Clear lens exchange effective for wide range of refractive errors

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August 06, 2021

2 min read

Biography:
Alldredge practices at Pacific Cataract and Laser Institute

Biography:
Norris practices at Pacific Cataract and Laser Institute

Disclosures: Alldredge and Norris report no relevant financial disclosures.


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In this month’s blog entry, we will discuss an intraocular refractive surgery that we may not see often but are likely already incredibly comfortable seeing for postop: refractive lens exchange.

Refractive lens exchange (RLE), which you may also hear called clear lens exchange or refractive lensectomy, is essentially cataract surgery without a visually significant cataract where the surgery is performed for prescription purposes only. Because of this, patients can be expected to have a similar postoperative experience with the same medications and postop schedule preferred by your local ophthalmologist who performs cataract extraction.

In this first article of a two-part series, we focus on patient selection, limitations and risks.

RLE not only rivals the results of corneal refractive surgery (LASIK and PRK) but addresses a much wider range of refractive errors and can treat a wider age range. In fact, RLE can be used to treat the widest range of prescriptions of any refractive surgery including high hyperopes, high myopes and everything in between.

RLE may be the only option for patients who are poor candidates for LASIK and fall out of the prescription range for implantable collamer lens (ICL), another intraocular surgery option that can treat only high myopes.

For hyperopes, one should start thinking of RLE over LASIK/PRK as early as +2.00 D. However, despite RLE’s otherwise extensive ability to treat high prescriptions, treatment of high astigmatism is unfortunately still dictated by the available range of toric IOL powers.

Beyond high prescriptions, refractive lens exchange is a sweet spot for those too old for LASIK or ICL but too young for cataract surgery. We have a patient population who is staying more active for longer, with higher visual demands. There are limited options for presbyopes if they do not want reading glasses and cannot tolerate contact lenses, and RLE should be considered for those willing to do anything to avoid readers. RLE has the benefit of being the only refractive surgery that can addresses presbyopia if the patient elects a multifocal IOL.

Additionally, when a patient 50 years old or older comes in for a LASIK evaluation, we always discuss the risk for their refraction changing in the future with emerging cataracts. Another benefit of RLE is that the incipient cataract is removed, and there is no cataract formation to dread down the road.

When comparing RLE to laser vision correction (LASIK and PRK), there are several benefits of RLE, including excellent stability of refractive correction. With RLE there is no risk for regression as with LASIK/PRK. Optically, RLE also reduces higher-order optical aberrations; therefore, quality of vision can be better after RLE than could be achieved with more traditional refractive surgery (especially hyperopic LASIK treatments) or even their preoperative glasses. Think about the benefit of contacts over glasses for a high myope; a patient can experience fewer higher-order aberrations and better contrast sensitivity with RLE compared to LASIK or their preoperative correction.

There is an instance where clear lens exchange can be a medically necessary surgery: narrow angles. We all know high hyperopes generally have smaller eyes with shallow anterior chambers and are more predisposed to closed-angle glaucoma. With RLE, high hyperopes get the additional benefit of deepening the angle by removing the natural lens. In this case, RLE can be a medical intervention (and preferred over laser peripheral iridotomy) for narrow angle patients older than 40 years. One can also expect about a 4.5% reduction in IOP following RLE, much like that seen after cataract surgery (Emarah et al.).

Join us next month for our continued discussion of RLE patient selection, limitations and risks.

Reference:

Emarah AM, et al. Clin Ophthalmol. 2010; doi:10.2147/opth.s11005.

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Elena Johaness

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