B patients with lesions between C5 and L3 who were unable to walk on admission for rehabilitation. The Functional Independence Measure (FIM-L) for walking, 15-m walking speed, and lower extremity motor score (LEMS) were collected every 2 weeks. RESULTS: No significant differences were found at entry and during the treatment phase (12-week mean FIM-L = 5, velocity = 0.8 m/s, LEMS = 35, distance walked in 6 min = 250 m). Combining the 2 arms, a FIM-L >or= 4 was achieved in < 10% of ASIA B patients, 92% of ASIA C patients, and all of ASIA D patients. Walking speed of >or= 0.6 m/s correlated with a LEMS near 40 or higher. CONCLUSIONS: Few ASIA B and most ASIA C and D patients achieved functional walking ability by the end of 12 weeks of BWSTT and CONT, consistent with the primary outcome data at 6 months. Walking-related measures assessed at 2-week intervals reveal that time after SCI is an important variable for entering patients into a trial with mobility outcomes. By about 6 weeks after entry, most patients who will recover have improved their FIM-L to >3 and are improving in walking speed. Future trials may reduce the number needed to treat by entering patients with FIM-L < 4 at > 8 weeks after onset if still graded ASIA B and at > 12 weeks if still ASIA C.

Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI.

OBJECTIVE: To compare the efficacy of step training with body weight support on a treadmill (BWSTT) with over-ground practice to the efficacy of a defined over-ground mobility therapy (CONT) in patients with incomplete spinal cord injury (SCI) admitted for inpatient rehabilitation. METHODS: A total of 146 subjects from six regional centers within 8 weeks of SCI were entered in a single-blinded, multicenter, randomized clinical trial (MRCT). Subjects were graded on the American Spinal Injury Association Impairment Scale (ASIA) as B, C, or D with levels from C5 to L3 and had a Functional Independence Measure for locomotion (FIM-L) score < 4. They received 12 weeks of equal time of BWSTT or CONT. Primary outcomes were FIM-L for ASIA B and C subjects and walking speed for ASIA C and D subjects 6 months after SCI. RESULTS: No significant differences were found at entry between treatment groups or at 6 months for FIM-L (n = 108) or walking speed and distance (n = 72). In the upper motor neuron (UMN) subjects, 35% of ASIA B, 92% of ASIA C, and all ASIA D subjects walked independently. Velocities for UMN ASIA C and D subjects were not significantly different for BWSTT (1.1 +/- 0.6 m/s, n = 30) and CONT (1.1 +/- 0.7, n = 25) groups. CONCLUSIONS: The physical therapy strategies of body weight support on a treadmill and defined overground mobility therapy did not produce different outcomes. This finding was partly due to the unexpectedly high percentage of American Spinal Injury Association C subjects who achieved functional walking speeds, irrespective of treatment. The results provide new insight into disability after incomplete spinal cord injury and affirm the importance of the multicenter, randomized clinical trial to test rehabilitation strategies.

Suturing a tear of the anterior capsulorhexis.

AIM: To describe a new technique of suturing a tear in the anterior capsulorhexis. METHODS: Continuous curvilinear capsulorhexis (CCC) with lens removal was done in five fresh cadaver eyes. The diameter of the CCC was measured with a calliper. Using the same calliper a tear of the CCC was created while opening the calliper's arms. The distance between the calliper's arms needed to tear the CCC was documented. Using 9-0 Ethilon 9011, CS 160-6 sutures in two eyes, 9-0 Prolene, D-8229, CTC-6L sutures in two eyes, and 10-0 Prolene, 9090, CTC-6 suture in one eye, the tears were sutured. A tear in the CCC was created again in the same way as the first tear. The distance between the calliper's arms needed to tear the CCC was documented again. RESULTS: Suturing of the tear restored some of the strength/elasticity of the CCC. Better results were found while using the 9-0 Prolene, D-8229, CTC-6L sutures than with the two others sutures. CONCLUSIONS: Suturing of a broken CCC can restore at least some of the strength/elasticity of the CCC. This can be important before intraocular lens (IOL) implantation for the safety of the implantation or after the implantation to ensure proper fixation of the IOL.

