Presbyopia

What is a Refractive Lens Exchange (RLE)?

Dr. Matthew Sharpe- Founder of SharpeVision

By Dr. Matthew R. Sharpe

February 23, 2022

You may have heard of a procedure called refractive lens exchange, or RLE, and wondered about it. A refractive lens exchange consists of removing the natural lens of your eye and replacing it with an artificial lens. It’s very important to know what are different types of eye surgery such as we have described in this and other blog posts. The benefits of a refractive lens exchange are:

  • See distant objects clearly 
  • See near objects clearly 
  • Corrects astigmatism 
  • You will not need cataract surgery when you’re older

You may not be aware that inside your eye you have a natural lens that helps you to focus light. The natural crystalline lens is about the size and shape of an M&M candy and sits directly behind your iris (the colored part of your eye). The lens goes through several stages in everyone’s life:

Four Stages of the lens of your eye:

  • Birth to age 18: ocular maturation
  • Age 18 to 45: ocular stability
  • Age 45 to 60: lens dysfunction stage 1: also known as presbyopia
  • Age 60 and older: lens dysfunction stage 2: lens opacification, also known as cataract

Let’s briefly discuss each of the 4 stages of the lens of your eye.

Stage one: birth to age 18

Ocular maturation occurs as our bodies grow from childhood to adulthood. In this time of life several things happen to our eyes: one is that your eyes grows slightly bigger (although not terribly much bigger than they are at birth) your eye may also get longer, in which case you will have a potentially progressive shift toward nearsightedness. These changes generally start around age 7 to 12 and progress through our teen years as the rest of our body grows. If you are going to become nearsighted, the later you begin to become nearsighted the less likely it is that you will become severely nearsighted. Sometimes children have a change in their prescription of up to one diopter per year or more. So if your eyes change an average of .75 diopters per year in the nearsighted direction for 10 years you may be highly nearsighted, however if they change starting at age 13 through 18 you may be less nearsighted, perhaps -3.75 or thereabouts. These are highly variable, but it’s just a rule of thumb. Currently, there are many theories about why our eyes get progressively nearsighted. It is outside the scope of this blog post to discuss all of these, but there has been some progress in this area. Nearsightedness has become somewhat of an epidemic with more and more people and a higher percentage of people who are becoming not only nearsighted but severely nearsighted. When we are severely nearsighted our risk increases of eye pathology such as glaucoma, retinal detachment, and early cataract.

Stage two: age 18 to 45:

The best time to have laser vision correction is in our young adult years. You don’t need to worry about reading glasses, you will typically have less dryness than someone who is much older, and you will have stability of results. Not to mention more time to enjoy life without contacts or glasses. I personally had my Lasik when I was 32 years old and have enjoyed clear distance vision ever since. We rarely recommend the refractive lens exchange for anyone in this age group. The exception is someone who is extremely farsighted. Farsightedness is a very difficult burden to bear. When you are extremely farsighted, you have difficulty seeing up close, distance and everything in between regardless of your age. The eyeglasses of a highly farsighted person magnify the eyes which esthetically is not palatable. Vision is distorted, and contacts are more difficult to wear successfully. Often times people with extreme farsightedness will have crossed eyes when they are babies. For these people, laser vision correction is not generally recommended. A refractive lens exchange may be an excellent option even for a young person who is extremely farsighted.

Stage three: age 45 to age 60: Presbyopia

In this period of our lives, the first noticeable sign of lens dysfunction is that the lens of our eye can no longer flex to see both distance and near objects without glasses. This is called presbyopia, which refers to the loss of flexibility of our natural lens. Even somebody who has had laser vision correction and sees perfectly at distance will need readers for near at about age 45 and older. This is not a function of the laser vision correction, but a function of aging. We do not have perfect eye surgery types for this initial stage of lens dysfunction, but there are some options that you should discuss with your surgeon.

The options for treating presbyopia are:

  • Monovision (see blog post: https://sharpe-vision.com/blog/lasik-for-reading/)
  • Reading glasses for anything within arm’s reach
  • Vuity (https://sharpe-vision.com/blog/what-is-vuity/ ) or other eyedrops that are coming over the next few years may help somewha,t but do not as of yet restore normal lens function
  • Refractive lens exchange. This may be recommended for anyone over the age of 45. The decision of which of the different types of eye surgery to recommend depends on multiple factors such as refractive error, eye anatomy which includes the thickness of your cornea and the space in your “anterior chamber,” and clarity of your lens. It’s always extremely important to discuss the procedure at length with your surgeon so you know all the pros and cons for your particular situation. It’s also good, in my opinion, to seek out a surgeon who has experience with all types of eye surgery, and all the refractive procedures available, so that there is no limitation with regards to which procedure is recommended. Refractive lens exchange (discussed at length below) is a definitive treatment (one and done-won’t need another refractive eye surgery) that allows you to focus on distant objects, near objects and not need cataract surgery as you get older

