Eyeworld

46 | EYEWORLD | FALL 2025 R EFRACTIVE BEYOND THE ROUTINE by Liz Hillman Editorial Co-Director About the physicians Nicole Fram, MD Advanced Vision Care Los Angeles, California William Trattler, MD Director of Cornea Center for Excellence in Eyecare Miami, Florida experience a hyperopic surprise might be a can- didate for a piggyback lens, if they have been previously victrectomized, have a higher risk for retinal detachment, or if they have potential for zonulopathy. "Some physicians opt for hyperopic LASIK/ PRK in a mild hyperopic refractive error and have reliable results, but it's much more difficult to get reliable results with laser vision correc- tion for a hyperopic outcome >2 D than for a myopic outcome," Dr. Fram said. "In those sce- narios, a piggyback lens is not very complicated to do and could be a good solution for those patients." Dr. Trattler also said there is a whole set of patients in whom LASIK enhancement, PRK, or an IOL exchange would be difficult or less accurate, making piggyback IOLs an attractive option. He, like Dr. Fram, mentioned the patient who ends up hyperopic after surgery and who has had a YAG capsulotomy. He also brought up prior LASIK patients as candidates for piggyback IOLs as well. "You could try to go back and lift the LASIK flap, but in a hyperopic ablation, the ablation's diameter is often much larger than the original LASIK flap," Dr. Trattler said, also noting risk for epithelial ingrowth from lifting the flap. Patients with a myopic surprise after LASIK face a risk for epithelial ingrowth if a flap lift is performed, and PRK after LASIK offers less predictability compared to PRK in eyes without previous LASIK. "In such cases, having the op- tion to implant a piggyback IOL can be an effec- tive solution with a high chance for a successful refractive outcome," Dr. Trattler said. What lenses to piggyback Both Dr. Fram and Dr. Trattler said their pre- ferred lens is the LI61AO (Bausch + Lomb). "My preference is to try to avoid a minus lens at all costs. If a patient is nearsighted after surgery, we will do laser vision correction to correct them. I won't place a minus lens in the sulcus because they're thicker in the periphery and can cause pigment dispersion. The resultant transillumination defects could lead to debilitat- ing glare, Dr. Fram said (Figure 2). The LI61AO, Dr. Fram explained, is ap- proved as a secondary IOL. While not rounded W hile laser vision correction and, at times, IOL exchange remain the preferred method for cor- recting residual refractive error, Nicole Fram, MD, and William Trattler, MD, said that there is still a place for piggyback IOLs. In fact, piggyback IOL incidence ranges from 3–10%. 1 Dr. Fram and Dr. Trattler spoke with EyeWorld about when they would consider a piggyback IOL, their preferred lenses for these cases, and their thoughts on newer generation IOL options in a piggyback setting. When to piggyback Dr. Fram said the postoperative situation that she thinks merits a piggyback IOL is that of a hyperopic outcome in a patient with a deep chamber, or if an IOL exchange would be considered difficult due to potential for zonu- lopathy or capsule phimosis. You can confirm the chamber depth with AS-OCT or ultrasound biomicroscopy (Figure 1). Dr. Fram said that as more patients with prior RK are coming in for cataract surgery— and it's harder to hit your target with these pa- tients—upward of 50% could end up hyperopic postoperatively. In addition, high myopes, which over time is becoming more prevalent, who Piggyback IOLs an important tool for postop precision Figure 1: Ultrasound biomicroscopy of well-positioned piggyback IOL Source: Nicole Fram, MD

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