Innovations in Refractive

Lens Exchange

BY LENA BECKERS, MD; DAVID BECKERS, MD; QUENTIN B.

ALLEN, MD; T. HUNTER NEWSOM, MD; TAL RAVIV, MD; AND
P. DEE G. STEPHENSON, MD, FACS

WHAT’S DRIVING THE SHIFT TO

LENS-BASED REFRACTIVE SURGERY?
The answer is less simple than it appears.

BY LENA BECKERS, MD, AND DAVID BECKERS, MD

The obvious answer to the question this article poses is
patient desire for spectacle independence. If we dig deeper,
however, it isn’t that simple.

A DESIRE FOR SPECTACLE INDEPENDENCE:

THE PATIENT PERSPECTIVE
Patients’ everyday lives demand a range of functional
vision because they are happening at all distances. They
use near vision for reading, distance vision for driving and
sports, and intermediate vision for viewing computers
and smartphones.
Rapid technological advances during the past decade,
both in and outside of medicine, have ratcheted up people’s
expectations of what is possible. Breathtaking progress in
cataract surgery has made it one of the most common
procedures worldwide.
Patients' desire for spectacle independence has shifted the
focus of cataract surgery more toward lens selection than
the operation itself. These factors combined with advances
in IOL technology and their advertisement, however,
contribute to high expectations regarding the level of crisp,
youthful vision that surgery can achieve and give patients
the impression that anything is possible.

48 CATARACT & REFRACTIVE SURGERY TODAY | OCTOBER 2023

 SHIFTING TOWARD REFRACTIVE LENSECTOMY

s
Exploring the next
frontier in lens
technology and
surgical techniques.

A SHIFT IN EYE CARE PROVIDER ATTITUDES: to myopia and hyperopia. Advocates of this approach
THE SURGEON PERSPECTIVE to presbyopia correction emphasize the advantages of
A high standard of care is important to success with cornea-based surgery and the risks of intraocular surgery
lens-based refractive correction. Criteria have been such as capsular tears, cystoid macular edema, retinal
developed for evaluating the risks and benefits of surgery, detachment, and endophthalmitis. Yet, as with any surgery,
and preoperative protocols have been established for IOL presbyopic LVC has disadvantages.
calculations and patient selection. Screening methods No. 1: A reduction in quality of vision and uncorrected
s

evaluate patient needs and personality traits,1,2 and distance visual acuity. LVC induces higher-order aberrations,
their occupation, hobbies, and activities of daily living particularly in the hyperopic population, often resulting in
are considered. lower uncorrected distance visual acuity (UDVA).2 RLE may
Advances in small-incision cataract surgery have be a better option for these patients.8
increased the procedure’s safety, efficacy, and efficiency.3,4 No. 2: Lack of reversibility. Most individuals in their
s

An advantage of a lens-based approach compared to laser 50s or 60s have healthy eyes without relevant comorbidities.
vision correction (LVC) is that the former eliminates the If they develop diseases such as age-related macular
patient’s future need for cataract surgery. degeneration or glaucoma, however, they may lose the visual
It is incumbent on eye care providers to offer an honest performance necessary for success with a presbyopic laser
explanation of the potential benefits and limitations of treatment profile.
surgery, the advantages and downsides of each IOL design, No. 3: Minimal overall knowledge of cataract surgery
s

and the compromises in visual performance patients can on patients who have undergone presbyopic LVC. IOL
experience after a lens-based refractive procedure. The risks formulas and the devices used for preoperative testing have
of surgical intervention must be described in detail. not been fine-tuned for these corneas yet, leading to less
Potential sight-threatening complications such as retinal accurate refractive outcomes after cataract surgery.9
detachment after surgery have a higher incidence in young Lens-based refractive surgery. One option for lens-based
patients.5,6 Routine screening for vitreous detachment is presbyopia correction gaining popularity is to implant
required, especially in myopic patients because they are at a monofocal IOL in the capsular bag and an add-on or
increased risk of retinal detachment after refractive lens piggyback lens in the sulcus. The partial reversibility of this
exchange (RLE).4 Myopic patients are also at greater risk of approach offers an advantage over laser refractive surgery.
cystoid macular edema than hyperopic patients. In contrast, The sulcus-fixated add-on IOL can be explanted while
patients with hyperopia and a shallow anterior chamber are the monofocal IOL stays in place if a patient develops a
at increased risk of angle-closure glaucoma,7 which can make comorbidity that negatively affects the visual performance
RLE an attractive option for these patient groups. of the trifocal optical system.10 Studies have found that the
As both patients and surgeons are open to RLE, a visual performance of two-lens systems can be similar to that
comparison to alternatives is needed. of a multifocal IOL and may provide patients and surgeons
with a sense of security about what the future holds.11-13
LASER VERSUS LENS-BASED REFRACTIVE SURGERY
Laser refractive surgery. Like lens-based refractive surgery, CONCLUSION
LVC has advanced in recent years. Algorithms have been The desire for a full range of vision stokes patient demand
developed for the treatment of presbyopia in addition for both lens-based and laser refractive surgery. Appropriate