Stage 4: age 60 and older

At this age, a refractive lens exchange becomes increasingly appealing. We all develop cataracts at some point in our lives, but typically don’t qualify for insurance coverage for the cataract until we are quite old (70 years and older). If you have a glasses prescription, this increases the appeal of a refractive lens exchange because it can do everything that LASIK can do and more for our older patients. Laser eye surgery types such as LASIK and PRK may not be appropriate as we get into our 50s and 60s. RLE allows you-through advanced technology intraocular lenses- to replace your glasses completely. Yes that’s right: it allows you to replace your distance glasses and has multifocality which allows you to see near objects also quite well. If you have astigmatism, that is also corrected with the intraocular lens or by what is called a limbal relaxing incision. Also, because you have had your lens replaced, you will not need cataract surgery in the future. My thought is that if you have glasses and you are 45 or older, a refractive lens exchange may be the best procedure for you. It is definitive, permanent and does not get worse as you get older. You have one 10 minute procedure, and you’re done with glasses forever!

Is Refractive Lens Exchange Painful?

This type of eye surgery, a refractive lens exchange, is one of the easiest procedures we do. There is no pain. In our practice, we use no needles and no blades, so there is no pain of any sort. We use a laser that first makes the cataract refractive lens exchange incision, then breaks up the lens in your eye. This allows us to simply use an instrument to gently vacuum out the lens material and then put an advanced technology intraocular lens in your eye. The incision is invisible at typically 3.0 mm or less. The procedure in its entirety can often be done in under 10 minutes. Most practices do one ophthalmological surgery at a time, although more and more practices are doing ocular surgeries on both eyes on the same day. Postoperatively, there is typically no pain whatsoever. Many, but not all people feel a slight irritation for the first day as they blink their eyes. Most surgeons still prescribe medicated eyedrops postoperatively, but many surgeons are now putting the medication in the eye at the end of the procedure, which obviates the need for ongoing eyedrops.

Is Refractive Lens Exchange Safe?

Ophthalmology surgeries all have risks, but the refractive lens exchange procedure has a very low risk of complications. You absolutely should discuss and understand all risks and benefits, and set your expectations with your surgeon preoperatively before deciding to go forward with the procedure. I will describe risks here.

There are generally lower probability risks and higher probability risks. The higher probability risks generally are fixable, and they include but are not limited to: residual refractive error. That means that you may have some slight residual prescription (nearsightedness, farsightedness, or astigmatism). The residual prescription could potentially be changed with a slight postoperative laser touchup procedure, or a by using a light adjustable lenses. Light adjustable lenses (LAL) are where the lens power can be adjusted through ultraviolet light postoperatively, if necessary. This technology has recently been approved and is very exciting. Surgeons are eager to adopt this technology since its introduction in 2020. The chance that you will need some postoperative laser touchup or light adjustable lens touchup is, in my hands, approximately one in 20. Not super rare, but not very likely either.

There are rare risks associated with any eye surgery that can be very serious, however. The first is infection. The risk of infection after cataract surgery has been estimated anywhere from one in 5000 surgeries to one in 15,000 surgeries. Infection in the eye can be very serious. It could lead to further surgery, partial loss of vision in the form of loss of visual field or loss of clarity of optics, glare haloes, or worse. Any procedure you do (even in fact wearing contact lenses) has a risk of infection that can be vision threatening. Obviously this is concerning, but as with any procedure or medical decision, you must weigh all of the risks versus the benefits.

Is Refractive Lens Exchange Covered by Insurance?

Refractive lens exchange is generally not covered by insurance. However, cataract surgery is  covered (barely) by insurance. Insurers, in general, including Medicare, have over the years paid less and less of the total cost of surgery. In my opinion, if you are able to have refractive lens exchanged at age 50 instead of waiting till age 70+, it may be worth it to pay the relatively small percentage amount that insurance might pay when you are 70 years old or older. The cost/benefit analysis must include a full discussion of what to expect. If you could have clear vision at age 50 onward, would that be worth paying an extra $2000 yourself at age 50 instead of waiting to age 70 to have insurance pay the $2000 (which may further decline over the years)? The cost varies, but with refractive lens exchange the total cost is usually somewhere between $6000 and $7000 per eye or a total of $12-$14,000. At SharpeVision, we will give you an exact quote when you come in. Because we currently (opening SharpeVision Eye Surgery Center in September 2022) operate at an outside ambulatory surgery center, the costs may change over time. The cost includes surgeon fees, advanced technology intraocular lens, hospital costs, anesthesia, postoperative eyedrops, follow up exams, and any potential laser touchup necessary postoperatively. (Again, the touch up is about a one in 20 chance, but you should not have to pay for it if the procedure does not get you exactly perfect distance vision.)

Refractive Lens Exchange Pros and Cons

The pros and cons of refractive lens exchange, as I see it:

PROS

  • Corrects distance vision
  • Corrects near vision
  • Corrects astigmatism 
  • You will never need cataract surgery
  • Safe, quick, painless

Not much more expensive than it would be if insurance covered it. That is to say, that insurance contributes only a small amount to the overall cost, but they may not even be willing to pay for any of it until you are in your late 60s or 70s.