Linear deposits on the surfaces of intraocular lenses implanted through a hexagonal cartridge which mimic scratches/cracks on the lenses.

AIM: To describe unique linear deposits on the surface of posterior chamber intraocular lenses (IOLs) occurring after implantation through a hexagonal cartridge. METHODS: Five ACR6D SE IOLs (Corneal Laboratories, Pringy, France) were injected/implanted through hexagonal cartridges. Two of these were injected into a petri dish and the remaining three were inserted into the evacuated capsular bag of cadaver eyes. In addition, three other ACR6D SE IOLs were injected into a petri dish through round cartridges. The latter served as controls. RESULTS: All lenses that were injected/implanted through the hexagonal cartridges demonstrated linear deposits on the posterior surface of the IOL optic component. The IOLs that were injected through the round cartridges had no deposits. All the hexagonal cartridges showed signs of internal cracking. None of the round cartridges were cracked. CONCLUSION: Implantation of at least one IOL model, the ACR6D SE IOL, through a hexagonal cartridge can result in linear deposits on the posterior optical surface of the IOL. The shape of the cartridge appears to be a significant factor in causing the depositions.

Histology of AlphaCor skirts: evaluation of biointegration.

PURPOSE: To report histologic findings in 14 AlphaCor artificial corneas implanted during clinical trials and subsequently explanted from human subjects following complications, so as to evaluate biointegration within the device skirt. METHODS: Explants were fixed and sectioned in paraffin. Histologic findings related to the device skirt were compared with earlier histologic results from animal studies and correlated with clinical histories. RESULTS: Two devices had been removed due to complications related to the optic alone, 11 following stromal melting overlying the biointegratable sponge skirt and 1 due to a retroprosthetic membrane. All devices demonstrated normal skirt porosity. Biointegration was similar to that found in animal studies but qualitatively appeared reduced in the affected areas in patients with overlying stromal melting prior to explantation. Patients with a longer history of melting prior to explantation demonstrated presence of inflammatory cells around the device. CONCLUSIONS: Histologic findings of the AlphaCor skirt in humans are consistent with earlier animal studies. This study confirms that biointegration by host fibroblastic cells, with collagen deposition occurs after AlphaCor implantation in humans. In cases in which stromal melting had occurred, biointegration is seen to be reduced. On correlating preoperative clinical factors with biointegration observed histologically, preoperative vascularization appears not to be required for AlphaCor biointegration.

Intramuscular fat and glucose tolerance after spinal cord injury--a cross-sectional study.

STUDY DESIGN: Survey. OBJECTIVE: Determine intramuscular fat (IMF) in affected skeletal muscle after complete spinal cord injury using a novel analysis method and determine the correlation of IMF to plasma glucose or plasma insulin during an oral glucose tolerance test. SETTING: General community of Athens, GA, USA. METHODS: A total of 12 nonexercise-trained complete spinal cord injured (SCI) persons (10 males and two females 40+/-12 years old (mean+/-SD), range 26-71 years, and 8+/-5 years post SCI) and nine nonexercise-trained nondisabled (ND) controls 29+/-9 years old, range 23-51 years, matched for height, weight, and BMI, had T(1) magnetic resonance images of their thighs taken and underwent an oral glucose tolerance test (OGTT) after giving consent. RESULTS: Average skeletal muscle cross-sectional area (CSA) (mean+/-SD) was 58.6+/-21.6 cm(2) in spinal cord subjects and 94.1+/-32.5 cm(2) in ND subjects. Average IMF CSA was 14.5+/-6.0 cm(2) in spinal cord subjects and 4.7+/-2.5 cm(2) in nondisabled subjects, resulting in an almost four-fold difference in IMF percentage of 17.3+/-4.4% in spinal cord subjects and 4.6+/-2.6% in nondisabled subjects. The 60, 90 and 120 min plasma glucose or plasma insulin were higher in the SCI group. IMF (absolute and %) was related to the 90 or 120 min plasma glucose or plasma insulin (r(2)=0.71-0.40). CONCLUSIONS: IMF is a good predictor of plasma glucose during an OGTT and may be a contributing factor to the onset of impaired glucose tolerance and type II diabetes, especially in SCI. In addition, reports of skeletal muscle CSA should be corrected for IMF.

