As technologies have improved and the number of patients with presbyopia has grown, the popularity of refractive lens exchange (RLE) or lens replacement surgery has increased.1 This can be attributed to several key factors. First, the global population is aging.2 Second, compared with earlier diffractive lenses, current IOLs offer better visual outcomes across a range of vision. Third, many contemporary patients wish to reduce their dependence on spectacles and contact lenses and are aware that surgical procedures and technologies are available that can help them achieve this goal.3 Lastly, advances in surgical techniques and diagnostic tools have improved the safety and predictability of RLE.4
This article describes our experience with RLE for the treatment of presbyopia.
RLE OR LASER VISION CORRECTION?
A lens-based approach to presbyopia offers several advantages over laser vision correction (LVC). For example, RLE provides a long-term solution to presbyopia by correcting the condition at its source—the dysfunctional crystalline lens. The procedure thus also eliminates the individual’s future need for cataract surgery. When a multifocal IOL is implanted, binocularity is preserved, which many patients appreciate.
LVC affects a person’s options for future cataract surgery. Depending on the magnitude of their preoperative refraction and the requisite ablation profile, LVC may induce higher-order aberrations that could make the patient a poor candidate for certain multifocal IOLs. Additionally, IOL calculations are less accurate in eyes that have undergone LVC. It may also be inadvisable to perform a refractive enhancement on an individual with a history of LVC.
PATIENT SELECTION
At our practice, a comprehensive patient evaluation includes a careful examination, biometry, tomography, OCT imaging of the macula, and analysis with the iTrace (Tracey Technologies). We discuss with each patient their occupation, lifestyle, activities, current use of spectacles and contact lenses, and visual goals to identify the most suitable surgical options.
An individual’s candidacy for RLE greatly depends on their refractive error and age. Patients with hyperopia and presbyopia who are older than 45 years of age are generally excellent candidates for the procedure. We also typically consider RLE for patients with presbyopia and myopia who are 50 years of age or older. A concern with younger myopic patients is that RLE increases their risk of retinal tears and detachment.1,4 For these individuals, we may consider a blended vision strategy using LVC or an EVO ICL (STAAR Surgical). We inform all myopic patients that RLE may change their near vision focal length.
Patients with emmetropic presbyopia are some of the most challenging to satisfy because they may have to accept a slight decrease in their distance visual acuity in exchange for an improvement in their near visual acuity. We have found blended vision LASIK, with one eye corrected for near, to be an extremely successful strategy for some of these patients. In other instances, we advise emmetropic presbyopic patients to delay surgery until they notice worsening of their distance vision.
In patients who have a history of LVC, we have achieved success with RLE using the Light Adjustable Lens+ (LAL+; RxSight) and a refractive target of -1.25 D in the near eye. We find this strategy provides greater blended vision between the eyes owing to an extended depth of focus.
PATIENT EXPECTATIONS
We thoroughly describe to patients the advantages and limitations of each IOL technology and what they can expect after RLE. Visual representations of potential glare and halos are displayed, and we explain that these symptoms typically diminish over time with neural adaptation. As part of informed consent, we show patients their near vision goal with RLE and the font size, for which they are likely to need reading glasses (Figure 1). We stress that better lighting may be necessary to read material up close. Similarly, we explain to patients who are choosing a blended vision strategy that they may need to wear spectacles for certain vision tasks and to optimize binocularity. Lastly, we mention that laser treatment may be required to address opacification of the lens capsule and/or residual refractive error (Figure 2).
Figure 1. Patients write their initials to indicate the limits of their preoperative UNVA and their desired outcome of RLE.
Figure 2. Patients write their initials to confirm that we discussed the three different lasers that may be used to correct their vision.
Unlike typical cataract surgery patients, those undergoing RLE generally have clear crystalline lenses and greater visual demands, so their expectations may be high. We therefore emphasize that all IOL technologies—including multifocal lenses, the LAL+, and extended depth of focus lenses—have limitations and it is impossible to achieve a perfect visual outcome.
In our experience, presenting detailed information during the preoperative consultation helps manage patients’ expectations and improve their postoperative satisfaction.
PATIENT OUTCOMES AND SAFETY
We conducted a retrospective analysis of 72 patients who received bilateral Clareon PanOptix IOLs (Alcon) for RLE and 72 patients who received bilateral Tecnis Synergy lenses (Johnson & Johnson Vision) for RLE. Most patients achieved J1 uncorrected near visual acuity (UNVA), and almost all obtained J3 UNVA postoperatively. Postoperative refractive enhancements were performed as necessary in both groups, with all patients who received an enhancement achieving satisfactory uncorrected distance visual acuity.
No cases of retinal detachment, endophthalmitis, or choroidal effusion occurred. Some patients experienced short-term ocular discomfort syndrome, dry eye symptoms, and prolonged ocular inflammation after RLE. One eye developed a horseshoe tear that required laser barrier treatment but did not progress to a detachment. All complications were manageable, and their incidence was similar to what we have observed with other refractive procedures.
Our clinical experience is in line with outcomes and safety data reported in the literature, suggesting that both IOLs are safe and effective options for RLE.1,3-6
CONCLUSION
We have found RLE to be a safe and effective treatment for presbyopia and concomitant baseline refractive error that achieves high patient satisfaction. It is a useful option for patients whose corneas or age is a contraindication for LVC and an EVO ICL. The keys to success with RLE are careful patient selection and a thorough discussion of their expectations.
1. Alio JL, Pederzolli M, Grzybowski A. Refractive lens exchange: What are the red lines? Eur J Ophthalmol. 2024;34(2):317-322.
2. Chen J, Zhu Y, Li Z et al. Global impact of population aging on vision loss prevalence: a population-based study. Global Transitions. 2024;6:28-36.
3. Kaweri L, Wavikar C, James E, Pandit P, Bhuta N. Review of current status of refractive lens exchange and role of dysfunctional lens index as its new indication. Indian J Ophthalmol. 2020;68(12):2797-2803.
4. Ang M, Gatinel D, Reinstein DZ, Mertens E, Alió Del Barrio JL, Alió JL. Refractive surgery beyond 2020. Eye (Lond). 2021;35(2):362-382.
5. Wallerstein A, Gauvin M, Trottier P, et al. Toric trifocal intraocular lens for refractive lens exchange: a multi-center, multi-surgeon large cohort study. J Refract Surg. 2023;39(5):302-310.
6. Yim CK, Dave A, Strawn A, Chan J, Zhou I, Zhu DC. Visual outcomes and patient satisfaction after bilateral refractive lens exchange with a trifocal intraocular lens in patients with presbyopia. Ophthalmol Ther. 2023;12(3):1757-1773.
