refractive lens exchange in younger and older presbyopes ...€¦ · Visual acuity was measured at distance with a Snellen visual acuity chart and at 40 cm (near) with a logarithmic
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http://dx.doi.org/10.2147/OPTH.S143201
refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes
steven C schallhorn1–3
Julie M schallhorn1
Martina Pelouskova3
Jan a Venter3
Keith a hettinger3
stephen J hannan3
David Teenan3
1Department of Ophthalmology, University of California, san Francisco, Ca, Usa; 2roski eye institute, University of southern California, los angeles, Ca, Usa; 3Optical express, glasgow UK
Purpose: To compare refractive and visual outcomes, patient satisfaction, and complication rates
among different age categories of patients who underwent refractive lens exchange (RLE).
Methods: A stratified, simple random sample of patients matched on preoperative sphere and
cylinder was selected for four age categories: 45–49 years (group A), 50–54 years (group B),
55–59 years (group C), and 60–65 years (group D). Each group contained 320 patients. All
patients underwent RLE with a multifocal intraocular lens at least in one eye. Three months
postoperative refractive/visual and patient-reported outcomes are presented.
Results: The percentage of patients that achieved binocular uncorrected distance visual acuity
20/20 or better was 91.6% (group A), 93.8% (group B), 91.6% (group C), 88.8% (group D),
P=0.16. Binocularly, 80.0% of patients in group A, 84.7% in group B, 78.9% in group C, and
77.8% in group D achieved 20/30 or better uncorrected near visual acuity (P=0.13). The pro-
portion of eyes within 0.50 D of emmetropia was 84.4% in group A, 86.8% in group B, 85.7%
in group C, and 85.8% in group D (P=0.67). There was no statistically significant difference
in postoperative satisfaction, visual phenomena, dry eye symptoms, distance or near vision
activities. Apart from higher rate of iritis in the age group 50–55 years, there was no statistically
significant difference in postoperative complication rates.
Conclusion: RLE can be safely performed in younger as well as older presbyopes. No significant
difference was found in clinical or patient-reported outcomes.
IntroductionRefractive lens exchange (RLE) is a popular surgical modality among presbyopes,
and it is no longer restricted to only patients with prescriptions outside of limits of
keratorefractive surgery.1–4 Intraocular lens (IOL) designs have advanced tremendously
over the past 3 decades,1,2 and more and more patients in presbyopic age range, regard-
less of the amount of preoperative refractive error, seek simultaneous correction of
distance, intermediate, and near vision.
RLE is often the best surgical option for older presbyopes, as it focuses on the main
reason for presbyopia development (aging crystalline lens) and prevents formation of
the cataract in the future.3,4 Some surgeons are, however, cautious about performing
RLE on younger presbyopes owing to the associated optical side effects and surgical
risks. In theory, younger presbyopic patients are more active and might have higher
visual demands. Some optical side effects associated with multifocal IOLs, such as
glare, halo, loss of contrast sensitivity,1,2 might therefore be more bothersome in this
group of patients. RLE is also associated with rare but vision-threatening complications,
Correspondence: steven C schallhorn11730 Caminito Prenticia, san Diego, Ca 92131, Usaemail [email protected]
Journal name: Clinical OphthalmologyArticle Designation: Original ResearchYear: 2017Volume: 11Running head verso: Schallhorn et alRunning head recto: RLE younger vs older presbyopesDOI: http://dx.doi.org/10.2147/OPTH.S143201
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It is also important to note, that most of the reported cases of
RD were in patients in pre-presbyopic age range (less than
40 years),6–9 which is different than our dataset. Although
only a small percentage of eyes (less than 3% in each age
category) had preoperative MSE less than -6.0 D, and most
of them were treated 2 or more years ago, none of them
developed an RD. Interestingly, the only case of RD in this
study was observed in a 61-year old patient with an axial
length of 22.38 mm, which would normally be considered as
a low risk for RD. It is still, however, advisable to carefully
counsel and perform a thorough preoperative vitreo-retinal
examination in younger patients with incomplete posterior
vitreous detachment. All other postoperative complications
were comparable between age groups, except for incidence
of iritis, which was higher in age category 50–54 years. One
would expect higher complication rates in older patients, but
this was not confirmed in this study.
