(Not) Seeing Eye to Eye

George Beiko’s controversial take on refractive lens exchange, published in our November issue, elicited a strong response from readers. Here, 12 respected surgeons provide a counterpoint.

In this piece, we hope to provide a different perspective to the article, A Clear-Eyed Look at RLE, writtenby our friend and colleague, George Beiko. Beiko notes that “refractive lens exchange (RLE) is becoming an increasingly common procedure” and then explains his rationale for discouraging his own patients from having an RLE. His reasons mainly point to limitations of the optics of multifocal IOLs, the potential for surgical and postoperative complications, and problems encountered with earlier lens materials. Though his argument appears to be compelling on the surface, it fails to adequately consider three main points:

1. Not all RLE patients are alike.

Risks for complications vary based on age, refraction, ocular history, co-morbidities, and other factors. To conflate the risk for retinal detachment (RD) in a high myope with that of a hyperope is not valid. Beiko’s own reference points this out (1). Careful pre-screening, with a detailed peripheral exam, and treating high myopes and others who have increased risk for retinal detachment (for example, via retinal barrier laser to at-risk peripheral areas) prior to RLE may actually lower the incidence of retinal detachment in these eyes. Beiko notes the increased risk of RD in “younger, more myopic patients” and states that these patients are “most likely to elect for RLE procedures,” but in the hands of a surgeon well-versed in vision correction options, these highly myopic patients are commonly directed toward phakic IOLs such as the STAAR Visian ICL , unless they have substantially dysfunctional lenses. If they do have dysfunctional lenses, they are simply embracing likely-inevitable lens replacement a few years early. It is true that high myopes who undergo lens replacement are accepting an increased risk of retinal detachment compared with those who do not, but if they are no longer an acceptable candidate for phakic IOL, it is generally a question of when, not if, they take that risk.

Lens centration is vital to the visual outcome of RLE with multifocal IOL technology. Beiko suggests that late decentration is surprisingly common, writing that “at 10 years there is a one percent risk of IOL dislocation requiring surgery, a 0.7 percent risk of pronounced pseudophakodonesis and a 1.4 percent risk of moderate pseudophakodonesis” based on a 2009 study by Mönestam (2).  He does not share, however, that in this study approximately 40 percent of patients had pseudoexfoliation syndrome. In fact, a more recent review of the literature states that “a predisposition to zonular insufficiency and capsular contraction is identified in 90 percent of reviewed cases” of late IOL dislocation, with pseudoexfoliation representing the most common risk factor (3). We agree with Beiko that the risk of dislocation is an important consideration in the implantation of a multifocal IOL; however, the true risk of this complication must be considered for an individual patient, and the risks of an at-risk population should not be the measure against which the general population is considered. Not every patient is a great candidate for every procedure, and it is incumbent upon the surgeon to be willing to say ‘no.’

2. No one promised perfection.

Beiko argues that current IOLs require compromise and do not satisfy 100 percent of the patients 100 percent of the time, and cites an impressive list of references to bolster his claim. No one disputes that current IOLs have optical limitations, and even blended vision with monofocal IOLs is a compromise. However, the optical compromise of presbyopia is 100 percent, and it is present in every eye. Where are Beiko’s references about the morbidity of presbyopia? The alternatives to RLE, including bifocals, contact lenses, or monovision LASIK do not provide complete satisfaction 100 percent of the time, either; nor are they without their own risks (particularly contact lenses, which have been shown to carry higher risk of infection than LASIK(4) and, by logical extension given relative rates of endophthalmitis, RLE). Choosing the right optical solution is one of the key skills in vision correction surgery. We would all prefer to have the vision of a 20-year-old emmetrope. To impose an expectation of perfection on presbyopia treatments is to discount the morbidity, inconvenience, and frustration of presbyopia. RLE provides a solution that is convenient and it is effective every waking minute, not just when you can find your readers.

Photic phenomena are indeed a concern with all multifocal IOLs (MFIOLs), and every patient receiving such a lens should first be screened carefully for candidacy and then be counseled regarding these phenomena, via thorough informed consent. RLE surgeons should be comfortable with performing lens exchange if needed, though fortunately this is rarely the case, as satisfaction rates with MFIOLs are high. The fact that about half of MFIOL recipients have some photic phenomena does not invalidate RLE; on the contrary, it speaks to the significance of presbyopia. The vast majority of patients who receive MFIOLs are pleased to ‘look past’ these phenomena in exchange for the benefits of unfettered sight. Beiko’s complaints about specific IOLs are grounded in old studies that most likely don’t apply to currently-implanted lenses. For example, eight of the nine studies he cites regarding glistenings and associated aberrations in Alcon’s Acrysof lenses are from prior to 2012, and the ninth study from 2015 is a five-case series describing IOLs implanted between 2000 and 2010.  This is important: in 2012, Alcon changed their manufacturing process leading to an 87 percent reduction in glistening formation in Acrysof lenses (5). Regardless of specific IOL critiques, there are many IOLs on the market, and neither concerns about one lens, nor comparative statements about an author’s opinion of the superiority of one IOL over another, should be used as evidence to question the efficacy of an entire surgical procedure.

3. Surgical skills vary. Not every ophthalmologist is qualified to be a vision correction surgeon.

Vision correction surgery is demanding. Complications carry high morbidity and the refractive outcomes must be excellent. Not all ophthalmologists have the skills, the interest, or access to state-of-the-art technology needed to succeed as vision correction surgeons. Nor are all ophthalmologists willing to embrace the range of surgical options needed to ensure that the right approach is used for the right patient. Many of the complications that Beiko cited would be unacceptable to most modern vision correction surgeons. Surgeons who break capsule, decenter IOLs, or who cannot deliver on a final refractive outcome in every eye probably should not perform vision correction surgery.

No one argues that surgery does not bring risks. It is the job of all vision correction surgeons to employ their skills to balance the risks of complications against the benefits sought by their patients. Not all patients will qualify, yet many will – and many will benefit. Generalized arguments that RLE is either good or bad without consideration of the context are misguided and potentially misleading. Conflating all patients into one group undermines reasonable discussion!

We agree with Beiko’s premise that vision correction should be performed safely, and that surgeons should exercise a very high level of skill in screening, pre-treating, counseling, and operating on every patient who undergoes vision correction surgery. We also agree that we need prospective studies using current technologies and methods. But we disagree with an article that argues against a valuable and important procedure, especially when it conflates arguments and ignores current methods. Let us not forget that vision – not physiology – is the primary purpose of eyes. Our ability to correct nearly all refractive errors at all stages of adulthood represents a turning point in the human condition. RLE holds an important place in that story and, in the right hands, provides great benefit to a great many people.