2. PIGGYBACK IMPLANTATION OF FOR HIGH HYPEROPIA 24 MONTHS FOLLOW UP JL. FEBBRARO I.VIELPEAU, F. KRIFA, S.BERBACHE, S. GANEM Department of Ophthalmology S. GANEM M.D. Rothschild Foundation - Institut de la myopie Paris - France

3. INTRODUCTION GAYTON 1993: First piggyback implantation in cataract surgery to obtain emmetropia in extremely short eyes.

4. PATIENTS and methods Retrospective study 30 eyes, 20 patients Mean age : 70 years (range : 8 – 90 Y) Sexe : 16 women, 4 men Mean follow-up : 18 M (range : 6 to 30 M)

5. Patients and METHODS CCI: 3.5 mm / Limbal: 6 mm Phacoemulsification 2 PCI in the bag : - Silicone : 13 (SI 40) - Acrylic hydrophilic : 9 (Stabibag, Quattro) hydrophobic : 6 (AR40) - PMMA : 2 (CP60)

6. Patients and METHODS Axial length : - Mean : 20.97 mm - Min : 19.75 mm - Max : 22.16 mm

7. Patients and METHODS IOL calculation formula: Combined Holladay / SRK/T

8. Patients and METHODS Total IOL emmetropic power : + 26 D to + 32 D 0 5 10 15 20 25 30 35 1471013161922252831 Eyes Diopters

9. IOLs power distribution: Equally distributed between anterior and posterior IOLs Patients and METHODS

10. SE postop Eyes RESULTS: SE Postop Mean SE : -0,50 D ; Range : -2.25 to +1.50 D

11. RESULTS: Distance UCVA 400 100 50 30 25 20 14710131619222528 VA Eyes Mean VA: 20/50; Range: 20/200 to 20/25+

12. RESULTS: Distance BCVA 400 100 50 30 25 20 14710131619222528 Eyes VA Mean VA: 20/30+ Range: 20/100 to 20/20

13. RESULTS: Near UCVA 0 1 2 3 4 5 6 7 8 1357911131517192123252729 Parinaud (P) Eyes Mean VA: P 4.3; Range: P 8 to P 2

14. RESULTS: Near BCVA 0 1 2 3 4 5 1357911131517192123252729 Eyes Parinaud (P) Mean VA: P 2.5; Range: P 5 to P 2

15. RESULTS : Near BCVA with distance correction VA mean :P 3.7 ; min : P 8 ; max : P 2

16. RESULTS: Near VA Pseudoaccomodation ? 0 1 2 3 4 5 6 7 8 Near UCVANear BCVA With distance correction Near BCVA With near correction

17. RESULTS: Complications Decentration : 1 case at 3 months PO

18. RESULTS: Complications Decentrement : 1 case at 3 months post op Hyperopic shift : 3 cases

19. RESULTS: Complications Decentrement : 1 case at 3 months Hyperopic shift : 3 cases PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG)

20. RESULTS : Complications Decentrement : 1 case à 3 months Hyperopic shift : 3 cases PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG) Pigment deposit between IOLs : 1 case at 8 months with 3 lines of loss BCVA (20/40)

21. RESULTS : Complications Decentration : 1 case at 3 months PO Hyperopic shift : 3 cases PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG) Pigment between IOLs : 1 case at 8 months with 3 lines of LBCVA (20/40) Interface opacification : 0 case

22. DISCUSSION Advantages of Piggyback : - Less spherical aberrations - Pseudoaccomodation - Wound size Ref : Gayton JL: J Cataract Refract Surg 1993 ; 19 : 776-777

23. DISCUSSION Inconvenients of Piggyback : - Interface opacification - Hyperopic shift - Surgical technique - Cost Ref : Shugar JK. J Cataract Refract Surg 1999 ; 25 : 863-867

24. DISCUSSION Which is the most appropriate IOL calculation formula? HOLLADAY, HOFFER Q, SRKT >>> SRKI & SRKII Ref : Shugar J, Lewis C, Lee A: J.cataract refract surg 1996 ; 22 : 1368-1372 Holladay JT, Gills JP, Leidlein J: Ophtalmology 1996 ; 103 : 1118-1123

25. DISCUSSION Which is the best type of IOL ? Silicone, acrylic hydrophilic or hydrophobic, PMMA ? Key points : - Biocompatibility (interface opacification) - Resistance to secondary deformation

26. DISCUSSION Prevention of interface opacification: - Large CCC - Meticulous I/A - Implantation bag/sulcus - IOL (acrylic hydrophilic/phobic) - Haptics perpendicular Ref : Masket S JCRS April 1998

27. CONCLUSION Seducing technique in extremely short eyes: IOL power > 29 D Secondary indications: Pseudophakic eyes with refractive errors

28. CONCLUSION Satisfactory results in our study in terms of reliability and refractive results Necessity of longer follow up to assess the best type of IOL and the most appropriate site of implantation