Refractive lens exchange in modern practice: when and when not to do it?

Abstract

Cataract surgery due to advances in small incision surgery evolved from a procedure concerned with the primary focus on the safe removal of cataractous lens to a procedure focused on the best possible postoperative refractive result. As the outcomes of cataract surgery became better, the use of lens surgery as a refractive modality in patients without cataracts has increased in interest and in popularity. Removal of the crystalline lens for refractive purposes or refractive lens exchange (RLE) presents several advantages over corneal refractive surgery. Patients with high degrees of myopia, hyperopia and astigmatism are still not good candidates for laser surgery. Moreover, presbyopia can currently only be corrected with monovision or reading spectacles.RLE supplemented with multifocal or accommodating intraocular lenses (IOLs) in combination with corneal astigmatic procedures might address all refractive errors including presbyopia, and eliminate the future need for cataract surgery.

Refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes

“…Most of the patients in this study had refractive error within the limits of keratorefractive procedures ( Figure 1 ), but elected to undergo RLE to achieve complete spectacle independence. New trends in intraocular surgery, such as introduction of femtosecond lasers to cataract surgery, 3 , 4 micro-incision surgery, 3 , 4 or use of prophylactic intracameral antibiotics to prevent endopthalmitis, 5 immensely improved the safety profile of this procedure, hence, phacoemulsification with implantation of IOL is no longer restricted only to patients with cataractous crystalline lens. Preoperative consultation and discussion of the optical side effects remain one of the most important factors in preoperative patient selection.…”

“…RLE is often the best surgical option for older presbyopes, as it focuses on the main reason for presbyopia development (aging crystalline lens) and prevents formation of the cataract in the future. 3 , 4 Some surgeons are, however, cautious about performing RLE on younger presbyopes owing to the associated optical side effects and surgical risks. In theory, younger presbyopic patients are more active and might have higher visual demands.…”

Correction of presbyopia: An integrated update for the practical surgeon

“…Multifocal IOL's aim to provide spectacle independence for both near and distance vision by dividing light into two or more foci,[ 69 70 71 72 ] independently of capsular mechanics and ciliary body function. [ 73 ] The perfect multifocal IOL should provide excellent vision for near, intermediate, and distance activities.…”

“…Rotationally symmetrical IOL's can be further divided into diffractive, refractive, or combined IOL designs. [ 70 71 72 73 74 ]…”

Problems With Different Meanings and Types of Refractive Lens Exchange

“…During lens surgery, a transient decrease in intraocular pressure (decompression effect) can cause changes in the vitreous body, especially if vitreous degenerations already exist. 5 Intraoperatively, minimal disturbance of the intraocular environment is of great importance. Thus, it would be relevant to know whether any retinal pathologies were found in the preoperative examination and how they were managed.…”