ARTICLE

Effect of intraocular lens glistening size

on visual quality
Bradley S. Henriksen, BS, Krista Kinard, MD, Randall J. Olson, MD

PURPOSE: To determine whether intraocular glistenings have an impact on light scatter and visual
function.
SETTING: John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA.
DESIGN: Retrospective cohort study.
METHODS: Pseudophakic patients with visual acuity no worse than 0.02 logMAR and no ocular pa-
thology were enrolled. All had received a single-piece high-refractive-index acrylic intraocular lens
(IOL). All IOLs were photographed, and glistenings were analyzed for size and density. Outcome
measures included logMAR corrected distance visual acuity (CDVA), mesopic 10% contrast
logMAR CDVA with and without glare, and straylight determination with a straylight meter
(C Quant log).
RESULTS: All 79 patients had glistenings within 2 diameter groups: 6 to 25 mm and over 25 mm.
Linear regression for the nonstratified group was significant for IOL glistening size versus contrast
visual acuity with glare. Linear regression for the 6 to 25 mm group was significant for a measure of
severity index (%area) versus the straylight meter measurements, %area/size versus straylight me-
ter measurements, IOL age versus CDVA, IOL age versus contrast visual acuity, and IOL age versus
contrast visual acuity with glare. Linear regression for the over 25 mm group was significant for IOL
age versus glistening size and %area/size versus contrast visual acuity, and density versus CDVA
and contrast visual acuity with glare.
CONCLUSIONS: Glistening %area, at a key size, correlated with random light scatter. The age of the
IOL likely affects glistening size and visual parameters.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2015; 41:1190–1198 Q 2015 ASCRS and ESCRS

Glistenings are fluid-filled microvacuoles within an
intraocular lens (IOL). They form when several, if
not all, types of hydrophobic IOLs are exposed to an
aqueous environment.1–3 The effect of IOL glistenings
on visual function has been an area of considerable
controversy. DeHoog and Doraiswamy4 recently
calculated the effect of glistening size and density on
light scatter measured by the modulation transfer
function and concluded that for the same percentage
of the IOL blocked by glistenings, a smaller size would
have a greater effect on image degradation. In our pre-
vious study of pseudophakic dysphotopsia,5 we pho-
tographed all IOLs and realized that this study could
provide clinical support or refutation of DeHoog and
Doraiswamy’s4 theoretical findings.
The relationship between glistening formation and
time since surgery has also been a subject of consider-
able debate. Multiple studies report progression of
glistening formation with time,6,7 while others report
a lack of progression 1 year after implantation.8,9 By
evaluating our cohort of patients whose IOLs varied
in age between 1 year and 4 years, we would have
the opportunity to further clarify this controversy as
well.
The impact of glistenings on visual function has been
documented previously, with correlations observed
between glistenings and high-frequency contrast
acuity loss,7,10,11 visual acuity,8,9 and significant visual
impairment to the point of IOL explantation.1,12 In
contrast, other reports show no significant impact of

