RLE in presbyopic patients is a growing treatment option in the United States
Refractive lens exchange (RLE) in presbyopic patients is a growing treatment option in the United States. "In general, the use of refractive lensectomy has increased recently as we achieve more accurate refractive outcomes with more modern methods for measuring eyes," said John A. Hovanesian, M.D., Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles.
"I love RLE and find it gratifying to perform," said Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland. "We're always up against the limits of the implants and technology, but even that has gotten better. I don't see any real limitations," he said. The only side effect he has commonly seen is dysphotopsia.
Surgeons have seen varying degrees of interest in RLE in presbyopic patients in recent years. At a practice like that of Daniel S. Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park, the majority of presbyopic patients will have RLE performed. However, his practice does not accept Medicare and is private pay only. By contrast, Y. Ralph Chu, M.D., adjunct associate professor of ophthalmology, University of Minnesota, Minneapolis, and clinical professor of ophthalmology, University of Utah, Salt Lake City, said only a small percentage of his patients are RLE. "Some of it is more of a mindset. My area is more conservative," Dr. Chu said. Dr. Packer, an avid supporter of RLE, said the number of RLEs he has performed has decreased since 2007 and 2008, a trend he thinks relates to the economic downturn.
That said, these surgeons agree that RLE will grow in the future as technology improves and femtosecond laser use in cataract surgery increases.
The ideal patient
Although surgeons will perform RLE in presbyopic patients with a range of refractive errors, the ideal patient seems to be one who is hyperopic and over the age of 50. "I favor RLE for hyperopic patients. They get a number of benefits with very little risk," said Kevin L. Waltz, M.D., Bloomington, Ind.
Many times, the patient who has RLE done is one who originally approached the surgeon about LASIK. However, "for patients in their 50s, LASIK can fail to provide perfect visual quality," Dr. Hovanesian said.
"[These] patients understand that they can go through a corneal refractive procedure today and cataract surgery in the future, or they can have a single surgery now. This is the gap that RLE patients fit into," Dr. Hovanesian said.
RLE can be done in younger patients—Dr. Packer has even performed RLE in hyperopic patients in their 20s with a refractive error of +6 or +7—but the ideal group is usually the 50+ age range because of growing opacity in the eye.
In a number of cases, laser vision correction (LVC) enhancement may follow RLE to further treat the patient's refractive error. Because enhancement is necessary in 10-20% of patients at Dr. Hovanesian's practice, the cost of laser enhancement is included with the cost of RLE. At Dr. Durrie's practice, 10-15% of patients with premium IOLs still need a laser touch up. Selecting the right patient for RLE involves a thorough diagnostic work up that includes retinal optical coherence tomography, endothelial cell counts, and evaluation (and possible treatment) of the patient's lashes, lids, and tear film, Dr. Durrie said. At his particular practice, a thorough work up is important as he and fellow surgeon Jason Stahl, M.D., try to make all patients spectacle-free for a lifetime.
Dr. Packer takes a more cautious approach with RLE if pre-op screening finds the patient has any concomitant pathology such as epiretinal membranes or glaucoma. "You can do RLE, but I'm more guarded about how it will turn out," he said.
RLE can be an ideal fit for many hyperopic patients, but it also can be an option for some myopes. However, most surgeons said they don't find RLE a good fit for high myopes.
"For a high myope, there's a fall off of accuracy and a greater risk of retinal detachment," Dr. Hovanesian said. There is also the risk for greater cystoid macular edema, Dr. Chu said.
"You can do a perfect surgery and if the patient is myopic, he or she can have a retinal detachment a year or two later. It's not always clear if that relates to the surgery," Dr. Waltz said. For this reason, he rarely will perform RLE in high myopes.
Although there is greater caution with high myopes and RLE, this risk is not a factor if the patient has previously had a posterior vitreous detachment, Dr. Packer said. A pre-op peripheral fundus exam can help check for lattice degeneration, he said.
Some studies have even shown that the association between retinal detachment and RLE may be debatable, Dr. Packer said. Ultimately, he believes the benefits of RLE may outweigh the risk for retinal detachment. However, he will maintain a closer observation of patients who are –6 or –8 D and have not previously had a posterior vitreous detachment.
Much of the decision of performing RLE in myopes—or any patient—goes back to careful patient selection and education, Dr. Waltz said.
The role of patient education
Although education is important with any procedure, it plays an even more important role in RLE to help patients understand risks and benefits. Dr. Hovanesian prefers to give much of the patient education himself. "You can save hours post-operatively by spending a few minutes with patients before surgery," he said. "I cannot trust that a video or brochure was well understood. I want to see that person's body language and hear feedback."
At Dr. Durrie's practice, he and Dr. Stahl discuss with patients their short-term and long-term vision goals to choose the best surgical options for them.
Other staff members and written or audiovisual materials have their role in the education process. "It's helpful to have well-trained technicians so the doctor does not have to do all the education. That can be daunting," Dr. Packer said.
The patient education process is also the time to broach the possibility of post-op LVC, Dr. Waltz said. "When you do RLE, you have to have the ability to do LVC or be prepared to farm it out because the precision with RLE is not as great as with the laser," he said.
Problem solving for a
Although many surgeons agree that RLE is great for a hyperopic presbyope and can be an option for myopes, the tough case to treat may be that of a 55-year-old emmetrope—this is the kind of patient who Dr. Hovanesian said should walk into practices with a big warning sign.
"You could do RLE in this patient, but it would be more controversial," Dr. Waltz said. "If you are starting with an emmetrope, that patient is more difficult to make happy."
"This patient may see that technology doesn't match Mother Nature," Dr. Chu said.
If there is no lens opacity, Dr. Hovanesian would recommend monovision LASIK for the patient. "The problem is that this patient is very spoiled with distance vision, and he or she may want better reading vision. You have to help the patient understand the limitations. The patient might be very unhappy from dysphotopsias from a multifocal IOL and may be underwhelmed by the near vision limitations of approved accommodative lenses," he said. If the emmetrope has no other signs of intraocular pathology, Dr. Chu will encourage the patient to hold off on surgery and educate him or her about other technology currently available or becoming available, such as corneal inlays. If this particular patient insists on a surgical option, physicians should emphasize pre-op education and provide realistic expectations, Dr. Packer said.
Editors' note: Dr. Chu has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.) and Bausch & Lomb (Rochester, N.Y.). Dr. Durrie has financial interests with AMO
and Alcon (Fort Worth, Texas). Dr.
Hovanesian has financial interests with AMO and Bausch & Lomb. Dr. Packer has financial interests with AMO and Bausch & Lomb. Dr. Waltz has a
financial interest with AMO.
Chu: 952-835-0965, firstname.lastname@example.org
Packer: 541-687-2110, email@example.com
Waltz: 317-845-9488, firstname.lastname@example.org