LimitationsOne of the limitations of this study was that retrospective
data were used for analyses. However, it would prove
difficult to conduct a study on such large scale prospec-
tively, and it would likely result in a much lower number
of patients in each category. Postoperative follow-up in
some patients was not long enough to accurately assess
long-term complications, although most of the complica-
tions specific to RLE (eg, macular or corneal edema, iritis,
raised IOP, endophthalmitis, etc)14 tend to occur during
early follow-ups. Although the questionnaire used in this
study was found effective for reporting subjective outcomes
of refractive procedures,14,25,26 use of a well-established,
validated quality of life instrument could also add to the
value of this study. It would also be interesting to com-
pare data samples stratified by axial length, however, in
our experience, patient-reported outcomes are mostly
dependent on patients’ preoperative refractive status,
rather than axial length. Therefore, the stratification of data
samples in this paper was based on preoperative refraction.
In conclusion, RLE in different age categories resulted
in similar clinical outcomes and patient satisfaction rates.
As long as all the precautions are taken to minimize the
risk of sight-threatening complications, RLE can be safely
performed in younger presbyopic patients. Most of the
patients in this study had refractive error within the limits
of keratorefractive procedures (Figure 1), but elected to
undergo RLE to achieve complete spectacle independence.
New trends in intraocular surgery, such as introduction of
femtosecond lasers to cataract surgery,3,4 micro-incision
surgery,3,4 or use of prophylactic intracameral antibiotics
to prevent endopthalmitis,5 immensely improved the safety
profile of this procedure, hence, phacoemulsification with
implantation of IOL is no longer restricted only to patients
with cataractous crystalline lens. Preoperative consultation
and discussion of the optical side effects remain one of the
most important factors in preoperative patient selection.
DisclosureSteven C Schallhorn is a chief medical officer for Zeiss,
consultant for Acufocus, and a chairman of the medical
advisory board for Optical Express. Julie M Schallhorn has
been a member of the advisory board for Malinckrodt Phar-
maceuticals and received a lecture honorarium payment from
Avellino Labs. None of the other authors have a financial or
proprietary interest in the products and materials presented
in this paper.
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Supplementary materials
Table S1 Postoperative patient-reported outcomes according to age category
Age category 45–49 years(n=320 patients)
50–54 years(n=320 patients)
55–59 years(n=320 patients)
60–65 years(n=320 patients)
P-value
Thinking about your vision during the last week, how satisfied are you with your vision? (1= very satisfied, 2= satisfied, 3= neither, 4= dissatisfied, 5= very dissatisfied)Satisfied (score 1 & 2)neither (score 3)Dissatisfied (score 4 & 5)
87.5%6.9%5.6%
86.9%5.0%8.1%
89.4%6.9%3.8%
89.4%4.7%5.9%
0.26
Would you recommend vision correction surgery to your friends and relatives?Yes/no 91.9%/8.1% 93.1%/6.9% 94.4%/5.6% 92.8%/7.2% 0.66Has surgery improved your quality of life?Yes/no 91.6%/8.4% 91.9%/8.1% 92.8%/7.2% 91.6%/8.4% 0.93If you had to do it over, would you have vision correction surgery again?Yes/no 91.3%/8.8% 94.1%/5.9% 94.4%/5.6% 93.8%/6.3% 0.37Think about your vision during the last week. Please rate the degree of difficulty you experienced with each of the visual symptoms/dry eyes.(Measured on discrete scale from 1= no difficulty to 7= severe difficulty).StarburstNo or little difficultyModerate difficultySignificant difficulty
61.3%32.8%5.9%
60.0%30.0%10.0%
56.6%36.6%6.9%
62.2%31.3%6.6%
0.26
GlareNo or little difficultyModerate difficultySignificant difficulty
59.7%32.2%8.1%
57.2%32.5%10.3%
