Clear Lens Extraction Myopia Treatment & Management

  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 14, 2015
 

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

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Surgical Therapy

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

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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
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Intraoperative Details

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

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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
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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.

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Complications

Complications include the following:

  • Posterior capsular opacification
  • Retinal detachment
    Comparison of published data on retinal detachment Comparison of published data on retinal detachment after clear lens extraction.
  • 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
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Outcome and Prognosis

Visual outcome is usually excellent.

A 2008 retrospective study of 129 eyes showed CLE with posterior chamber IOL implantation to be safe, predictable, and effective. CLE was shown to achieve excellent visual acuity and refractive outcome with few complications.[4]

The latest reports with prophylactic 360° therapy of peripheral retina show a statistically lower rate of retinal detachment in those eyes than if they had not been subjected to prophylactic treatment.

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Future and Controversies

CLE is becoming a more accepted procedure. Arguments in favor of CLE are as follows: predictability, stability, ease and cost with which a general surgeon can perform the technique, use of toric or multifocal lens technologies and small-incision surgery, and better optical quality vision. Arguments against CLE are as follows: seriousness of complications, rate of complications, and availability of other less invasive refractive procedures.

In a 2004 study comparing the 2 procedures, Arne believed that phakic IOL placement was a safer modality than CLE in the same selected group of patients that corneal refractive surgery cannot address.[5]

If clouding of the capsule can be eliminated and if a truly accommodating and adjustable lens can be achieved, CLE could become a much more prevalent refractive procedure.

The advent of the ReSTOR and ReZoom lenses in 2005 and 2006, respectively, increased the frequency of this procedure, and the advent of newer and better lenses continues to increase demand and quality of results.

Studies from 2010 show that CLE is a also a financially better and easier modality for treating high myopia in the developing world and that supracapsular phacoaspiration for clear lens extraction in correction of high myopia seems to present no risk for the posterior capsule, although there is a marginal risk to the endothelial cell count.[6, 7]

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Contributor Information and Disclosures
Author

Mounir Bashour, MD, PhD, CM, FRCSC, FACS Assistant Professor of Ophthalmology, McGill University Faculty of Medicine; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, PhD, CM, FRCSC, 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, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Pierre E Demers, MD Regional Medical Director, Lasik MD Centers in Quebec; National Director of Professional Services, Lasik MD; Former Assistant Professor of Ophthalmology, University of Montreal, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Louis E Probst, MD, MD Medical Director, TLC Laser Eye Centers

Louis E Probst, MD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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, Association for Research in Vision and Ophthalmology

Disclosure: Received grant/research funds from Alcon Labs for independent contractor; Received grant/research funds from Abbott Medical Optics for independent contractor; Received ownership interest from Acufocus for consulting; Received ownership interest from WaveTec for consulting; Received grant/research funds from Topcon for independent contractor; Received grant/research funds from Avedro for independent contractor; Received grant/research funds from ReVitalVision for independent contractor.

References
  1. Nanavaty MA, Daya SM. Refractive lens exchange versus phakic intraocular lenses. Curr Opin Ophthalmol. 2011 Nov 10. [Medline].

  2. 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. 2008 Feb. 34(2):199-204. [Medline].

  3. El-Helw MA, Emarah AM. Assessment of phacoaspiration techniques in clear lens extraction for correction of high myopia. Clin Ophthalmol. 2010 Mar 24. 4:155-8. [Medline]. [Full Text].

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

  5. 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. 2004 Oct. 30(10):2092-6. [Medline].

  6. Emarah AM, El-Helw MA, Yassin HM. Comparison of clear lens extraction and collamer lens implantation in high myopia. Clin Ophthalmol. 2010 May 14. 4:447-54. [Medline]. [Full Text].

  7. El-Helw MA, Emarah AM. Assessment of phacoaspiration techniques in clear lens extraction for correction of high myopia. Clin Ophthalmol. 2010 Mar 24. 4:155-8. [Medline]. [Full Text].

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

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

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

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

  12. 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. 1998 Oct. 24(10):1310-6. [Medline].

  13. 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. 1994 Nov. 20(6):652-5. [Medline].

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

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

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

  19. 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].

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

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

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

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

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Comparison of published data on retinal detachment after clear lens extraction.
 
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