OCTOBER 2023 | CATARACT & REFRACTIVE SURGERY TODAY 49

s SHIFTING TOWARD REFRACTIVE LENSECTOMY

patient selection and education are integral to the success is the dramatic improvement in presbyopia-correcting
of either approach. Surgeons who treat presbyopia must set IOL technology, which has made lens-based refractive
realistic expectations and be prepared to address refractive surgery an option for younger patients. These individuals
surprises. Patients should be informed preoperatively that are typically in their 50s when they begin to experience
neural adaptation can take 3 months or longer.14 Compared symptoms of presbyopia and some degree of dysfunctional
to LVC, a major advantage of RLE for a two-lens system is its lens syndrome.1
partial reversibility.
PATIENT EDUCATION
1. Mester U, Vaterrodt T, Goes F, et al. Impact of personality characteristics on patient satisfaction after multifocal intraocu-
lar lens implantation: results from the “happy patient study.” J Refract Surg. 2014;30(10):674-678.
Counseling patients with presbyopia over the age of
2. Balgos MJTD, Vargas V, Alió J. Correction of presbyopia: an integrated update for the practical surgeon. Taiwan J Ophthal- 50 years regarding vision correction involves explaining
mol. 2018;8(3):121-140. the limitations of addressing refractive error at the
3. Kaweri L, Wavikar C, James E, Pandit P, Bhuta N. Review of current status of refractive lens exchange and role of dysfunc-
tional lens index as its new indication. Indian J Ophthalmol. 2020;68(12):2797. corneal plane, especially in the presence of progressive
4. Packard R. Refractive lens exchange for myopia: a new perspective? Curr Opin Ophthalmol. 2005;16(1):53-56. lenticular aberrations. LASIK offers mainly distance-only
5. Fernández-Vega L, Alfonso JF, Villacampa T. Clear lens extraction for the correction of high myopia. Ophthalmology.
2003;110(12):2349-2354. or monovision solutions in this population, and the
6. Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH. Retinal detachment after phacoemulsification in effect may reduce as lens dysfunction worsens. If
high myopia: analysis of 2356 cases. J Cataract Refract Surg. 2008;34(10):1644-1657.
7. Preetha R, Goel P, Patel N, et al. Clear lens extraction with intraocular lens implantation for hyperopia. J Cataract Refract these patients want a more permanent solution after
Surg. 2003;29(5):895-899. learning about the risks and benefits of lens-based
8. Ma L, Atchison DA, Albietz JM, Lenton LM, McLennan SG. Wavefront aberrations following laser in situ keratomileusis and
refractive lens exchange for hypermetropia. J Refract Surg. 2004;20(4):307-316.
procedures, they may be good candidates for RLE with a
9. Pantanelli SM, Lin CC, Al-Mohtaseb Z, et al. Intraocular lens power calculation in eyes with previous excimer laser surgery presbyopia-correcting IOL.
for myopia: a report by the American Academy of Ophthalmology. Ophthalmology. 2021;128(5):781-792.
10. Khoramnia R, Yildirim TM, Son HS, Łabuz G, Mayer CS, Auffarth GU. Reversible Trifokalität durch das Duett-Verfahren.
For RLE, I typically choose between an extended
Ophthalmologe. 2020;117(10):999-1004. depth of focus (EDOF) IOL (Clareon Vivity, Alcon) and a
11. Schrecker J, Feith A, Langenbucher A. Comparison of additional pseudophakic multifocal lenses and multifocal intraocular diffractive trifocal IOL (Clareon PanOptix, Alcon). These
lens in the capsular bag. Br J Ophthalmol. 2014;98(7):915-919.
12. Schrecker J, Zoric K, Meßner A, Eppig T. Effect of interface reflection in pseudophakic eyes with an additional refractive lenses have met patient expectations most consistently, in
intraocular lens. J Cataract Refract Surg. 2012;38(9):1650-1656. my hands.
13. Gerten G, Kermani O, Schmiedt K, Farvili E, Foerster A, Oberheide U. Dual intraocular lens implantation: monofocal lens in
the bag and additional diffractive multifocal lens in the sulcus. J Cataract Refract Surg. 2009;35(12):2136-2143. Preoperative discussions for RLE and cataract surgery
14. Alió JL, Pikkel J. Multifocal intraocular lenses: neuroadaptation. In: Alió JL, Pikkel J, eds. Multifocal Intraocular Lenses: the at my practice are similar. Ideal candidates have some
Art and the Practice. Springer; 2014:47-52.
degree of hyperopia, and any astigmatism is regular. These
individuals are accustomed to distance blur and a nearly
full-time need for glasses or contact lenses. A thorough
DAVID BECKERS, MD history is obtained that addresses their history of contact
n Resident, Asklepios Klinik Barmbek, Hamburg, Germany lens wear, including any experience with monovision
n d [email protected] and/or multifocality. Their motivation and desire for
n F inancial disclosure: None surgical intervention are also assessed.

