Eyeworld

46 | EYEWORLD | WINTER 2025 R EFRACTIVE OPENING DOORS by Liz Hillman Editorial Co-Director About the physicians Jorge Alió, MD, PhD Professor and Chairman of Ophthalmology University Miguel Hernández of Elche Alicante, Spain Jason Stahl, MD Durrie Vision Overland Park, Kansas George Waring IV, MD Waring Vision Institute Mt. Pleasant, South Carolina D ysfunctional lens syndrome (DLS) has evolved from a theoretical framework to a clinically validated tool that's reshaping patient education and sur- gical decision making. Described over a decade ago, the dysfunctional lens staging system now plays a role in identifying the right intervention at the right time—particularly in the growing field of custom lens replacement. DLS background The term dysfunctional lens syndrome was coined by George Waring IV, MD, Jason Stahl, MD, and Daniel Durrie, MD, around the concept of optical lens dysfunction originally proposed by Jorge Alió, MD, PhD. 1 Dr. Alió and colleagues described for the first time the evolution of the density and of the anterior and posterior nucleus, and MTF value using an optical quality analysis system from 8–80 years of age finding their association over a person's life. This was the basis of the theory of dysfunctional lens syndrome. The early concept, Dr. Waring said, de- scribed early opacification of the human crystal- line lens. "We knew the other aspects of crystal- line lens aging such as presbyopia and higher order aberrations were also important and could be characterized, in addition to lens opacifica- tion, in a syndromic term." Through the years, Dr. Waring recounted, they proposed a system of staging, with Stage 1 being presbyopia, Stage 2 being presbyopia, increased aberrations, and early opacification, and Stage 3—the final stage—being a manifest cataract that consistently adversely affected daily activities. Over time, published research increased, and a scientific basis for lens dysfunction and its various stages was established. Dr. Waring said the staging system became useful for surgical decision making and for patient education. "One of the main reasons that we set out to study and better characterize this was the standard of care for vision correction was LASIK in the dysfunctional lens cycle. We realized a phenomenon over and over where we may have performed LASIK in patients and they'd come back a number of years later saying, 'My LASIK wore off.' We all knew that wasn't true. We learned that the internal lens had become dys- functional, hence the opportunity for scientific study and validation." DLS as a patient education tool Dr. Waring said that, over time, dysfunctional lens syndrome staging and related diagnostic and imaging equipment has helped patients better understand the need for refractive lens exchange/custom lens replacement. "When we would talk about lens replacement, [patients] were unsettled and, because this was a foreign concept to them, would often go elsewhere seeking LASIK. They just were not comfortable with this idea … but we knew that it was the right thing to do because if we're going to fix something, we want to go to the source of the problem, and we had a scientific basis for this as well. Showing the additional opportunities for lens replacement, based on our research, we were able to demonstrate not only improvement in uncorrected visual acuity for distance but also improvement in other objective measures, qualitative measures, to improve quality of vision," Dr. Waring said. "This is where the tables started to turn. We could fix things that we couldn't fix with LASIK with lens replace- ment. As the terminology became progressively adopted by the medical community, we also saw the adoption start to increase." In the early 2000s when patients who were initially happy with their LASIK were coming back to say it had worn off, there was not the diagnostic technology to show what was actu- ally happening, Dr. Stahl said. "You can explain to them that it's the lens. Then they ask, 'Do I have a cataract?' It's not a cataract, but it's dysfunctional. So that's where we came up with dysfunctional lens syndrome, and we started to characterize the different stages. What made our discussion easier was the development of new diagnostics that could actually show the patient their lens and describe what's happen- ing and why this is going to continue to be an issue in the future." Dr. Stahl said he has found the Pentacam (Oculus) densitometry image of the patient's lens to be helpful from an educational stand- point. "You can show them the lens scatter," he said, and compare that to the scatter with Dysfunctional lens syndrome: opening doors to earlier and customized interventions

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