Patient Selection

Indications
The indications for refractive lens exchange (RLE)—that is, removal of the
crystalline lens with IOL implantation for the primary purpose of
correcting
refractive error—are evolving. Refractive lens exchange is usually
considered only if alternative refractive procedures are not feasible and
there is a strong reason that spectacles or contact lenses are
unacceptable
alternatives. RLE may be preferable to a PIOL in older patients who no
longer have adequate accommodation and in patients with lens opacity
that
may progress in the relatively near future. RLE is generally not considered
medically necessary and is usually not covered by the patient’s insurance.
As all FDA-approved IOLs are approved specifically for implantation at
the time of cataract surgery, implantation for RLE is considered an off-
label
use in the United States.
Informed consent
Refractive lens exchange carries risks and complications identical to those
for routine cataract extraction with IOL implantation. Potential
candidates
must be capable of understanding the short-term and long-term risks of
the
procedure. Patients should be informed that unless they are targeted for
residual myopia with monofocal, toric, or accommodating IOLs, or have a
multifocal IOL implanted, they will not have functional near vision
without
correction. A consent form should be given to the patient prior to surgery
to
allow ample time for review and signature. A sample consent form for
RLE
for the correction of hyperopia and myopia is available from the
Ophthalmic
Mutual Insurance Company (OMIC) at www.omic.com.
Myopia
Refractive lens exchange can be considered in patients with myopia;
however, in addition to the risks associated with cataract surgery, the
surgeon must specifically inform the patient about the risk of retinal
detachment associated with removal of the crystalline lens. Myopia is a
significant risk factor for retinal detachment in the absence of lens
surgery,
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and this risk rises with increased axial length. The risk of retinal
detachment
in eyes with up to 3.00 D of myopia may be as much as 4 times greater
than
it is in emmetropic eyes, whereas in eyes with >3.00 D of myopia, the risk
may be as high as 10 times that in emmetropia. In the absence of trauma,
more than 50% of retinal detachments occur in myopic eyes.
American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Patterns
Guidelines. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. San
Francisco: American Academy of Ophthalmology; 2008. Available at: www.aao.org/ppp.
Hyperopia
If the amount of hyperopia is beyond the range of alternative refractive
procedures, RLE might be the only available surgical option. As with
correction for myopia, the patient must be informed about the risks of
intraocular surgery. A patient with a shallow anterior chamber from a
thickened crystalline lens or small anterior segment would not be a
candidate for a PIOL and could benefit from the reduced risk of
angleclosure
glaucoma after RLE. Patients with hyperopia have a lower risk of
retinal detachment than do patients with myopia.
Nanavaty MA, Daya SM. Refractive lens exchange versus phakic intraocular lenses. Curr Opin
Ophthalmol. 2012;23(1):54–61.
Astigmatism
Patients with significant astigmatism are also candidates for RLE with the
advent of toric IOLs that cover an expanded range. In the United States,
there are currently no FDA-approved combined toric multifocal IOLs.
Thus,
US patients planning to undergo implantation of a toric IOL must
understand
the lack of uncorrected near acuity if targeted for distance; patients
considering multifocal IOL implantation should understand that these
IOLs
will not sufficiently reduce astigmatism. Also, patients need to
understand
that an additional surgical procedure, usually LASIK or photorefractive
keratectomy, may be necessary to maximize spectacle independence and
that
laser vision correction candidacy should be determined prior to lens-
based
surgery if it is being considered. Smaller amounts of astigmatism may be
managed with corneal incisional surgery.
Surgical Planning and Technique
Although RLE is similar to cataract surgery, there are some additional
considerations for planning and performing the procedure because the
primary surgical goal is refractive rather than merely reduction of vision
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loss due to cataract. First, in contrast to keratorefractive procedures,
which
are usually performed as immediately sequential procedures in the same
surgical session, RLE is usually performed as sequential surgery on
separate days to minimize the potential for bilateral endophthalmitis.
However, this standard continues to evolve, and some surgeons are
performing bilateral RLE in the same surgical session.
Preoperative corneal topography is essential to determine the degree of
irregular astigmatism present and identify patients with borderline
corneal
ectatic disorders such as keratoconus and pellucid marginal
degeneration.
Patients with these conditions may still have RLE performed; however,
they
must understand the limits of vision correction obtainable, and if there is
suspicion of ectatic corneal disease, patients must understand that they
are
not good candidates for postoperative treatment with LASIK or
photorefractive keratectomy to refine the refractive correction.
Surgeons must identify the degree of corneal versus lenticular
astigmatism present, as only the corneal astigmatism will remain
postoperatively. The patient should be informed if substantial
astigmatism is
expected to remain after surgery, and a plan should be devised to correct
it
in order to optimize the visual outcome. Small amounts of corneal
astigmatism (<1.00 D) may be reduced if the incision is placed in the
steep
meridian.