56.6%36.3%7.2%
57.8%35.0%7.2%
0.69
HaloNo or little difficultyModerate difficultySignificant difficulty
58.8%33.1%8.1%
58.4%30.9%10.6%
59.1%33.1%7.8%
62.5%31.3%6.3%
0.57
Ghosting/double visionNo or little difficultyModerate difficultySignificant difficulty
75.9%19.7%4.4%
72.5%22.2%5.3%
72.5%23.1%4.4%
75.6%20.0%4.4%
0.90
Dry eyesNo or little difficultyModerate difficultySignificant difficulty
72.8%24.7%2.5%
69.7%26.6%3.8%
72.8%25.9%1.3%
67.8%29.4%2.8%
0.40
No or little difficulty (score 0, 1), Moderate difficulty (score 3, 4, 5), Significant difficulty (score 6, 7)Because of your eyesight, how much difficulty do you have with the following activities?(1= No difficulty, 2= A little difficulty, 3= Moderate difficulty, 4= A lot of difficulty, 5= never try to do this because of my vision, 6= never do this for other reasons)Driving at nightNo or little difficultyModerate difficultySignificant difficulty
73.2%15.7%11.2%
71.8%16.8%11.3%
72.5%16.8%10.7%
73.9%19.1%7.0%
0.55
Doing work or hobbies that require you to see well up close, such as cooking, fixing things around the house, sewing, using hand tools, or working with a computerNo or little difficultyModerate difficultySignificant difficulty
91.2%6.0%2.8%
89.3%7.8%2.8%
90.9%7.2%1.9%
89.7%6.9%3.4%
0.88
Taking part in active sports or other outdoor activities that you enjoy (like hiking, swimming, aerobics, team sports, or jogging)No or little difficultyModerate difficultySignificant difficulty
95.2%3.5%1.3%
95.1%4.2%0.6%
96.6%2.7%0.7%
96.3%3.0%0.7%
0.88
No or little difficulty (score 0, 1), Moderate difficulty (score 3), Significant difficulty (score 4, 5)
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rle younger vs older presbyopes
Table S2 Patient-reported outcomes: difference between postoperative and preoperative scores
Age category 45–49 years(n=146 patients)
50–54 years(n=153 patients)
55–59 years(n=162 patients)
60–65 years(n=161 patients)
P-value
Think about your vision during the last week. Please rate the degree of difficulty you experienced with each of the visual symptoms/dry eyes.(Measured on discrete scale from 1= no difficulty to 7= severe difficulty).StarburstWorseUnchangedBetter
20.5%78.8%0.7%
22.9%75.8%1.3%
24.1%75.3%0.6%
19.9%77.6%2.5%
0.71
GlareWorseUnchangedBetter
19.9%78.8%1.4%
23.5%74.5%2.0%
22.8%76.5%0.6%
18.6%78.9%2.5%
0.76
HaloWorseUnchangedBetter
22.6%75.3%2.1%
22.2%77.8%0.0%
22.2%77.2%0.6%
21.7%77.6%0.6%
0.63
Ghosting/double visionWorseUnchangedBetter
15.1%82.9%2.1%
12.4%87.6%0.0%
11.7%87%1.2%
16.1%81.4%2.5%
0.43
Dry eyesWorseUnchangedBetter
13.0%84.2%2.7%
14.4%83.7%2.0%
12.3%86.4%1.2%
16.8%81.4%1.9%
0.87
Worse: increase in symptoms by more than 2 scoresUnchanged: preoperative minus postoperative score 0±2 scoresBetter: decrease in symptoms by more than 2 scoresBecause of your eyesight, how much difficulty do you have with the following activities? (1= No difficulty, 2= A little difficulty, 3= Moderate difficulty, 4= A lot of difficulty, 5= never try to do this because of my vision, 6= never do this for other reasons)Driving at nightWorseUnchangedBetter
21.7%72.7%5.6%
17%76.9%6.1%
17.8%73.0%9.2%
12.0%81.7%6.3%
0.35
Doing work or hobbies that require you to see well up close, such as cooking, fixing things around the house, sewing, using hand tools, or working with a computerWorseUnchangedBetter
6.3%72.7%21%
4.6%69.1%26.3%
1.3%75%23.8%
3.8%74.8%21.4%
0.34
Taking part in active sports or other outdoor activities that you enjoy (like hiking, swimming, aerobics, team sports, or jogging)WorseUnchangedBetter
2.9%79.7%17.4%
1.3%80.5%18.1%
0.0%74.3%25.7%
1.4%79.7%18.9%
0.25
Worse: increase in symptoms by more than 1 scoreUnchanged: preoperative minus postoperative score 0±1 scoreBetter: decrease in symptoms by more than 1 score
Notes: Patients rated their preoperative symptoms/difficulties with best spectacle/contact lens correction; postoperative symptoms were rated without any spectacle/contact lens correction.