1190 Q 2015 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2014.09.051

Published by Elsevier Inc. 0886-3350
 IOL GLISTENING SIZE AND VISUAL QUALITY
Table 1. Patient characteristics.
Characteristic Value
IOL power (D)
Mean G SD 19.5 G 3.4
Range 6.0, 25.5
Age (y)
Mean G SD 69.1 G 7.9
Range 45, 91
Sex (%)
Female 42 (53.2)
Male 37 (46.8)
IOL Z intraocular lens
glistenings on visual function.13–16 Although the po-
wer to detect a difference was not strong in any of these
studies, especially for more severe presentations of
glistenings, the new findings regarding the potential
impact of IOL size might help explain why these con-
clusions have differed.
The aim of this pilot study was to determine
whether intraocular glistenings have an impact on
light scatter and visual function. Our primary
endpoints were visual function parameters and light
scatter; patient satisfaction with visual quality was a
secondary endpoint. Our hypothesis was that the
%area of glistenings at small cavitation sizes would
Submitted: July 9, 2014.
Final revision submitted: September 19, 2014.
Accepted: September 24, 2014.
From the Department of Ophthalmology and Visual Sciences,
Moran Eye Center, University of Utah School of Medicine, Salt
Lake City, Utah, USA.
Supported in part by an unrestricted grant from Research to Pre-
vent Blindness, Inc., New York, New York, to the Department of
Ophthalmology and Visual Sciences, University of Utah, Salt Lake
City, and by the University of Utah Study Design and Biostatistics
Center, with funding in part from the National Center for Research
Resources and the National Center for Advancing Translational Sci-
ences, National Institutes of Health, Bethesda, Maryland, USA,
through grant 8UL1TR000105 (formerly UL1RR025764).
Molly McFadden, MS, Division of Epidemiology, Department of In-
ternal Medicine, University of Utah, assisted with the statistical
analysis of the data. Deborah Harrison, MS, Department of Ophthal-
mology and Visual Sciences, University of Utah, assisted with study
implementation. Susan Schulman, MA, University of Utah School of
Medicine, provided editorial assistance.
Corresponding author: Randall J. Olson, MD, John A. Moran Eye
Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake
City, Utah 84132, USA. E-mail: randallj.olson@hsc.utah.edu.
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
1191
have a significant impact on light scattering and
possibly visual function parameters.
PATIENTS AND METHODS
This study was reviewed by the University of Utah Institu-
tional Review Board. All participants provided informed
consent.
Patient selection and the study design were adapted from
the methods described in the Kinard et al. study.5 Briefly, a
retrospective review of Moran Eye Center, University of
Utah, Salt Lake City, Utah, USA, surgery logs was used to
determine patients’ eligibility for clinical study evaluation.
Participation in the study involved a single visit to the Moran
Eye Center outpatient clinic. If both eyes were eligible for
study evaluation, the better-seeing eye (or dominant eye
when visual acuity was similar) was chosen.
Selection criteria included uneventful cataract surgery,
implantation of a 1-piece aspheric high-refractive-index hy-
drophobic acrylic IOL including models SN60WF,
SN60AT, SN60T5, SN60T4, SN60T3, or SN6AD3 (all Acry-
sof, Alcon Laboratories, Inc.), and the presence of glistenings
on slitlamp examination. Implantation of all IOLs occurred
1 to 4 years before enrollment as follows: SN60WF (July
2007 to June 2010), SN60AT (July 2007 to March 2010),
SN60T5 (April 2008 to January 2009), SN60T4 (December
2008), SN60T3 (July 2008), and SN6AD3 (November 2007).
Inclusion criteria also included a corrected distance visual
acuity (CDVA) of 20/20 1 or better on the Early Treatment
Diabetic Retinopathy Study (ETDRS) logMAR chart
(logMAR 0.02 or less) and no reported patient complaints
about vision. Exclusion criteria included central corneal pa-
thology other than mild guttata, glaucoma, macular pathol-
ogy except for minimal hard drusen without changes to the
retinal pigment epithelium, diabetic retinopathy other than
minimal nonproliferative background diabetic retinopathy,
any cause of central visual acuity loss including optic nerve
or occipital cortex dysfunction, amblyopia, dry-eye syn-
drome, central posterior capsule opacification, and any
contraindication to pupil dilation. To increase the study
