Refractive
September 2021

by Liz Hillman
Editorial Co-Director

Refractive lens exchange (RLE), clear lens extraction, custom lens replacement—the removal of a dysfunctional crystalline lens that doesn’t have a visually significant cataract goes by different names, depending on who you talk to.

Regardless of what the procedure is called, improvements in IOL technologies have increased interest in these procedures, and there is more confidence among surgeons in its ability to deliver expected outcomes.

Blake Williamson, MD, said he does this procedure routinely each week. Thanks to a local marketing campaign in his area, Dr. Williamson said he has patients coming in asking for a procedure that can address presbyopia.

“They walk in saying ‘I’m 45 years old and I hate my reading glasses, what can I do?’” he said. “If someone does come in for LASIK, if they’re hyperopic and 45 or above, they’re automatically getting switched to a [custom lens replacement] evaluation instead of a LASIK evaluation.”

Sarah Nehls, MD, said she often has patients in their 50s and 60s coming in for a LASIK consult that she usually ends up shifting to a lens-based discussion. Dr. Nehls said the most common patient is someone who has had great vision most of their life, but as they aged, they experienced a hyperopic shift along with presbyopia. Sometimes they also have early lenticular changes.

Patients in this age group, she said, are going to benefit from correction of their distance vision and presbyopia. In addition, it’s a one-time procedure; they won’t develop cataracts.

“To be able to use lenses to capture the distance and reading vision is amazing,” Dr. Nehls said. “I tell patients that this lens is going to last your lifetime. … There are things that can happen as you age that might affect your vision like glaucoma or macular degeneration. … You still need to get regular eye health checkups, but the lens is going to correct your vision most permanently.”

Recent improvements in presbyopia-correcting IOLs, in general, are generating a lot of excitement in Dr. Nehls’ practice. She described one patient who was referred to her by a prior happy RLE patient who had received Vivity (Alcon). Another case was a hyperopic and presbyopic fishing boat captain who Dr. Nehls met on vacation with her family. Four years ago, he described his frustration with his vision, and Dr. Nehls recalled telling him that there were options available for him, but they were “not perfect.” This year when he took her family out fishing again, she was able to tell him how the technology had improved. He’s now coming to see her for extended depth of focus lenses as part of an RLE procedure.

Dr. Nehls said she is selective about offering this procedure, choosing mainly hyperopic and presbyopic patients. She doesn’t do this procedure for moderately or highly myopic patients due to their higher risk for retinal detachment.

“It’s a limited patient pool because there are far more myopes out there than hyperopes, and I have limited my clear lens extraction to people in the hyperopic prescription range, but they can be super happy,” she said.

The workup and procedure are the same as for cataract surgery. She’s careful to explain the drawbacks and potential side effects of multifocal and EDOF lens options as she guides the patient in IOL selection.

“It’s a combination of not only candidate selection but also the type of implant you’re going to place, looking at what their needs are, what they do for a living, what their hobbies are,” Dr. Nehls said.

Dr. Williamson also said he works up the patient like he would a cataract case.

“I tell my patients one of the great things about a custom lens replacement is you are eliminating the chance of ever getting a cataract … removing a dysfunctional lens before a cataract ever forms,” he said.

“For patients with good corrected distance acuity preop, I over communicate on the front end that some of the implants that provide excellent near could change their contrast and how they see at distance and in low light,” Dr. Williamson said. “I explain that for more than 99% of my patients, this is tolerable, and with modern lenses it gets better and better. It does them well to set the expectation that there can be some compromise with any diffractive optic. I tell them that I’ll restore the zoom function and likely get rid of readers for most tasks, but it will take some time for them to get used to distance vision and driving at night.”

He is wary of the plano presbyope for this surgical procedure. He said he would usually try to advise them to use a monovision or multifocal contact to achieve their goals.

“I don’t like operating on a 20/20 eye with a clear lens,” he said, noting, however, that drops that alleviate presbyopia temporarily are in the pipeline and could be great for these patients. (See page 59 for more about pharmaceutical options on the horizon.)

A review paper published in the journal Eye and Vision described RLE as beneficial in eyes with high refractive error without a cataract that are presbyopic.¹ The authors wrote that it “requires an approach with the risk-benefit ratio in mind depending on age, refractive condition and preoperative condition.”

“Successful integration of RLE into the general ophthalmologist’s practice is fairly straightforward if the surgeon is following the modern methods of minimally invasive, small incision cataract surgery,” the authors concluded.

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About the physicians

Sarah Nehls, MD
Chief, Cornea and Anterior Segment Service
Department of Ophthalmology and Visual Sciences
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Blake Williamson
Williamson Eye Center
Baton Rouge, Louisiana

Reference

1. Alio JL, et al. Refractive lens exchange in modern practice: when and when not to do it? Eye Vis (Lond). 2014;1:10.

Relevant disclosures

Nehls: None
Williamson: None

Contact

Nehls: nehls@wisc.edu
Williamson: blakewilliamson@weceye.com