EyeWorld India December 2018 Issue

Supplementary IOLs are effective for secondary enhancements and for primary duet implantations B iometrical surprises after cataract and refractive surgery are unwelcome and need to be dealt with promptly. The best approaches involve uncomplicated surgery, such as those offered by secondary, supplementary IOLs, designed to provide simple, adjustable solu- tions. Presenting an overview on supplementary IOLs for the pseu- dophakic eye at the 22nd ESCRS Winter Meeting, Michael Amon, MD , Academic Teaching Hospital of St. John, and Sigmund Freud Private University, Vienna, Aus- tria, explained that the success of secondary IOL implantations was a result of the progress made on many different levels. “One of the problems encoun- tered in early supplementary IOL implantations in the 1990s was that the lenses were implanted together with the primary lens into the capsular bag. As we all know, the proliferative cells from the equator invaded the interface, and the lenses needed to be explanted,” Dr. Amon said. “The second prob- lem was the use of two biconvex lenses, which resulted in a central contact that led to a flattening of by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Reversible and adjustable lens solutions the contact zone and a resultant hyperopic defocus. The third prob- lem was if we put a lens into the sulcus, there could be iris chafing (pigment dispersion), inflamma- tion, raised IOP, or hemorrhage.” New technologies Current lens designs for use as secondary implants incorporate targeted improvements drawn from the lessons learned over time. Secondary lens designs are hydro- philic acrylic, single-piece IOLs. Hydrophilic acrylic material has a high uveal biocompatibility, which is important due to the direct contact between the device and the uvea. There are three supplemen- tary lenses available, the Reverso (Cristalens, Lannion, France), the Sulcoflex (Rayner, West Sussex, U.K.), and the 1stQ (1stQ GmbH, Mannheim, Germany), that share basic characteristics. They have relatively large optics of between 6 and 6.5 mm in diameter, which overlap the primary lens to avoid iris/optic capture; they are round- edged devices, resulting in less dysphotopsia and less posterior capsule opacification (PCO); they have a concave posterior surface to avoid hyperopic defocus at the contact zone; they have long hap- tics, 13.5–14 mm diameter for good centration and rotational stability; and they are angulated to ensure uveal clearance. “I mostly implant aspherical monofocal supplementary lenses to correct biometric surprises,” Dr. Amon said. “But all options are available, multifocals, both refractive and diffractive; torics, as a supplementary toric correction, like for post-PKP patients where we have a dynamic change of the axis; and multifocal toric lenses.” Other supplementary lenses include the Black Pinhole IOL (Morcher, Stuttgart, Germany), an extended depth of focus IOL using a stenopeic hole, which offers a fea- sible option in eyes with irregular astigmatism that standard lenses cannot address; and the iolAMD Eyemax (iolAMD, London, U.K.), which uses a hyperaspheric optic to magnify 1.3x and is useful in AMD patients who greatly benefit from the extra magnification. Why use a secondary sulcus fixated IOL? The key benefit of supplementary lenses is their reversibility. Sup- plementary lenses represent an adjustable and exchangeable choice as primary add-ons. They also of- fer a reversible alternative to laser enhancements and the option to avoid IOL exchange in cases of a post-surgical refractive surprise or astigmatism correction. One example of when second- ary lenses can benefit a situation Multifocal toric additive IOL in mydriasis Slit lamp photo with IOL surface re exes Source: Michael Amon, MD continued on page 54 EWAP CATARACT/IOL 53 December 2018