sample size, the study included patients 45 years or older
Table 2. Characteristics by glistening diameter.
Glistening Diameter
Parameter 6 to 25 mm O25 mm
Size (mm)
Mean G SD 19.0 G 4.1 30.5 G 2.7
Range 6.0, 25.1 26.0, 35.7
%area
Mean G SD 1.1 G 0.9 0.7 G 0.6
Range 0.9, 3.5 0.2, 2.9
%area/size (mm2)
Mean G SD 5293 G 6392 928 G 825
Range 207, 33 401 272, 3016
IOL age (y)
Mean G SD 2.6 G 1.1 2.9 G 1.1
Range 1.1, 4.8 1.1, 4.4
IOL Z intraocular lens
1192 IOL GLISTENING SIZE AND VISUAL QUALITY
(rather than 50 years, which was the lower age limit of the
cohort in the Kinard et al. study5).
All eligible patients who consented to participate had an
ophthalmic examination that included slitlamp bio-
microscopy and imaging, with and without retroillumina-
tion, to confirm the presence of glistenings. Further testing
included photopic logMAR CDVA after manifest refraction,
10% contrast logMAR acuity (Regan charts, Good-Lite Co.)
with mesopic lighting (13 ft/4 m ETDRS charts with
photopic lighting at 85 candelas [cd]/m2 and mesopic light-
ing at 3 cd/m2) with and without glare. Glare of car lights at
night was simulated with 2 halogen beams, 1 on each side of
the low-contrast acuity chart. Straylight scattering was
measured using the C-Quant straylight meter (Oculus
Optikger€ate GmbH).
Glistening quantification and analysis methods were
similar to those reported by Waite et al.7 Multiple boxes
ranging from 0.5 to 1.0 mm2 in area within the visual axis
from the clearest single image of each IOL were analyzed,
and measurements were averaged. Glistenings were evalu-
ated using the public domain Java image-processing pro-
gram ImageJ software.17
Intraocular lenses were placed in 2 relatively equal groups
based on average glistening size (diameter) of 6 to 25 mm or
greater than 25 mm. For each size grouping, a linear correla-
tion coefficient was computed with a measure of severity in-
dex (%area) described by Waite et al.,7 size, and a measure of
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
Figure 1. The IOL age in the nonstratified group
(N Z 79). Left: The IOL age correlated with glistening
size. Right: The IOL age correlated with contrast visual
acuity. Bottom: The IOL age correlated with CDVA
(CDVA Z corrected distance visual acuity; IOL Z intra-
ocular lens; VA Z visual acuity).
density (%area/size) that was similar to the analysis
described by DeHoog and Doraiswamy.4 These measure-
ments were compared versus CDVA, contrast visual acuity
with and without glare, and straylight meter log to look at
straylight scatter and visual quality. Linear correlation coef-
ficients were used to examine relationships between IOL age
and %area, glistening size, and %area/size as well as rela-
tionships between visual parameters including CDVA,
contrast visual acuity with and without glare, and the log
of straylight. Statistical analysis was completed using Stat-
plus:mac software (version 2009, Analystsoft, Inc.). A
P value less than 0.05 was considered statistically significant.
RESULTS
The records of 2953 patients were reviewed, and 79 (9
more patients than the cohort in the Kinard et al.
study) met all criteria and enrolled. Table 1 shows
the characteristics for the nonstratified data. The
SN60WF IOL was implanted in 36 eyes (45.5%), the
SN60AT in 36 eyes (45.5%), the SN60T5 in 4 eyes
(5.2%), the SN60T4 in 1 eye (1.3%), the SN60T3 in 1
eye (1.3%), and the SN6AD3 in 1 eye (1.3%).
Table 2 shows the characteristics of the 2 glistening
diameter groups (6 to 25 mm and O25 mm). The
 IOL GLISTENING SIZE AND VISUAL QUALITY
diameter ranged from 6.0 to 36.0 mm (2.8E-5 to 1.0E-3
mm2 in area), and the count/box area ranged from 2
to 336 glistenings/mm2.
Linear regressions for the entire group (nonstrati-
fied) were significant for positive correlations between
IOL age and glistening size (R Z 0.26, P Z .019)
(Figure 1, left) as well as between IOL age and contrast
visual acuity with glare (R Z 0.28, P Z .014) (Figure 1,
right). They approached significance for correlation be-
tween IOL age and CDVA (R Z 0.22, P Z .050)
(Figure 1, bottom).
Linear regressions for the 6 to 25 mm diameter group
were significant for positive correlations between
%area and straylight meter measurements (R Z 0.32,
P Z .033) (Figure 2, left), and %area/size and stray-
light meter measurements (R Z 0.30, P Z .047)
(Figure 2, right). A negative correlation for size and
straylight meter measurements also approached sig-
