Eyeworld

54 | EYEWORLD | WINTER 2025 R EFRACTIVE Contact Dickson: ddickson@kuglervision.com Rebenitsch: lrebenitsch@gmail.com Rocha-de-Lossada: carlosrochadelossada5@gmail.com References 1. Rocha-de-Lossada C, et al. Systematic review of the use of supplemental multifocal intraocular lenses in the ciliary sulcus for presbyopia correction. J Refract Surg. 2021;37:830–835. 2. Rocha-de-Lossada C, et al. Supplemental toric intraocular lenses in the ciliary sulcus for correction of residual refractive astigmatism: a review. Ophthal- mol Ther. 2023;12:1813–1826. Relevant disclosures Dickson: RxSight, STAAR Surgical Rebenitsch: Bausch + Lomb, Johnson & Johnson, STAAR Surgical, Zeiss Rocha-de-Lossada: Alcon, Bausch + Lomb, Medicontur, Oculus, SIFI, Zeiss to –3, which is –2.5 at the spectacle plane. He agreed with Dr. Dickson that you'd have to real- ly miss the target to use the ICL as a piggyback. "That being said, there's some talk of having lower powered ICLs in the U.S.," he said. "This could be used in the future potentially, even though it's off label." Dr. Rebenitsch works in a 31-year-old cataract refractive practice, and he sees patients with previous RK and complex corneas. "Before the LAL, given that we see so many post-refrac- tive patients, there were times when we just missed the target," he said. "In those rare cases, I've used the ICL to hit the target, and it's been effective. The chamber is typically already larg- er, so vault is a non-issue, and there's no risk of inducing cataract. You do have to look at the an- gle and make sure it's open enough to implant. But if anything, it's easier to place in these cases than in a primary case." With a piggyback IOL, Dr. Rebenitsch said there can be a small risk of an interlenticular membrane, but with the ICL, there's no lens-to- lens touch, so the risk of a membrane is zero. He added that there is also less risk of iris chaf- ing or UGH syndrome with the ICL. Dr. Rocha-de-Lossada said ICLs have be- come more common in refractive surgery, and based on the literature, the quality of the IOL materials, the visual acuity, refraction, and what the IOL produces in patients is very high. "Some authors started to think that if it was a good op- tion in patients with a crystalline lens, why not use it in patients who have already had cataract surgery with some refractive error." Dr. Rocha-de-Lossada and colleagues have studied the usefulness of supplementary intraocular lenses. 1 One study focused on the correction of presbyopia with supplementary IOLs and then to correct refractive error, focus- ing on astigmatism, 2 he said. He and colleagues began to look at the ICL as an option. "It's an interesting new option," he said, adding that outcomes were very good. "We recently had the opportunity to review the literature on this topic and publish a scoping review highlighting the benefits of this new therapeutic option." Some ophthalmologists might want to re- move the IOL in the bag and put in a new IOL, but this comes with more risk, and he said that using a supplementary IOL is easier. The ICL as a supplementary IOL is reversible and easy to perform because it's in the sulcus. Other options for these patients include IOL exchange or laser vision correction. With an IOL exchange, if it's an IOL that's been there for a few years, or if they've had a YAG, if the capsule has contracted, etc., these exchanges could be harder to do, Dr. Dickson said. But if you can insert an ICL without messing with the IOL, that can be safer and quicker for patients. "You can still consider refractive enhancements like LASIK or PRK, but often if they're getting these higher levels of prescription, it can be better to leave the cornea alone if you don't have to mess with it," he said. Dr. Rebenitsch said piggyback is the least common enhancement option. Laser vision correction is the most common way to enhance. "An ICL would be used in patients with complex corneas where laser vision correction is not as precise." He added that IOL exchange has its own risks. "For me, I tend to do piggybacks when there's an open capsule and complex cornea," he said. "IOL exchange is also fairly straightforward within the first year or two with a closed capsule, but once it's open, the risk profile changes." Dr. Rebenitsch noted that using any piggy- back IOL is considered off label. "As physicians, we can use any FDA-approved technology how we see fit." That being said, he explains to pa- tients that if he uses an ICL as a supplementary option, it is considered off label. Dr. Rocha-de-Lossada noted that risks of using the ICL in this way are more or less the same as in indicated patients. There is a risk of infection and high intraocular pressure, but you have more space in the eye when you compare the size of the ICL to the normal crystalline lens. He said that so far the literature shows good results with low complications. Dr. Dickson also said the same risks apply in these cases as with standard ICL surgery. He only considers this as an option in patients who had normal cataract surgery with the lens in the capsule. He noted that he wouldn't choose to do a piggyback ICL if the lens were in the sulcus because the ICL sits in the sulcus. It's important to ensure the patient has a healthy endothelium and that they don't have glaucoma. Since cataract surgery measurements are pretty accurate, Dr. Dickson said he only uses this technique on a couple of patients a year. continued from page 53

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