Refractive lens exchange or Clear lens extraction

2.  Abbe Desmonceaux(1776)- first surgeon to
perform clear lens extraction
 Vincenz Fukala(1890)- first systematically
performed RLE in high myopics
 Introduction of first PCIOL by Harold Ridley in
1949 was the first big step in contemporary
cataract surgery
 Invention of foldable IOL in 1980

3. Refractive errors with associated lens
opacities ,specially in presbyopic age
High refractive error myopia >10D and
hyperopia >5D in patients >40 years age
are ideal for RLE
Hyperopes in presbyopic age are the best
candidates

4. Retinal diseases that are potentially vision
impairing – macular degeneration
- peripheral degenerations
- retinal breaks
Occupational night drivers
Patients with unrealistic expectations

5.  Anatomically minimally invasive surgery with
minimal trauma to the ocular tissues.
 A secure, watertight 2.5 mm or less micro
incision in clear cornea, optimally 1.0 mm
from the limbus, situated at the steepest
corneal meridian
 Fixation of an appropriate PC-IOL in the
capsular bag with low induction of PCO

6.  In eyes with high axial myopia, depth and
stability of the anterior chamber are
abnormal, which necessitates the use of
dispersive viscoelastic.
 In eyes with excessive axial length, the risk
of perforation during retrobulbar injection is
high.
 In short, hyperopic eyes, an increased risk of
choroidal effusion and macular edema should
be considered.

7.  ADVANTAGES
- Technique familiar to all ophthalmologists
- Does not need further instrumentation or
training
 DISADVANTAGES
- Intraocular procedure
- retinal complications increased with
removal of crystalline lens

8. Proper informed consent
Workup and surgery should be meticulous
Detailed anterior segment and posterior
segment examination should be done to
rule out any preexisting pathology
- raised IOP
- vitreous degeneration
- retinal degeneration

9.  Any retinal lesions should be treated first
 Accurate refraction and corneal topography
should be done
 IOL BIOMETRY
- keratometry and A-scan
- Single most important factor
- to get emmetropic eye biometry
should be error free

10. Keratometry
- first step of biometry
- manual or auto keratometer
- 1D error in corneal power resulting
in 1D postoperative refractive
error

11.  A- scan
a) Applanation/contact A-scan
- supine position is preferable
- do not indent the cornea
- place the probe in the center of
the cornea while maintaining the probe
vertical
- multiple readings should be taken
- most accurate readings should be
averaged

12. b) Immersion A- scan
- more accurate
 1mm error in AL resulting in 2.35D
postoperative refractive error in 23.5mm eye
 IOL master is more
accurate than ultrasound biometry
 Best formula to calculate IOL power in
Myopia- SRKt
Hyperopia- Holladay II

13.  RLE is a refractive procedure not one of
visual rehabilitation
 Extreme care should be taken to avoid any
complications
 Aseptic precautions should be taken
 Topical or Peribulbar anaesthesia
 Surgical steps are same as routine
phacoemulsification

14.  Incision
– temporal clear corneal incision is the
best route of entry
- size 2.5mm or less
 Capsulorhexis
- good dispersive viscoelastic(Na
chondrotin sulphate) should be used
- central and just smaller than the optic
of IOL to be used
- large/decentered rhexis will cause
capsular fibrosis, PCO, IOL decentration
- runaway rhexis or extension of rhexis
results in PCR

15. Irrigating solution used should be of best
quality preferably BSS with glutathione
All tubings, cannulae, knives should be
single use disposable
Hydrodissection
- should be complete
- forced rotation of nucleus in the
absence of good hydrodissection
results in severe zonular damage

16. Low phaco power with moderate flow and
vaccum will be ideal
Removal of the nucleus by creating a
wide, deep, long trench with just irrigation
and aspiration
Cortical cleanup should be complete
Posterior capsular polishing should be
done if necessary

17. IOL used should give good centration with
minimal PCO incidence
Posterior square edge design with haptics
will be the best choice
If IOL were to be placed in the sulcus
power should be reduced by 0.5D

18.  TRADITIONAL
MONOFOCAL IOLs
- Very effective in
providing one optimal
focusing distance
- require additional
spectacle correction to
correct vision at all other
distances

19. MULTIFOCAL IOLs
- provide good uncorrected distance
and near vision
- 2 types
a) Refractive – very pupil dependent
b) Diffractive- less pupil dependent
- Disadvantages
- loss of contrast sensitivity
- glare and halos from light
sources during night vision

21. PSEUDOACCOMMODATIVE IOLs
- less pupil size dependent
- do not provide good intermediate
vision

22. ACCOMMODATIVE IOLs
- move anteriorly during near vision

23.  Patients with high myopia are often willing to have
RLE
 Contraindications
– Eyes with advanced peripheral lattice
degenerations
– Young eyes with no posterior vitreous
detachment
– Laquer cracs in high myopia or myopic
CNV in the fellow eye
– Presbyopic eyes with macular degeneration
beginning in the fellow eye

24.  Complications

1.Retinal detachment
- most vision threating
Risk factors – increased axial length
- age <50 years
- males
- caucasian race
- peripheral retinal
degenerations
- intraoperative PCR
- Nd:YAG capsulotomy

25. 2. myopic macular degeneration
3. cystoid macular edema
4. posterior capsular opacification
5. halos and glare
6. choroidal neovascularization(CNV)
7. ARMD

26.  Indications
– Beginning presbyopia with weakened
accommodation of crystalline lens
– High order aberrations, when laser
surgery need to be avoided
– High hyperopia in patients with
congenital systemic condition who
are unable to wear spectacles or
contact lenses

27. Small hyperopic eyes with shallow AC are
more predisposed to closed angle
glaucoma
This makes even moderate hyperopia an
indication for RLE with good benefit/risk
ratio

28. Complications
- PCO – most common
- secondary postoperative IOP raise
- postoperative uveal effusion

29.  Indications
– High anisometropia or severe
bilateral ametropia
– Congenital conditions disabling
proper binocular vision
– Non-compliant children with high
refractive errors where treatment
with refractive laser surgery is
impossible

30.  Shimizu (1992) – invented Toric IOL
 Posterior chamber toric lens implantation is a
new highly predictable surgical option for
patients with pre existing corneal astigmatism

31. Accommodative or Multifocal IOLs
Aim – to restore good distance, near and
intermediate visual function