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A Clear-Eyed Look at RLE

At a Glance

  • For the typical patient, RLE does not satisfactorily resolve dysfunctional lens syndrome, and may cause more problems than it cures
  • Many implanted lenses cause significant forward light scatter, and none improve presbyope accommodation
  • Over time, lens implantation increases the risk of photic phenomena, retinal detachment, lens dislocation and visual impairment 
  • It is time to rethink the rationale behind RLE – and re-evaluate whether it is as safe and effective as people think.

Refractive lens exchange (RLE) is becoming an increasingly common procedure. Typically, people in their early 40s and 50s, who have disposable funds, elect for the operation to address deteriorating vision or gain spectacle independence. In the short term, they appear happy with the procedure; RLE seems to gives them what they want (1). But is patient satisfaction with early postoperative outcomes lulling us into a false sense of security? Some ophthalmologists are starting to question whether RLE is as safe – and effective – as we think. Indeed, in my practice, I now try to talk patients out of it. Why? Because I believe that, for the typical RLE patient, the procedure risks adverse outcomes for little or no long-term benefit. Let’s look at the evidence.

It’s useful to consider what visual problems RLE patients seek to resolve, and to what extent current IOLs actually address those problems. Briefly, patients request RLE because they have one or more symptoms of dysfunctional lens syndrome (DLS) – presbyopia, disability glare, decreased contrast sensitivity and decreased night-time vision. DLS symptoms such as disability glare are caused by forward light scatter from an early cataract; it’s been said that if the ocular scatter index (OSI) value is greater than one, then you should consider surgical intervention (2). The assumption is that providing an IOL will improve their DLS symptoms – but I believe this deserves to be examined more closely.

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