EyeWorld Asia-Pacific December 2018 Issue

is when choosing a multifocal solution. Multifocals may not be for everyone, and despite informed decision making, it is prudent to allow for change if patients be- come dissatisfied somewhere down the line. In a study that evaluated diffractive multifocal IOLs as part of dual surgery with monofocal capsular bag IOL implantation, there was high safety and effi- cacy for the combined procedure, with preliminary visual acuity results similar to those obtained in eyes with single-piece diffractive multifocal IOLs. 1 Add-on patients had the option to reverse or adjust their treatment. Dr. Amon said, “Indications for primary implantation, also called duet implantation, where both lenses are implanted in the same stage, are high ametropia, for instance when you don’t have the lens in stock for the high cor- rection and can add the missing power through the second lens; high astigmatism; a multifocal duet procedure, which for me is one of the main options and benefits from these lenses because you have reversibility if the patient is incompatible with the lens; and deconversion. More importantly, if the patient within the next decades develops AMD or diabetic macular edema, you can explant the supplementary lens at any time. Uses as a secondary im- plant include spherical correction because of biometrical surprises, astigmatic correction, conversion from monofocal to multifocal, dysphotopsia, magnification, and stenopeic hole. It is a big advan- tage to be able to step back and reverse it.” A prospective non-randomized study that Dr. Amon co-investigat- ed showed that the implantation of the Sulcoflex 653L (Rayner) secondary IOLs in the ciliary sulcus to correct residual refractive error after phaco with in-the-bag IOL implantation in 12 eyes of 10 patients was safe, predictable, and well-tolerated. 2 None of the study eyes showed pigment dispersion, interlenticular opacification, optic capture, or pupil ovalization. In a separate study that reviewed the charts of 46 secondary IOL patients in which one surgeon performed surgery in one practice, study investigators concluded that supplementary IOLs were a viable surgical option to correct residual refractive error after primary IOL implantation, including 10 cases involving secondary toric IOLs. 3 In the study, rotation did not exceed 10% in eyes with toric secondary lenses. Practical and easy The IOL calculation for secondary implantations in cases of biometri- cal surprise is straightforward. In cases of ametropia between ±7 D, the surgeons multiplies the spheri- cal equivalent by 1.5 in hyperopic cases and by 1.2 in myopic cases. Dr. Amon usually uses a 2.4 mm incision. He injects viscoelastic, folds the device into the injector or uses forceps, and positions the IOL into the ciliary sulcus. He performs aspiration of OVD from the interface to avoid a secondary pressure increase, places an iri- dotomy in children, short, or odd eyes, and applies an antibiotic. When part of a duet procedure, he removes the viscoelastic from the bag from the first procedure, then adds viscoelastic behind the iris and continues as above, placing the secondary lens behind the iris. Dr. Amon suggested placing a suture for toric add-ons, as a 10% rotation would change refraction by 30%. However, the centration of monofocal sulcus fixated sup- plementary IOLs was significantly better than bag fixated IOLs when compared to the limbus and with the dilated pupil, according to a study that he co-authored that looked at centration of sulcus fixated supplementary IOLs implanted anteriorly to preexist- ing capsular bag IOLs in 48 eyes of 43 patients. 4 He explained that lenses implanted in the sulcus do not experience shrinkage, cap- sular contraction, or any form of change, like IOLs implanted in the capsular bag might. “Children present a challenge because their eyes grow and the lens power has to be adapted. That is where the reversibility comes in that I like so much in this lens system. You can remove the lens when you need to and exchange it at any time, for instance when eyeball growth creates a myopic shift,” he said. “The explantation works easily. You do not have to cut the lens or fold it within the eye. You just grasp it and pull it out through the incision.” EWAP References 1. Gerten G, et al. Dual intraocu- lar lens implantation: Monofocal lens in the bag and additional diffractive multifocal lens in the sulcus. J Cataract Refract Surg. 2009;35:2136–43. 2. Kahraman G, Amon M. New supplementary intraocular lens for refractive enhancement in pseudophakic patients. J Cataract Refract Surg. 2010;36:1090–4. 3. Gunderson KG, Potvin R. A re- view of results after implantation of a secondary intraocular lens to correct residual refractive error after cataract surgery. Clin Ophthal- mol. 2017;11:1791–1796. 4. Prager F, et al. Capsular bag- fixated and ciliary sulcus-fixated intraocular lens centration after supplementary intraocular lens implantation in the same eye. J Cataract Refract Surg. 2017;43:643– 647. Editors’ note: Dr. Amon has financial interests with Alcon (Fort Worth, Texas), Bausch + Lomb (Bridgewa- ter, New Jersey), Johnson & Johnson Vision (Santa Ana, California), Carl Zeiss Meditec (Jena, Germany), Morcher, and Rayner. Contact information Amon: michael.amon@med.sfu. ac.at Reversible and adjustable – from page 53 54 EWAP CATARACT/IOL December 2018