March/April 2011 PS250 Survey

Issue: March/April 2011

When using a lens in a piggyback procedure, which do you prefer to use?

Perspectives

It is not surprising to me that the STAAR AQ lens is the favored IOL for piggyback purposes. It is a non-acrylic, three-piece lens that sits well in the sulcus and has been recommended by many doctors during the past years in trade publications and message forums.

Although the Alcon MA series (particularly the MA50BM, with its forgiving 6.5-mm optic) also sits well in the sulcus, it is an acrylic material IOL, and as the majority of IOLs today are acrylic, I would be concerned about interlenticular opacification. If I knew the IOL was a non-acrylic lens, I think the MA series would be a good choice.

My personal preference, however, is for the Bausch + Lomb LI series. It is silicone-based, so there is no worry about interlenticular opacification. It is also the only choice in this series that incorporates zero spherical aberration, which I think is very important as sulcus-based lenses may not center perfectly. Additionally, it injects in a planar configuration, allowing very easy delivery into the sulcus without concerns of having to rotate the haptics or interfere with the previously placed IOL. — David A. Goldman, MD

A low-power piggyback IOL has the capability of correcting small, spherical residual refractive errors, and in the rare patient who presents with apparently disabling dysphotopsias, its placement in the sulcus has the potential of reducing or eliminating these symptoms that complicate an otherwise perfect surgical result.

The Clariflex lens from Abbott Medical Optics has been my go-to lens with its third-generation silicone optic, rounded anterior edge and 10° angulation. It’s available in 0.5 D steps from –10 D to +1.5 D. The AQ5010V silicone IOL from STAAR Surgical, with its 6.3-mm optic size, may be even more helpful in those patients with dysphotopsias; however, it is only available in whole diopter steps between –4 D and +4 D, not in 0.5 D steps.

The Alcon MA60MA, available from –6 D to +6 D, is an excellent albeit square-edged acrylic IOL. I made the mistake of putting in this lens with a –1.5 D residual refractive error and in a few months, the patient had all of the posterior pigment from her mid iris rubbed off. This lens is contraindicated as a piggyback sulcus lens, precisely because of its square-edge profile, as well as the high likelihood of massive iris dispersion and possible secondary glaucoma. — Satish Modi, MD, FRCSC, CPI

A patient with a history of LASIK desires cataract removal and implantation with a multifocal lens; however, the patient has 2 D of against-the-rule astigmatism. What course of action would you take?

Perspectives

The first question to ask this patient is how much he or she desires multifocal IOLs. I have had very good results using multifocal IOLs in post-LASIK or even post-RK patients. I like to use the ReSTOR with +3 add SN6AD1 lens (Alcon) as my multifocal lens of choice. Once the patient decides on the multifocal lens, then the real challenge is to estimate the corneal power correctly, because the keratometric values do not accurately predict the corneal power after refractive surgery.

Because of this, there is about a 20% chance you will be off by more than 0.5 D. I usually use the hard contact lens method to estimate the corneal power if the pre-LASIK refraction and keratometry are not available, which is usually the case. I believe the contact lens method to be a more precise way to calculate the corneal power if the LASIK was a hyperopic treatment.

I usually do immersion biometry using the PalmScan AP2000 on all patients who desire premium IOL implantation. After customization of the A-constant for this lens, I achieve identical results and I aim for +0.125 D final postop refraction.

I will perform limbal relaxing incisions (LRI) at the time of surgery, using the NAPA nomogram. I only perform adjustable-depth LRI because I want to know exactly how deep the cornea is where I am cutting it. To streamline my LRI, I use the PalmScan P2000 LRI system, which also takes into account any cataract-induced astigmatism and provides an easy-to-follow graphical surgical plan.

I then wait 4 to 6 weeks for the post-cataract refraction to stabilize, and if there are any visually significant corrections to be done, I lift the flap and do the treatment. — Rafi Israel, MD

In this instance, I would recommend a toric IOL. It is the most predictable IOL in these patients, who often have significant post-LASIK higher order aberrations and therefore may not do well with any of the available accommodative or pseudoaccommodative lenses. However, I will implant the latter if the patient is highly motivated and understands that an IOL exchange may be necessary if his or her quality of vision is not satisfactory. — Richard J. Mackool, MD

Disclosures: David A. Goldman, MD, has no relevant financial disclosures to report. Rafi Israel, MD, is a co-inventor of the PalmScan and the medical director of Micro Medical Devices. Richard J. Mackool, MD, is a consultant for Alcon. Satish Modi, MD, FRCSC, CPI, is a member of the Alcon speaker’s alliance and has consulted for Ista Pharmaceuticals.

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