Think PRELEX for Ultimate Patient Satisfaction
Why a growing number of surgeons consider it the procedure of choice for the most common types of presbyopia.
By Kevin L. Waltz, M.D., O.D. and R. Bruce Wallace, M.D., F.A.C.S.

One of us recently operated on a 50-year-old woman who we'll call Pam. She was +0.25 OU and 20/20 pre-op, but she couldn't read without glasses. Pam had the universal refractive error of people in her age group -- presbyopia. And she hated it. To her, it was no different than a bad hip. She wanted her near vision back, and she was perfectly willing to accept the risks of intraocular surgery.

The operation she had is called PRELEX -- or Presbyopic Lens Exchange -- and she now sees well at distance and near. The woman is Pam Wallace, wife of Dr. R. Bruce Wallace.

In this article, we'll explain why we believe PRELEX is the best treatment yet developed to reverse the unwanted effects of the most common types of presbyopia. We'll also identify the best candidates for this procedure and tell you how you can develop the skills necessary to perform PRELEX.

PRELEX is simply the name we've coined for a surgical procedure that allows us to restore a more natural range of vision. We accomplish that by replacing the defective, natural lens with a multifocal intraocular lens (IOL) to simulate the natural range of vision from near to far.

If you're like most ophthalmologists, you believe that restoring the full range of vision to patients is the ultimate goal of refractive surgery. PRELEX may be the best surgical option to accomplish that aim for presbyopes with either hyperopia or myopia. Though the procedure has received little public attention, it's become increasingly popular over the past 2 years as eye surgeons have become proficient in doing the operation. The authors have now performed PRELEX on more than 200 eyes with excellent results and have provided PRELEX training to many other eye surgeons.

A step above clear lens exchange

We believe there are three broad categories of lenticular surgery -- cataract surgery, refractive cataract surgery and refractive surgery. In our opinion, cataract surgery, as it's most commonly practiced today, is safer and more effective than ever, but it gives only a weak nod to refractive rehabilitation. In our practices, many people having lenticular surgery have traditional cataract surgery. We remove the lens because it's obstructing the patient's vision and leave the patient dependent on glasses because that's what the patient wants. These patients would be angry with us if we provided them with the "benefits" of refractive cataract surgery. They want the perceived cosmetic benefits of their glasses.

Recently, interest has grown in the potential of refractive cataract surgery, which assumes the presence of a cataract but focuses on the simultaneous refractive reconstruction of the eye. This is in contrast to typical refractive surgery, which assumes the absence of a visually significant cataract and focuses solely on the refractive rehabilitation of the eye.

Refractive cataract surgery is the natural evolution of cataract surgery. While you have the patient anesthetized and the eye sterile, why not provide refractive surgery?

PRELEX is refractive lenticular surgery and can be performed with or without simultaneous cataract removal. The goal of PRELEX is to dramatically reduce a patient's dependence on refractive prostheses such as glasses in the most natural way possible. PRELEX offers a distinct advance beyond clear lens exchange (CLE) for these reasons:

• CLE typically attempts to correct distance vision only.
• CLE typically uses monofocal IOLs.
• Sometimes, CLE utilizes monovision in an attempt to correct near and far vision. This is a severe compromise of a patient's distance and near vision, and may permanently compromise the patient's stereopsis.

Many patients find refractive cataract surgery highly beneficial. These patients believe the longer healing time and slightly increased surgical risk is worth the cost of a procedure that greatly improves their quality of life. We believe the most complete, but the most complex, refractive rehabilitation with refractive cataract surgery is with a multifocal IOL. This is the procedure that we call PRELEX.

We believe the ultimate expression of refractive lenticular surgery is refractive PRELEX. When providing refractive surgery by exchanging the natural lens for an artificial one, why not go for the whole range of vision with a multifocal IOL? There's no additional surgical risk, and the potential results are incredible. And of course, the side effect of refractive PRELEX is that the patient won't ever get cataracts. Does it work? Yes, it works extremely well. Does it make sense for you or your patients? It depends on your surgical skills and your belief system.

Hyperopic patients benefit most

The best candidates for PRELEX are hyperopic presbyopes, with or without cataracts. Hyperopic presbyopes as a group are quite unhappy with their vision. They almost always want refractive surgery. They benefit greatly from all forms of lenticular surgery, including routine cataract surgery. Hyperopic presbyopes are difficult to correct refractively with corneal surgery. But their eyes are shorter than 24 mm, so their retinal detachment risk after uneventful intraocular surgery isn't significantly increased. They can see nothing without their glasses, and they don't see well with their glasses.