nificance (R Z 0.29, P Z .052) (Figure 2, bottom). Signif-
icant positive correlations were also found for IOL age
versus CDVA (R Z 0.033, P Z .031) (Figure 3, left), IOL
age versus contrast visual acuity (R Z 0.33, P Z .031)
(Figure 3, right), and contrast visual acuity with glare
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
1193
Figure 2. Straylight meter measurements in the 6 to 25
mm group. Left: The %area correlation with straylight
meter measurements. Right: The %area/size correlation
with straylight meter measurements. Bottom: The size
correlation with straylight meter measurements.
(R Z 0.37, P Z .014) (Figure 3, bottom). Although not
statistically significant, there was also a relationship
with %area versus CDVA, contrast visual acuity, and
contrast visual acuity with glare (CDVA: R Z 0.16,
P Z .346; contrast visual acuity: R Z 0.29, P Z .09;
contrast visual acuity with glare: R Z 0.21, P Z
0.226) (Figure 4).
Linear regression for the over 25 mm diameter group
was significant for a positive correlation between
IOL age and glistening size (R Z 0.45, P Z .006)
(Figure 5, top), and there was a negative correlation
between %area/size and contrast visual acuity
(R Z 0.34, P Z .048) (Figure 5, bottom). Negative corre-
lations were observed between glistening density
(counts per box) and CDVA (R Z 0.39, P Z .02) and
contrast visual acuity with glare (R Z 0.34, P Z .04),
and approached significance with contrast visual
acuity (R Z 0.33, P Z .05) (Figure 6).
DISCUSSION
Glistenings of variable size and density were found in
100% of the IOLs of patients enrolled in this study. Our
1194 IOL GLISTENING SIZE AND VISUAL QUALITY
findings are similar to previously reported diameters
(5.2 to 30.7 mm) and count/box area measurements
(0.8 to 223 glistenings/mm2) in a study that used
similar quantification methods.7 Although the clinical
impact of glistenings remains to be determined defin-
itively, the literature consistently has suggested that
visual function can be affected by glistening forma-
tion.1,4,7–12
The results of the DeHoog and Doraiswamy theo-
retical study4 suggest that at the same %area, a
smaller size would create more light scatter and vi-
sual quality degradation. Our cohort, although
small, naturally split at above and below 25 mm.
Figure 7 shows slitlamp photographs (original
magnification 25) of IOL glistenings with average
glistening sizes in the 6 to 25 mm group and in the
over 25 mm group. Furthermore, our evaluation
confirmed DeHoog and Doraiswamy’s findings in
2 ways: (1) Light scatter as shown in the C-Quant
straylight meter was only significantly correlated
with the less than 25 mm size. (2) In the less than
25 mm group there was a significant linear correla-
tion between %area/size and the straylight meter
measurements, showing that smaller glistenings
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
Figure 3. The IOL age in the 6 to 25 mm group. Left: Cor-
relation between IOL age and CDVA. Right: Correlation
between IOL age and contrast visual acuity. Bottom:
Correlation between IOL age and contrast visual acuity
with glare (CDVA Z corrected distance visual acuity;
IOL Z intraocular lens; VA Z visual acuity).
created more scatter even at an equal percentage
of obscured area.
Previously reported measurements of straylight
scatter using the C-Quant correlated with glare.18–20
It is not surprising that glistenings would affect stray-
light and, consistent with the DeHoog and Doraisw-
amy report,4 that the impact is greatest in a range of
smaller glistening sizes. These findings are particu-
larly interesting because our straylight meter log read-
ings were clearly important in a specific small
glistening group, even though the actual straylight
meter values were low (little scatter) compared with
the results in other reports.21,22
In our study, we did not measure glistenings less
than 6 mm in diameter, so we might not be able to
detect smaller sizes with our photographs. The De-
Hoog and Doraiswamy study4 showed that 2 mm glis-
tenings had the most impact on light scatter;
however, 2 mm glistenings might not be detectable
even with the slitlamp, and it seems unlikely that
we could detect glistenings of this size. Thus,
although our study cannot prove or disprove effects
of smaller glistenings on light scatter or visual func-
tion, it is possible that glistenings not visible at the
 IOL GLISTENING SIZE AND VISUAL QUALITY 1195

