Eyeworld

FALL 2025 | EYEWORLD | 47 R Contact Fram: nicfram@yahoo.com Trattler: wtrattler@gmail.com Reference 1. Khoramnia R, et al. Polypseu- dophakia: from "Piggyback" to supplementary sulcus-fixated IOLs. Graefes Arch Clin Exp Oph- thalmol. 2025;263:603–624. Relevant disclosures Fram: Bausch + Lomb, Johnson & Johnson Vision, RxSight Trattler: Bausch + Lomb, Johnson & Johnson Vision, RxSight anteriorly, it is silicone, which she said seems more friendly in the ciliary sulcus. Dr. Trattler said he has found this lens to be well tolerated in front of the capsule, behind the iris. In addi- tion, it goes down to very low powers. When it comes to newer IOLs that could have applications as a piggyback lens, both Dr. Trattler and Dr. Fram expressed interest in the Light Adjustable Lens (LAL, RxSight). Dr. Trat- tler said this lens is attractive from an accuracy standpoint. "You can not only correct any resid- ual spherical refractive error but you can correct residual astigmatism as well," Dr. Fram said. She added that she's had variable results with the LAL+ and thinks she'll be more interested in using the original iteration of the LAL when it comes without the increase in negative spherical aberrations centrally of the LAL+. When it comes to other "non-traditional" lens options that could be used as piggyback, Dr. Fram also mentioned an implantable collamer lens in the form of the EVO ICL (STAAR Surgi- cal). "I think it's an interesting option for eyes that are myopic with residual astigmatism," she said, noting a case presented by John Berdahl, MD. "I thought it was a brilliant solution. There are still nuances to work out in terms of sizing." Dr. Trattler also said the ICL could be useful as a piggyback IOL, though he acknowledged it's an expensive solution. "You'd have to de- termine the right patient, but the ICL likely has some advantages, as it is very soft and does not have an edge that would interact with the iris," he said. The IC-8 Apthera (Bausch + Lomb) is a sin- gle-piece acrylic, and Dr. Fram said she would not put this in the sulcus. The perfect piggyback IOL in the setting of a deep chamber with ade- quate sulcus, Dr. Fram said, would be made of silicone or collamer. If it had wavefront-guided adjustability, that would be even better. "If we had a piggyback lens that we could put in and we could then adjust it to be wavefront guided to their aberrated cornea, we could rehabilitate not only the patients that we currently have but patients who have older technology from the past. That's the dream," she said. "I'm hoping that's where we're going with IOLs in the direc- tion of adjustability and the correction of higher order aberrations within the lens itself." Piggyback IOL calculations Dr. Fram said there are two ways to perform calculations for piggyback IOLs. 1) Use the Barrett Rx Formula or the refrac- tive vergence formula from Warren Hill, MD. 2) Use the Gills-Hoffer anecdotal shortcut. For a myopic outcome, Dr. Fram said you want to do 1.2 times the spherical equivalent to get the power of the piggyback lens. "But I don't want to do a piggyback IOL for a myopic outcome. I'd rather do laser vision correction." For a hyperopic outcome, Dr. Fram said she normally would exchange if the lens were the wrong power, but if that wasn't advis- able, a piggyback would be 1.5 times the spherical equivalent to get the power of the piggyback lens. Figure 2: Iris chafing with significant transillumination defects from a minus sulcus IOL Source: Michael Snyder, MD

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