LENA BECKERS, MD PATIENT SELECTION

n Resident, Augenärzte am Rathausmarkt, Hamburg, Germany I tell appropriate candidates that two types of lenses
n d [email protected]
can reduce or possibly eliminate their need for reading
n F inancial disclosure: None
glasses. In several studies, four out of five patients with
the PanOptix IOL never wore glasses after surgery.2,3 I
emphasize the potential for visual phenomena such as
glare and halos in low-light conditions, provide a visual
A BROADER POOL OF CANDIDATES FOR representation, and answer any questions.
If concerns about visual disturbances arise, I discuss the
REFRACTIVE LENS EXCHANGE option of an EDOF IOL. I explain that it functions like a
bifocal lens, offering two zones of vision, either distance
Technological advances allow younger patients to consider this option. and intermediate or intermediate and near, depending
on the focal target. EDOF IOLs offer excellent distance
vision during the day and night with a low risk of visual
BY QUENTIN B. ALLEN, MD
disturbances such as glare or halos. If patients have
The number of patients coming to my practice monovision experience or are not suitable for a trifocal IOL
interested in RLE has increased significantly during owing to mild coexistent ocular pathology, I may suggest a
the past decade. This includes those seeking a LASIK mini-monovision approach to increase their range of vision
evaluation but who are better suited for RLE. One reason and minimize their need for glasses at near.

