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Refractive lens exchange (RLE) is a type of eye surgery used to treat refractive vision errors. Almost identical to cataract surgery, RLE can be used to treat myopia, hyperopia, and presbyopia.
The ideal candidate for RLE is over the age of 40, doesn’t have fully developed cataracts, and does not qualify for laser eye surgery.
There is a debate among eye care experts about the use of RLE to treat refractive errors. Though it can be highly effective, it removes the patient’s clear natural lens and exposes them to the risks of surgery.
RLE is a relatively safe procedure, but there are inherent risks with eye surgery. Risks associated with RLE include infection, bleeding, eye pressure, retinal detachment, and lens displacement.
The options for RLE are nearly the same as lens options for cataract surgery. The types of intraocular lenses you can choose for RLE are monofocal, multifocal, accommodative, and toric.
It is important to closely follow your ophthalmologist’s instructions for preparation and recovery from RLE surgery. They will give you instructions about taking medications, using eye drops, and when it is safe to start being more active again.
RLE is a relatively straightforward procedure that typically takes less than an hour. You will probably be awake during the surgery, though you won’t feel anything thanks to anesthetic eye drops.
As with any eye surgery, there are limitations to RLE. For the majority of people, it is an effective procedure, though not everyone will experience perfect vision following surgery.
RLE can be a costly procedure. It is not covered by most insurance plans, and it is usually performed in private clinics.
Although it is costly, RLE is very successful for most people. Clinics report as much as 85 percent of patients, over the age of 40, achieve their goals of clear vision without the help of eyeglasses after surgery.
What Is Refractive Lens Exchange?
Refractive lens exchange (RLE) is a type of eye surgery used to treat multiple eye conditions. It is the same as cataract surgery and can be a good alternative for people who are not candidates for LASIK eye surgery but are looking for a long-term treatment option that doesn’t involve relying on glasses.
Conditions that RLE can treat include:
- Myopia (nearsightedness).
- Hyperopia (farsightedness).
- Presbyopia (problems with focusing up close).
With RLE, the natural lens in your eye is removed, and a clear artificial lens is put in its place. It is the same process that happens with cataract surgery, with the only difference being the state of the lens that is being removed. In cataract surgery, a cloudy lens that is impairing vision is removed. With RLE, the lens is still clear but misshapen, leading to refractive errors.
Who Is it Meant For?
RLE can be a good eye surgery option for people who do not qualify for laser eye surgery and meet a few other conditions. People who meet the following conditions may qualify for RLE:
- You have myopia or hyperopia.
- You have presbyopia but do not want to wear reading glasses.
- You are over the age of 40.
- You do not have fully developed cataracts.
- You need vision correction but do not want glasses or contact lenses.
- You do not qualify for LASIK, photorefractive keratectomy, or phakic intraocular lens surgery.
Consult with your eye doctor if you are interested in RLE. Together, you can assess the current state of your vision along with your vision goals and decide if RLE is your best treatment option.
Refractive Lens Exchange for Presbyopia
As you age, the muscles surrounding the eye’s natural lenses weaken and lose flexibility, making it hard to focus on objects at a close range. The result is that some basic tasks, such as close-up reading or the reading of fine print, gets difficult, leading to eye strain and headaches.
Refractive Lens Exchange (RLE) is an eye surgery procedure meant to replace your crystallized, or inflexible, natural lens with an artificial Intraocular Lens (IOL). The IOL improves vision significantly.
RLE surgery helps correct long-sightedness and eliminates the need for eyeglasses or contact lenses. Doctors can opt for monofocal IOLs, multifocal IOLs or accommodating IOLs, depending on the severity of the presbyopia.
Five types of presbyopia exist:
- Incipient: This is the earliest stage, when it starts to become hard to read small print
- Functional: This is when you start to notice an increasing number of issues with your near sight.
- Absolute: Here, you cannot focus at all on objects close to you.
- Nocturnal: This refers to presbyopia when it only occurs in low-light conditions.
- Premature: This is the term doctors use to describe when presbyopia happens before the age of 40.