[Nonbiodegradable drug-sustained capsular ring for prevention of secondary cataract. Part II: In vivo evaluation]. / Anneau capsulaire non biodégradable relargant pour la prévention de la cataracte secondaire. Partie II: évaluation in vivo.

PURPOSE: The appearance of a secondary cataract constitutes the most common complication of cataract surgery since the advent of phacoemulsification. Prevention is today one of the crucial challenges of research in ophthalmology. We have developed a drug-sustained capsular ring releasing 5-fluorouracil (5-FU). This system targets the goal of combining advantageous mechanical and pharmacological properties with the ability to interfere on the epithelial cellular processes of secondary cataract. This paper presents the results of animal evaluation. MATERIAL AND METHODS: The study first developed the in vitro delivery system as a preliminary step to the animal in vivo approach. After a pilot study conducted on micro pigs, lens extraction was performed on the right eye of 22 female albino rabbits. The four study groups included: group 1 (6 animals) as a control group receiving only phacoemulsification; group 2 (6 animals) receiving phacoemulsification and the implantation of a nonsustained capsular tension ring; and group 3 (6 animals) receiving a drug-sustained ring. Group 4 (4 animals), implanted with a 5-FU-sustained ring, was reserved for staged samples of aqueous humor for kinetic determination of active agent release. RESULTS: Clinical evaluation based on biomicroscopy and histology showed a lesser reaction of secondary cataract in eyes with the ring. Compared to group 1, central posterior capsular opacification appeared significantly lower in density and surface in groups 2 and 3. No intraocular toxicity was observed. The poor sensitivity of the 5-FU detection method (high-performance chromatography) impaired pharmacokinetic evaluation. CONCLUSIONS: The decrease in secondary cataract reaction in cases of implanted capsular ring demonstrated the advantages of its mechanical effect. However, the benefit of an additive pharmacological action related to the release of 5-FU could not be proved. Nevertheless, the theoretical concept of a drug-sustained delivery system seems attractive and thus calls for evaluation of other potential modulators of cell behavior.

Calcification of modern foldable hydrogel intraocular lens designs.

PURPOSE: To report and compare clinical and pathological features of hydrophilic acrylic intraocular lenses (IOLs) of three major designs, explanted from patients who had visual disturbances caused by opacification of the lens optic. METHODS: Eighty-seven hydrophilic acrylic IOLs (25 Hydroview, 54 SC60B-OUV, and 8 Aqua-Sense lenses) were explanted and sent to our center. Most patients became symptomatic during the second year after cataract surgery. A fine granularity was observed on the surface of the lens optic in the case of Hydroview. With the SC60B-OUV and Aqua-Sense lenses, the opacity resembled a nuclear cataract. Gross examination, light microscopy and staining with alizarin red and the von Kossa method (for calcium) were performed. Some lenses were submitted for scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). RESULTS: Light microscopic and SEM analyses revealed the presence of irregular granular deposits on the external optical surfaces of Hydroview lenses. With the SC60B-OUV lenses, the opacity was caused by the presence of multiple fine, granular deposits within the lens optic, distributed in a line parallel to the anterior and posterior curvatures of the optic, with a clear zone just beneath its external surfaces. The Aqua-Sense lenses exhibited both patterns simultaneously. The deposits in all cases stained positive with alizarin red and von Kossa method. EDS also demonstrated the presence of calcium and phosphates within the deposits. CONCLUSION: Differences in the water content of the hydrophilic acrylic materials used in the manufacture of these three lens designs may be responsible for the different patterns of calcium precipitation. Careful clinical follow up of patients implanted with these lenses is necessary to determine if this phenomenon is rare and sporadic or may be more widespread.

[Non-biodegradable drug-sustained capsular ring for prevention of secondary cataract. Part I: In vitro evaluation]. / Anneau capsulaire non biodégradable relargant pour la prévention de la cataracte secondaire. Partie I: Evaluation in vitro.

