32 EyeWorld Asia-Pacific | March 2025 REFRACTIVE SURGERY Dr. Rebenitsch said there are different schools of thought on handling the ocular surface. If there is significant OSD present, they’ll most likely suffer for years to come, he said. Even though we can improve it, we’ll avoid a traditional diffractive multifocal and maybe even a ClearView 3 and move to an LAL or monovision, he said. If there’s OSD in advance, you want to treat it. “With RLE, we want to know we can hit that refractive target, so we want OSD to be known in advance rather than a perceived complication in the future,” he said. Contraindications For RLE According to Dr. Rebenitsch, RLE should be done in two settings: if the surgeon can almost always do the procedure without complications and if there are no systemic risks. With anything that’s going to increase risk beyond baselines, we don’t do RLE, he said. Dr. Farid said she would be cautious with RLE for patients who have very high myopia. Those patients at baseline have a higher risk of peripheral retinal tears, higher risk of detachments, more of a formed vitreous. They’re better phakic IOL candidates. “But if they really want a refractive lens exchange, those are patients who need to see their retina specialist,” she said. Certain patient personalities may be a contraindication as well, and Dr. Farid said it’s all about setting proper expectations and patient education. “Any refractive patient needs to understand that the goal of the surgery is to decrease the dependence on glasses. I almost never say ‘completely eliminate’ the need for glasses because even with the best lenses, there are some occasions where the patient needs to wear glasses,” she said. Dr. Hamilton said it’s important to look out for certain pathologies before performing RLE. For example, he said you wouldn’t want to put a Tecnis Odyssey or multifocal lens in someone with keratoconus. Additionally, he said it would be hard to meet expectations for those with retinal disease or diabetes. The bigger issue, he said, is the younger patients and the quality of vision at distance and the plano presbyope. “I’ve done RLE on plano presbyopes who are in my chair because of reading glasses, doing the procedure not to get distance better but to get near vision. They assume the distance vision will be the same after RLE. I am cautious in these patients and explain they may initially be disappointed with the distance vision. If they decide not to do surgery, that’s fine. They leave understanding the natural course of vision with aging as it gets worse as presbyopia progresses and cataract develops. Patients appreciate not being pressured into surgery and come back when their vision gets worse.” Dr. Hamilton also takes patient personalities into consideration. He uses a simulator (Rendia) to show the potential vision as well as night dysphotopsia. You must discuss nighttime issues, he said. If someone is a plano presbyope and doing this for near vision, for example, we must explain what to expect regarding quality of vision, particularly in dim light. “I tell them that they’re going to see halos; that’s how the lens works, and the brain has to adapt. Then I wait for a reaction.” He noted that the TECNIS Odyssey lens seems to have less nighttime dysphotopsia, and neuroadaptation occurs faster than with previous multifocal IOLs. Growth In RLE Dr. Hamilton has noticed an uptick in RLE over the last year or two and added that using the TECNIS Odyssey lens has made him even more confident with a wider range of patients. “One of the great features about RLE is I’m doing them bilaterally on the same day,” Dr. Hamilton said. “The primary reason we don’t do cataract surgery bilateral same day is a financial one, but RLE is cash pay.” Patients are happy to get both eyes done at the same time. Neuroadaptation is faster, and there is no in-between time with anisometropia that can sometimes muddy the waters for the patient deciding to move on to the second eye. Dr. Rebenitsch estimated that more than 50% of his practice revenue is from RLE. “We started doing RLE 10 years ago, and it has now grown to be bigger than our other refractive volume in terms of revenue,” he said. He estimated that he’s now doing around 1,000 RLEs per year (500 patients). “People want it,” he said. Everyone is frustrated with readers and bifocals, and while patients have heard for many years and know about the benefits of LASIK, they often have in their mind that with LASIK they’ll have to give something up in their 40s. “That’s where RLE shines,” Dr. Rebenitsch said.
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