BLOG: Categorize prospective refractive lens exchange candidates
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Many of us have noticed that refractive lens exchanges recently are a boom business. They have always been the only refractive solution for some patients, but increasingly sophisticated IOLs are turning more patients into candidates.
However, refractive lens exchanges (RLEs) cost significantly more than LASIK, all natural accommodation is lost and there is a small but real risk for complications. These exams can present challenges to the provider, and, contrary to a common belief, the counseling is quite different than that for a cataract surgery candidate.
!["Identifying which [RLE] category applies to your patient greatly simplifies the counseling." Oliver Kuhn-Wilken, OD](/~/media/slack-news/optometry/misc/infographics/2023/pcon0723kuhnwilkenblog_ig2_web.jpg?w=800)
There are three distinct types of RLE candidate, and identifying which category applies to your patient greatly simplifies the counseling.
The extreme myope
If your patient’s myopia is too extreme for LASIK and implantable collamer lenses (ICLs) are not an option, RLE can offer a low-risk path to excellent vision. During an RLE evaluation on an extreme myope, I stress three points.
Unlike their vision with contacts, they will not be able to see close targets without readers. Getting a younger patient to understand the reality of absolute presbyopia can be challenging. Multifocal IOLs must be considered.
Long axial lengths are at greater risk for refractive inaccuracies, and the patient must understand that they may need to consider LASIK or a light pair of glasses even after RLE.
The risk for retinal detachment (RD) increases after any lens extraction surgery, but even more so in long eyes and in eyes too young to have undergone posterior vitreous detachment (PVD) — very often the exact patients seeking RLE for myopia. The 5-year risk for RD after RLE in a myope greater than –6 D is likely around 3% (Alió JL, et al). If PVD has not yet occurred, this risk may be double that (Haug SJ, et al), and the presence of lattice degeneration increases the risk even more. The patient must acknowledge and accept this risk. Some authors have recommended avoiding RLE in any myope over –8 D in whom PVD has not occurred (Huang D, et al).
The hyperope
Because ICLs are not manufactured to help hyperopes, and LASIK only works well on lower hyperopic powers, moderate and extreme hyperopes have no refractive surgery options other than RLE. This process is straightforward for those simply interested in regaining good uncorrected distance vision, but all hyperopes must be thoroughly counseled on the option of multifocal IOLs.
Because a multifocal IOL improves their uncorrected vision at all distances, these can be some of our happiest RLE patients. They should be carefully evaluated for personality traits that react poorly to the optics of multifocal IOLs, however.
The presbyopic emmetrope
In a testament to the power of the newest multifocal IOLs, we are now seeing presbyopic emmetropes seeking RLE simply to restore their near vision — a new category of surgical candidate. This choice, however, is fraught with peril.
Although multifocal IOLs have become quite good at restoring near vision, this always comes with the trade-off of nighttime aberrations and usually some slight compromise even to distance photopic vision. If your patient is willing to trade a slight loss of distance clarity for increased independence from glasses, this might be a good choice, but beware if the drop in distance acuity is even a remote concern.
Every year we have seen new multifocal IOLs come to market. As this field becomes more and more sophisticated, the frequency of patients seeking RLEs will grow. We should all be adept at this type of exam, and categorizing your RLE candidate into these three groups can greatly clarify your counseling.
References:
- Alió JL, et al. Eye Vis (Lond). 2014;doi:10.1186/s40662-014-0010-2.
- Haug SJ, et al. Curr Opin Ophthalmol. 2012;doi:10.1097/ICU.0b013e32834cd653.
- Huang D, et al. Ophthalmology. 2009;doi:10.1016/j.ophtha.2009.08.018.
For more information:
Oliver Kuhn-Wilken, OD, is a staff optometrist at Pacific Cataract and Laser Institute’s Tualatin Clinic in Oregon.
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