The Pros & Cons of RLE
While RLE is a relatively straightforward procedure, there is some debate among eye care experts about whether the benefits of the surgery outweigh the potential risks. Opponents of RLE are wary of removing a perfectly clear lens in order to correct refractive issues. There are many safer alternatives to correcting refractive errors that don’t expose patients to the risks associated with a major eye surgery.
Some ophthalmologists question the ethics of clear lens exchange, such as RLE. Though the risks are small overall, there is always the potential for complications due to surgery. Proponents of RLE, however, argue that the procedure is no different than any other type of refractive surgery. They acknowledge that there are risks to the procedure, but they stress that the risks are small and the benefits outweigh them.
Lens replacement surgery does not yet have FDA approval, though it can be legally prescribed for off-label purposes. If it is in the patient’s best interest, a doctor may decide it is the most effective way to correct the refractive errors the patient has. For people who are farsighted and presbyopic, for example, RLE can be very effective.
Risks of Refractive Lens Exchange
In general, RLE is a safe surgery that most people respond well to. Complications are rare, but there are risks associated with any surgery, including RLE.
According to the American Academy of Ophthalmology, potential risks of RLE include:
- Eye infection.
- Increased eye pressure.
- Retinal detachment.
- Dislocated intraocular lens.
- Blurry vision.
- Seeing glare or halos.
- Droopy eyelid.
Types of Refractive Lens Exchange
Your options for RLE are the same as they are for cataract surgery. Depending on the eye condition you are treating, you have three intraocular lens (IOL) implants to select from.
The IOL refracts light properly onto your retina so you can see clearly once again. Just like eyeglass or contact lenses, IOLs come in different prescriptions, which your ophthalmologist will determine prior to surgery.
Types of IOLs include:
- Monofocal IOLs. Set to one focusing distance, this is the most common type of IOL used in surgery. Typically, people have their monofocal lens set for distance vision and then wear reading glasses for close-up activities.
- Multifocal IOLs. More expensive than monofocal IOLs, multifocals correct for distance and near vision at the same time. Different zones on the lens are set to different prescription powers.
- Accommodative IOLs. These lenses sit slightly differently in your eye, allowing them to move and change shape with your eye’s natural movement. They allow for focusing at many different distances. Glasses are often not needed after accommodative IOLs are implanted.
- Toric IOLs. Toric lenses are designed to correct for astigmatism, a type of refractive error. Toric lenses are also accommodative IOLs. Thus, they correct for multiple vision distances at once.
Each type of IOL has been designed with a specific purpose in mind. Prior to RLE, speak with your eye doctor about which type of lens will best support your vision goals.
In many cases, people don’t need to wear glasses at all after surgery. Some people, however, still prefer to wear glasses for extended periods of close-up work.
Preparation & Recovery
Prior to an RLE procedure, you should speak with your doctor about how to prepare. They will give you some instructions for what to do leading up to surgery.
To prepare for an RLE, you may need to:
- Stop taking certain medications.
- Use antibiotic eye drops ahead of time.
- Not eat after midnight the night before your surgery.
- Arrange for someone to drive you home.
Post-surgery instructions often include:
- Take eye drops as directed to prevent infection.
- Don’t let soap or water get into your eyes.
- Wear an eye patch or protective shield.
- Follow your doctor’s orders about when you can safely exercise again.
The recovery period typically lasts a few days to a few weeks, depending on your response to the surgery. You will likely notice improved results very quickly, but be sure to give your eyes sufficient time to recover.
You may experience some mild pain following surgery, but it shouldn’t be anything that an over-the-counter pain medication can’t effectively address. If you experience substantial pain, call your eye surgeon immediately.
What to Expect During RLE
You can be comforted to know that RLE is not a painful procedure. You will most likely be awake during the procedure, but you won’t feel anything. You will be given anesthetic eye drops to numb your eyes. For patients who are particularly nervous, some doctors offer additional medication to help you relax during the procedure.
An RLE surgery takes less than an hour, and most patients report experiencing better vision as soon as the procedure is done. You will need someone else to drive you home, but you will already enjoy better vision.
If you need the lens in each eye to be replaced, they will likely be done during two different surgeries.