Figure 4. The %area in the more than 25 mm group.

Linear relationship between %area and CDVA (left),
contrast visual acuity (right), and contrast visual acuity
with glare (bottom) (CDVA Z corrected distance visual
acuity; VA Z visual acuity).

slitlamp could have clinical significance. Further
studies that are focused on detecting even the small-
est of glistenings with the slitlamp are needed to
address this issue.
In our cohort, the average glistening size increased
with IOL age. These findings are in line with previous
reports of glistenings that worsened over time.6,7
Although the %area did not increase with time, this
could be a result of our sample size (N Z 79), which
might have been inadequate to detect a difference.
Using the correlation coefficient for this relationship
in our cohort, a post hoc power calculation indicated
that enrollment of approximately 200 patients would
have been necessary for an association to reach signif-
icance. Because increasing size decreases scatter, this
might be an advantage to increasing IOL age;
however, a concurrent increase in the %area would
likely increase scatter. The overall clinical impact of
increasing glistening size and the %area would likely
depend on which of these parameters changed the

Figure 5. Correlations in the more than 25 mm group. Left: The IOL age correlation with size. Right: The %area/size correlation with contrast
visual acuity (IOL Z intraocular lens; VA Z visual acuity).

J CATARACT REFRACT SURG - VOL 41, JUNE 2015

1196 IOL GLISTENING SIZE AND VISUAL QUALITY
most over time. The relative impact of changes in size
compared with changes in the %area might be better
addressed with a larger study with sufficient power
to examine these relationships in greater depth.
The age of the IOL was also correlated with contrast
visual acuity with glare and approached significance
with CDVA. These findings were also seen in the less
than 25 mm group, along with correlations between
IOL age and contrast visual acuity without glare. How-
ever, correlations were not seen between IOL age and vi-
sual parameters in the more than 25 mm group, again
suggesting that IOLs with smaller glistenings had a
greater impact on visual function than IOLs with larger
glistenings. In general, the %area was also greater in the
6 to 25 mm cohort. Although these IOL age correlations
might simply be the result of the glistenings alone, it is
probable that surface light scattering, which has also
been shown to increase with IOL age for the IOL studied,
contributes to decreased visual function as well, espe-
cially with glare. Although we did not include IOL opa-
cification resulting from surface light scatter as an
outcome measure, previous studies1,15,23,24 suggest that
surface irregularity progresses over time for the IOL
studied; this might have been a factor in our findings.
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
Figure 6. Density in the more than 25 mm group. Left:
Density correlation with CDVA. Right: Density correla-
tion with contrast visual acuity with glare. Bottom: Den-
sity correlation with contrast visual acuity (CDVA Z
corrected distance visual acuity; VA Z visual acuity).
In future studies of intraocular glistenings, the addition
of surface light scattering as an endpoint, as well as spe-
cial attention to and documentation of smaller vacuole
glistenings (!25 mm), will help to further elucidate the
role of glistening size and surface light scattering on
IOL opacification and visual functioning. In addition,
the impact of increasing IOL age on visual function
might also include external factors such as age-related
decline and although we have attempted to control for
these factors with thorough examinations and tight
screening to exclude any other type of pathology, it is
possible such factors contributed to these findings.
As was the case with the Kinard et al. study,5 this
cohort was super normal, with low levels of light scat-
ter and excellent visual quality metrics in all enrolled
patients. At some level of light scatter, there is bound
to be a correlation with clinical glare. Interestingly, in
the 6 to 25 mm group, the %area versus CDVA, contrast
visual acuity, and contrast visual acuity with glare all
had similarly suggestive but nonsignificant correla-
tions. The similarity between all 3 of these relation-
ships would be unusual if there were no correlation
at all. A power calculation using these correlation coef-
ficients shows that with a sample size between 85 and
 IOL GLISTENING SIZE AND VISUAL QUALITY
