RLE raises the bar for cataract surgery, experts say

Differences between cataract surgery and refractive lens exchange are few but important.

Refractive lens exchange and standard cataract surgery are essentially the same surgical procedure, but there are a number of important differences for surgeons to consider when adopting the lens-based refractive surgical technique, according to practitioners interviewed by Ocular Surgery News.

Differences between refractive lens exchange (RLE) and cataract surgery include the softness of the lens and, especially, the higher expectations of RLE patients. Because of the greater risk-benefit ratio of RLE relative to cataract surgery, patients should be well informed of any potential risks, experts said. Also, patients should understand before the initial surgery that a second procedure may be needed to refine refractive results of the initial surgery and that this should not be considered a complication of the surgery.

“The biggest difference between RLE and cataract surgery is that cataract patients have a visual deficit that they’re seeking relief for and, in general, are going to be happy with any improvement,” said I. Howard Fine, MD. “RLE patients generally see quite well with an optical device – contact lenses or glasses – and are going to be far less forgiving for less than an excellent result without glasses.”

He added, “The bar is a lot higher for refractive lens exchange than for a cataract patient.”

Conversely, others pointed out, the precision now being demanded by RLE patients is also affecting the expectations of cataract patients.

“The older cataract patient is demanding to have the same type of refractive results, especially if they’re choosing to have a presbyopic lens implant,” said Y. Ralph Chu, MD. “All of a sudden, a cataract surgery is a refractive type surgery.”

Ocular Surgery News interviewed experts to learn where they believe the management strategies for cataract surgery and RLE patients are similar and where they diverge.

Same surgery

When the question is first raised, many surgeons initially say there is little or no difference between RLE and cataract surgery. But in subsequent discussion, distinctions emerge.

“I don’t approach the two techniques any differently because I’m trying to give my cataract patients and my RLE patients the best possible vision,” Farrell C. Tyson, MD, said.

He added, “For me, they’re similar. It’s just that [for RLE] you’re going to have higher expectations and, therefore, you better spend more time preoperatively so you don’t have to spend more time postoperatively.”

Louis D. “Skip” Nichamin, MD, said routine cataract surgery is a refractive surgery today, including “limbal relaxing incisions and all the same kinds of things.”

The surgeries are similar in practice, Dr. Fine agreed, but the risk-benefit ratio in operating on a generally healthy eye is different from replacing a cataract-clouded lens in an aging patient.

“It isn’t that you need more caution. It’s just that the patient has more to lose,” Dr. Fine said.

Higher expectations

Higher patient expectations and the surgeon’s need to meet them are the most important differences between RLE and standard cataract surgery, the physicians said. Potential risks, lens choices and the possibility of needing a second refractive procedure must be discussed with each patient before moving forward with the surgery. And the surgeon performing the RLE must be able to deliver the desired results.

David F. Chang

“The main difference between the two surgeries is that RLE is much less forgiving,” David F. Chang, MD, wrote in an e-mail interview. “Patients’ refractive expectations are obviously much higher, which means that residual astigmatism or spherical error will be less acceptable. For this reason, it is important to explain before surgery that LASIK enhancement may be necessary in some cases to reach emmetropia.”

Dr. Fine agreed: “You’ve got to be right on. You’ve got to have low or no astigmatism. Your lens has to produce what it is that the patient was asking for that you felt you could deliver.”

The patient education process includes making sure the patient is fully informed of the positives and negatives of the procedure and the IOLs chosen, surgeons said.

“The informed consent process, because this is an elective, refractive-based procedure, has to be rigorous in terms of explaining to the patient the serious potential complications of this type of surgery as a refractive surgery.” Dr. Chu said.

Dr. Fine said conversations with RLE patients must cover a variety of topics, such as the demands of the patient’s work environment, hobbies and even the patient’s height, in order to choose the correct lens.

“It involves much more discussion than we have to have with cataract patients,” Dr. Fine said.

Roger F. Steinert, MD, agreed that the consent process is different, but he said the single biggest issue is surgical outcome, requiring a normal pupil aligned with the artifical lens.

“The implant is king; the implant is everything,” Dr. Steinert said. “If your implant isn’t going to be centered relative to the pupil and it isn’t going to be stable, then you’re setting the stage for an unhappy patient.”

Enhancement surgery

All of the surgeons interviewed said patient expectations should be tempered with full knowledge on the patient’s part that additional refractive surgical procedures may be needed to obtain the best possible vision.

“We have to be honest with patients and recognize that although our refractive outcomes are excellent, they’re not always perfect, and we may need to refine the initial outcome in some fashion,” Dr. Nichamin said. He said secondary interventions can include LASIK or insertion of a piggyback IOL.

“The good news is you have a pretty wide range [of secondary procedures] to pick from,” Dr. Steinert said. “On the flip side, we have the issue that it involves an added procedure, and patients need to be adequately informed so they don’t view that as a complication in and of itself.

“The most important thing is that it has to be addressed ahead of time so there are no surprises on anybody’s part,” Dr. Steinert continued. “The pressure is greater than ever to be complication-free. You want to be as close to 100% perfect as you can in everything.”

Dr. Chu noted that every surgeon performing RLE should have the knowledge and tools to perform secondary corrections or work with a physician who does.

“You do need to have other techniques at your disposal to help your patients achieve their refractive outcome,” Dr. Chu said.

Hard and soft nucleus

The most notable physical difference between RLE and standard cataract surgery is the likelihood that the RLE patient will be younger and have a soft, pliable lens, not the harder lens that cataract surgeons are used to dealing with.

“To me, the main difference is the density of the lenses we’re removing,” Dr. Nichamin said. He said it is reasonable to think that a soft lens would be easier to remove than a cataractous lens, but this is not necessarily the case.

“Some of these nebulous, mushy soft lenses can be difficult to manipulate,” he said.

Dr. Fine added, “Most refractive lens exchange lenses are soft and pliable, and to me they represent a bit of a challenge since they can distort unpredictably, and so they can be a little more difficult to take out” than a harder lens.

Dr. Fine said he performs bimanual microincision phaco techniques in all lens surgeries “because we think it is the safest and least invasive way to take a soft, pliable lens out.”

For more information:

• David F. Chang, MD, can be reached at 762 Altos Oaks Drive, Suite 1, Los Altos, CA 94024; 650-948-9123; fax: 650-948-0563.
• Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 7760 France Ave. South, Suite 140, Edina, MN 55435; 952-835-0965; fax: 952-835-1092.
• I. Howard Fine, MD, is a clinical professor of ophthalmology at the Casey Eye Institute at Oregon Health & Science University in Portland and in clinical practice with Drs. Fine, Hoffman & Packer, LLC, at 1550 Oak St., Suite 5, Eugene, OR 97401; 541-687-2110; fax: 541-484-3883.
• Louis D. “Skip” Nichamin, MD, can be reached at Laurel Eye Clinic, 50 Waterford Pike, Brookville, PA 15825; 814-849-8344; fax: 814-849-7130.
• Roger F. Steinert, MD, can be reached at Eye Institute at University of California, Irvine, 118 Med Surge I, Irvine, CA 92697-4375; 949-824-8089; fax: 949-824-4015.
• Farrell C. Tyson, MD, can be reached at 4120 Del Prado Blvd., Cape Coral, FL 33904; 239-542-2020; fax: 239-542-0704.

• Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.