With evolving cataract surgical techniques and advanced-technology intraocular lenses (IOLs)
, we now have the facility to offer patients spectacle-independent vision akin to their youth. Under normal circumstances, the discussion of natural lens extraction and replacement comes at the heels of the diagnosis of cataracts. More and more, however, well-informed individuals are requesting lens extraction for refractive purposes even though their natural lenses are clear.
Refractive lens exchange—also referred to as clear lens exchange or, more recently, refractive lensectomy—is now a viable option for patients who are not candidates for other refractive procedures (such as LASIK, PRK, or ICL
) or who simply wish to avoid the visual consequences of presbyopia with multifocal or accommodating IOLs. There is significant debate among cataract surgeons regarding the ethics of clear lens exchange. The crux of the issue, of course, is the risk, albeit small, of loss of vision (infection, retinal detachment, etc.). The polar opinion is that refractive lensectomy is no different from any other elective refractive procedure.
Comanaging non-corneal refractive surgery
Another consideration is the potential for a dissatisfied self-pay patient for whom surgical results are underwhelming: the limitations of presbyopia-correcting IOLs are no different for refractive lensectomy patients than they are for cataract patients. Additionally, IOL calculation is less accurate in the patients who would benefit the most from the procedure, that is, those of higher ammetropia, resulting in a post-operative refractive miss.
The importance of patient selection
Derek Cunningham, OD, is director of optometry at Dell Laser Consultants in Austin, TX. Dr. Cunningham is integrally involved in patient selection and IOL planning for clear lens exchange patients that, at Dell Laser Consultants, are 50 percent of its lens surgical volume. Dell Laser estimates that 85 percent of its patients achieve the goal of full-time spectacle independence; the majority of these patients are 40 years of age and older. Half of Dell Laser’s refractive lensectomy patients come to the practice referred from patients who are satisfied with their own procedures, or those interested in LASIK, Dr. Cunningham says.
Patient selection and realistic expectations are essential to success with refractive lens exchange, Dr. Cunningham explains. Often IOLs and refractive endpoints are blended to maximize clear vision at all distances. For example, a diffractive multifocal IOL will be placed in the patient’s dominant eye, and a -0.50 D aimed accommodating IOL in the non-dominant eye. The multifocal IOL functions best for distance-near, and the -0.50 D accommodating IOL would give better intermediate vision. The availability of a toric accommodating IOL broadens the scope of patients for whom clear lens exchange can become an option.
Cost of clear lens exchange
Clear lens exchange is not covered by insurance and the IOL, facility, and surgical fees are not inexpensive. Many practices that offer refractive lens exchange will bundle surface laser touch-up and astigmatic correction in their fees. Remember also that multifocal and accommodating IOL patients require early YAG laser treatment of posterior lens capsule opacities/contraction for optimum performance of the IOL, adding to the cost of the process.
Notwithstanding the aforementioned, clear lens exchange can be the best refractive option for patients with high myopia or hyperopia, the contact lens intolerant, or those who wish to avoid the inconvenience and aesthetic compromise of presbyopia. Be prepared to guide your patients through the non-surgical and surgical options available for their visual concerns.
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