Refractive Lens Exchange

What is refractive lens exchange?

Refractive lens exchange is an elective outpatient surgery that removes your eye’s natural lens and replaces it with an intraocular lens (IOL). Like a contact lens or the lens of your eyeglasses, an IOL contains a vision prescription that’s customized to your eyes. The difference is that your provider permanently implants the IOL in your eye.

Once it’s in place, the IOL functions just like your eye’s natural lens. It refracts (bends) light as it enters your eye, helping it land properly on your retina so you can see clearly. Many people don’t need to wear glasses or contacts after their surgery, or if they do, it’s only for specific tasks like reading.

Refractive lens exchange offers an alternative to laser surgeries that change the shape of your cornea to correct your vision. Such surgeries, like LASIK and PRK, aren’t suitable for some people who have high refractive errors or certain eye conditions. If you’re not a candidate for corneal surgery, your provider may recommend refractive lens exchange.

Am I a candidate for refractive lens exchange?

An eye care specialist will evaluate your eyes and tell you if this surgery is appropriate for you. You may be a candidate for refractive lens exchange if you:

• Have extreme myopia (nearsightedness) or hyperopia (far-sightedness) that makes you ineligible for laser vision correction.
• Have presbyopia (age-related farsightedness) and want to rely less on glasses or contacts.

If you have any of the following conditions, this surgery may not be suitable for you:

• An eye disease that affects your cornea.
• Age-related macular degeneration.
• Diabetes-related retinopathy.
• Risk factors for retinal detachment.
• Uveitis.

Refractive lens exchange age

Generally, the surgery is best suited for people over 40.

Ideal candidates are usually 40 or older because they may face a lower risk of complications. Also, the surgery is most helpful in people who have started to develop presbyopia because they’ve already lost some of the natural near-focus capabilities related to aging. Presbyopia typically begins after age 40.

What does this procedure treat?

Refractive lens exchange improves vision in people who have:

• Nearsightedness.
• Farsightedness.
• Age-related farsightedness (presbyopia).
• Astigmatism.

What is the difference between cataract surgery and refractive lens exchange?

Both cataract surgery and refractive lens exchange are types of eye lens replacement surgery. This means a provider removes your eye’s natural lens and replaces it with an IOL. The main difference is the reason for the surgery:

• You have cataract surgery because your eye’s natural lens is cloudy. The cloudy lens interferes with your vision. So, you receive a new, clear IOL to help you see clearly again.
• You have refractive lens exchange because refractive errors (like extreme nearsightedness) prevent you from seeing clearly. In this case, you don’t have cataracts, and your natural lens is clear. But replacing your lens allows you to correct focus problems and more easily go about your daily routine. You can rely less on glasses or contacts, which offers convenience for certain jobs and activities.

How should I prepare?

Your ophthalmologist will give you a pre-operative evaluation to check the health of your eyes and discuss your IOL implant options with you. They’ll perform a thorough eye exam, checking for any underlying conditions that could raise your risk of surgical complications. They’ll also talk with you about your lifestyle and preferences to learn what type of IOL is most suitable for you.

It’s essential to learn about available IOL options. Ask about the pros and cons of each type, and how each type will affect your day-to-day routine.

For example, multifocal IOLs improve your vision at multiple ranges, but they may cause glare and halos around lights. For some people, this is a minor inconvenience, while for others, it’s highly disruptive. Monofocal lenses typically avoid this side effect, but they can only correct for one range (like distance or near, but not both). So, if you have monofocal IOLs, you may need glasses for reading or other tasks that require precise close-up vision. Choosing to have one eye focused for distance and the other for near, called monovision, is a popular strategy for balancing these needs.

Talk to your provider to get all the information you need to make the decision that’s best for you.

What happens during this procedure?

To perform refractive lens exchange surgery, a surgeon:

1. Gives you eye drops to numb the surface of your eye. They may also give you medicine to help you feel relaxed. You’ll be awake, but your vision will be blurry. You’ll just see light and general movements around you.
2. Uses a laser or blade to make a small incision in your eye at the place where your sclera and cornea meet.
3. Uses a pen-shaped tool to break up and remove your natural lens (phacoemulsification). During this process, the lens is broken into many small pieces. Then, ultrasound waves liquefy the pieces, and a vacuum system suctions them out.
4. Inserts your new IOL through the same incision and positions it within your lens capsule (the thin membrane that holds your lens). The incision is so small that you don’t need stitches. It’ll seal shut on its own.
5. Tapes a shield over your eye to protect it.

How long does this procedure take?

The surgery usually takes 15 to 30 minutes.

What happens after this procedure?

