Eyeworld

EW CATARACT 36 August 2018 diabetic macular edema, you can ex- plant the supplementary lens at any time. Uses as a secondary implant include spherical correction because of biometrical surprises, astigmatic correction, conversion from mono- focal to multifocal, dysphotopsia, magnification, and stenopeic hole. It is a big advantage to be able to step back and reverse it." A prospective non-randomized study that Dr. Amon co-investigated showed that the implantation of the Sulcoflex 653L (Rayner) secondary IOLs in the ciliary sulcus to correct residual refractive error after phaco with in-the-bag IOL implantation in 12 eyes of 10 patients was safe, predictable, and well-tolerated. 2 None of the study eyes showed pigment dispersion, interlenticular opacification, optic capture, or pupil ovalization. In a separate study that reviewed the charts of 46 secondary IOL patients in which one surgeon performed surgery in one practice, study investigators concluded that supplementary IOLs were a viable surgical option to correct residual refractive error after primary IOL implantation, including 10 cases in- volving secondary toric IOLs. 3 In the study, rotation did not exceed 10% in eyes with toric secondary lenses. Practical and easy The IOL calculation for secondary implantations in cases of biomet- rical surprise is straightforward. In cases of ametropia between ±7 D, the surgeons multiplies the spheri- cal equivalent by 1.5 in hyperopic cases and by 1.2 in myopic cases. Dr. Amon usually uses a 2.4 mm incision. He injects viscoelastic, folds the device into the injector or uses forceps, and positions the IOL into the ciliary sulcus. He performs aspiration of OVD from the inter- face to avoid a secondary pressure increase, places an iridotomy in children, short, or odd eyes, and applies an antibiotic. When part of a duet procedure, he removes the viscoelastic from the bag from the first procedure, then adds viscoelas- tic behind the iris and continues as above, placing the secondary lens behind the iris. Dr. Amon suggested placing a suture for toric add-ons, as a 10% rotation would change refraction by 30%. However, the centration of monofocal sulcus fixated supple- mentary IOLs was significantly bet- ter than bag fixated IOLs when com- pared to the limbus and with the dilated pupil, according to a study that he co-authored that looked at centration of sulcus fixated supple- mentary IOLs implanted anteriorly to preexisting capsular bag IOLs in 48 eyes of 43 patients. 4 He explained that lenses implanted in the sulcus do not experience shrinkage, cap- sular contraction, or any form of change, like IOLs implanted in the capsular bag might. "Children present a challenge because their eyes grow and the lens power has to be adapted. That is where the reversibility comes in that I like so much in this lens system. You can remove the lens when you need to and exchange it at any time, for instance when eyeball growth creates a myopic shift," he said. "The explantation works easily. You do not have to cut the lens or fold it within the eye. You just grasp it and pull it out through the incision." EW References 1. Gerten G, et al. Dual intraocular lens implantation: Monofocal lens in the bag and additional diffractive multifocal lens in the sulcus. J Cataract Refract Surg. 2009;35:2136–43. 2. Kahraman G, Amon M. New supplementary intraocular lens for refractive enhancement in pseudophakic patients. J Cataract Refract Surg. 2010;36:1090–4. 3. Gunderson KG, Potvin R. A review of results after implantation of a secondary intraocular lens to correct residual refractive error after cataract surgery. Clin Ophthalmol. 2017;11:1791–1796. 4. Prager F, et al. Capsular bag-fixated and ciliary sulcus-fixated intraocular lens centration after supplementary intraocular lens implantation in the same eye. J Cataract Refract Surg. 2017;43:643–647. Editors' note: Dr. Amon has finan- cial interests with Alcon (Fort Worth, Texas), Bausch + Lomb (Bridgewater, New Jersey), Johnson & Johnson Vision (Santa Ana, California), Carl Zeiss Meditec (Jena, Germany), Morcher, and Rayner. Contact information Amon: michael.amon@med.sfu.ac.at Reversible continued from page 35

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