Eyeworld

R EFRACTIVE EVOLVING 50 | EYEWORLD | WINTER 2024 by Ellen Stodola Editorial Co-Director About the physicians Marjan Farid, MD Director of Cornea, Cataract, and Refractive Surgery Gavin Herbert Eye Institute University of California, Irvine Irvine, California D. Rex Hamilton, MD Medical Director Hamilton Eye Institute Beverly Hills, California Luke Rebenitsch, MD Medical Director ClearSight Oklahoma City, Oklahoma W ith expanding options in re- fractive surgery for patients at different ages, many physicians are seeing an uptick in refractive lens exchange (RLE). Marjan Farid, MD, D. Rex Hamilton, MD, and Luke Rebenitsch, MD, discussed their experience with RLE, including considerations when explaining this option to patients. The average age of cataract surgery in this country has come down with advancing tech- nologies and the ability to restore vision with advanced-optic IOLs, Dr. Farid said. "We have a lot of patients who come in who are pre-cataract and very frustrated with their vision and spectacle and contact lens requirements and want refractive solutions," she said. "The whole arena of refractive surgery has expanded beyond LASIK, with phakic IOLs, SMILE, PRK. Patients come in and ask if they're a candidate for LASIK because they don't want to wear glasses anymore, and in a certain pop- ulation of patients, refractive lens exchange is a much better solution." Dr. Farid said patients who are presbyopic, between the ages of 40–60, may not be the best candidates for LASIK because that will keep them in glasses for certain activities. Other patients who are great candidates for refractive lens exchange are younger patients who are very hyperopic; hyperopic LASIK is less pre- dictable, even with available nomograms, Dr. Farid said. Patients with higher hyperopia have smaller eyes and are at risk for future narrow angle-related glaucoma. "We have 40-year- olds coming in who have been told they have narrow angles and might need laser peripheral iridectomy and are high hyperopes where laser peripheral iridectomy is temporary. [RLE] is a refractive solution because these patients often have poor vision and need coke bottle specta- cles or contact lenses." Given that RLE patients generally want spectacle independence, Dr. Farid considers advanced-technology IOLs for them first. She particularly likes the TECNIS Odyssey IOL (Johnson & Johnson Vision) and the Light Adjustable Lens (LAL, RxSight). The TECNIS Odyssey, she said, is more of a full range of vision lens, and patients have been blown away by its optical quality and enhanced contrast sensitivity. There is a free-form technol- ogy on the optic that minimizes the side effects of glare and starbursts, so these patients have minimal complaints of nighttime dysphotopsias, and they get good range of vision. "The other one I love is the LAL+ for pa- tients because they come out of surgery already with some range of vision, then we can build in a little more with adjustments postoperatively, and this is another lens that gives great quality of vision," she said. Dr. Hamilton said he frequently sees pa- tients who want to get out of their glasses and tell him they want LASIK. "That might work for someone in their 20s–30s, or even into their 40s, but if someone in their 50s comes in, and they've never worn glasses before and are having trouble seeing up close, but they want LASIK, I say, 'LASIK is done on the cornea. The reason you're having trouble at 50 is not due to the cornea but rather the lens inside, which loses its flexibility and doesn't focus as well. It will become cloudy in the future as a cataract A shift toward RLE This night driving simulation (Rendia) shows initial large halos (left) around headlights that are less noticeable over time (right) as neuroadaptation occurs. Source: D. Rex Hamilton, MD

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