EyeWorld India December 2021 Issue

REFRACTIVE EWAP DECEMBER 2021 29 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. 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 straight-forward if the surgeon is following the modern methods of minimally invasive, small incision cataract surgery,” the authors concluded. EWAP 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. Editors’ note: Dr. Nehls is Chief, Cornea and Anterior Segment Service, Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Dr. Williamson practices at Williamson Eye Center, Baton Rouge, Louisiana. Neither declared any relevant financial interests. Dr. Williamson said the Refractive Surgery Alliance Society has discussed terminology of this procedure and determined that custom lens replacement might be the best description for it. Dr. Williamson said it is accurate and understandable to the patient. “I’m taking out their dysfunctional lens and putting in something far superior. … Exchange makes you think you’re exchanging it for something of equal value,” Dr. Williamson said. Patients are familiar and comfortable with the word “replacement” in medical procedures because of other replacement surgeries like knee and hip. The word custom, he said, is advantageous because it describes that the patient is receiving a procedure that is customized to their needs. Words matter