primary piggyback IOL implantation at time of cataract surgery

In highly hyperopic eyes and nanophthalmic eyes the required IOL power can be very high, sometimes in excess of +40 diopters. For these patients, we can special order IOLs up to +40 D in the USA and even higher in other countries. We all agree that if the patient needs a +44 D IOL power for a plano outcome, the best option is to implant a special order +44 D IOL. But in the USA, when that is not an option, what are the options? The three main options in the USA are: Primary Piggyback IOL implantation at the time of the cataract surgery implant the maximum +40 D IOL into the bag and then come back later for a secondary piggyback IOL to be placed in the sulcus implant the maximum +40 D IOL into the bag and then have the patient return to spectacles or contact lenses for the remainder of the refractive power In the video below, we have guest surgeon Dr. Michael Patterson showing option 1: he implants a three-piece acrylic IOL (Alcon MA50BM with 6.5mm optic) into the capsular bag, then he places a three-piece silicone IOL (Bausch & Lomb Li61 with 6.0mm optic) with the haptics in the sulcus and the optic captured behind the capsulorhexis. Dr. Patterson used the Holladay 2 software to calculate the split of the total dioptric power between the two IOLs (totaling +44 D) and he achieved an accurate post-op outcome.  When we remove the 4 mm thick crystalline lens, there is certainly room in the capsular bag for two IOLs since they are much thinner. What we want to avoid, however, is inter-lenticular proliferation of cells leading to opacification. This inter-lenticular opacification is not easily treated with a YAG laser and a intra-ocular procedure to remove these cells may be needed. To minimize this risk, surgeons often will put in IOLs of different materials (one acrylic, one silicone) and then achieve a degree of optic separation by implanting the piggyback lens partially or fully in the sulcus.

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