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Up Front | Feb 2009

Refractive Lens Exchange—an Art

Having just read many of the articles in this month's issue, I am struck by a number of points, including (1) the numerous pearls of wisdom offered by the authors and (2) the variety of preferences in terms of lens and patient choice. With respect to the latter, all I can say is, like choice of occupations, thank goodness we have diversity—else the world would be boring and deficient. The pearls of wisdom generously imparted are superb, and one can almost feel the pain of the author, who at some stage learned through bitter experience, the benefit of some techniques to avoid short- and long-term issues. (Yes, I have been there too.)

There is no doubt that refractive lens exchange (RLE) is a specialty on its own. Tayo Akingbehin, MD, FRCS, FRCOphth, has correctly addressed the differences in dealing with a RLE patient versus a cataract patient. I agree entirely; however, I also suggest that surgeons consider taking patient care one stage further, to treating cataract patients as refractive patients. We certainly do in our private practice. All our patients are handled like refractive patients and undergo similar processing, including topography, education, and counselling about premium lenses. All lens-based surgeries are performed similarly using microincision cataract surgery, along with many of the pearls provided by the authors in this cover focus. Ninety percent of our patients elect to have a premium lens implanted, and do so with a phenomenal level of satisfaction. I receive regular word-of-mouth referrals from happy patients. Granted, providing this level of care does involve more time and effort; however, when performed routinely, it becomes less arduous.

Two other issues worthy of mention (and discussed in this issue) are dealing with patient expectations as well as having a contingency plan. Brian Little, MA, DO, FRCS, FRCOphth, in discussing patient expectations, sums it up well in his recommendation to under-sell and over-deliver. Handling patient expectations, in my personal view, is best accomplished by the operating surgeon, with whom the patient develops a relationship and level of trust. This is especially important when outcomes do not go according to plan (and periodically they will not). At these times, hand-holding is vital and also makes the suggestion of a refractive rescue acceptable. Patients deserve to know and trust they will be looked after. Having the facility—or access to one—to provide other forms of refractive correction, in particular laser ablative surgery, is important to deliver the expected outcome. It is a contingency that every surgeon wishing to provide RLE should have in place.

Successful RLE, as discussed extensively in this issue, involves attention to detail in terms of patient selection, education, relationship, technique, and postoperative care—clearly an art and what good doctoring is all about. We hope you enjoy this issue, which we believe will be useful for novices and experts alike.

Feb 2009