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Cataract Surgery | Mar 2011

Duet Implantation: An Update

Correcting residual presbyopia with a supplementary IOL.

Before cataract surgery, patients have high visual expectations and often ask for a solution that will result in spectacle independence. Premium IOL designs have helped to improve the outcomes of cataract surgery. For instance, multifocal IOLs provide useful near and intermediate vision without spectacles and without adversely affecting distance vision.1,2 However, multifocal IOLs also have drawbacks, the most prominent of which are halos.

Although most patients adapt to halos, by their nature even the best diffractive multifocal IOLs are only about 80% to 82% efficient, resulting in a significant loss of incident light to higher-order aberrations. In most cases, the same lens model is implanted in both eyes of a patient so that his or her brain can adapt to the new visual system. Patient satisfaction and spectacle independence with these lenses is high, but still well below 100%.


The piggyback technique. Originally developed to provide adequate power in highly hyperopic patients, piggybacking IOLs has been extended to secondary cases in which additional power is added to or subtracted from an under- or overpowered pseudophakic eye. Piggybacking a secondary IOL in the ciliary sulcus is an effective, safe, and easy treatment for a pseudophakic refractive surprise.3 Implanting a second IOL in the sulcus offers a better solution than exchanging the primary IOL for several reasons. First, it is easier than exchanging the original IOL, which may have become adherent to the bag. Second, IOL exchange may be associated with an increased risk of retinal tears, cystoid macular edema, or capsular rupture with vitreous loss.

Duet implantation. We have previously reported on our use of the Sulcoflex Multifocal 653F IOL (Rayner Intraocular Lenses Limited, East Sussex, United Kingdom; Figures 1 and 2) for supplementary implantation in the ciliary sulcus.3 This IOL corrects refractive errors in the pseudophakic eye.

The Sulcoflex is a one-piece, foldable IOL with an overall length of 14.0 mm and an optic diameter of 6.5 mm. The multizoned refractive aspheric optic is made of a hydrophilic acrylic material and designed for ciliary sulcus fixation. The lens optic has a rounded edge and a concave posterior surface. The haptics have 10° posterior angulation and an undulating configuration with rounded edges. Its power ranges from -3.00 to 3.00 D in 0.50 D increments, with a 3.50 D addition (equivalent to 3.00 D at the spectacle plane).

Duet implantation is the term we have coined to describe a single surgical procedure combining primary capsular bag lens implantation with supplementary sulcus placement of the Sulcoflex. If the patient is dissatisfied after surgery or notices the presence of disturbing halos, this supplementary multifocal IOL can be removed or exchanged without trauma. Sulcus placement of a multifocal IOL simultaneous with implantation of the primary IOL within the capsular bag can be a successful strategy for correcting presbyopia. For an example of implantation in a pediatric eye, visit http://www.eyetube.net/video/wobiso/.

Michael Amon, MD, is a Professor and Head of the Department of Ophthalmology, Academic Teaching Hospital of St. John, Vienna, Austria. Dr. Amon is the inventor of the Sulcoflex and a member of the CRST Europe Editorial Board. He may be reached at tel: +43 1 211 21 1140; e-mail: amon@augenchirurg.com.

Guenal Kahraman, MD, practices in the Department of Ophthalmology, Academic Teaching Hospital of St. Johns, Vienna, Austria. Dr. Kahraman states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +43 1 21121 1140; fax: +43 1 21121 1144; e-mail: kahraman@gmx.at.

  1. Brydon KW,Tokarewicz AC,Nichols BD.AMO Array multifocal lens versus monofocal correction in cataract surgery. J Cataract Refract Surg.2000;26:96-100.
  2. Vaquero-Ruano M,Encinas JL,Millan I,Hijos M,Cajigal C.AMO Array multifocal versus monofocal intraocular lenses:long-term follow-up.J Cataract Refract Surg.1998;24:118-123.
  3. Kahraman G,Amon M.New supplementary intraocular lens for refractive enhancement in pseudophakic patients. J Cataract Refract Surg.2010;36(7):1090-1094.