RLE indicated on case-by-case basis

Refractive lens exchange (RLE) is not reversible so doctors need to apply their surgical wisdom to identify the most appropriate cases, Jorge Alió of the Instituto Oftalmologico de Alicante, Spain said. Often indications are based on the simplicity of the procedure but that doesn't always balance well with the best patient benefit.

Speaking about RLE for myopia, hyperopia and presbyopia, Dr Alió noted that adequate IOLs do not exist for all cases but RLE is an important area of future research and improvements are emerging all the time.

"Refractive lensectomy is the preferred refractive technique, offering precise outcomes, and it's becoming more popular as a result," he said, adding that RLE is generally indicated for high myopia (>10 D), high hyperopia (> 6 D), presbyopia and high astigmatism.

Doctors, however, must consider indications on a case-by-case basis. Important factors to consider include the presence of useful residual accommodation, the risk of endophthalmitis, intraoperative hazards, potential postoperative complications and refractive alternatives, Dr Alió remarked.

Postoperatively there are many risks, including loss of accommodation, posterior capsular opacification (PCO), posterior vitreous detachment (PVD), retinal detachment (RD) and macular disease.

He said RLE indications for myopia include early cataract or patients older than 55 years where useful residual accommodation is less than 1 D and where there are no other local risks, especially RD and vitreous conditions.

Myopic RLE is not indicated for patients younger than 40 years, or those with useful residual accommodation greater than or equal to 2 D, or where there is local risk to the peripheral retina or where there are suspicions of active macular disease.

Analysing risks, including infection, RD, macular disease and intraoperative complications, Dr Alió said the lowest potential cumulative risk ran at 3.13%, while the highest possible is 13.2%

For hyperopia, Dr Alió noted that RLE is indicated when useful residual accommodation is less than 1 D and if the patient presents a normal anterior segment. RLE should not be indicated in high myopia where patients are under 35, useful residual accommodation remains greater or equal to 2 D, or where refractive ambylopia associated to hyperopia is greater than or equal to 9 D.

Hyperopic RLE risks include infection and macular disease and the lowest cumulative risk for this type of operation is 4.01% while the highest is 10.5%.

He said the best cases for presbyopic RLE are accommodative IOLs, where there's a short axial length in the eye, low-powered corneas and a high power IOL.

Ophthalmology Times Europe reporting from the XXIV Congress of the ESCRS, London, 9-13 September, 2006.