Eyeworld

EW CATARACT 35 August 2018 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer One example of when second- ary lenses can benefit a situation is when choosing a multifocal solution. Multifocals may not be for everyone, and despite informed decision making, it is prudent to allow for change if patients be- come dissatisfied somewhere down the line. In a study that evaluated diffractive multifocal IOLs as part of dual surgery with monofocal capsu- lar bag IOL implantation, there was high safety and efficacy for the com- bined procedure, with preliminary visual acuity results similar to those obtained in eyes with single-piece diffractive multifocal IOLs. 1 Add-on patients had the option to reverse or adjust their treatment. Dr. Amon said, "Indications for primary implantation, also called duet implantation, where both lens- es are implanted in the same stage, are high ametropia, for instance when you don't have the lens in stock for the high correction and can add the missing power through the second lens; high astigmatism; a multifocal duet procedure, which for me is one of the main options and benefits from these lenses because you have reversibility if the patient is incompatible with the lens; and deconversion. More importantly, if the patient within the next decades develops AMD or and they are angulated to ensure uveal clearance. "I mostly implant aspherical monofocal supplementary lenses to correct biometric surprises," Dr. Amon said. "But all options are available, multifocals, both refrac- tive and diffractive; torics, as a supplementary toric correction, like for post-PKP patents where we have a dynamic change of the axis; and multifocal toric lenses." Other supplementary lenses in- clude the Black Pinhole IOL (Morch- er, Stuttgart, Germany), an extended depth of focus IOL using a stenopeic hole, which offers a feasible option in eyes with irregular astigmatism that standard lenses cannot address; and the iolAMD Eyemax (iolAMD, London, U.K.), which uses a hy- peraspheric optic to magnify 1.3x and is useful in AMD patients who greatly benefit from the extra mag- nification. Why use a secondary sulcus fixated IOL? The key benefit of supplementary lenses is their reversibility. Supple- mentary lenses represent an adjust- able and exchangeable choice as primary add-ons. They also offer a reversible alternative to laser en- hancements and the option to avoid IOL exchange in cases of a post-sur- gical refractive surprise or astigma- tism correction. resulted in a central contact that led to a flattening of the contact zone and a resultant hyperopic defocus. The third problem was if we put a lens into the sulcus, there could be iris chafing (pigment dis- persion), inflammation, raised IOP, or hemorrhage." New technologies Current lens designs for use as sec- ondary implants incorporate target- ed improvements drawn from the lessons learned over time. Secondary lens designs are hydrophilic acrylic, single-piece IOLs. Hydrophilic acryl- ic material has a high uveal biocom- patibility, which is important due to the direct contact between the device and the uvea. There are three supplementary lenses available, the Reverso (Cristal- ens, Lannion, France), the Sulcoflex (Rayner, West Sussex, U.K.), and the 1stQ (1stQ GmbH, Mannheim, Germany), that share basic charac- teristics. They have relatively large optics of between 6 and 6.5 mm in diameter, which overlap the primary lens to avoid iris/optic capture; they are round-edged devices, resulting in less dysphotopsia and less posteri- or capsule opacification (PCO); they have a concave posterior surface to avoid hyperopic defocus at the contact zone; they have long hap- tics, 13.5–14 mm diameter for good centration and rotational stability; Supplementary IOLs are effective for secondary enhancements and for primary duet implantations B iometrical surprises after cataract and refractive surgery are unwelcome and need to be dealt with promptly. The best approaches involve uncomplicated surgery, such as those offered by secondary, supplementary IOLs, de- signed to provide simple, adjustable solutions. Presenting an overview on supplementary IOLs for the pseu- dophakic eye at the 22nd ESCRS Winter Meeting, Michael Amon, MD, Academic Teaching Hospital of St. John, and Sigmund Freud Private University, Vienna, Austria, explained that the success of sec- ondary IOL implantations was a result of the progress made on many different levels. "One of the problems encoun- tered in early supplementary IOL implantations in the 1990s was that the lenses were implanted togeth- er with the primary lens into the capsular bag. As we all know, the proliferative cells from the equator invaded the interface, and the lenses needed to be explanted," Dr. Amon said. "The second problem was the use of two biconvex lenses, which Reversible and adjustable lens solutions Presentation spotlight Multifocal toric additive IOL in mydriasis Slit lamp photo with IOL surface reflexes Source: Michael Amon, MD continued on page 36

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