For years, patients of all ages would present to my clinic for LASIK for correction of age-related blurry near vision. And for a number of those years, my colleagues and I would perform LASIK, if in fact the patient was a suitable candidate. We noticed a trend, however; the very same patients were returning years later with the notion that their LASIK had “worn off.” Of course, this was not the case — we may have simply worked on the wrong lens in that first procedure; it may have been a different lens we needed to treat.
LENS DYSFUNCTION AND OUR SOLUTION
The concept of optical crystalline lens dysfunction was first described by Jorge Alio in 2005.1 In an attempt to further characterize the changes associated with the aging crystalline lens, namely presbyopia and higher-order aberrations, in addition to opacification, the addition of the term “syndrome” to dysfunctionality was suggested by Durrie, Stahl and Waring IV, making it “DLS.”2 Waring IV, Durrie and Thompson reported a grading scale of dysfunctionality, which was utilized in a paper presented at the 2016 ASCRS meeting (Figure).3
In this proposed staging system, the first stage is presbyopia, the second stage is increasing higher-order aberrations and early opacification, and the third and final stage is a manifest cataract adversely affecting daily activities.
Since then, our group has gone on to analyze DLS in a multimodal fashion, utilizing advanced diagnostics, ranging from Scheimpflug imaging, ray tracing, double pass wavefront, OCT and volumetric analysis in an attempt to characterize these changes at various stages. Originally met with controversy, the term DLS has gradually been adopted by surgeons and organizations, including the AAO.3,4
As technology has improved with diagnostics, IOLs and lasers, so has our understanding of and approach to addressing lens dysfunction earlier and more appropriately, at the source. Furthermore, our ability to educate our clients has also evolved — namely, the language of lens replacement.
Lens-based procedures are the most rapidly growing segment of our practice, and custom lens extraction and replacement (CLEAR), or custom lens replacement (CLR) for short, has been a pillar of our offerings. For those referred or presenting for a surgical solution for age-related blurry near vision, our technical team follows a standard operating procedure for the diagnostic evaluation for presbyopia evaluation. We evaluate their candidacy based on the typical considerations of presenting complaint, age, distance and near acuity, lens status, vitreous status and retinal health.
For those who are appropriate candidates for CLEAR, we take them on a tour of their eye and use client-centric terminology that is easy to understand. We educate them not only on lens replacement benefits, risks and alternatives but also why LASIK may not be the most appropriate choice for their condition.
THE LANGUAGE OF THE AGING LENS
Using the example of the case of the plano presbyope, the consultation goes a little something like this: We explain that through the advanced vision analysis we have performed on the patient, we have insights into the past, present and future. We go on to describe their past, how they may have seen extraordinarily well for most of their life, and in fact may have been “spoiled rotten” with their vision. They did not grow up with the requirement for eyeglasses or contact lenses to function, unlike many of their friends and relatives who were habituated to this. They saved significantly financially from not purchasing vision aids for three or four decades and never needed to consider LASIK or other vision correction procedures.
Next, we describe the present, which is much easier to do when you yourself are presbyopic. We describe the struggles of presbyopia: they now require eyeglasses to read, they have them laying all over the house, when they cannot locate them, they have difficulty functioning, feel fatigued and insecure. Most importantly, they did not grow up habituated to this requirement of needing glasses to function, so it is not intuitive.
Lastly, we describe the future — that this will only get worse. Their reading-glass requirement will increase, their prescription will grow stronger and stronger, then they will need bifocals, then trifocals, then will come cataracts and cataract surgery.
THE LANGUAGE OF LENS REPLACEMENT
Once it is established that a client is a suitable candidate for lens replacement, we educate the patient on the similarities and differences of this approach relative to LASIK. We explain that LASIK was designed for vision problems people are born with — not necessarily for age-related issues. Second, we explain that LASIK was designed primarily to fix distance vision, not necessarily reading vision. In most cases, plano presbyopes continue to see great without glasses for distance but have age-related blurry near vision.
