Eyeworld

EW FEATURE 50 by Vanessa Caceres EyeWorld Contributing Editor Weighing the pros and cons of RLE in presbyopes RLE in presbyopic patients is a growing treatment option in the United States R efractive lens exchange (RLE) in presbyopic pa- tients is a growing treat- ment option in the United States. "In general, the use of refractive lensectomy has increased recently as we achieve more accurate refractive outcomes with more modern meth- ods for measuring eyes," said John A. Hovanesian, M.D., Jules Stein Eye Institute, David Geffen School of Medicine, University of Califor- nia, Los Angeles. "I love RLE and find it gratifying to perform," said Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland. "We're always up against the limits of the implants and tech- nology, but even that has gotten bet- ter. I don't see any real limitations," he said. The only side effect he has commonly seen is dysphotopsia. Surgeons have seen varying de- grees of interest in RLE in presbyopic patients in recent years. At a practice like that of Daniel S. Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park, the majority of presbyopic patients will have RLE performed. However, his practice does not accept Medicare and is private pay only. By contrast, Y. Ralph Chu, M.D., adjunct associate professor of ophthalmology, University of Min- nesota, Minneapolis, and clinical professor of ophthalmology, Univer- sity of Utah, Salt Lake City, said only a small percentage of his patients are RLE. "Some of it is more of a mind- set. My area is more conservative," Dr. Chu said. Dr. Packer, an avid sup- porter of RLE, said the number of RLEs he has performed has de- creased since 2007 and 2008, a trend he thinks relates to the economic downturn. That said, these surgeons agree that RLE will grow in the future as technology improves and femtosec- ond laser use in cataract surgery in- creases. The ideal patient Although surgeons will perform RLE in presbyopic patients with a range of refractive errors, the ideal patient seems to be one who is hyperopic and over the age of 50. "I favor RLE for hyperopic patients. They get a number of benefits with very little risk," said Kevin L. Waltz, M.D., Bloomington, Ind. Many times, the patient who has RLE done is one who originally ap- proached the surgeon about LASIK. However, "for patients in their 50s, LASIK can fail to provide perfect vi- sual quality," Dr. Hovanesian said. "[These] patients understand that they can go through a corneal refractive procedure today and cataract surgery in the future, or they can have a single surgery now. This is the gap that RLE patients fit into," Dr. Hovanesian said. RLE can be done in younger pa- tients—Dr. Packer has even per- formed RLE in hyperopic patients in their 20s with a refractive error of +6 or +7—but the ideal group is usually the 50+ age range because of grow- ing opacity in the eye. In a number of cases, laser vi- sion correction (LVC) enhancement may follow RLE to further treat the patient's refractive error. Because en- hancement is necessary in 10-20% of patients at Dr. Hovanesian's prac- tice, the cost of laser enhancement is included with the cost of RLE. At Dr. Durrie's practice, 10-15% of patients with premium IOLs still need a laser touch up. Selecting the right patient for RLE involves a thorough diagnostic work up that includes retinal optical coherence tomography, endothelial cell counts, and evaluation (and possible treatment) of the patient's lashes, lids, and tear film, Dr. Durrie said. At his particular practice, a thorough work up is important as he and fellow surgeon Jason Stahl, M.D., try to make all patients specta- cle-free for a lifetime. Dr. Packer takes a more cautious approach with RLE if pre-op screen- ing finds the patient has any con- comitant pathology such as epiretinal membranes or glaucoma. "You can do RLE, but I'm more guarded about how it will turn out," he said. And myopes? RLE can be an ideal fit for many hy- peropic patients, but it also can be an option for some myopes. How- ever, most surgeons said they don't find RLE a good fit for high myopes. "For a high myope, there's a fall off of accuracy and a greater risk of retinal detachment," Dr. Hovanesian said. There is also the risk for greater cystoid macular edema, Dr. Chu said. "You can do a perfect surgery and if the patient is myopic, he or she can have a retinal detachment a year or two later. It's not always clear if that relates to the surgery," Dr. Waltz said. For this reason, he rarely will perform RLE in high myopes. Although there is greater cau- tion with high myopes and RLE, this risk is not a factor if the patient has previously had a posterior vitreous detachment, Dr. Packer said. A pre- op peripheral fundus exam can help check for lattice degeneration, he said. Some studies have even shown that the association between retinal detachment and RLE may be debat- able, Dr. Packer said. Ultimately, he believes the benefits of RLE may out- weigh the risk for retinal detach- ment. However, he will maintain a closer observation of patients who are –6 or –8 D and have not previ- ously had a posterior vitreous de- tachment. Much of the decision of per- forming RLE in myopes—or any pa- tient—goes back to careful patient selection and education, Dr. Waltz said. The role of patient education Although education is important with any procedure, it plays an even more important role in RLE to help patients understand risks and bene- fits. Dr. Hovanesian prefers to give much of the patient education him- self. "You can save hours post-opera- tively by spending a few minutes with patients before surgery," he said. "I cannot trust that a video or brochure was well understood. I want to see that person's body lan- guage and hear feedback." At Dr. Durrie's practice, he and Dr. Stahl discuss with patients their short-term and long-term vision goals to choose the best surgical op- tions for them. Other staff members and writ- ten or audiovisual materials have their role in the education process. "It's helpful to have well-trained technicians so the doctor does not have to do all the education. That can be daunting," Dr. Packer said. February 2011 PRESBYOPIA June 2011 process of developing a neurocogni- tive quantitative test to help look for that issue. EW Reference J Cataract Refract Surg 2011;37:446–453 Q 2011 ASCRS and ESCRS. Editors' note: Dr. Barrett has no finan- cial interests related to his comments. Dr. Davison has a financial interest with Alcon. Dr. Logan has financial interests with AMO and Alcon. Dr. McDonald has financial interests with Bausch & Lomb (Rochester, N.Y.), Hoya Surgical Optics (Chino Hills, Calif.), and STAAR Surgical (Monrovia, Calif.). Contact information Barrett: barrett@cyllene.uwa.edu.au Davison: 800-542-7957, jdavison@wolfeclinic.com Logan: 562-938-9945, dklogan@atlantiseyecare.com McDonald: 479-521-2555, mcdonaldje@mcdonaldeye.com The great continued from page 48 AT A GLANCE • RLE is a growing option in presby- opic patients as related technology improves • Hyperopic presbyopes over the age of 50 are often ideal candidates for RLE • RLE also is a treatment possibility in myopes, although the risk for retinal detachment is a concern • Patient education, both from the surgeon and from supporting edu- cation materials, is crucial with RLE

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