Routine major incision of a minimum of 2.2 mm is required. Anterior chamber is filled with viscosurgical device. The Scharioth Macula Lens is placed in the cartridge. Special care is taken that during the folding of the winglets of the cartridge the optic of the lens is folding upwards. This will result in a controlled intraocular unfolding during implantation. While the plunger of the injector is pushed a second instrument is used through the side port incision to guide the leading haptic into the ciliary sulcus (Fig. 10.2). Usually the trailing haptics are placed into the ciliary sulcus in a second step. Proper position of the haptics and IOL centration is checked. Finally ophthalmic viscosurgical device is removed. Special care is taken to remove residual OVD between the lenses. We prefer hydroxypropylmethylcellulose to reduce the risk for postoperative intraocular pressure spikes. Additionally one might prescribe acetazolamide per os. Finally incisions are hydrated to prevent leakage (Fig. 10.3).

The implantation can be performed during an uncomplicated cataract surgery after the standard IOL is placed in-the-bag or any time after a previous cataract surgery. If relevant cataract is present we prefer to perform first phacoemulsification and in-the-bag PCIOL implantation. SML implantation can be performed any time after if the patient is unsatisfied with the outcome of cataract surgery alone. In case of a near clear lens we perform a simultaneous surgery with immediate implantation of the Scharioth Macula Lens. In contrast to a secondary implantation years after in-the-bag implantation in this situation the SML has tendency to unfold with the leading haptics into the capsular bag. As the haptics are very soft it should not be difficult to lift the haptic and position it into the ciliary sulcus. In our experience a moderate secondary cataract does affect safeness and visual outcome. But in case of excessive secondary cataract (thick Soemmering) one should consider to remove the material to prevent decentration or tilt. All manipulations should be performed very carefully to prevent zonular damage as this could result in unstable SML positioning.

Patients with advanced maculopathy (e.g. AMD, diabetic maculopathy, myopic maculopathy etc.) and distance visual acuity between 0.3 (0.4) and 0.1 are good candidates. If BCDVA is better then 0.4 patients do not require low vision aid to read. In our experience preoperative testing of BCNVA at 40 cm with +2.5 D vs. 15 cm with +6.0 D gives a valid information about the potential of SML and if BCNVA is better at 15 cm and the patient is motivated he might be a good candidate. Patients with BCDVA worse then 0.1 or no improvement in near test (+2.5 D vs +6.0D) might be also candidates for SML implantation but should be informed that reading vision will not be achieved. In this case a slight improvement might be helpful for daily activities (e.g. looking for coins in a wallet) if the patient is motivated and compliant.