Refractive Lens Exchange (Clear Lens Extraction) for Myopia Correction Treatment & Management

Updated: Jun 06, 2019
  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
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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

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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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