1. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Eric C. Amesbury MD Kevin M. Miller MD The authors have no financial interest

2. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION

3. Purpose: To report the safety and efficacy of piggyback IOL implantation for residual hyperopia following cataract extraction and diffractive multifocal IOL implantation

4. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Methods: Case Report  61-year-old male  Right eye phaco with in-the-bag multifocal IOL (AcrySof ReSTOR), 20/50 and J1 uncorrected acuity  +1.00 sphere  20/20; patient satisfied with spectacles (20/20 cataract left eye)

5. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Methods (continued):  3 years later: Left eye phaco with multifocal IOL (ReSTOR), 20/15 and J1 uncorrected acuity  Right eye symptomatic with blur and ocular imbalance uncorrected  +1.00 diopter 3-piece, rounded-edge silicone piggyback IOL (Staar AQ5010V) implanted in the ciliary sulcus of the right eye

6. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Results:  No intraoperative complications  20/15 and J1 uncorrected acuity  Mild pigment dispersion at 2 weeks postop with 30mmHg IOP

7. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Results (continued):  Aqueous suppressant + prednisolone acetate 1% therapy controlled IOP  Pigment resolved at 1 month postop  Off all meds with normal IOP and no pigment dispersion at 3 months

8. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Discussion: Piggyback IOL advantages vs. other options Piggyback Advantages Better patient satisfaction than corrective contact lens or spectacles Avoids induced aberration, other risks of H-LASIK/PRK Less risk of incorrect IOL power, capsular rupture, vitreous loss, CME vs. IOL exchange 1,2

9. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Discussion (continued): Piggyback IOL Possible Complications: Intraoperative ComplicationPostoperative Complication Capsular Rupture Zonular Dehiscence Vitreous Loss Inflammation/Pigment Dispersion 3 Infection Ocular Hypertension 3 Optic Capture 4 Interlenticular Opacification 5 * Hyperopic Shift (Late) 5 * *Avoided with sulcus piggyback and in-the-bag primary IOL

10. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Discussion (continued): Alternatives to Piggyback IOL:

11. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION Conclusion:  Piggyback lens implantation is a safe and effective option for treating hyperopia following multifocal IOL in the short term  Pigment dispersion may be a cause for concern in the long term  Corrective lens, H-PRK/LASIK, IOL exchange options have separate advantages/disadvantages to consider

12. PIGGYBACK LENS AFTER MULTIFOCAL IOL IMPLANTATION References: 1.Jin JC, Crandall AS, Jones JJ. Intraocular lens exchange due to incorrect lens power. Ophthalmology 2007; 114:417-424. 2.Hill, WE. Refractive enhancement with piggybacking IOLs. In: Chang DF, editor. Mastering refractive IOLs: the art and science. Thoroughfare, NJ: Slack Inc.; 2008, pp. 792-793. 3.Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intraocular lens implantation. J Cataract Refract Surg 2005; 31:1821-1823. 4.Gayton JL, Sanders V, Van Der Karr M. Pupillary capture of the optic in secondary piggyback implantation. J Cataract Refract Surg 2001; 27:1514-1515. 5.Gayton JL, Apple DJ, Peng Q, et al. Interlenticular opacification: clinicopathologic correlation of a complication of posterior chamber piggyback intraocular lenses. J Cataract Refract Surg 2000; 26:330-336. 6. Qazi MA, Roberts CJ, Mahmoud AM, Pepose JS. Topographic and biomechanical differences between hyperopic and myopic laser in situ keratomileusis. J Cataract Refract Surg 2005; 31:48-60. 7.Freedman KA, Brown SM, Mathews SM, Young, RSL. Pupil size and the ablation zone in laser refractive surgery: considerations based on geometric optics. J Cataract Refract Surg 2003; 29:1924-1931. 8.Jin JC, Crandall AS, Jones JJ. Changing indications for and improving outcomes of intraocular lens exchange. Am J Ophthalmol 2005; 140:688-694. 9.Marques FF, Marques DMV, Osher RH, Freitas LL. Longitudinal study of intraocular lens exchange. J Cataract Refract Surg 2007; 33:254-257.