PIGGYBACK IMPLANTATION OF FOR HIGH HYPEROPIA

24 MONTHS FOLLOW UP

JL. FEBBRARO

I.VIELPEAU, F. KRIFA, S.BERBACHE,

S. GANEM

Department of Ophthalmology S. GANEM M.D.

Rothschild Foundation - Institut de la myopie

Paris - France

INTRODUCTION

GAYTON 1993:

First piggyback implantation in cataract surgery to obtain

emmetropia in extremely short eyes.

PATIENTS and methods

• Retrospective study

• 30 eyes, 20 patients

• Mean age : 70 years (range : 8 – 90 Y)

• Sexe : 16 women, 4 men

• Mean follow-up : 18 M (range : 6 to 30 M)

Patients and METHODS

• CCI: 3.5 mm / Limbal: 6 mm

• Phacoemulsification

• 2 PCI in the bag :

- Silicone : 13 (SI 40)

- Acrylic hydrophilic : 9 (Stabibag, Quattro) hydrophobic : 6 (AR40)

- PMMA : 2 (CP60)

Patients and METHODS

• Axial length :

- Mean : 20.97 mm

- Min : 19.75 mm

- Max : 22.16 mm

18

19

20

21

22

23

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31Eyes

mm

Patients and METHODS

IOL calculation formula:

Combined Holladay / SRK/T

Patients and METHODS

Total IOL emmetropic power :

+ 26 D to + 32 D

0

5

10

15

20

25

30

35

1 4 7 10 13 16 19 22 25 28 31Eyes

Diopters

IOLs power distribution:

Equally distributed between anterior and posterior IOLs

Patients and METHODS

-2,5

-2

-1,5

-1

-0,5

0

0,5

1

1,5

1 4 7 10 13 16 19 22 25 28

SE postop

Eyes

RESULTS: SE Postop

Mean SE : -0,50 D ; Range : -2.25 to +1.50 D

RESULTS: Distance UCVA

400

100

50

30

25

20

1 4 7 10 13 16 19 22 25 28

VAVA

Eyes

Mean VA: 20/50; Range: 20/200 to 20/25+

RESULTS: Distance BCVA

400

100

50

30

25

20

1 4 7 10 13 16 19 22 25 28 Eyes

VA

Mean VA: 20/30+ Range: 20/100 to 20/20

RESULTS: Near UCVA

0

1

2

3

4

5

6

7

8

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Parinaud (P)

Eyes

Mean VA: P 4.3; Range: P 8 to P 2

RESULTS: Near BCVA

0

1

2

3

4

5

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29Eyes

Parinaud (P)

Mean VA: P 2.5; Range: P 5 to P 2

RESULTS : Near BCVA with distance correction

0

1

2

3

4

5

6

7

8

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Parinaud

Nbre patients

VA mean :P 3.7 ; min : P 8 ; max : P 2

RESULTS: Near VA Pseudoaccomodation ?

01

2

3

4

5

6

7

8

Near UCVA Near BCVAWith distance correction

Near BCVAWith near correction

RESULTS: Complications

• Decentration : 1 case at 3 months PO

RESULTS: Complications

• Decentrement : 1 case at 3 months post op• Hyperopic shift : 3 cases

RESULTS: Complications

• Decentrement : 1 case at 3 months• Hyperopic shift : 3 cases

• PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG)

RESULTS : Complications

• Decentrement : 1 case à 3 months• Hyperopic shift : 3 cases

• PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG)• Pigment deposit between IOLs : 1 case at 8

months with 3 lines of loss BCVA (20/40)

RESULTS : Complications

• Decentration : 1 case at 3 months PO• Hyperopic shift : 3 cases

• PCO : - at 3 months : 3 cases without LBCVA - at 1 year : 4 cases (2 YAG) - at 2 years : 6 cases (4 YAG)• Pigment between IOLs : 1 case at 8 months

with 3 lines of LBCVA (20/40)

• Interface opacification : 0 case

DISCUSSION

• Advantages of Piggyback : - Less spherical aberrations - Pseudoaccomodation - Wound size Ref : Gayton JL:

J Cataract Refract Surg 1993 ; 19 : 776-777

DISCUSSION

• Inconvenients of Piggyback : - Interface opacification - Hyperopic shift - Surgical technique - Cost

Ref : Shugar JK. J Cataract Refract Surg 1999 ; 25 : 863-867

DISCUSSION• Which is the most appropriate IOL calculation

formula?

HOLLADAY, HOFFER Q, SRKT >>> SRKI & SRKII

Ref : Shugar J, Lewis C, Lee A: J.cataract refract surg 1996 ; 22 : 1368-1372

Holladay JT, Gills JP, Leidlein J: Ophtalmology 1996 ; 103 : 1118-1123

DISCUSSION

• Which is the best type of IOL ?

Silicone, acrylic hydrophilic or hydrophobic, PMMA ?

Key points :

- Biocompatibility (interface opacification)

- Resistance to secondary deformation

DISCUSSION

• Prevention of interface opacification: - Large CCC - Meticulous I/A - Implantation bag/sulcus - IOL (acrylic hydrophilic/phobic) - Haptics perpendicular

Ref : Masket S JCRS April 1998

CONCLUSION

• Seducing technique in extremely short eyes: IOL power > 29 D

• Secondary indications: Pseudophakic eyes with refractive errors

CONCLUSION

• Satisfactory results in our study in terms of reliability and refractive results

• Necessity of longer follow up to assess the best type of IOL and the most appropriate site of implantation