piggyback implantation of for high hyperopia 24 months follow up jl. febbraro i.vielpeau, f. krifa,...

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