Limitations of Refractive Lens Exchange
It is possible for the results of RLE to be underwhelming. Following the operation, some patients may not experience 20/20 vision.
As with any corrective eye surgery, the goal is for improved vision. Perfect vision cannot be guaranteed. There is a possibility that eyeglasses will still need to be worn for certain activities, such as reading.
Costs of the Procedure
RLE can come at a high out-of-pocket expense to individuals. According to the USC Roski Eye Institute, RLE lens replacement surgery is about twice the cost of LASIK, and it is typically not covered by insurance. Most RLE procedures are done at private clinics, so prices can vary greatly based on location.
If you have one, employer-sponsored flexible spending accounts (FSAs) can often be used for surgery upgrades, like RLE, that standard insurance doesn’t cover.
Additional costs will also be added for premium lenses. Multifocal lenses, for example, are not always covered by insurance. Some insurance plans cover the cost of standard lenses and then you have to pay the difference for premium lenses.
To find out the exact cost of RLE to you, consult with your induvial insurance plan provider. Your eye surgeon’s office can also coordinate with your insurance provider to determine the exact cost you’ll be expected to pay out of pocket.
Although there are limitations to RLE, many people are highly satisfied with their results. The majority of patients who get RLE do not need glasses for most activities following the procedure. This success rate is seen primarily in patients over the age of 40.
While it is important for eye doctors to set realistic expectations for their patients going into RLE, the majority of the time it is a highly successful surgery. Patients need to be informed, however, about the pros and cons of the procedure, costs associated with it, and what to do to promote a healthy and speedy recovery.
Overall, RLE is not the recommended first course of action to correct for vision issues like myopia, hyperopia, and presbyopia. LASIK and other forms of refractive surgeries are generally the surgeries of choice.
RLE may be an appropriate choice for people who are not good candidates for LASIK or PRK. In these cases, an eye doctor will assess the situation, including your eye health, level of vision issues, and overall physical condition, to determine if RLE is a good choice for you.
FAQs About Refractive Lens Exchange (RLE)
How safe is refractive lens exchange?
Because the eye surgeon performs the RLE inside the eye, the procedure exposes you to risks such as bleeding, septicity, lens dislodgement, eye pressure and, in some cases, retinal disengagement. However, research shows Clear Lens Exchange (CLE) is one of the safest surgeries, with the average success rates reaching more than 90 percent.
Is RLE Permanent?
Yes, implanting an IOL is a permanent procedure that replaces your natural lens forever. The surgery also eliminates the need for future cataracts removal. Your eye surgeon may conduct a simple laser treatment to restore clarity if you notice blurred vision after the surgery.
Who is a candidate for RLE?
If you’re older than 40 and are experiencing blurred vision, difficulty reading nearby text and have vision issues while using eyeglasses or contact lens, then you probably need RLE. Constant headaches, eyestrain and having to hold things at arm’s length to focus clearly may also be an indication that you need RLE.
Is RLE Painful?
RLE is a painless procedure that takes about 15 to 20 minutes to complete for both eyes. The eye surgeon will typically perform the subsequent procedure on the other eye at least a week apart to ensure the first eye is making good recovery progress. The surgeon will apply local anesthesia drops to minimize discomfort during the surgery. Your ophthalmologist will prescribe eye drops and painkiller for about four weeks to aid the recovery process and minimize pain.
Cataract Surgery. (September 2019). American Academy of Ophthalmology.
The Refractive Lens Exchange Debate. American Academy of Ophthalmology.
The Pros and Cons of Clear Lens Exchange. (August 2014). Optometry Times.
IOL Implants: Lens Replacement After Cataracts. (October 2019). American Academy of Ophthalmology.
Refractive Lens Exchange in Modern Practice: When and When Not to Do It? 2014. Eye and Vision.
RLE for High Myopia Considered Safe, Effective in Short Term. September 2014. Ophthalmology Times.
Review of current status of refractive lens exchange and role of dysfunctional lens index as its new indication. (November 2020). National Center for Biotechnology Information.
Refractive lens exchange in modern practice: when and when not to do it? (December 2014). National Center for Biotechnology Information.
Refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes. (August 2017). National Center for Biotechnology Information.