The primary problem with PRELEX for hyperopes is loss of magnification. They have become accustomed to the significant magnification of their prescription and they notice when it's taken away. They will adapt to a normal level of magnification after PRELEX, but it will take several months depending on how much magnification they lose with the procedure. (The most difficult patients for PRELEX are emmetropic presbyopes. Generally, they are very demanding, and the surgical margin of error is nonexistent.)

The results of PRELEX are so good they're difficult to believe. (See "Initial Data Report on PRELEX".) Results are good immediately post-op and improve with time. So far, our enhancement rate is approximately 12%, which compares favorably to the enhancement rate for LASIK. (The predictability of our refractive outcome has also been greater than with LASIK.) But we think we can reduce our enhancement rate even further. We consider an enhancement after PRELEX to be any further surgical intervention, including a YAG capsulotomy or another limbal relaxing incision.

PRELEX carries some risk

We discuss the risks of PRELEX with all potential patients. These risks are the same for refractive PRELEX and refractive cataract PRELEX. The most important is the patient's level of satisfaction with the procedure. What will he think of his new visual system? If he's strongly motivated to be less dependent on glasses, he'll love multifocal vision. It's similar to adapting to contact lenses. If an individual wants to wear contacts instead of glasses, almost nothing will stop him. If he doesn't really want to wear contacts, no lens will fit properly.

Other risks are endophthalmitis, retinal detachment and surgical misadventure, which are almost completely under the control of the surgical team. The risk of endophthalmitis should be known in every facility with a track record. The surgeon's specific risk should be disclosed to the patient.

The risk of a retinal detachment is largely dependent on the eye's axial length and any intraoperative problems. The surgeon controls the axial length factor by choosing to operate on hyperopes or myopes. If the axial length is less than 24 mm, the risk is very low. The surgeon and the surgical team control the risk of any intraoperative problems. If the surgeon's rate of a ruptured capsule is high, refractive PRELEX is a poor option for the surgeon and the patient.

Pricing PRELEX

PRELEX is priced differently than LASIK because it's a different procedure with a different outcome. The patient profile is different, too. The typical PRELEX patient is much more hindered by his disability than the typical LASIK patient. Many PRELEX patients are in their 50s and have had cosmetic surgery, or at least a cosmetic surgery consult. They need an outstanding result and are willing and able to pay for it.

The price of PRELEX today in the United States ranges from $2,200 per eye to $5,000 per eye. The average fee is currently around $3,000 per eye. The fee quoted includes the preoperative evaluation, anesthesia, the surgical facility, the surgical fee and post-op care. It compares favorably to the cost of a rhinoplasty or facelift. The cost of enhancements with PRELEX varies. Most surgeons include enhancements for a limited period of time in the price of the original surgery. Some surgeons don't include enhancements in their basic fee.

Getting started

The best way to get started with PRELEX is with refractive cataract PRELEX. Many patients need cataract surgery anyway. If they want to be less dependent on glasses, you can offer them a value-added service However, be very clear here and consult your advisors prior to charging for refractive services when they're an add-on to a covered service like a cataract procedure. Generally, you can charge for limbal relaxing incisions, but not for using the Array IOL.

Choose your first 100 patients carefully. They should all have cataracts and most should be hyperopic presbyopes. Start with minimal levels of cylinder and work your way to higher levels of astigmatism.

Change your informed consent. You're no longer providing cataract surgery by itself. You're now providing refractive surgery and cataract surgery at the same time. You can obtain our informed consent videos from Patient Education Concepts (PEC). The videos are specifically for refractive PRELEX and refractive cataract PRELEX. They're available to all. We have no financial interest in them.

You can also take our proprietary PRELEX training course. This 1-day course teaches you all you need to know about PRELEX. Attendees often say this is one of the most complete and useful courses they've ever taken. 

Take the time to learn more about PRELEX. We think you'll share our sense of excitement about the potential of this procedure to change millions of lives for the better.

Kevin L. Waltz, M.D., O.D., is in private practice with Eye Surgeons of Indiana in Indianapolis. He's the first ophthalmologist in the world to be implanted with the Array multifocal lens.

R. Bruce Wallace, M.D., F.A.C.S., is founder and medical director of Wallace Eye Surgery in Alexandria, La., and is assistant clinical professor of ophthalmology at Tulane School of Medicine in New Orleans.