This study seems to confirm the sandwich theory of posterior capsule opacification in eyes with an IOL and suggests that fibronectin may be the major extracellular protein responsible for the attachment of hydrophobic soft acrylate (AcrySof(R)) IOLs to the capsular bag. This may represent a true bioactive bond between the IOL and lens epithelial cells or between the IOL and the capsular bag and may be one reason the PCO and neodymium:YAG capsulotomy rates are lower in eyes with a soft acrylate IOL.

The degree of IOL bioactivity could explain the difference in PCO and the neodymium:YAG rates with different IOL materials. In theory, a bioactive IOL would prevent PCO better than poly(methyl methacrylate) and silicone IOLs, which have good biocompatibility but are bioinert.

It can be hypothesized that if an IOL has more fibronectin bound to it, the IOL can also attach to the capsule better as it consists mainly of collagen. The stronger binding of fibronectin and laminin to acrylate IOLs could be an explanation for the better adhesion of the acrylate IOL to the anterior and posterior capsules and thus for the lower rate of posterior capsule opacification.

Each IOL material had a different affinity to each protein. Significant binding to 1 protein does not indicate that the IOL will bind significantly to all proteins; instead, each protein should be studied separately. Fibronectin bound significantly better to hydrophobic acrylate IOLs than to hydrophilic acrylate IOLs, suggesting that the HEMA-containing IOLs should be classified with the hydrogel IOL group.

The greater amount of protein on the hydrophobic soft acrylate (AcrySof(R)) IOLs seems to support an adhesive mechanism for their attachment to the capsular bag. Fibronectin and vitronectin have functional domains to bind them to lens epithelial cells and the collagenous capsule. This kind of attachment could be a true bioactive bond and may be 1 reason the PCO and neodymium:YAG capsulotomy rates are lower in eyes with a soft acrylate IOL.