Refractive: Beyond the routine
Fall 2025
by Liz Hillman
Editorial Co-Director
While laser vision correction and, at times, IOL exchange remain the preferred method for correcting residual refractive error, Nicole Fram, MD, and William Trattler, MD, said that there is still a place for piggyback IOLs. In fact, piggyback IOL incidence ranges from 3–10%.1
Dr. Fram and Dr. Trattler spoke with EyeWorld about when they would consider a piggyback IOL, their preferred lenses for these cases, and their thoughts on newer generation IOL options in a piggyback setting.
Source: Nicole Fram, MD
When to piggyback
Dr. Fram said the postoperative situation that she thinks merits a piggyback IOL is that of a hyperopic outcome in a patient with a deep chamber, or if an IOL exchange would be considered difficult due to potential for zonulopathy or capsule phimosis. You can confirm the chamber depth with AS-OCT or ultrasound biomicroscopy (Figure 1).
Dr. Fram said that as more patients with prior RK are coming in for cataract surgery—and it’s harder to hit your target with these patients—upward of 50% could end up hyperopic postoperatively. In addition, high myopes, which over time is becoming more prevalent, who experience a hyperopic surprise might be a candidate for a piggyback lens, if they have been previously victrectomized, have a higher risk for retinal detachment, or if they have potential for zonulopathy.
“Some physicians opt for hyperopic LASIK/PRK in a mild hyperopic refractive error and have reliable results, but it’s much more difficult to get reliable results with laser vision correction for a hyperopic outcome >2 D than for a myopic outcome,” Dr. Fram said. “In those scenarios, a piggyback lens is not very complicated to do and could be a good solution for those patients.”
Dr. Trattler also said there is a whole set of patients in whom LASIK enhancement, PRK, or an IOL exchange would be difficult or less accurate, making piggyback IOLs an attractive option. He, like Dr. Fram, mentioned the patient who ends up hyperopic after surgery and who has had a YAG capsulotomy. He also brought up prior LASIK patients as candidates for piggyback IOLs as well. “You could try to go back and lift the LASIK flap, but in a hyperopic ablation, the ablation’s diameter is often much larger than the original LASIK flap,” Dr. Trattler said, also noting risk for epithelial ingrowth from lifting the flap.
Patients with a myopic surprise after LASIK face a risk for epithelial ingrowth if a flap lift is performed, and PRK after LASIK offers less predictability compared to PRK in eyes without previous LASIK. “In such cases, having the option to implant a piggyback IOL can be an effective solution with a high chance for a successful refractive outcome,” Dr. Trattler said.
Source: Michael Snyder, MD
What lenses to piggyback
Both Dr. Fram and Dr. Trattler said their preferred lens is the LI61AO (Bausch + Lomb).
“My preference is to try to avoid a minus lens at all costs. If a patient is nearsighted after surgery, we will do laser vision correction to correct them. I won’t place a minus lens in the sulcus because they’re thicker in the periphery and can cause pigment dispersion. The resultant transillumination defects could lead to debilitating glare, Dr. Fram said (Figure 2).
The LI61AO, Dr. Fram explained, is approved as a secondary IOL. While not rounded anteriorly, it is silicone, which she said seems more friendly in the ciliary sulcus. Dr. Trattler said he has found this lens to be well tolerated in front of the capsule, behind the iris. In addition, it goes down to very low powers.
When it comes to newer IOLs that could have applications as a piggyback lens, both Dr. Trattler and Dr. Fram expressed interest in the Light Adjustable Lens (LAL, RxSight). Dr. Trattler said this lens is attractive from an accuracy standpoint. “You can not only correct any residual spherical refractive error but you can correct residual astigmatism as well,” Dr. Fram said. She added that she’s had variable results with the LAL+ and thinks she’ll be more interested in using the original iteration of the LAL when it comes without the increase in negative spherical aberrations centrally of the LAL+.
When it comes to other “non-traditional” lens options that could be used as piggyback, Dr. Fram also mentioned an implantable collamer lens in the form of the EVO ICL (STAAR Surgical). “I think it’s an interesting option for eyes that are myopic with residual astigmatism,” she said, noting a case presented by John Berdahl, MD. “I thought it was a brilliant solution. There are still nuances to work out in terms of sizing.”
Dr. Trattler also said the ICL could be useful as a piggyback IOL, though he acknowledged it’s an expensive solution. “You’d have to determine the right patient, but the ICL likely has some advantages, as it is very soft and does not have an edge that would interact with the iris,” he said.
The IC-8 Apthera (Bausch + Lomb) is a single-piece acrylic, and Dr. Fram said she would not put this in the sulcus. The perfect piggyback IOL in the setting of a deep chamber with adequate sulcus, Dr. Fram said, would be made of silicone or collamer. If it had wavefront-guided adjustability, that would be even better. “If we had a piggyback lens that we could put in and we could then adjust it to be wavefront guided to their aberrated cornea, we could rehabilitate not only the patients that we currently have but patients who have older technology from the past. That’s the dream,” she said. “I’m hoping that’s where we’re going with IOLs in the direction of adjustability and the correction of higher order aberrations within the lens itself.”
ARTICLE SIDEBAR
Piggyback IOL calculations
Dr. Fram said there are two ways to perform calculations for piggyback IOLs.
- Use the Barrett Rx Formula or the refractive vergence formula from Warren Hill, MD.
- Use the Gills-Hoffer anecdotal shortcut. For a myopic outcome, Dr. Fram said you want to do 1.2 times the spherical equivalent to get the power of the piggyback lens. “But I don’t want to do a piggyback IOL for a myopic outcome. I’d rather do laser vision correction.”
For a hyperopic outcome, Dr. Fram said she normally would exchange if the lens were the wrong power, but if that wasn’t advisable, a piggyback would be 1.5 times the spherical equivalent to get the power of the piggyback lens.
About the physicians
Nicole Fram, MD
Advanced Vision Care
Los Angeles, California
William Trattler, MD
Director of Cornea
Center for Excellence in Eyecare
Miami, Florida
Reference
- Khoramnia R, et al. Polypseudophakia: from “Piggyback” to supplementary sulcus-fixated IOLs. Graefes Arch Clin Exp Ophthalmol. 2025;263:603–624.
Relevant disclosures
Fram: Bausch + Lomb, Johnson & Johnson Vision, RxSight
Trattler: Bausch + Lomb, Johnson & Johnson Vision, RxSight
Contact
Fram: nicfram@yahoo.com
Trattler: wtrattler@gmail.com
