1136: Refractive Lens Exchange Surgery

For high degrees of hyperopia in presbyopic patients, the best surgical solution is refractive lens exchange. For a younger patient, it is usually preferred to retain the crystalline lens since it provides a range of accommodation and for these people I would recommend wearing contact lenses. Once presbyopia hits in the late 40s, my recommendation shifts to performing a refractive lens exchange. These cases are more challenging because the lens capsule is elastic, the nucleus is soft, the anterior chamber is shallow, and the entire anterior segment is small. In the case shown here, we elected for a toric monofocal IOL and a target of plano instead of using a trifocal IOL. This is because this patient has naturally small pupils both in mesoptic and scotopic environments. With a trifocal IOL the benefit of the diffractive rings would not be achieved. Also remember that smaller pupils give a naturally wider depth of field and this patient does not mind wearing reading glasses for near work and smaller print.

click to learn the pearls for refractive lens exchange in high hyperopia:


  1. Dr Devgan,

    Nice 6 minute video, great to hear you did an ISBCS. Is this ISBCS procedure your standard approach? Did the fellow eye also get a toric implant? I see that you mark your axis with black ink, do you mark this manually? Do you have experience with an toric projection marker? Which way of marking the axis gives the best results for the patient? I perform the marking of the cornea and axis manually. During the last 11 years i had to rotate the toric lens twice. How often do you have to reposition the toric IOL?

    Best regards

    1. Black ink marks are just for back up. The actual axis is marked on the cornea with three dots in the epithelium along the axis

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