EyeWorld Asia-Pacific September 2011 Issue
22 September 2011 EW REFRACTIVE Weighing the pros and cons of RLE in presbyopes by Vanessa Caceres EyeWorld Contributing Editor RLE in presbyopic patients is a growing treatment option in the United States R efractive 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, MD, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Calif., USA. “I love RLE and find it gratifying to perform,” said Mark Packer, MD, clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., USA. “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, MD, clinical professor of ophthalmology, University of Kansas, Overland Park, Kan., USA, 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, MD, adjunct associate professor of ophthalmology, University of Minnesota, Minneapolis, Minn., USA, and clinical professor of ophthalmology, University of Utah, Salt Lake City, Utah, USA, 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, MD, Bloomington, Ind., USA. Many times, the patient who has RLE done is one who originally approached the surgeon about AT A GLANCE • RLE is a growing option in presbyopic patients as related technology improves • Hyperopic presbyopes over the age of 50 are often ideal candidates for RLE • RLE also is a treatment possibility in myopes, although the risk for retinal detachment is a concern • Patient education, both from the surgeon and from supporting education materials, is crucial with RLE Mohan RAJAN, MD Chairman & Medical Director, Rajan Eye Care Hospital #5 Vidyodaya 2nd Street, T. Nagar, Chennai-600017, Tamilnadu, India Tel. no. +91-044-28340500 Fax no. +91-044-28343711 rajaneye@vsnl.com R efractive lens exchange (RLE) has become a very popular option for many reasons, including: 1. Cataract removal has become much safer with excellent postoperative results. 2. The quality of lenses which are available now is able to give patients better quality vision. In my practice, hyperopic presbyopes in the age group between 50 and 60 are the ideal candidates for RLE. These patients are also very happy with the results, especially with multifocal IOLs (MFIOLs, such as ReSTOR) or even accommodative lenses (such as Crystalens). I tend to use both MFIOLs and Crystalens in equal numbers in this group, but I would prefer Crystalens because of the excellent contrast sensitivity and good distance, near and intermediate vision it provides in this group of patients. MFIOLs also work very well, the only problem being that 30 to 40% of patients have glare and halos that, however, disappear with time. Patient education is a very important integral component of the surgery preoperatively. The patient should be guided towards realistic expectations before surgery. As far as the RLE is concerned, the four take home messages I’d like to give are: 1. Accurate IOL power calculation, good biometry (IOLmaster) or Lenstar (Haag-Streit, Mason, Ohio, USA), whichever is available, address astigmatism issue. 2. Minimize complications like posterior capsule rupture, cystoid macular edema, corneal edema, etc., by doing consistently good surgery. 3. Choose the IOL which provides the best visual quality. 4. Under-promise and over-deliver. These are the four main mantras as far as the RLE is concerned. The number of patients in my practice who are having RLE is increasing because of the strict protocols we follow preoperatively, intraoperatively and postoperatively. I do not recommend RLE for patients with high myopia because the incidence of retinal detachment is high in this group and after YAG laser capsulotomy, which you have to do earlier in Crystalens and multifocal IOLs. The incidence of retinal detachment goes up to 25 to 30% (we might have to do YAG capsulotomy many times in patients with MFIOLs or Crystalens). The incidence of cystoid macular edema in my group is almost nil because of the simple reason that all these patients are given NSAIDs (Nepafenac, Nevanac, Alcon) intraoperatively and 4 weeks postoperatively. Editors’ note: Dr. Rajan has no financial interests related to his comments. Views from Asia-Pacific
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