Indications and risk factors in refractive lens exchange: outcomes and special cases (extremes hyperopes and myopes)

Refractive lens exchange (RLE) has become an effective option for the correction of ametropia and presbyopia in patients over 50 years of age. Unlike conventional cataract surgery, this procedure requires more comprehensive preoperative counseling, as patients often have high expectations. However, it is essential to emphasize that simultaneous vision intraocular lenses and other alternatives provide functional vision, though not perfect. The success of RLE largely depends on the surgeon's ability to select the most appropriate intraocular lens, considering its optical design, the management of higher-order aberrations, and the minimization of residual astigmatism. It is also crucial to anticipate and, when necessary, correct residual refractive error. Candidate selection should be based on both the patient's visual needs and anatomical and biological factors, including age, axial length, the vitreoretinal interface, and the risk of glaucoma in hyperopic patients. Primary indications include high hyperopia, myopia in patients who are not candidates for corneal refractive surgery or phakic intraocular lenses, significant corneal astigmatism, and presbyopia. In high myopia, the risk of retinal detachment is increased, whereas in high hyperopia, patient satisfaction is generally high when indications are appropriate. By contrast, the risk of dissatisfaction in emmetropic presbyopic patients is higher, making this indication controversial. In conclusion, RLE requires careful patient selection, appropriate intraocular lens choice, and effective expectation management to optimize visual outcomes.