Eyeworld

48 | EYEWORLD | WINTER 2025 R EFRACTIVE Reference 1. Alió JL, et al. Crystalline lens optical dysfunction through aging. Ophthalmology. 2005;112:2022–2029. Relevant disclosures Alió: None Stahl: None Waring: None If the patient is a low myope in their 40s with decent accommodation, Dr. Stahl said they could be a candidate for LASIK with a slight blend. He said he is sure to explain to these pa- tients that they are "kicking the reading glasses can down the road." If this and future distance vision changes might upset them, they should consider refractive lens exchange. Dr. Alió said due to the risk of retinal detachment in myopes, he does not perform refractive lensectomy on patients younger than 55 years old. For patients younger than 55 in Europe, he has access to the Artiplus iris-fixated lens (Ophtec), which he's had success with. "After the age of 55, we do refractive len- sectomy, and the implant we decide on depends on the patient and the condition of the retina, but we use a lot of asymmetrical lenses and other lenses that are diffractive," Dr. Alió said, adding that he'll sometimes use monofocal lens- es depending on the power needed and status of the macula. For hyperopes, Dr. Alió said refractive len- sectomy is an option even at younger ages in his practice due to the low risk of retinal compli- cations and macular edema. Many lenses can be used for these patients, but his favorites are EDOF and accommodative IOLs. Dr. Alió said that they have not had good results with the ICL and avoid it in the dysfunc- tional lens syndrome patient, in part due to its limited near vision gain. Dr. Alió said for young- er patients, LASIK is still a good option as well. Twenty-plus years ago, Dr. Stahl said it was frustrating trying to discuss refractive lens exchange with someone who didn't have a cataract but couldn't be shown diagnostically why you were recommending that procedure for them, not to mention the lens technologies were not as advanced. Fast forward to today, Dr. Stahl said it is a wonderful experience both diagnostically and surgically. "It's such a nice conversation now because patients understand it. It's been a fun ride through the last 20-plus years and seeing how this has evolved." include presbyopia-correcting IOLs that have improved contrast sensitivity and optical quality, as well as full range of vision lenses, Dr. War- ing said. Dr. Stahl said diagnostics that allow the surgeon to show the patient what's going on with their lens have been pivotal as well. In addition, the use of the femtosecond laser in custom lens replacement provides a LASIK-like experience, Dr. Waring added. "We're still pro- viding a laser eye procedure with a femtosecond laser. … But custom lens replacement has ad- ditional benefits and features: 1) it goes to the source of the problem and 2) we keep both eyes balanced, both eyes seeing distance and near. … Custom lens replacement is designed to not only improve upon the distance vision but also restore the reading. … Custom lens replacement is enduring, it's anti-aging, it prevents the even- tual aging changes and prevents the necessity for cataract surgery." Even with all the benefits of custom lens replacement for patients with dysfunctional lens syndrome, Dr. Waring said it's important to remember that, as with all procedures, not everyone is a candidate. "On occasion we see the "in-betweeners," who might not be an ideal candidate for anything, and we recommend no surgery. The good news is with advanced tech- nology and advanced diagnostics, many people are a candidate." Dr. Stahl said his DLS nomogram comes down to what he sees on the evaluation and where the patient says they're struggling with their vision. If the patient is 20–44, he or she is a candidate for laser vision correction or the EVO ICL (STAAR Surgical) in his prac- tice. There's the rare 35-year-old who is a +5 hyperope and, if they're experiencing reading issues, could be a candidate for refractive lens exchange, but usually these patients are advised to wait until they're in their 40s and officially in Stage 1 DLS. The 45- to 50-year-old patient is interesting, according to Dr. Stahl, because 10 years ago, he would have done LASIK on these patients, espe- cially if they were myopic. Now he's talking to them about refractive lens exchange. "We tried doing LASIK in these patients years ago, and they're happy initially but then they come back in a few years as they continue to lose more accommodation." Contact Alió: jlalio@vissum.com Stahl: jstahl@durrievision.com Waring: georgewaringiv@gmail.com continued from page 47

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