We explain that the CLEAR procedure is very LASIK like. Specifically, that it is often performed with (femtosecond) laser like LASIK, that it takes about the same amount of time as a LASIK procedure, that we typically do both eyes at the same time, like LASIK, and patients typically see well within a few days, like LASIK.
We go on to explain that the CLEAR procedure has numerous features that differentiate it from LASIK, which is why it has become the procedure of choice for lens dysfunction in the appropriate candidate. First, it goes to the source of the problem, the dysfunctional lens, which is typically the sensible approach. Second, it keeps you balanced; both eyes are designed for distance, intermediate and near, which can maintain or improve depth perception and improve overall vision with binocularity.
Lastly, the CLEAR procedure is anti-aging in that it prevents the patient from continuing to “fall off the vision cliff” and prevents the eventual formation of cataracts, which everyone develops and typically gets fixed if you live long enough, so it is not an “if,” it’s a “when”.
We explain that patients may also choose not to proceed with the CLEAR procedure. They may wait for eventual cataract formation instead then have the procedure. We state that at that point we can submit portions of the procedure through insurance and/or Medicare. However, many have come to realize that, even at that point, the refractive aspects of cataract surgery often are not covered by insurance even in the presence of cataract, so they elect not to wait to progress to the third and final stage of lens dysfunction, a cataract, when they could benefit from CLEAR now.
THE LANGUAGE OF EXPECTATION SETTING
We carefully outline and document the risks and benefits of lens replacement to our patients. This discussion includes appropriately setting expectations as well and may include but not be limited to the customary risks and benefits of lens surgery, including retinal changes. We spend time educating our clients on the fact that they have had their eyes for, say, 50 years, they do not work well (for reading), but they have become accustomed to them not working. When we are done, their eyes are going to work beautifully, but they will not be used to them working.
We explain that they may see the implants doing their job in certain lighting conditions and that their peripheral vision may seem different. That takes some getting used to and tends to improve over time, unlike their aging lens, which will continue to lose function over time. Also, while the implants are designed to restore a full vision range, they are not designed to magnify microscopic detail in low light. For these circumstances, they may need an occasional pair of low-power reading glasses.
We go on to explain that their body will “heal in” their implants, and they will build up some healing cells that may require a maintenance lens polishing (ie, YAG capsulotomy). Additionally, we explain that if their eyes heal out of focus in a way that we cannot entirely predict, they may benefit from a customization treatment with laser vision enhancement.
CLEAR GETS THE BEST KIND OF ADVERTISING
Lens replacement continues to be one of the most rapidly growing segments of our practice, and for good reason. The growth has primarily been organic, mostly by word of mouth from people who have had their lives changed for the better by having the procedure. More and more, patients are self-referred or referred from others who have benefitted from CLEAR, asking for this specifically. As always, a balanced discussion regarding the risks and benefits for any elective vision correction procedure is recommended. We believe that a client-centric approach in easy-to-understand terms facilitates the educational process, which our clients appreciate. OM
References
1. Alio JL, Schimchak P, Negri HP, Montes-Mico R. Crystalline lens optical dysfunction through aging. Ophthalmology. 2005; 112;2022-2029. https://tinyurl.com/2zj9nfj8. Accessed July 8, 2024.
2. Waring GO, Rocha KM. Characterization of the dysfunctional lens syndrome; a review of the literature. Curr Ophthalmol Rep. 2018;6:249-255. https://tinyurl.com/mw85v3cj. Accessed July 11, 2024.
3. Waring GO IV, Rocha KM, Durrie DS, Thompson VM. Use of dysfunctional lens syndrome grading to guide decision making in the surgical correction of presbyopia. Paper presented at: ASCRS/ASOA Symposium & Congress; May 10, 2016; New Orleans.
4. Waring IV GO, Rocha KM. Focal points – Dysfunctional Lens Syndrome. American Academy of Ophthalmology. 2018;36:12.
