eMedicine Specialties > Ophthalmology > Refractive Disorders

Myopia, Clear Lens Extraction: Treatment

Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Coauthor(s): Pierre E Demers, MD, Assistant Professor, Department of Ophthalmology, Notre Dame Hospital, Centre Hospitalier de l'Université de Montréal; Consulting Surgeon, Lasik MD, Canada
Contributor Information and Disclosures

Updated: Oct 31, 2008

Treatment

Medical Therapy

Essentially, most ophthalmologists should follow their standard protocol for cataract extraction.

  • Consideration should be given to antibiotic prophylaxis beforehand (eg, Ocuflox qid 1 day preoperatively).
  • Preoperative prophylactic treatment of the peripheral retina, especially in patients with preexisting abnormalities and in those with high myopia, should be considered. So far, published results on CLE have shown that prophylactic 360° laser therapy provides a lower incidence of postoperative detachment than direct treatment limited to the visible abnormalities, which shows little difference from no treatment at all.
  • Topical antibiotics and steroids, separately or in combination, should be used postoperatively.

Prednisolone acetate 1% (Pred Forte)

  • Sterile ophthalmic suspension that is a topical anti-inflammatory agent for treating steroid responsive inflammation of the palpebral and bulbar conjunctiva, corneal and anterior segment.
  • Adult dose: Instill 1-2 gtt 2-4 times/d into conjunctival sac; during initial 24-48 h, dosage may be increased in frequency prn; shake well prior to use; do not discontinue therapy prematurely
  • Pediatric dose: Not established
  • Contraindications: Documented hypersensitivity; contraindicated in most viral diseases of the cornea and the conjunctiva, including epithelial herpes simples keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and in fungal diseases of ocular structures; prolonged use may lead to glaucoma and cataracts
  • Pregnancy: Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus.
  • Precautions: Fungal infections of the cornea are prone to develop coincidentally with long-term local corticosteroid use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use; obtain fungal cultures when appropriate; if used for 10 d or longer, monitor intraocular pressure.

Ciprofloxacin 0.3% (Ciloxan Ophthalmic, Cipro)

  • Adult dose: 1 gtt q30min for 12 doses, then 1 gtt qh for the first 24-48 h; gradually taper off according to the clinical course
  • Pediatric dose: Administer as in adults
  • Pregnancy: Fetal risk not revealed in controlled studies in humans.
  • Precautions: May inhibit reepithelialization by crystallizing over the epithelial defect

Surgical Therapy

Essentially, surgeons should follow their standard cataract procedure, making allowances for the softer lenses.

Preoperative Details

  • One standard procedure is as follows:
    • Ocuflox qid for 1 day preoperatively
    • Mydriacyl 1%, 3 sets separated by 10 minutes, 1 hour preoperatively
    • Betadine 5-10% ophthalmic solution, 2 drops to cul-de-sac before starting procedure

Intraoperative Details

  • CLE is similar to cataract surgery, except less ultrasound and more aspiration are used.

Postoperative Details

  • Consider Miochol or postoperative pilocarpine if not contraindicated.
  • Follow standard protocol for postoperative medication. One recommended protocol is as follows:
    • Ocuflox 1 gtt qid for 10 days (or until the bottle runs out)
    • Pred Forte 1 gtt qid for 4 days, then taper to 1 gtt every 4 days until discontinued

Follow-up

  • Postoperative follow-up care is arranged with patients on day 1, at 1 week, and at 1 month, at which point refraction may usually be performed.
  • Follow-up care is similar to that for cataract surgery, with attention given to the same possible complications. Patients and/or their caregivers are instructed to call the ophthalmologist if vision suddenly deteriorates instead of slowly improves, if pain occurs, or if the eye becomes red or inflamed.

Complications

  • Complications include the following:
    • Posterior capsular opacification
    • Retinal detachment (see Media file 1) 
    • Macular edema
    • All of these complications are particularly prevalent in cases of extreme refractive error; macular edema is more common in patients with hyperopia.
  • The remaining complications are the same as for any cataract surgery; a detailed discussion can be found in Cataract, Senile. 
    • Endophthalmitis
    • Corneal edema from endothelial disruption, vitreous touch
    • Wound distortion or disruption, leading to astigmatism and iris prolapse
    • Shallow or flat anterior chamber
    • Glaucoma
    • Uveitis
    • Intraocular lens dislocation
    • Hemorrhage (anterior segment or vitreous)
    • Capsular rupture or zonular dialysis
    • Corneal melting with ocular surface disease
    • Filtering bleb
    • Hypotony
    • Iridodialysis
    • Malignant glaucoma
    • Retained lens material
    • Suprachoroidal hemorrhage or effusion (particularly in patients with hyperopia)
    • Wound leak
    • Retinal light toxicity
    • Wrong power IOL

More on Myopia, Clear Lens Extraction

Overview: Myopia, Clear Lens Extraction
Workup: Myopia, Clear Lens Extraction
Treatment: Myopia, Clear Lens Extraction
Follow-up: Myopia, Clear Lens Extraction
Multimedia: Myopia, Clear Lens Extraction
References
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References

  1. Fernandez-Vega L, Alfonso JF, Montes-Mico R, et al. Visual acuity tolerance to residual refractive errors in patients with an apodized diffractive intraocular lens. J Cataract Refract Surg. Feb 2008;34(2):199-204. [Medline].

