What's in a Name?

The terms PRELEX, clear lens exchange, clear lensectomy, refractive lens exchange, and refractive lensectomy all refer to essentially the same procedure. If ophthalmologists can reach a general agreement on the use of one of these terms, it will benefit our patients and our practices.

CHOOSING A NAME

Making It Memorable
Several patients visiting my office have voiced confusion about which procedure we are discussing. If ophthalmologists home in on a single name for this procedure, that term will gain the strength of familiarity through repetition and thereby increase the popularity of the procedure. I prefer the term PRELEX because I believe that it is easier for patients to remember, just as LASIK is easier for them to recall than laser in situ keratomileusis. Because I teach PRELEX programs, I do have a bias on this score, but I have found that my patients adopt this term easily and spread the word about the procedure to their friends.

The ASCRS has elected to use the term refractive lens exchange. I myself use this name when referring broadly to the procedure using all types of IOLs and monovision.
I use the term PRELEX, however, for cases of presbyopic lens exchange that involve the implantation of the Array (Advanced Medical Optics, Inc., Santa Ana, CA). I notice this wording appears more frequently in the literature, even internationally.
I dislike the terms clear lens exchange and clear lensectomy, although I know that the former is used frequently. Both imply that surgeons always remove clear natural lenses. In actuality, many of the lenses we remove have evidence of early cataract formation.

Drawing on Experience
I refer to both precataract and cataract refractive surgery with the implantation of a multifocal IOL as PRELEX. One benefit of this approach relates to surgical experience. Distinguishing between the two procedures forces a surgeon, initially, to acknowledge limited experience with the precataract refractive procedure and attempt to explain its relation to the cataract surgery he has performed. Recognizing the procedures' similarity enables us to point legitimately to our more extensive experience with PRELEX as also a cataract procedure using a multifocal lens.

FOCUSING ATTENTION
Surgeons who recall the early days of IOL implantation will remember explaining to patients how the procedure they were about to undergo would differ from those previously performed on their friends and family. At that time, we informed patients that using IOLs would reduce their need for thick glasses postoperatively. This emphasis on the IOL, however, often led patients to blame the implant for any postoperative problems, including a loose suture or dry eye.

Similarly, if we focus today's patients' attention on the IOL, many will automatically blame it for their postoperative problems and may demand its removal. Instead, surgeons must educate patients that a successful PRELEX procedure entails accurate IOL calculations, the implantation of an IOL, and careful surgery with astigmatism control. Referring to the procedure as PRELEX or refractive lens exchange stresses the process, rather than any specific product.

A PROCEDURE WITH GREAT POTENTIAL

The Importance of Near Vision
Ophthalmologists commonly omit measuring patients' near visual acuity during routine eye examinations. We must recognize the importance of uncorrected near vision in our patients' daily lives. Many of them wish to see better at near without glasses. The only procedure that has consistently delivered stereoscopic near and distance vision is PRELEX.

From the Cornea to the Lens
The location for refractive correction is shifting from the cornea to the crystalline lens thanks to the contemporary phaco and IOL technologies that have given rise to lower-risk, small-incision procedures and rapid patient recovery. Researchers are also presenting a growing amount of evidence that most aberrations in patients over 40 years old lie within the lens, rather than the cornea, a finding that makes the crystalline lens a more sensible location for vision correction.

New Technology
A real source of excitement for surgeons is the development of new multifocal lens designs and accommodative IOLs. My practice is an investigational site for the diffractive multifocal MA60D3 IOL from Alcon Laboratories, Inc. (Fort Worth, TX). Although it is too early to comment on our results, those of other investigators show promise. Multiple lens options will enable surgeons to improve refractive lens exchange further.

A Growing Market
The market for PRELEX is already large, and the aging population of Baby Boomers will help to increase the procedure's popularity. Presently, my practice only markets PRELEX internally. We have also worked with Patient Education Concepts (Houston, TX), a company that develops educational brochures and informed consent videos for use in patient counseling.

CONCLUSION
In the US, the number of unhappy presbyopes is growing rapidly. As we develop a better understanding of methods such as wavefront technology to measure the source of visual aberrations in this aging population, surgeons will more frequently offer lens-based procedures to solve patients' visual problems. Fortunately, newer cataract surgery techniques will bolster ophthalmologists' confidence in surgically correcting presbyopia. Now is the time for cataract surgeons to hone their skills so that they will consistently be able to provide the best results with procedures such as PRELEX.

R. Bruce Wallace III, MD, FACS, is Medical Director of Wallace Eye Surgery in Alexandria, Louisiana, and serves as Clinical Professor of Ophthalmology at the LSU School of Medicine in New Orleans. He consults for AMO but holds no financial interest in any product mentioned herein. Dr. Wallace may be reached at (318) 448-4488; rbw123@aol.com.