Implantation of multiple intraocular lenses (IOLs; polypseudophakia or piggyback IOLs) has been described as a solution to the problem of providing adequate IOL power to adult patients with microphthalmos and extreme hyperopia.¹,²,³,⁴ We have used this concept in children, when indicated, since the mid-1990s (Figs. 28.1, 28.2, 28.3). Children with nanophthalmos can require very high IOL powers. Initially, when standard IOL powers extended only to a maximum of 30 diopters (D), primary piggyback IOLs were needed to attain the required power. More recently, IOL power ranges have extended to 40 D, reducing the need for this type of IOL piggybacking. We also sometimes use piggyback secondary IOL implantation in aphakic patients who become contact lens intolerant and are nearly full-grown but still have microphthalmia and require a high IOL power. Finally, a piggyback IOL is sometimes used instead of an IOL exchange when residual refractive error is present or develops over time. In each of these situations, the piggyback IOLs are expected to remain in the eye from that point forward.

In contrast, we introduced and developed (in the mid-1990s) the concept and technique of piggybacking IOLs to develop the technique of temporary polypseudophakia for infantile eyes.⁵,⁶,⁷ By mid-1999, one of us (M.E.W.) had implanted 13 eyes (10 of them infant eyes) with this temporary piggyback IOL technique. These were unilateral cataract patients who were deemed unlikely to comply with contact lenses for aphakia or thick hyperopic glasses for the residual hyperopia after a single IOL implantation. In a report published in 2000, we reported on bilateral piggyback implantation as well.⁵ In 2001, we reported on the short-term outcome of pseudophakia and polypseudophakia in the 1st year of life.⁶ This 2001 report included outcomes for 15 eyes of 11 infants who received piggyback IOLs in the first year of life (from 16 days to 6.8 months of age) and were followed for up to 22 months.

In the temporary piggyback technique, the posterior IOL is implanted in the capsular bag (permanent) and the anterior IOL is placed in the ciliary sulcus (temporary). This approach may help in the prevention and treatment of amblyopia by eliminating residual hyperopia in small children after IOL implantation. The combination of a permanent IOL sequestrated in the capsular bag and a temporary IOL placed in the ciliary sulcus—a location from which it can be easily removed later—makes this temporary polypseudophakia

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