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EW CATARACT 33 April 2018 YES connect by Liz Hillman EyeWorld Staff Writer in these patients due to the insta- bility of their corneas after RK and because IOL power formulas don't do as well with targeting in post-RK patients. These patients also tend to have a deep chamber, which Dr. Fram said is nice when putting in a piggyback IOL. If the patient is 3 months post-cataract surgery and there's a refractive miss, Dr. Fram will perform an IOL exchange, but if she's seeing them 10 years later, then a piggyback can be an appro- priate choice. Dr. Fram also said a piggyback lens might be used if the patient has a hyperopic outcome and pseudo- exfoliation or zonule issues, and you don't want to reopen the bag or stress the zonule. This patient would need to have an appropriate anterior chamber depth and a "good solid sulcus," Dr. Fram added. If a patient with these issues had a myopic refractive surprise, Dr. Fram would prefer to perform PRK or LASIK as a correction. Piggyback IOLs have been suc- cessful in correcting negative dys- photopsias. Dr. Fram said she and Samuel Masket, MD, Los Angeles, have found piggyback IOLs to have a 73% success rate in reversing nega- tive dysphotopsias, but reverse optic capture of the primary IOL was more effective with a success rate of more than 90%. The Sulcoflex (Ray- ner, West Sussex, U.K.), an acrylic sulcus-fixated IOL not available in the U.S., has been shown to reduce negative dysphotopsia as well, Dr. Fram noted. 1 IOL for the correct one is the better option." There are cases, Dr. Hill ac- knowledged, when exchange might not be possible, such as when too much time has passed since the initial cataract surgery. "There are many factors that go into whether or not to perform a piggyback lens," Dr. Crandall said. The first of those is whether it's actually necessary. If the patient is comfortable and happy with glasses or contacts, there is no need for him or her to go through this procedure. The second is whether there is room for a second lens in the eye. "If there is not, then that deci- sion is made for us," Dr. Crandall said. "Any other anterior chamber abnormalities will lead me away from doing this because they may already be at risk for glaucoma, and a mild UGH syndrome could push them over the ledge. If they have pseudophacodonesis or exfoliation syndrome, I think it is best avoided or you may risk having to exchange or reposition two lenses in the future." Overall, Dr. Crandall said if a significant refractive error is detect- ed early, he prefers IOL exchange over a piggyback, performing the procedure a few weeks after initial cataract surgery. If the posterior capsule is intact, Dr. Crandall will also lean toward exchange, even if a longer time has passed after surgery. Dr. Fram said the perfect pig- gyback IOL candidate would be a post-RK patient who is hyperopic and years out from surgery. Hypero- pia is a common refractive outcome Piggyback IOLs for the young eye surgeon I n this month's "YES connect" column, we explore the subject of piggyback IOLs. This refers to placement of a second IOL in front of the first IOL, with the second IOL either in the sulcus or in the bag. While we do not typically learn much about this topic in residency or fellowship, it may arise in the first several years of practice. When patients have residual refractive error after cataract surgery, several options exist: observa- tion, glasses, contact lenses, laser vision correction, IOL exchange, and piggyback IOL placement. The techniques and instrumen- tation available for IOL exchange procedures have improved over the years, and frequent- ly IOL exchange can be a more attractive option, but there are still situations when piggyback IOL placement is preferable. Piggyback IOLs can also be used to correct large refractive errors in eyes with unusual axial lengths or keratometry, when the refractive error cannot be entirely corrected by any available single IOL. Additionally, they may be useful for treatment of negative dys- photopsias. There are many considerations to ensure proper patient selection as well as safe and stable IOL placement. We asked David Crandall, MD, Nicole Fram, MD, Warren Hill, MD, Douglas Koch, MD, and Liliana Werner, MD, PhD, for advice. Naveen Rao, MD, YES connect co-editor When to do one, lens choice, calculations, and more O phthalmologists are not typically trained in residency or fellowship about how and when to do a piggyback IOL. The reason for this could be multifacto- rial. According to Nicole Fram, MD, Advanced Vision Care, Los Ange- les, (1) it might be assumed if the surgeon can put a three-piece lens in the sulcus, he or she should be able to put in a piggyback lens, and (2) with indications for a piggyback IOL narrowing, the need to implant them is rare. David Crandall, MD, Henry Ford Eye Care Services, Detroit, said most residents, without realizing it, learn the surgical mechanics of placing a piggyback lens. "I teach them that it is just like placing a sulcus lens, but they have the safety of a lens already in the eye between them and the vitreous, so it's a more controlled situation than they are usually dealing with after a ruptured posterior capsule," Dr. Crandall said. "The best thing young eye surgeons can do when first encountering this is ask for advice from more experienced colleagues; [ASCRS] EyeConnect is a great resource for this." Dr. Fram, who has a referral practice for unhappy cataract pa- tients and thus, theoretically, would be more likely to see piggyback IOL candidates, said she only performed two such procedures within the last year. Douglas Koch, MD, professor and Allen, Mosbacher, and Law Chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, said he has only performed one piggyback IOL within the last 3 or more years. "My concern is the risk of developing chronic iris chafing and uveitis, so I avoid piggyback IOLs whenever possible," Dr. Koch said. Dr. Koch and Warren Hill, MD, East Valley Ophthalmology, Mesa, Arizona, and member at large of the ASCRS Governing Board, said they prefer to do an IOL exchange rather than a piggyback. "I generally do not implant pig- gyback IOLs," Dr. Hill said. "Instead, I think exchanging the incorrect continued on page 34 Ultrasound biomicroscopy of a piggyback PCIOL in the sulcus Source: Nicole Fram, MD Piggyback IOL PCIOL

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