PURPOSE: The appearance of secondary cataract constitutes the most common complication of cataract surgery since the advent of phacoemulsification. Prevention is today one of the most crucial challenges of research in ophthalmology. We have developed a drug-sustained capsular ring releasing 5-fluorouracil (5-FU). This system aims to combine mechanical and pharmacological properties with the ability to interfere on the lens epithelial cellular processes of secondary cataract. This first article will report on the in vitro evaluation of this system. MATERIALS AND METHOD: Development of a hydrogel that can serve as a mechanical support and as a release of an active agent requires a comparative trial of multiple hydrophobic products providing rigidity to the ring and of hydrophilic products providing the ability to release a drug. The choice of 5-FU as a non-proliferate agent was based on its well-known pharmacological properties and its wide use in ophthalmology. Evaluation comprised adjustment of the adequate copolymer, then of the loading phase, and finally assessment of 5-FU release. The mechanical characteristics and cytocompatibility of the ring were also assessed. RESULTS: The characteristics of drug release differed depending on the water content and resulting volume of the copolymer. The pharmaceutical and mechanical testing led to selecting the HPMA-MMA combination (75:25). However, a burst effect within the first 2 hours was observed in all cases. That limit was eliminated by creating a biodegradable surface coating of Poly Lactid-co-Glycolid (PLG 50:50) that could provide a positive barrier effect against migration and a controlled continual release of 0.25 microg/h extended to 9 days. Mechanical tests of tension, compression, and traction showed the crucial influence of the ring's hydration state. The cytocompatibility study showed no evidence of cellular toxicity. DISCUSSION/CONCLUSIONS: The synthesized copolymer is able to release a constant, regular and safe rate of 5-FU, higher than CI50 over a period of 9 days for a cell proliferation phase of 3-5 days. We adjusted the ring associating the mechanical properties and the ability to release 5-FU, allowing further evaluation on animal models, the subject of the second part of this report.

[Techniques for preparing postmortem human eyes to perform anterior segment intraocular surgery]. / Técnicas para la preparación de ojos de cadáver utilizadas para practicar cirugía intraocular del segmento anterior.

We describe different methods to prepare postmortem human or animal eyes used at the Center for Research in Ocular Therapeutics and Biodevices at the Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA. These techniques have been utilized for performing different surgical procedures (phacoemulsification, extracapsular cataract extraction, etc.), and for training of surgeons in-transition. Performing these techniques in the wet-laboratory contributed to improve surgical skills to perform the critical steps of the phacoemulsification surgery. Pathological evaluation of pseudophakic postmortem human eyes using the Miyake-Apple posterior view and histology was helpful to analyze postoperative complications of cataract surgery (anterior capsule opacification and posterior capsule opacification) secondary to postoperative proliferation of lens epithelial cells into the capsular bag. Modifications in the surgical techniques and/or lens design may be helpful to reduce these postoperative complications. Implantation of various aphakic and phakic intraocular lenses in postmortem human eyes as well as animal eyes was helpful to analyze the sizing and fitting of new lens designs within the eye.

[Diffuse lamellar keratitis: prophylactic treatment with ketorolac tromethamine 0.5% in an animal model]. / Queratitis lamelar difusa: tratamiento profiláctico con ketorolaco trometamina 0,5% en un modelo animal.

PURPOSE: The objective of this study is to evaluate the use of a topical non-steroidal anti-inflammatory drug in the treatment of induced diffuse lamellar keratitis (DLK) in an animal model. MATERIALS AND METHODS: A corneal flap was created in 40 eyes of 20 Dutch-belted rabbits using the ASC microkeratome. The interface was inoculated with either Pseudomonas Aeruginosa Lipopolysaccharide (LPS) endotoxin or Ultra Palmolive liquid dish washer. The rabbits were divided in two groups: Group I (n=20) treated with ketorolac tromethamine ophthalmic solution 0.5% 4 times a day and the group II (n=20) used as control. The rabbits were examined at the slit lamp at day 1, 3, 5 and 7 postoperatively. DLK was graded from I-IV. RESULTS: At the end of the study 31 eyes were available for evaluation. 28 eyes (90%) developed DLK: 86% of the treated group and 94% of the control group during the follow-up. The treated group showed a lower rate of DLK as well as a lower severity. However, no statistically significant difference was found when comparing both groups (P>0.05). CONCLUSION: Pseudomonas aeruginosa LPS endotoxin and Palmolive Ultra can induce DLK in rabbit eyes. The postoperative prophylactic treatment with a topical non-steroidal anti-inflammatory drug showed a tendency towards a lower DLK rate as well as the severity of the disease.