Limbal relaxing incisions with either blade or femtosecond laser may be
used to correct residual corneal astigmatism of less than 2.00 D (see
Chapter 3). Supplemental surface ablation or LASIK could also be
considered (see the following discussion on bioptics). Although glasses or
contact lenses are an alternative for managing residual astigmatism,
refractive surgery patients frequently reject this option.
Some surgeons obtain preoperative retinal OCT to identify potential
macular pathology. Careful attention should be paid to the peripheral
retinal
examination, especially in patients with higher myopia. If relevant
pathology
is discovered, appropriate treatment or referral to a retina specialist is
warranted. In patients with high axial myopia, retrobulbar injections
should
be performed with caution because of the risk of perforating the globe.
Peribulbar, sub-Tenon, topical, and intracameral anesthesia are
alternative
options. In a highly hyperopic eye with an axial length <18 mm,
nanophthalmos should be considered. Eyes with these characteristics
have a
higher risk of uveal effusion syndrome and postoperative choroidal
detachment.
Many surgeons believe that an IOL should be implanted after RLE in a
patient with high myopia rather than leaving the patient with aphakia,
even
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when little or no optical power correction is required. Plano power IOLs
are available if indicated. The IOL acts as a barrier to anterior prolapse of
the vitreous, maintaining the integrity of the aqueous–vitreous barrier, in
the
event that Nd:YAG laser posterior capsulotomy is required. Some IOL
models also reduce the rate of posterior capsule opacification.
IOL Power Calculations in Refractive Lens Exchange
High patient expectations for excellent uncorrected distance visual acuity
(UDVA; also called uncorrected visual acuity, UCVA) after RLE make
accurate IOL power determination crucial. However, IOL power formulas
are less accurate at higher levels of myopia and hyperopia. In addition, in
high myopia, a posterior staphyloma can make the axial length
measurements less reliable. Careful fundus examination and B-scan
ultrasound imaging can identify the position and extent of staphylomas.
The
subject of IOL power determination is covered in greater detail in BCSC
Section 3, Clinical Optics, and Section 11, Lens and Cataract.
In the case of a patient with high hyperopia, biometry may suggest an
IOL power beyond what is commercially available. The upper limit of
commercially available IOL power is now +40.00 D. A special-order IOL
of a higher power may be available or may be designed, but acquiring or
designing such a lens usually requires the approval of the institutional
review board at the hospital or surgical center, which delays the surgery.
Another option is to use a “piggyback” IOL system, in which 2 posterior
chamber IOLs are inserted. One IOL is placed in the capsular bag, and the
other is placed in the ciliary sulcus. When piggyback IOLs are used, the
combined power may need to be increased +1.50 to +2.00 D to
compensate
for the posterior shift of the posterior IOL. One serious complication of
piggyback IOLs is the potential for developing an interlenticular opaque
membrane. These membranes cannot be mechanically removed or
cleared
with the Nd:YAG laser; the IOLs must be removed. Interlenticular
membranes have occurred most commonly between 2 acrylic IOLs,
especially when both IOLs are placed in the capsular bag. When piggyback
lenses are used, they should be of different materials and the fixation
should
be split between the bag and the sulcus. Piggyback IOLs may also shallow
the anterior chamber and increase the risk of iris chafing, especially in
smaller eyes.
Hill WE, Byrne SF. Complex axial length measurements and unusual IOL power calculations. Focal
Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of
Ophthalmology; 2004, module 9.
Shammas HJ. IOL power calculation in patients with prior corneal refractive surgery. Focal Points:
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ophthalmologyebooks.com
Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology;
2013, module 6.
Complications
At more than 2 years postoperatively, the incidence of retinal
detachment in
1519 consecutive patients (2356 eyes) with an axial length greater than
27.0
mm was reported to be 1.5%–2.2%, a level that corresponds to the
incidence of idiopathic retinal detachment in myopia.
Horgan N, Condon PI, Beatty S. Refractive lens exchange in high myopia: long term follow up. Br J
Ophthalmol. 2005;89(6):670–672.
Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH. Retinal detachment
after phacoemulsification in high myopia: analysis of 2356 cases. J Cataract Refract Surg.
2008;34(10):1644–1657.
Advantages
Refractive lens exchange has the advantage of greatly expanding the
range of
refractive surgery beyond what can be achieved with other available
methods. The procedure retains the normal contour of the cornea, which
may
enhance the quality of vision, and it may be used to treat presbyopia as
well
as refractive error with incorporation of multifocal and/or
accommodating
IOLs.
Disadvantages
Quality of vision may not be as good with current multifocal IOLs as with
other forms of vision correction. Patient expectations for excellent
uncorrected visual acuity may be higher for RLE than for cataract surgery,
underscoring the need for thorough preoperative discussion, close
attention
to detail preoperatively and intraoperatively, and postoperative
treatment of
residual refractive error.