Debating RLE in Younger Adults

An unacceptably high risk of retinal detachment (RD) that could result in blindness argues strongly against performing refractive lens exchange (RLE) for extreme refractive error in patients younger than 40 years, according to Murtaza K Adam MD, who took the con position in a point-counterpoint debate held during the annual conference of the American Academy of Ophthalmology.

Assigned as the proponent for performing RLE, Kamran M Riaz MD prefaced his presentation with a “protest” that he had a very difficult position to argue. He acknowledged that RLE is not a “cookie-cutter option” for all such patients but said careful patient selection and extensive counselling could make it a reasonable, definitive, and durable option for certain individuals for whom corneal laser vision correction (LVC) or a phakic IOL are not safe, viable, or economical.

Why not RLE?

To emphasise the risk of RD, Dr Adam, a retina specialist, reported a case from his personal files involving a 40-year-old female who presented with a macula on RD and vitreous haemorrhage in her left eye four months after undergoing bilateral RLE. The repair seemed to have gone well. Then, one month later, the patient returned needing surgery for a macula on RD in the right eye, which also seemed to go well. Over the next several months, however, the patient required additional surgeries in both eyes for new complications. At last follow-up, her vision was 20/20 in the right eye and “count fingers” in the left eye.

“I ask you, are glasses and contacts really that bad?” Dr Adam said.

Admitting that this case, which he encountered in his second year of practice, might have pushed him to be an alarmist, Dr Adam presented evidence on RD risk to strengthen his position against performing RLE. He cited a paper reporting a 17.1% incidence in eyes with an axial length greater than or equal to 27 mm, along with a Danish registry-based cohort study of patients who had unilateral cataract surgery, that found the risk of RD was significantly higher in pseudophakic than phakic eyes among younger individuals and males.^1,2

“There are many other risk factors to consider, including hyaloid status, presence of lattice degeneration, family history of RD, and fellow eye history,” Dr Adam cautioned. “So, when you are feeling pretty good about a patient who wants RLE, do not ignore that feeling of unease that something might go wrong.”

Possible scenarios for RLE

Asking his colleagues to keep their minds open to the possibility of performing RLE for extreme refractive error in young patients, Dr Riaz outlined features describing potential candidates. He said the easiest argument for performing RLE could be made for addressing anisometropia in patients with unilateral cataract or traumatic aphakia. Other possibilities included patients with contact lens intolerance who had a contraindication to LVC or phakic IOL surgery, patients at risk for angle closure, and those with a dysfunctional lens index measured by raytracing technology.

He also proposed cost as a consideration, noting that compared with RLE, a phakic IOL or LVC may be more expensive and require a second surgery.

“Why choose RLE? When we approach corneal limits or higher refractive limits for LVC or phakic IOLs, and there is excellent anatomy, RLE has a predictable refractive outcome, does not alter the cornea, avoids induction of higher-order aberrations and corneal compromise, and removes future cataract risk,” Dr Riaz said. “It is especially effective for hyperopes for whom there is not a phakic IOL option in the United States and who, according to literature reports, achieve high satisfaction using modern IOLs.”

While addressing the risk of RD after RLE in high myopes, Dr Riaz cited literature suggesting that the incidence appears to have decreased over time. Nevertheless, with the RD risk in mind, he said he would advise against bilateral RLE to correct high myopia in young patients.

Before performing RLE in young patients with extreme refractive error, Dr Riaz said surgeons should mitigate RD risk by taking a careful history, doing a thorough retinal evaluation, and performing appropriate prophylactic treatment for existing pathology, such as lattice degeneration. Patients should also be counselled on RD symptoms, and surgeons should obtain additional informed consent.

Dr Riaz closed his defence of performing RLE in select patients by presenting a personal example. This female patient was in her 30s, had +6.0 D hyperopia bilaterally, and had already undergone peripheral iridotomy.

“The patient was counselled about the potential for residual hyperopia but said she would be happy if she could just get out of her thick glasses,” Dr Riaz stated.

Six weeks after RLE with implantation of simultaneous vision IOLs, the patient’s binocular visual acuity was 20/20 at distance and 20/25 at both near and intermediate. It was stable at her last visit at one year postoperatively, and the patient was very happy.

Both presenters spoke at AAO 2025, Orlando, Florida, US.

Murtaza K Adam MD, FASR is a Vitreoretinal Surgeon and Chair of Clinical Research, Colorado Retina Associates, Denver, Colorado, US, and Adjunct Clinical Associate Professor, Rocky Vista University, Parker, Colorado, US. murtaza.adam@gmail.com

Kamran M Riaz MD is the Thelma Gaylord Endowed Chair in Ophthalmology and Vice Chair for Clinical Research at the Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, US. Kamran-Riaz@dmei.org

1. Laube T, et al. PLoS One, 2017 Aug 31; 12(8): e0184187.

2. Bjerrum SS, et al. Ophthalmology, 2013; 120(12): 2573–2579.