1) The document describes a study on using secondary intraocular lens (IOL) implantation through the piggyback technique to correct residual refractive errors after cataract surgery. 2) 5 eyes that had primary IOLs implanted in the capsular bag underwent secondary Sulcoflex IOL implantation in the ciliary sulcus. 3) Results found median uncorrected and corrected distance visual acuity improved after secondary IOL implantation. The median spherical equivalent refractive error was within 0.00 diopters of the targeted correction.

1. SECONDARY PIGGYBACK IOL
IMPLANTATION FOR CORRECTION
OF RESIDUAL REFRACTIVE ERROR
POST CATARACT SURGERY.
Presented by- Dr Hardik Jain
Co-authors- Dr Mrunal Patil
Dr Dhiraj Balwir
( Disclosure: Author has no financial interest )
Dr Vasantrao Pawar Medical College, Nashik

2. INTRODUCTION
• The piggyback technique was first described in 1993 by
Gayton and Sanders in a case of cataract and
microphthalmos, in which the calculated IOL power
was +46 diopters (D)3.
• Subsequently, it began to be used to correct
postoperative refractive errors. The same authors
published in 1999 a case series of 8 eyes of 8 normal
pseudophakes and 7 eyes of 7 postpenetrating
keratoplasty pseudophakes in which a secondary IOL
was implanted by the piggyback technique.9

3. • Secondary piggyback IOLs are available as
monofocal, multifocal, toric and multifocal toric
models.10
• There are three IOLs specifically designed for
secondary implantation in the ciliary sulcus to
correct pseudophakic ametropias or
pseudophakic presbyopia: the Sulcoflex (Rayner
Intraocular Lenses Ldt, East Sussex, United
Kingdom), which was the first to be commercially
available, the Add-On (HumanOptics, Erlangen,
Germany) and the 1st Add-On (1st Q GmbH,
Mannheim, Germany).

4. • PURPOSE:
To report the visual and refractive outcomes following
secondary piggyback intraocular lens(IOL) implantation
to correct residual refractive errors following cataract
surgery.
• DESIGN:
Retrospective interventional case series.

5. MATERIALS & METHODS
• 05 pseudophakic eyes with primary IOL in the capsular
bag underwent planned secondary piggyback IOL
implantation in the ciliary sulcus to correct residual
refractive error.
• Data collected:
- Uncorrected distance visual acuity (UDVA), corrected
distance visual acuity (CDVA) and manifest refraction
following primary implant surgery.
- Design and type of piggyback lens implant
- Manifest refraction, postoperative UDVA and CDVA
following secondary piggyback IOL implantation
• Follow up duration: 1 month

6. •Hydrophilic acrylic material, undulating haptics,
posterior haptic angulation
•Physical Parameters:
- 6.5 mm optic body diameter
- 14.0 mm overall length
- 10o haptic angulation
- Anterior Convex and Posterior Concave

7. Sulcoflex Power Availability
Aspheric (653 L) Standard range: Up to +/- 5.0 D in 0.5 D
increments
Premium range: Up to +/- 10.0 D in 0.5 D
increments
Toric (653 T) Standard range: SE Up to +/- 3.0 D in 0.5 D
increments and cyl up to + 3.0 D in 1 D
increments
Premium range: SE Up to +/- 6.0 D in 0.5
D increments and cyl up to + 6.0 D in 0.5
D increments

8. Number of patients (n) 05
Gender (M:F) 1:4
Median age 56 +/- 11
Intraocular Lens Sulcoflex Toric (n=4)
Sulcoflex Aspheric (n=1)
Corneal comorbidities High Astigmatism (n=2)
Previous Penetrating Keratoplasty (n=1)
None (n=2)

9. RESULTS
• Pre and Post-Secondary Piggyback IOL
Implantation Visual Acuity :-
A. Pre-Op: Median UCVA- 6/36, Median BCVA-
6/6
B. Post-Op: Median UCVA- 6/9, Median BCVA-
6/6

10. SPHERICAL EQUIVALENT(SE)
• Spherical Equivalent(SE): Pre-Sulcoflex
Implantation, Sulcoflex IOL Target, Post-
Sulcoflex Implantation
n =05 Pre- Sulcoflex
implantation
SE (D)
Sulcoflex SE
(D)
Post-
Sulcoflex
implantation
SE (D)
Median -1.25 -1.50 +0.00
Min/Max -6.25/+2.50 -7.00/+4.00 -1.00/+1.75

11. DISCUSSION
• Implanting a second IOL in the sulcus offers a
better solution than exchanging the IOL.
-Technically easier than exchanging the original
IOL
-Late removal of the IOL placed in the capsular
bag can result in capsule rupture and zonule
damage.
• Our finding is consistent with Awady et al who
reported postoperative SE of -0.28 D to 0.03 D.

12. CONCLUSION
• Secondary piggyback intraocular lens is a safe
and effective method to correct residual
refractive error following cataract surgery.

13. REFERENCES
1.Habot-Wilner Z, Sachs D, Cahane M, et al.
Refractive results with secondary piggyback
implantation to correct pseudophakic refractive
errors. J Cataract Refract Surg 2005; 31:2101–2103
2.El Awady HE, Ghanem AA. Secondary piggyback
implantation versus IOL exchange for symptomatic
pseudophakic residual ametropia. Graefes Arch Clin
Exp Ophthalmol. 2013; 251(7):1861-6