50 CATARACT & REFRACTIVE SURGERY TODAY | OCTOBER 2023

s SHIFTING TOWARD REFRACTIVE LENSECTOMY

If preoperative discussions and examinations confirm their dependence on glasses and contact lenses and enjoy
that a patient is suitable for RLE, they can then choose their daily activities without the hassle of visual aids. Some
between an EDOF and a trifocal IOL. Those with individuals, such as pilots, have professions that demand
monovision experience often choose the Vivity lens. Even clear vision, and others choose to undergo RLE to enhance
patients without monovision experience who select a their career performance.
Vivity IOL typically tolerate a mini-monovision strategy RLE is an option for some individuals who are not
if reasonable expectations are set preoperatively. A plano candidates for other vision correction procedures due to
result is targeted in the first eye, and possible offset thin corneas or extreme refractive errors. As premium IOL
options (-0.50 to -0.75 D) for the second eye are discussed technology has advanced, more of my patients have elected
postoperatively. to undergo RLE at younger ages. They are usually in their
Over the past 2 years, my RLE patients have been 50s and presbyopic, have not yet developed cataracts, and
roughly evenly divided between EDOF and trifocal IOLs. are still working and/or have active lifestyles.
Those who frequently drive at night and enjoy hobbies Of all the premium IOLs available, the Light Adjustable
that require excellent distance vision typically choose the Lens (LAL; RxSight) is the biggest driver of my patients'
Vivity IOL and expect to wear glasses to read fine print. adoption of RLE.
My colleagues and I evaluated patient satisfaction and
spectacle independence after the implantation of various ADVANTAGES
presbyopia-correcting IOLs and found that 33% who The LAL’s refractive power can be adjusted
received the Vivity lens with a distance target never wore postoperatively with a UV light treatment that modifies
glasses, echoing my clinical experience.4 the implant’s curvature. The patient’s vision is assessed and
Some patients are candidates for a trifocal IOL in fine-tuned over a series of weeks.
only one eye due to preexisting ocular pathology. In my The LAL’s adjustability has substantially reduced
experience, a mix-and-match approach with a Vivity in the refractive surprises after cataract surgery. A case series of
eye with mild ocular pathology can be successful in this 86 of my patients who received the LAL bilaterally found
situation, but formal studies are warranted. that 90% and 85% achieved UDVAs and uncorrected
1. Waring GO, Rocha KM. Characterization of the dysfunctional lens syndrome and a review of the literature. Curr Ophthalmol
near visual acuities (UNVAs) of 20/20, respectively.1
Rep. 2018;6:249-255. The results give me confidence that I can satisfy high
2. Hovanesian JA, Jones M, Allen Q. The PanOptix trifocal IOL vs the ReSTOR 2.5 Active Focus and ReSTOR 3.0-add multifocal
lenses: a study of patient satisfaction, visual disturbances, and uncorrected visual performance. Clin Ophthalmol.
patient expectations.
2021;15:983-990. The LAL can address a wide range of refractive errors,
3. Zhu D, Ren S, Mills K, Hull J, Dhariwal M. Rate of complete spectacle independence with a trifocal intraocular lens: a
systematic literature review and meta-analysis. Ophthalmol Ther. 2023;12(2):1157-1171.
including myopia, hyperopia, astigmatism, and presbyopia.
4. Hovanesian JA, Jones M, Allen Q. The Vivity extended range of vision IOL vs the PanOptix trifocal, ReStor 2.5 Active Focus The lens is a versatile option for patients with complex
and ReStor 3.0 multifocal lenses: a comparison of patient satisfaction, visual disturbances, and spectacle independence. Clin
Ophthalmol. 2022;16:145-152.
vision needs. The LAL’s postoperative adjustability,
moreover, obviates the need for an invasive surgical
procedure to alter its power if a patient is unhappy with
QUENTIN B. ALLEN, MD their initial vision outcome.
n Private practice, Florida Vision Institute, Stuart, Florida
n M ember, CRST Editorial Advisory Board CANDIDACY
n q [email protected] In my experience, the best candidates for RLE with the
n F inancial disclosure: Consultant (Alcon) LAL have had stable refractive errors for at least 1 year
and have healthy eyes with no ocular comorbidities. The
preoperative consultation has determined that their
specific needs can be addressed by RLE and that its benefits
ADJUSTABILITY IS ONE DRIVING FORCE OF outweigh its risks.

EARLIER ADOPTION 1. Newsom TH. Premium custom blended vision with the RxSight Light Adjustable Lens. White paper. 2021.

Postoperative adjustability can increase patient confidence and thus

T. HUNTER NEWSOM, MD
procedural volume. n Newsom Eye & Laser Center, Brooksville, Carrollwood, Clearwater,
Sebring, and South Tampa, Florida
BY T. HUNTER NEWSOM, MD n h [email protected]

RLE has become increasingly popular at my practice. n F inancial disclosure: Consultant and principal investigator

Patients’ primary motivation is to reduce or eliminate (RxSight)