CONS

If you understand all the risks and benefits of refractive lens exchange alternatives, such as other laser surgery types, I think you will do very well with it. As with anything, no procedure is 100% perfect for 100% of the people, but please educate yourself as much as you possibly can during your time with your surgeon. Obviously, he or she will do the best job that they possibly can. SharpeVision has one of the most experienced and talented surgeons I have ever seen during my career in Dr. Kent Leavitt, MD. Dr. Leavitt has been performing cataract surgery for 30 years. His training and technique are unequaled.

Refractive Lens Exchange Surgery Cost

As mentioned above, the cost can range from $6000-$7000 per eye. Because of the resources used: operating room, anesthesia, advanced technology intraocular lens, laser assisted cataract surgery, limbal relaxing incision, surgeon skills, operating room staff, and phacoemulsification machine, the procedure is not inexpensive. But when you think about the value- seeing clearly without glasses for distance and near surgery in one 10 minute operation- it does not seem like a terribly great expense.

Refractive Lens Exchange Recovery Time

The beauty of refractive lens exchange is that the recovery time is negligible. Typically, you are in the ambulatory surgery center for 2 to 3 hours. The procedure itself takes under 10 minutes, but getting you checked in and administering an oral sedative takes a little more time. We offer a sedative to help relax you for the procedure. We don’t use any needles, but there is a pulse oximeter clipped to your index finger, a couple heart monitor stickers to your chest, and a blood pressure cuff on your upper arm. We also use eyedrops to dilate your pupils maximally which makes the surgery even easier for the surgeon. The laser part of the surgery typically takes about 2 to 3 minutes (most of that just getting you set up under the laser) but the laser itself takes 30 to 40 seconds. Then the removal of the lens material and implant of the intraocular lens takes under 10 minutes. Immediately following the procedure you go straight home. Your vision initially will be foggy and your pupil will still be dilated for several hours. The vast majority of our patients will see 20/20 on a vision chart without any glasses the very next day. However, the vision will continue to improve from its somewhat foggy appearance in the first few days to great clarity. Due to the multifocal lens implant, you will be able to see distance and near objects clearly! Typically we follow up the first day postoperatively, one week postoperatively and one month postoperatively.

Refractive Lens Exchange versus LASIK

LASIK is a fabulous procedure for people aged 18 to 45 but gets less appealing after age 45 due to the Presbyopia that will affect everyone as we get older. LASIK is also awesome for low to moderate degrees of nearsightedness and astigmatism. Over 98% of people will see 20/20 or better after LASIK. After age 45, however, there is the stage of dysfunction of the lens, as discussed above, whereby the lens no longer is flexible enough to see both distant and near objects clearly. This is why people need reading glasses, multifocal contact lenses, monovision contact lenses, monovision LASIK, or refractive lens exchange. The lens of our eye does age and is no longer able to do at age 45 and older what it could do when you are in your 20s and 30s. Depending on your refractive error, anatomy, and age, your surgeon will recommend one of several procedures in our eye surgery types armamentarium that will allow you to get the best, safest results that we can get for you. Your surgeon is highly motivated to have you be incredibly happy about the procedure. This is part of why the risks and benefits discussion for your particular needs should be discussed until you are absolutely certain that you are making the best possible decision you can.

Other Names for Refractive Lens Exchange

  • RLE
  • Clear lens exchange
  • Lens replacement surgery
  • Cataract surgery: cataract surgery is exactly the same as refractive lens exchange except for the fact that the natural lens of your eye is clear with refractive lens exchange. Cataract surgery removes the cataract lens. As the lens of our eye gets progressively cloudy (or loses transparency), we will see more glare from oncoming headlights, lose contrast sensitivity (a sort of washed out appearance to objects), or even the loss of ability to drive and see clearly. Cataracts become progressively worse and can happen at any age, but in general will typically happen in our late 60s and older. At some point along the progression of loss of transparency, it will be called a Cataract. Cataract is a somewhat arbitrary term depending on your visual needs and the degree of loss of transparency. For insurance purposes, generally one must demonstrate symptoms such as glare and haloes that impair your activities of daily living. This is subjective and should be discussed with your surgeon. The implication is that insurance companies will pay a small part of the overall cost of your cataract surgery if you choose to have it after the designation of cataract is applied. Understand that it is a slow transition (potentially over a decade or more) from a totally clear lens to a cloudy lens that impairs your activities of daily living.

I hope this helps you to understand some of the basics of refractive lens exchange as an option for people as we get older and need glasses to see clearly. It’s never too late to consider one of the high-tech Laser surgeries that SharpeVision performs and get rid of your glasses and contacts!

Dr. Matthew Sharpe- Founder of SharpeVision

Dr. Matthew R. Sharpe

Dr. Matthew Sharpe is an Ophthalmologist specializing in refractive surgery and the owner SharpeVision MODERN LASIK, with offices in Seattle, Austin, and Chicago. Dr. Sharpe is a world traveler, pianist, marathon runner, motorcyclist, and fluent French speaker. He enjoys every second of life, but finds he is happiest at home watching Netflix or cheering on The Ohio State Buckeyes with his wife, three children, and two dogs.
Signature of Dr. Matthew Sharpe, MD