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20 Questions About RLE

At our recent ASCRS meeting, it was clear: We're embroiled in a new lens surgery controversy, and it has jumped quickly to the front of the line. This year, the usual discussions about phakic implants vs. LASIK were on hold while we tried to determine the positioning of refractive lens exchange.

Will it become the best operation for hyperopia, or will lasers and phakic implants still have a role? Will lens exchange grab a foothold in myopia surgery, or will the natural lens be spared in favor of current treatments?

What will be the deciding factor in selecting a lens exchange over a laser procedure? Will lens removal be performed only to treat a traditional cataract, or will our indications extend to an otherwise healthy lens that is losing its function? Will higher-order aberrations in the lens steer us towards removing it, and if so, how will that be determined? Will insurance companies redefine cataract in terms of aberrations, or will they still demand opacification? Do we want them to get involved, or is it best if they don't meddle?

If lens surgery is performed, can we reliably hit our refractive targets with precision? Are our keratometry, biometry and calculations up to the task of creating perfect refractive outcomes, or is our statistical distribution of results too wide for patient happiness? Will lens procedures sparkle exclusively in spherical eyes, or will they one day match the precision of the laser for astigmatism?

What are the comparative outcomes of LASIK and lens replacement? What about quality-of-vision issues in the 55-year-old LASIK candidate who has spherical aberration in his lens? Should the lens be replaced or should the cornea be reshaped to refocus the light that will pass through the aberrated lens? Will lens surgery be absolutely indicated and LASIK contraindicated above a certain age or aberration?

Now for the Biggest Question

If the 1980s was the decade of lens surgery, and the 1990s the decade of corneal refractive surgery, then it looks as if the 2000s will be the decade when the previous two blur into a comprehensive amalgam. It appears there will be a continuum of procedures ranging from exclusively laser to solely lens surgery, with any number of bioptic combinations in between. All we need to do now is sort out who needs what and why.