Piggyback IOL refers to the implantation of a second intraocular lens onto an existing one to correct postoperative refractive errors, requiring specific preconditions such as a stable primary IOL and a healthy anterior chamber. The procedure has particular indications, including hyperopic postoperative refractive errors, but is contraindicated in cases of loose zonules or significant corneal endothelial cell loss. While it has advantages like improved image quality and better depth of focus, potential complications include intralenticular opacification and postoperative pigment dispersion.

1. DISCUSSION
PIGGYBACK IOL

2.  1st described in 1993 by Gayton & Sanders in a case
of cataract & microphthalmos, in which the
calculated IOL power was +46 Diopters.
 Later on, it is used to correct post operative refractive
errors.

3. WHAT IS PIGGYBACK IOL?
 An IOL that ”piggybacks” onto an existing IOL or two
IOLs implanted simultaneously.
 1st
IOL is placed in the capsular bag
 2nd
IOL (piggyback) is placed in the bag or sulcus.

4. PRE REQUISITES
 a stable PCIOL within an intact capsular bag,
 a normal or deep anterior chamber,
 a normal corneal endothelium, and
 no evidence of pigment dispersion syndrome.

5. CONSIDERATION
The relevant considerations for piggyback IOL procedures
are:
the IOL power, material, edge design, and position.
IOLs with low negative or low positive dioptric power are
required.
The material should be different from that of the existing IOL in the
eye (i.e., acrylic vs. silicone) to minimize the risk of an intra
lenticular membrane formation.

6.  The piggyback lens is
 placed in the ciliary sulcus and
 should have a rounded (not square) edge,
 a posterior angulation, and
 a 3-piece design with sufficient overall length (to prevent
pigment dispersion and iris damage from chafing the
posterior iris surface.)

7. INDICATION
 patients with a hyperopic postoperative refractive error.
 Patients with a history of RK, because they are prone to
hyperopic surprises after cataract surgery.

8. CONTRAINDICATION
 loose zonules from trauma or pseudoexfoliation
 Posterior synechiae to the capsular bag
 significantly reduced corneal endothelial cell count

9. ADVANTAGE
 Easier to place 2nd
IOL than to explant IOL & replace it
 Better image quality
 Increased depth of focus

10. COMPLICATIONS
 Intralenticular opacification (interpseudophakos Elshnig’s
pearls) -- RED ROCK SYNDROME
 Postoperative pigment dispersion, which occurs when
the piggyback lens rubs against the posterior surface of
the iris.
 Iris chafing,
 Chronic iridocyclitis,
 Glaucoma (secondary angle closure glaucoma)
 Hyphema, and
 Corneal decompensation.

11. OPTIONS FOR PIGGYBACK IOL
 For placement in the capsular bag, an IOL with a negative
shape factor such as the three-piece hydrophobic acrylic IOL
is an excellent choice.
 single-piece hydrophobic acrylic IOLs should not be placed
into the sulcus because they may induce uveitis- glaucoma-
hyphema syndrome.
 For the ciliary sulcus lens, a large diameter, low profile,
round edge, biconvex newer generation silicone IOL is
recommended.

12.  Secondary piggyback IOLs are available as monofocal,
multifocal, toric & multifocal toric models.
 There are three IOLs specially designed for secondary
implantation in the ciliary sulcus to correct pseudophakic
ametropias or pseudophakic presbyopia: the Sulcoflex, the
Add- on & the 1st
Add- on.

13. TYPES OF PIGGYBACK IOL IMPLANTATION
 Primary Polypseudophakia:
High hyperopia or myopia (mostly both in the bag)
 Secondary Polypseudophakia:
To manage postoperative refractive surprise (mostly lower
power IOL in sulcus), done after 6 weeks of the first surgery.

14. PIGGYBACK IOL POWER
CALCULATION
Easily calculated utilizing the Holladay
IOL Consultant (R Formula)

15. No holladay consultation

16. Piggyback IOL
(Gills Nomogram)
 Underpowered pseudophakes (hyperopes):
1. Small eye (<21 mm): power = (1.5 X SE) + 1
2. Average eye (22 – 26 mm): power = (1.4 X SE) + 1
3. Long eye (>27 mm): power = (1.3 X SE) + 1

17.  Overpowered pseudophakes (myopes):
1. Small eye (<21 mm): power = (1.5 X SE) - 1
2. Average eye (22 – 26 mm): power = (1.4 X SE) - 1
3. Long eye (>27 mm): power = (1.3 X SE) - 1

18. Thank you…