194, there would be sufficient power for these associa-
tions to reach significance; however, only 44 such pa-
tients were included in our study sample. We
observe that the issue of underpowered studies has
been a factor in all clinical glistening studies to date,
including this study. The impact of IOL glistenings
merits a large and adequately powered study, both
to definitively answer questions and to assess changes
over time as millions of patients have and will
continue to have this phenomenon. The present pilot
study represents the largest population studied to
date without confounding visual problems that might
affect visual quality. We hope that our study will lead
to a study with a larger sample and will point the way
to delineation of glistening correlates of visual quality.
In the more than 25 mm group, we found 4 correlations
that run counter to our other findings. The %area/size
when compared with contrast acuity would suggest
that visual quality was better with a smaller size (all still
O25 mm however). Furthermore, density measure
(number of glistenings per mm2 irrespective of size)
correlated negatively (the greater the density, the better
the visual quality) with CDVA and contrast acuity with
and without glare. That all were in the more than 25 mm
group (mean %area of glistenings was 40% less than in
the 6 to 25 mm group) and that the correlation was
only for density (density did not show a significant cor-
relation in the 6 to 25 mm group) suggest these are false-
positive findings. Nonetheless, these correlations exist
and further support the case for a significantly powered
definitive study that focuses on the specific findings that
our pilot study suggests.
Weaknesses of this study are the relatively small
number of patients, the lack of severe manifestations
of the glistening phenomenon, and that any patient
with less than 20/20 1 CDVA or who had ever com-
plained about their visual quality were also excluded.
Because of the difficulty with recruitment of patients ful-
filling all inclusion criteria, a relatively small number of
patients were enrolled in each group (44 patients in the 6
to 25 mm group; 35 patients in the O25 mm group). As
the number of comparisons increases, so does the risk
for false-positive correlations. However, the consistency
J CATARACT REFRACT SURG - VOL 41, JUNE 2015
1197
Figure 7. Slitlamp photographs of
IOL glistenings. Left: Intraocular
lens glistenings with an average
diameter of 6 to 25 mm. Right: Intraoc-
ular lens glistenings with an average
diameter of more than 25 mm.
of our positive findings is supportive of our suggested
conclusions. The contrary results further point out the
critical need for a well-powered, more definitive study.
In conclusion, we suggest that our data provide clin-
ical support for DeHoog and Doraiswamy’s simulation
findings4 that at smaller glistening sizes, a similar
%area obscured by glistenings is associated with
increased light scatter. We also provide additional ev-
idence that glistening size increases with IOL age and
that visual parameters also decrease with increasing
IOL age; possibly, this is related both to glistenings
and to IOL surface changes. Larger clinical studies
are needed to further examine the effects of glistening
size, the %area, and the %area/size on visual function
parameters. We also understand that the manufacturer
of the IOL studied has implemented recent changes in
the manufacturing process in an attempt to minimize
the formation of glistenings. Clinical validation and
testing of the formation of IOL glistenings over time us-
ing the different IOL manufacturing models for com-
parisons of visual functioning parameters similar to
those reported in our study is needed to examine the
true clinical impact of such changes.
WHAT WAS KNOWN
 Glistenings in hydrophobic acrylic IOLs have been docu-
mented. Conflicting reports have evaluated the clinical
significance of glistenings and the specific impact on vi-
sual acuity, glare, and light scatter.
WHAT THIS PAPER ADDS
 The %area and %area/size of glistenings correlated with
light scatter at a key size of 6 to 25 mm. These findings
suggest that at a specific size, glistenings have an effect
on light scatter.
 The IOL age also had negative correlations with CDVA,
contrast visual acuity, and contrast visual acuity with
glare, highlighting the impact of IOL age on visual function
in patients with 6 to 25 mm diameter glistenings.
1198 IOL GLISTENING SIZE AND VISUAL QUALITY

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