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New supplementary

intraocular lens for refractive


enhancement in
pseudophakic patients
Gunal Kahraman, MD, Michael Amon, MD
J Cataract Refract Surg- Vol 36, July
2010

Introduction

Refractive errors are unavoidable in some cases


Gayton & Sanders (1993)
piggiback IOL in
highly hyperopic patients
less extreme cases
Concern:
2 piggiback IOL in the capsular bag
interlenticular opasification (ILO) with Elschnig
pearl proliferation in the peripheral interface
between 2 IOLs
Preventing methods: primary IOL in capsular
bag and the secondary IOL in the ciliary sulcus

Introduction
Purpose:
to asses the efficacy and safety of
implanting a secondary IOL (newly
introduced IOL designed) in the ciliary
sulcus to correct pseudophakic
ametropia

Methods

Setting:
Depart of Ophthalmology, Medical Univ of
Vienna, Vienna, Austria
Prospective nonrandomized study
Patients:
patients who had implantation of a
secondary IOL (Sulcoflex 653L) to correct
residual refractive error after phaco with IOL
implantation in capsular bag

Methods

Preop assessment:
UDVA, CDVA, tonometry, funduscopy,
biometry (IOL Master, Carl Zeiss Meditec), the
power of the secondary IOL (Haigis formula)
Surgical technique
the 2ndary IOL was implanted in the ciliary
sulcus using supplied 1-piece single use
injector

Methods

IOL
- a foldable
aspheric,
- 1-piece hydrophilic
acrylic,
- 13.5 mm,
- 6.5 mm optic,
-concave posterior
surface

Methods

Evaluation:
- visual & refractive outcomes
- inflammation
laser flare-cell meter
- the position and rotation of the IOLs
- Scheimpflug images
Postoperative follow-up : 1 week,
1,6,12, and 17 months

Result

12 eyes of 10
patients
Mean spherical
equivalent
-1.25D0.25 to 0.250.40
UDVA
Mean Snellen:
0.90.1

Result

All surgeries
uneventful
Follow-up
- no signs of pigment dispersion, iris bulging,
foreign-body giant cell formation, or ILO
- 1 decentration of the 2ndary lens <0.5mm
- no cases of IOL rotation or tilt
- the Scheimpflug images
the same IOL
lens distancees at all postoperative visits

Result

Result

The UBM images


all cases

the IOL position was stable in

Result
Laser flare
There was no
significant
difference
between preop &
postop

Discussion

Postop residual refractive error is


frustrating for surgeon and patient
This study
Habot-Wilner et al. (2005)
2ndary IOL implantation in the ciliary
sulcus is safe, less traumatic, &
predictable
Werner et al. (2000)
this procedure prevents ILO formation

Discussion

Scheimpflug photography
to evaluate the distance between the optics of 2
IOLs
showed:
- well-centered IOL except in 1 case (AL:
31.53mm)
caused by the eyes large ciliary
diameter and weak zonular support
- the distance was always good in the optic
zone
- concave design of the 2ndary IOL prevented
contact between and distortion of the optical zone

Discussion

2ndary IOL with thick haptic, square-edge


haptic/optic
optic margin/haptics chafe
againts the iris pigment epithelium
sulcus irritation
pigment dispersion
This study
pigment dispersion or iris chafing because:
- the haptic & optic edges of the 2ndary IOL are
rounded
- 10 degrees posterior angulation of the haptic
keeping the optic away from the iris

Discussion

Rotational instability
optical distortion & ciliary body irritation
Undulating haptic
preserve IOL stability
& reduce the risk for IOL rotation
Elevated IOP
1 eye had a rise in IOP
OVD postop
Pupil capture
no cases
2ndary IOL has a large optic
(6.5 mm) + 10 degrees posterior haptic
angulation

Discussion

Caporossi et al. (2002)


the strength & memory of haptics of 1-piece
hydrophobic acrylic IOLs
excellent

IOL material in this study has high memory


of the hydrophylic acrylic material
contribute to the IOLs stability in the sulcus
and the decrease risk for tilt and decentration

Conclusions

Sulcus implantation of the 2ndary IOL to


correct pseudophakic refractive error
was safe & predictable

The IOL was well tolerated in all eyes

dr. Yuniati Wisma, SpM & Keluarga

Haigis formula:
d = the effective lens position, where ...
d = a0 + (a1 * ACD) + (a2 * AL)
ACD is the measured anterior chamber depth of the eye
(corneal vertex to the anterior lens capsule), and ...
AL is the axial length of the eye; the distance from the cornea
vertex, to the vitreoretinal interface. *
The a0 constant basically moves the power prediction curve up,
or down, in much the same way that the A-constant, Surgeon
Factor, or ACD does for the Holladay 1, Holladay 2, Hoffer Q
and SRK/T formulas.
* The a1 constant is tied to the measured anterior chamber
depth.
* The a2 constant is tied to the measured axial length.