52 CATARACT & REFRACTIVE SURGERY TODAY | OCTOBER 2023

 SHIFTING TOWARD REFRACTIVE LENSECTOMY

s
A RISING PATIENT DEMAND AND SURGEON No. 4: High myopia. The risk of postoperative retinal

s
detachment must be assessed. When one of these patients
is interested in RLE, I consult a retina colleague to assess
ENTHUSIASM ARE FUELING GROWTH and treat the retinal periphery and determine whether a
complete posterior vitreous detachment (PVD) is present.
Exploring four treatment strategy scenarios. Studies have shown that the presence of a PVD almost
eliminates the increased risk of retinal detachment due to
BY TAL RAVIV, MD high myopia.1,2 If a complete PVD is present bilaterally, I
In my practice, the increase in RLE volume is due to both discuss RLE with the patient. Otherwise, I may recommend
my growing enthusiasm and rising patient demand for an EVO ICL (STAAR Surgical) or deferring RLE.
the procedure. There are exceptions. For example, I might consider
RLE for a patient with high myopia but no PVDs who has
PRESENTING PATIENTS become intolerant of contact lenses. Patients can make an
Patients seek RLE in various ways. Initially, most came in informed choice based on their circumstances.
wanting LASIK but were 45 to 60 years old and experiencing
presbyopia. Recently, more patients have specifically TREATMENT STRATEGIES
requested RLE or custom lens replacement. This second Regardless of which of the four categories a patient
group typically knows someone who recently underwent the falls into, there are two main strategies for achieving
procedure. A third group comprises spouses of my cataract good UDVA, uncorrected intermediate visual acuity, and
patients who received a lifestyle presbyopia-correcting IOL. UNVA after RLE: a multifocal IOL or monovision. The
These spouses, envious of the spectacle-free vision achieved, decision between the two is often determined by several
don’t wish to wait until they develop cataracts. patient-specific factors, and sometimes a hybrid approach
RLE can be performed on a prepresbyopic eye, such as is used.
one with high hyperopia or myopia, but I generally reserve Scenario No. 1. For patients satisfied with contact lens or
s

the procedure for patients with presbyopia. For younger LASIK-induced monovision, I typically replicate the strategy
individuals, I recommend other refractive modalities or using a monofocal plus IOL such as the Tecnis Eyhance
postponing lens surgery. (Johnson & Johnson Vision) or the LAL. After operating on
the distance eye, I gauge the near vision obtained to decide
FOUR CATEGORIES OF PATIENTS on the offset for the nondominant eye.
I categorize the presbyopic RLE population into Scenario No. 2. If a patient has monovision experience
s

four groups. but became dissatisfied, and if they are a candidate for a
No. 1: Plano presbyopia. These patients, generally between multifocal IOL (ie, healthy retina and cornea), they receive
s

43 and 55 years old, never wore glasses before developing a Tecnis Symfony OptiBlue EDOF IOL (Johnson & Johnson
presbyopia and are often challenging to satisfy. Most Vision) in the dominant eye and a Tecnis Synergy in the
are intolerant of any residual refractive error. I typically nondominant eye. This approach usually provides the
recommend waiting for lens surgery unless they are already vision balance they were missing with monovision as well
wearing one contact lens to induce myopia for monovision. as crisp vision in all three zones (and in between).
In such cases, I consider a multifocal IOL such as the Tecnis Scenario No. 3. For hyperopic patients desiring maximum
s

Synergy (Johnson & Johnson Vision), which can provide spectacle independence, I consider bilateral implantation
consistent, crisp near vision while maintaining balanced of a Clareon PanOptix or Tecnis Synergy IOL. If the patient
distance visual acuity. requests what I term distant intermediate vision (> 24 inches
No. 2: Hyperopia. These are typically the easiest patients such as for viewing a painting at a museum or a distant
s

to please with RLE. They appreciate improvements in both computer screen), I implant a Symfony OptiBlue in the
UDVA and UNVA and tolerate small residual refractive dominant eye and a multifocal in the nondominant eye.
errors well. Scenario No. 4. For post-LASIK eyes, I prefer the Tecnis
s

No. 3: Low myopia. This category can be broken down Symfony OptiBlue IOL, which tends to be forgiving of
s

into two subgroups: those who read mostly without higher-order aberrations and astigmatism. Moreover,
glasses and those who always wear them for reading, often patients generally experience a significantly lower
owing to astigmatism. The second group is generally easy amount of nighttime dysphotopsias with the lens’
to please with a multifocal or EDOF IOL or a monovision second-generation InteliLight features. The other option
strategy. For the former group, a solution that maintains is the LAL, whose adjustability and some near-eye
that crisp near vision is critical—typically a multifocal lens extended depth of focus are well suited to postrefractive
in one or both eyes. surgery patients.