[Miyake-Apple video analysis of movement patterns of an accommodative intraocular lens implant]. / Miyake-Apple-Video-Analyse des Bewegungsmusters einer akkommodativen Intraokularlinse.

BACKGROUND: The potentially accommodative intraocular lens (IOL) is a new development in IOL design METHODS: We evaluated the new Humanoptics 1CU accommodative IOL in a laboratory study with human post mortem autopsy eyes. Using the Miyake-Apple posterior view video technique, the movement pattern of the IOL was tested and observed from the posterior perspective. RESULTS. A circular bend at the level of the ciliary body applied slight circular force onto the sclera allowing the relaxation of the zonules. The shift of focus was demonstrated by using a reading target. In addition, viscoelastic was injected into the vitreous resulting in the same anterior movement of the IOL optic. CONCLUSIONS: The 1CU Humanoptics accommodative IOL showed potential accommodative behaviour in the laboratory. The accommodative (respectively pseudoaccommodative) effect was based on the anterior shift principle with anterior movement of the IOL-optic in the state of relaxing zonules. Whether this reflects the clinical situation, especially to this extent, must be further evaluated.

[Diffuse lamellar keratitis. Postoperative prophylactic treatment with corticosteroids in an experimental animal study]. / Diffuse lamelläre Keratitis Tierexperimentelle Studie zur Evaluierung einer postoperativen Kortikosteroidprophylaxe.

PURPOSE: The aim of this experimental ani-mal study was to induce diffuse lamellar keratitis (DLK), and investigate a prophylactic treatment with corticosteroids. MATERIALS AND METHODS: A corneal flap was cut in 40 eyes from 20 Dutch-belted rabbits and the interface inoculated with either Pseudomonas aeruginosa lipopolysaccharide (LPS) endotoxin ( n=21) or Palmolive Ultra soap ( n=19). Half of the eyes were treated with topical corticosteroids and the other half remained untreated. Slitlamp examinations were performed 1, 3, 5 and 7 days postoperatively and DLK was graded from I-IV. RESULTS: At the end of the study 33 eyes were available for evaluation and 94% of the non-treated eyes developed DLK. Out of those eyes treated with steroids 19% developed DLK during the 1 week follow-up period. This was statistically significantly lower ( P=0.018) when compared to the untreated group. CONCLUSION: Pseudomonas aeruginosa LPS endotoxin as well as Palmolive((R)) Ultra caused a very high rate of DLK in rabbit eyes. The postoperative prophylactic treatment with corticosteroids showed a statistically significant lower DLK rate in this rabbit eye model.

Post cataract-intraocular lens (IOL) surgery opacification.

Intraocular lens (IOL) implantation has no doubt been one of the most satisfying advances of medicine. Millions of individuals with visual disability or frank blindness from cataracts had and continue to have benefit from this procedure. It has been reported by ophthalmologists that the modern cataract-intraocular lens (IOL) surgery is safe and complication-free most of the time. This makes the watchword for any cataract surgeon to be 'implantation,' 'implantation,' 'implantation.' In the mid-1980s, as IOLs were evolving rapidly, the watchword of the implant surgeon was 'fixation,' 'fixation,' 'fixation.' Most techniques, lenses and surgical adjuncts now allow us to achieve the basic requirement for successful IOL implantation, namely long-term stable IOL fixation in the capsular bag. However despite this advancement some items 'slipped through cracks.' In this article, we would like to alert the reader to a new watchword, namely 'opacification,' 'opacification,' 'opacification.' Here we will be talking about the good, the bad, and the ugly. Examples of the 'good' include the recent successes now being achieved in reducing the incidence of posterior capsule opacification. Examples of the 'bad' include various proliferations of anterior capsule cells, problems caused by silicone oil adherence to IOLs and problems with piggyback IOLs. The 'ugly' include the sometimes striking and often visually disabling opacifications occurring on and within IOL optics, both on some modern foldable IOLs as well as a poly(methyl methacrylate) (PMMA) optic degradation occurring with some models a decade or more after implantation.