Patients should be informed that enhancement surgery after IOL implantation is a possibility.
Patients should be informed that enhancement surgery after IOL implantation is a possibility. Photo: Ethan Zimmerman, OD. Click image to enlarge.

As presbyopia-correcting IOLs get increasingly better with each new generation, more patients are apt to consider the option of refractive lens exchange (RLE), wherein the crystalline lens is removed even in the absence of cataract, purely for the vision gains to be had from an elective implantation. Findings of a recent study support the safety and efficacy of RLE with trifocal IOLs for presbyopia, but the authors point out that patient counseling for possible future enhancement surgery is important. 

The multicenter, retrospective, interventional case series included 17,603 patients with bilateral presbyopic RLE with trifocal IOLs. The three-month mean manifest refraction spherical equivalent (MRSE) of 0D and a mean binocular UDVA -0.03D for 82% of patients; 86% of eyes were within 0.5D of MRSE. 

Myopic eyes had significantly higher safety and efficacy indices. Approximately 0.38% of eyes lost two or more lines of CDVA and after care (most commonly for cystoid macular edema and posterior capsular opacification), final incidence was 0.08%. 

The researchers also recommended adding preoperative OCT to the workup for RLE due to a reported 4.6% incidence of positive findings including epiretinal membrane, choroidal neovascular membrane, macular hole and macular edema. “Patients with positive retinal findings by the retinal OCT must be considered unsuitable for RLE with trifocal implants,” they wrote. 

Enhancement surgery wasn’t uncommon, occurring in 16.5% of eyes. The authors noted that IOL power calculation refining improved the accuracy and reduced the rate of enhancements from 20% to 12% during the six-year study period. 

They concluded that “enhancement surgery with excimer laser or supplementary IOL should be considered as part of the treatment, and all patients must be informed before the surgery about this possibility for the improvement of uncorrected visual performance from three to six months after presbyopic RLE with trifocal IOLs.”

Brenner LF, Nistad K, Schonbeck U, et al. Rethinking presbyopia: results of bilateral refractive lens exchange with trifocal intraocular lenses in 17,603 patients. Br J Ophthalmol. February 2, 2022. [Epub ahead of print].