  2. Dúbravska Z, Rozsival P. [Refractive lensectomy--long-term results]. Cesk Slov Oftalmol. Jan 2007;63(1):28-35. [Medline].

  3. Arne JL. Phakic intraocular lens implantation versus clear lens extraction in highly myopic eyes of 30- to 50-year-old patients. J Cataract Refract Surg. Oct 2004;30(10):2092-6. [Medline].

  4. Colin J, Robinet A. Retinal detachment after clear lens extraction in 41 eyes with high axial myopia. Retina. 1997;17(1):78-9. [Medline].

  5. Colin J, Robinet A, Cochener B. Retinal detachment after clear lens extraction for high myopia: seven-year follow-up. Ophthalmology. Dec 1999;106(12):2281-4; discussion 2285. [Medline].

  6. Dholakia SA, Vasavada AR, Singh R. Prospective evaluation of phacoemulsification in adults younger than 50 years. J Cataract Refract Surg. Jul 2005;31(7):1327-33. [Medline].

  7. Gris O, Guell JL, Manero F, et al. Clear lens extraction to correct high myopia. J Cataract Refract Surg. Jul-Aug 1996;22(6):686-9. [Medline].

  8. Jimenez-Alfaro I, Miguelez S, Bueno JL, et al. Clear lens extraction and implantation of negative-power posterior chamber intraocular lenses to correct extreme myopia. J Cataract Refract Surg. Oct 1998;24(10):1310-6. [Medline].

  9. John ME, Noblitt RL, Coots SD, et al. Clear lens extraction and intraocular lens implantation in a patient with bilateral anterior lenticonus secondary to Alport's syndrome. J Cataract Refract Surg. Nov 1994;20(6):652-5. [Medline].

  10. Kolahdouz-Isfahani AH, Rostamian K, Wallace D, et al. Clear lens extraction with intraocular lens implantation for hyperopia. J Refract Surg. May-Jun 1999;15(3):316-23. [Medline].

  11. Lee KH, Lee JH. Long-term results of clear lens extraction for severe myopia. J Cataract Refract Surg. Dec 1996;22(10):1411-5. [Medline].

  12. Lyle WA, Jin GJ. Clear lens extraction for the correction of high refractive error. J Cataract Refract Surg. May 1994;20(3):273-6. [Medline].

  13. Lyle WA, Jin GJ. Clear lens extraction to correct hyperopia. J Cataract Refract Surg. Sep 1997;23(7):1051-6. [Medline].

  14. Osher RH. Clear lens extraction. J Cataract Refract Surg. Nov 1994;20(6):674. [Medline].

  15. Ripandelli G, Billi B, Fedeli R, et al. Retinal detachment after clear lens extraction in 41 eyes with high axial myopia. Retina. 1996;16(1):3-6. [Medline].

  16. Seiler T. Clear lens extraction in the 19th century--an early demonstration of premature dissemination. J Refract Surg. Jan-Feb 1999;15(1):70-3. [Medline].

  17. Siganos DS, Pallikaris IG. Clear lensectomy and intraocular lens implantation for hyperopia from +7 to +14 diopters. J Refract Surg. Mar-Apr 1998;14(2):105-13. [Medline].

  18. Sinskey RM. Clear lens extraction. J Cataract Refract Surg. Nov 1994;20(6):673-4. [Medline].

  19. Smith SE. Crystalens gains approval. Cataract & Refractive Surgery Today 2004 Jan;. 4(1):67-8.

  20. Wallace RB 3rd. Multifocal vision after cataract surgery. Curr Opin Ophthalmol. Feb 1998;9(1):66-70. [Medline].

  21. Werblin TP. Barraquer lecture 1998. Why should refractive surgeons be looking beyond the cornea?. J Refract Surg. May-Jun 1999;15(3):357-76. [Medline].

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Further Reading

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Keywords

myopia, clear lens extraction, CLE, refractive lens exchange, RLE, shortsighted, nearsighted, nearsightedness, vision loss, visual loss, visual deficit, ametropia, refractive error, refractive surgery, refractive procedures, laser in situ keratomileusis, LASIK, photorefractive keratoplasty, PRK

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Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

Pierre E Demers, MD, Assistant Professor, Department of Ophthalmology, Notre Dame Hospital, Centre Hospitalier de l'Université de Montréal; Consulting Surgeon, Lasik MD, Canada
Disclosure: Nothing to disclose.

Medical Editor

Daniel S Durrie, MD, Director, Department of Ophthalmology, Division of Refractive Surgery, University of Kansas Medical Center
Daniel S Durrie, MD is a member of the following medical societies: American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Louis E Probst, MD, Medical Director of Refractive Surgery, Chicago, Madison, Milwaukee, and Windsor Centers, TLC the Laser Eye Centers
Louis E Probst, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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