Vincenz Fukala (1847-1911) and the early history of clear-lens operations in high myopia

Retinal detachment after refractive lens exchange: A narrative review

Refractive lens exchange (RLE) allows to correct ametropias and presbyopia by replacing the crystalline lens with an extended depth of focus or multifocal intraocular lens (IOL). Retinal detachment (RD) is one of the most serious adverse events after RLE. This study aimed to review the evidence related to the risk of RD after RLE and clinical outcomes. A search using PubMed and a snowball search approach was conducted to identify articles and case reports. According to the literature, the risks of RD should be considered in patients <60 years old with axial lengths >23 mm. Only nine articles reported visual acuity (VA) after RD in RLE, and only 25% of eyes had a VA > 20/40. Considering that the decrease in VA might be uniform for all types of IOLs after RD, surgeons should focus on selecting the patient to prevent RD rather than on a particular IOL optical design based on the potential risk of DR.

Review of current status of refractive lens exchange and role of dysfunctional lens index as its new indication

Advances in phacodynamics and intraocular lenses (IOLs) has given second life to clear lens extraction (CLE) or refractive lens exchange (RLE) in recent years for the treatment of patients with high degrees of myopia, hyperopia, and astigmatism who are unsuitable for laser surgery. Furthermore, presbyopia treatment with RLE supplemented with multifocal or accommodating IOLs gives the dual benefit of correcting refractive errors with eliminating the need for cataract surgery. RLE should be consistent and effective for a good refractive outcome along with safety during the surgical procedure and in the postoperative period. Therefore, proper patient selection and accurate preoperative protocols for IOL power calculations and selection are important along with an appropriate choice of surgical procedure. Dysfunctional lens index is a new objective tool that helps surgeon to aid in diagnosing, counseling, and educating patients with dysfunctional clear lens. In this article, we give a brief overview about the application of RLE for individuals with presbyopia and refractive errors like myopia, hyperopia, and astigmatism who are not suitable for laser correction.

Modern Phacoemulsification and Intraocular Lens Implantation (Refractive Lens Exchange) Is Safe and Effective in Treating High Myopia

Improved efficacy, predictability, and safety of modern phacoemulsification have resulted in cataract surgery being considered as a refractive procedure. Refractive lens exchange by definition is a surgery aimed at replacing the cataractous or clear crystalline lens with an intraocular lens (IOL) in cases of high ametropia. The excellent intraocular optics of this procedure provide a better visual outcome as compared with laser refractive surgery in high myopia. With advances in technology and IOL formulas, the predictability of refractive outcome after cataract surgery in high myopes has improved. The option of addressing presbyopia using multifocal/accommodating IOLs or monovision results in patients achieving reasonable spectacle independence. The most important concern with respect to phacoemulsification in high myopia is the risk of pseudophakic retinal detachment. High myopia is an independent risk factor for retinal detachment, and recent publications have reported a much lesser risk of retinal detachment specifically attributable to phacoemulsification in high myopes, especially if a thorough posterior segment evaluation is done and patients are followed up until development of complete posterior vitreous detachment. Refractive lens exchange is an effective and safe option to correct high myopia and can significantly improve quality of life in select patients.

Refractive lens exchange in modern practice: when and when not to do it?

Cataract surgery due to advances in small incision surgery evolved from a procedure concerned with the primary focus on the safe removal of cataractous lens to a procedure focused on the best possible postoperative refractive result. As the outcomes of cataract surgery became better, the use of lens surgery as a refractive modality in patients without cataracts has increased in interest and in popularity. Removal of the crystalline lens for refractive purposes or refractive lens exchange (RLE) presents several advantages over corneal refractive surgery. Patients with high degrees of myopia, hyperopia and astigmatism are still not good candidates for laser surgery. Moreover, presbyopia can currently only be corrected with monovision or reading spectacles.

RLE supplemented with multifocal or accommodating intraocular lenses (IOLs) in combination with corneal astigmatic procedures might address all refractive errors including presbyopia, and eliminate the future need for cataract surgery.