Almost a quarter-century after the FDA approved LASIK vision correction for myopia, an estimated 800,000 laser vision correction procedures, including LASIK’s sibling, photorefractive keratectomy (PRK), are now performed each year in the United States, per a 2021 study by Joffe.

It’s easy to see why: Cornea-based laser procedures are pinpoint precise and have excellent outcomes in the vast majority of patients.

However, the accuracy, precision and outcomes of lens-based options, such as EVO ICL (Staar Surgical) and custom lens replacement (CLR), also known as refractive lens exchange (RLE), are approaching those of LASIK and PRK. This makes them a viable option for a large proportion of patients who are both eligible and ineligible for laser correction.

Here, I’ll provide advice on choosing candidates for these procedures and explain why you are not maximizing the potential of your practice if you aren’t offering lens-based refractive procedures.

MY EXPERIENCE

Conventional wisdom among those in the ophthalmic community calls for a corneal-based procedure such as LASIK or PRK in most patients under age 40 to 45 with clear lenses who desire improved distance vision without relying on contacts or spectacles. On the other hand, in the case of a 45-year-old +2.0 or +2.25 patient, most surgeons are going to be more comfortable offering a CLR instead of LASIK.

I would not disagree with this line of thinking, but I would say there is a case to be made for offering lens-based refractive procedures even to patients who are otherwise great candidates for LASIK, simply because the technology has improved so dramatically in the past decade. Today’s multifocal implants have improved greatly compared to the original technology; extended depth of focus (EDOF) technology is advancing quickly as well, as are phakic IOLs.

I perform more than 10 CLRs and about 20 LASIK procedures per week. With respect to phakic EVO ICLs, I routinely notice that these patients see better than many of my post-LASIK patients, especially the high myopes. It’s not uncommon to see patients gain at least one line of BCVA with EVO ICL, which I don’t commonly see with LASIK in my practice.

CHOOSING FROM THE OPTIONS: THE DECISION TREE

As with any refractive surgery patient, there are four basic questions that must be answered at the outset to help patients choose the optimal lens:

1. Has the patient had previous refractive surgery? The answer to this question is of paramount importance, as it may limit their options. For example, post-RK patients are less likely to be a candidate for CLR than are LASIK patients.
2. What is the patient’s current refraction? Obviously, a myopic patient would appreciate an IOL that delivers excellent near vision, which would be available in a trifocal lens design vs pinhole or small-aperture lenses, which may deliver better intermediate-range and functional near vision.
3. What is the patient’s personality? If they’re a super type-A engineer, for example, you might want to choose a lens with a more limited dysphotopsias profile, such as an EDOF, or the new Rayner RayOne EMV with a little bit of micro monovision. The important thing in this case is to make sure the patient knows they’re going to have to use readers occasionally.
4. What does the patient do for a living? Is the patient a long-haul trucker, a pilot, a riverboat captain? Some of these and similar jobs require excellent nighttime vision; consequently, a lens with a more favorable dysphotopsia profile would be appropriate.

CHOOSING FROM THE OPTIONS

Once you and the patient have reached the answers and determined they are a candidate for a lens-based procedure, it’s time to offer recommendations. I tend to recommend EVO ICLs to patients who are myopic to at least -3.00 D and to those in their early 20s to early 40s with no lens changes whatsoever. Indeed, I’ve gotten more aggressive with respect to offering ICL EVO; I used to offer it only to patients who weren’t candidates for LASIK, mostly those with at -9.00 or -10.00. But my results have gotten so good that I now offer the choice of LASIK or ICL EVO to any patient at -3.00 or more. The patient’s choice often comes down to cost because ICL EVO is slightly more expensive than LASIK. I would add that I’m especially bullish on EVO for patients who are 20 to 25 years old. If they experience refractive drift over time, I would rather perform a primary LASIK to touch them up years down the road than perform a PRK on top of an old LASIK.

POST-PRK, POST-LASIK OPTIONS

Based on my experience, I believe most post-RK patients should be offered Light Adjustable Lenses (LAL, RxSight). This is because with post-RK patients, it can be very difficult to nail their refractive target postoperatively. Touching them up with a refractive corneal procedure postoperatively is also challenging, because they’ve had RK previously. Therefore, they’re not optimal candidates for a LASIK touch-up following IOL surgery. The LAL would be the best choice for this population.