OCTOBER 2023 | CATARACT & REFRACTIVE SURGERY TODAY 53

s SHIFTING TOWARD REFRACTIVE LENSECTOMY

1. Qureshi MH, Steel DHW. Retinal detachment following cataract phacoemulsification—a review of the literature. Eye.
2020;34:616-631.
surgery—or the ophthalmologist—caused their ocular
2. Daien V, Lepape A, Heve D, Carriere I, Villain M. Risks factors of retinal detachment following cataract surgery in a national surface disease.
population study between 2009 and 2012. Invest Ophthalmol Vis Sci. 2015;56:672.

IOL CONSIDERATIONS
Monofocal lenses. I prefer monofocal IOLs for patients
TAL RAVIV, MD with a history of refractive surgery. My go-to lenses are
n Founder and Medical Director, Eye Center of New York the preloaded monofocal and monofocal toric IOLs from
n A ssociate Clinical Professor of Ophthalmology, Icahn School of Medicine at Bausch + Lomb’s MX60E series. These IOLs are aspheric and
Mount Sinai, New York tend to perform well in this patient population because
n M ember, CRST Executive Advisory Board they do not exacerbate corneal aberrations.
n t [email protected]; X (formerly Twitter) @TalRavivMD A monovision approach targeting -0.50 to -0.75 D
n F inancial disclosure: Consultant (Johnson & Johnson Vision) of sphere in the nondominant eye typically increases
patients’ depth of field and provides some near vision. In
my experience, these IOLs center well, exhibit minimal
rotation, and provide a stable refraction.
ACHIEVING LASIK-LIKE OUTCOMES AFTER The consistent power distribution from center to edge in
the MX60E series also works well for patients at increased
CATARACT SURGERY risk of IOL dislocation due to pseudoexfoliation or other
zonulopathies. The IOLs are available in a large range of
Tips for maximizing patient satisfaction. dioptric and toric powers, which is advantageous for the
correction of high astigmatism.
BY P. DEE G. STEPHENSON, MD, FACS Small-aperture lenses. The Apthera IC-8 (Bausch + Lomb)
serves as an excellent alternative for patients with a
Ophthalmology is a technology-driven field, and recently history of radial keratotomy, multiple refractive surgeries,
there has been increased patient interest in lens-based or keratoconus. A postoperative refraction of -0.75 D of
solutions for refractive errors. Younger patients with a sphere is targeted.
history of refractive surgery who visit my practice for a The Apthera can mitigate the effects of presbyopia by
cataract surgery evaluation have high expectations for extending depth of focus. Its pinhole effect can improve
achieving LASIK-like outcomes. They arrive armed with patients’ intermediate and near visual acuity without
information from websites, referrals from friends, questions compromising their distance vision. Patients with
about outcomes and postoperative satisfaction, and keratoconus, in particular, seem to be highly satisfied with
requests for specific IOLs and techniques. This article shares their outcomes.
my tips for success in this population.
CONCLUSION
PREOPERATIVE COUNSELING Learning the pros, cons, and other important information
I emphasize to patients that their visual recovery following about lens technology can help you be a better surgeon.
cataract surgery will differ from that after refractive surgery. Educating patients and guiding them toward the right
More healing time is required overall, and the recovery of decision increases their chances of achieving the best
one eye may differ from that of the other. I often say, “Your possible outcome. Take the time to answer their questions;
eyes are sisters, not identical twins.” a good referral will always follow you. n
Comorbidities have a significant impact on a
patient’s surgical journey. Ocular surface disease,
regardless of its cause, must be diagnosed and managed P. DEE G. STEPHENSON, MD, FACS
before cataract surgery. The procedure may need to n Founder and CFO, Stephenson Eye Associates, Venice, Florida
be postponed until an optimal surface is achieved. It n I mmediate Past President, American Board of Eye Surgery

is essential to inform patients if their ocular surface is n M ember, CRST Editorial Advisory Board

compromised and to explain how this can affect surgical n e [email protected]; www.stephensoneye.com

results. Failing to do so may lead them to believe that the n F inancial disclosure: Consultant (Bausch + Lomb)

54 CATARACT & REFRACTIVE SURGERY TODAY | OCTOBER 2023