Your provider will monitor you for about 30 minutes after your surgery ends. Then, you can go home. Make sure to arrange for someone to drive you home. You should also ask someone to drive you to and from your first follow-up appointment (typically the next day). At that point, your provider will tell you when it’s safe for you to drive again.

You may have blurred vision right after your surgery. That’s normal. Your vision will clear up quite a bit after several days. It’s also common to experience other temporary side effects as your eyes heal, such as:

• Double vision.
• Gritty feeling in your eyes.
• Red or bloodshot eyes.
• Watery eyes.

Visual side effects

You may notice visual side effects as you recover from your surgery. IOLs can cause such effects, and they’re not a cause for concern. You may notice:

• A shadow in your peripheral (side) vision.
• A shimmering arc of light in your peripheral vision.
• Halos or glare around lights, especially when driving at night.

These effects happen more often from multifocal IOLs compared to monofocal IOLs. Usually, they lessen over time. But if they greatly interfere with your daily routine, talk to your provider.

What are the benefits of this procedure?

Like any surgery, refractive lens exchange has pros and cons. The main benefits are:

• The surgery can treat all types of refractive errors.
• You can be free or mostly free of glasses. About 4 out of 5 people don’t need glasses at all after their surgery.
• You don’t have to worry about developing cataracts later in life. Cataracts only form on natural lenses, not IOLs.

How successful is refractive lens exchange?

About 95% of people are happy with their vision after surgery.

What are the risks or complications of refractive lens exchange?

Retinal detachment is the most serious complication of refractive lens exchange. Your risk may be higher if you have extreme nearsightedness or are under age 50.

Other possible complications include:

• Vison loss. Varying degrees of vision loss can occur due to damage to your retina.
• Posterior capsular rupture. This is when the membrane that holds your lens breaks during surgery. Your surgeon will make adjustments to address the problem. But in some cases, you may need to come back for additional procedures.
• Posterior capsular opacification (“secondary cataract”). A secondary cataract is a gradual clouding of the membrane that holds your lens (not a clouding of the lens itself). It can occur months or years after surgery. Your ophthalmologist can correct this problem through a laser procedure.

Talk to your ophthalmologist before your surgery to learn your individual level of risk and what you can do to lower the chances of any complications. In general, your risk of complications is lower when you receive care from ophthalmologists experienced in performing these surgeries.

What is the recovery time?

It’ll take up to eight weeks for your eye to fully heal. But you should be able to return to most of your normal activities within a few days or weeks. Your provider will tell you how long you should wait to:

• Drive.
• Go back to work.
• Swim.
• Exercise (in general, you need to wait longer for contact sports).

Your provider will prescribe eye drops to help your eyes heal. Be sure to use these drops according to the schedule your provider gives you.

When should I call my healthcare provider?

Call your provider right away if the following side effects get worse rather than improve:

• Pain or discomfort in your eyes.
• Sensitivity to light.
• Redness in your eyes.
• Blurred vision.

When should I seek emergency care?

Seek care immediately if you have signs of retinal detachment. The sooner you receive medical attention, the better your chances of a successful repair.

Signs to look out for include:

• Sudden, new onset of floaters.
• Flashes of light that you can see with eyes open or closed.
• The sense that a shadow or curtain is spreading across your line of sight.

What options do I have besides refractive lens exchange?

Refractive lens exchange isn’t for everyone. There are other methods for vision correction that your provider may recommend first. The least invasive option is wearing glasses or contacts. But many people wear glasses or contacts for years and decide they don’t want to wear them anymore, or they want to wear them only occasionally. In that case, procedures that can help include:

• Laser vision correction. This type of surgery uses lasers to change the curvature and focusing power of your cornea (the clear window on the front of your eye). Your provider may recommend a laser surgery like LASIK or PRK if you have mild or moderate refractive errors and meet specific criteria. However, if you have high refractive errors or certain eye conditions, you won’t be a candidate.
• Phakic intraocular lens (PIOL) implantation. Phakic IOLs are implants that rest in front of your natural lenses (the surgeon doesn’t remove your natural lens). Phakic IOLs may suit your needs if you have high nearsightedness but haven’t yet developed presbyopia (age-related farsightedness). Keeping your natural lens allows you to preserve your close-up vision. A phakic IOL works with your eye’s natural lens to give you clear vision at multiple ranges.

If you’re not a candidate for laser vision correction or phakic IOLs, your provider may suggest refractive lens exchange. An eye care specialist can talk with you about the pros and cons of all these procedures and help you decide what’s best for your needs.

A note from Cleveland Clinic

Refractive lens exchange can help you see the world in a whole new way. But it’s not for everyone. Before scheduling your surgery, you should evaluate the pros and cons so you can make an informed decision. Talk with your provider to learn more about procedure details, IOL options and what you can expect in the months and years after your surgery.