Lately, I have been mixing and matching LALs with the IC-8 Apthera (Bausch + Lomb) (eg, implanting an LAL in the dominant eye and the IC-8 Apthera lens in the non-dominant). For patients with irregular corneas or keratoconus, I recommend bilateral IC-8 Apthera lenses. Patients who have keratoconus or ectasia have very irregular corneas, and we know that the IC-8 Apthera, with its small-aperture optic, is able to reduce a large amount of the aberrations in those patients. As a result, the pinhole optic is usually the best choice for a complex cornea.

For post-LASIK patients, I’ll typically offer bilateral Tecnis Symfony OptiBlue (Johnson & Johnson Vision) lenses to those who desire a wide range of vision, primarily because the OptiBlue lenses have a wide sweet spot. They are very forgiving in that even patients who are left a little myopic or hyperopic, or those with a little residual astigmatism, still enjoy very good vision.

My preferred approach for patients with virgin corneas who want full range of vision, meanwhile, is to place a Synergy (Johnson & Johnson Vision) in the non-dominant eye and an OptiBlue in the dominant eye.

I find that mixing and matching lenses for these patients with virgin corneas provides the best attributes of each lens: the Synergy provides J1+ and the OptiBlue gives them improved distance vision. In addition, the InteliLight technology on the OptiBlue provides for good low-light reading, which many patients appreciate.

HYPEROPIC VIRGIN CORNEAS

Recently, I have begun offering Rayner’s RayOne EMV lens for hyperopic virgin corneas in +2.00 hyperopes. As with colleagues I have spoken with overseas, I have found that the RayOne EMV provides substantial depth of focus without the dysphotopsias, nighttime halos and glare and loss of contrast that can accompany the trifocal technologies. The only drawback I see is the need to offset the non-dominant eye by about - 0.75 to -1.00 D. Patients won’t see perfectly at distance in the near eye, and they won’t see perfectly up close in the distance eye, but they’re typically able to tolerate mini-monovision when there’s less than -1.25 D of change between the eyes.

BENEFITS TO PRACTICES: GREATER MARKET PENETRATION

Your patients aren’t the only ones who can benefit from lens-based refractive procedures. Offering them also gives you the opportunity to expand your practice’s market penetration just by attracting more patients who are willing to pay out-of-pocket for elective procedures. Not many practices offer a full suite of refractive options beyond LASIK or PRK, which I find surprising given the fact that cornea-based surgeries are closed to many patients with hyperopia that cannot be treated with LASIK. They are also not the best option for patients with dry eye syndrome, irregular astigmatism or insufficient corneal tissue — all of which make RLE a better option.

Paradoxically, by offering CLR, a practice could also realize more LASIK business. By marketing CLR, many of the patients who walk through my door fall into the range of -1.50 to -2.00 D, which cannot be addressed with ICLs. This provides the opportunity to discuss these options with patients and potentially convert them to LASIK. In my practice, we’re up 39% on ICLs over this quarter in 2022, and we’re up about 28% on custom lens replacements from the same period last year.

LENS-BASED SURGERY ISN’T GOING AWAY

Laser vision correction no doubt retains a high level of popularity among patients who want to get out of eyeglasses or contact lenses. However, not everyone is a candidate for LASIK or PRK, and taking the time to educate them on lens-based refractive options can pay big dividends for them and for your practice.

What most patients want is freedom from spectacles, and we now have many different options to help them achieve their goals. New and better lenses are coming out every year, and we have found that a growing number of patients are willing to pay out-of-pocket for them if it means they can avoid laser surgery.

Presbyopia is a massive problem, and with our dependence on devices such as smartphones and computers, I don’t see it slowing down. Now is as good a time as ever to take advantage of the many upsides to offering phakic IOLs and custom lens replacement. Refractive surgery today is far more than just LASIK, and I think that gap is going to widen over time. OM

Blake Williamson, MD, MPH, MS, is president and managing partner of Williamson Eye Center, Baton Rouge, La. Disclosures: Dr. Williamson serves as a consultant to Bausch + Lomb, Johnson & Johnson Vision, Staar Surgical and Zeiss.