Laser Lens Replacement
This vision correction option – Laser Lens Replacement involves replacement of the natural lens inside the eye with a high-performance lens implant. Trifocal lenses and “Extended Depth of Focus” (EDOF) lenses reliably provides independence from distance, intermediate and near vision glasses.
Laser Lens Replacement (LLR) is also known by other terms such as Natural Lens Replacement (NLR), Refractive Lens Exchange (RLE) and Presbyopia Lens Exchange (PRELEX). In an attempt to “demedicalise” the procedure, brand names such as Clarivu™ or NuVu have been used.
What is Laser Lens Replacement (LLR)?
Behind the pupil in the eye is a lens that is used for fine focusing. With advancing age, the lens becomes harder and stops moving, which results in the need for reading glasses. With time the same lens becomes cloudy and eventually affects the ability to see, this is then called a cataract.Laser lens replacement is similar to cataract surgery in that the dysfunctional lens is removed and replaced with a sophisticated intraocular lens implant measured specifically to suit each eye.
The only difference is a laser is used (rather than a manual technique) to assist the process in Laser Lens Replacement / Exchange and is performed in this manner in 100% of cases at Centre for Sight.
The aim of the surgeon is to provide spectacle independence and to accomplish this a phenomenal level of accuracy is required. The procedure is achieved through an incision measuring just 1.8mm across, with the most critical portion of the surgery performed by laser.
Suitability for Laser Lens Replacement
Generally those who are over the age of 50 who have any level of hyperopic (farsighted) and 55 with any level of myopia (short sight) and astigmatism.Those who have cataracts may also be suitable for high performance trifocal lenses.
To be suitable for multifocal lenses, eye health has to be good with no identified problems that can affect lens performance. Those with macular degeneration or visual field loss from glaucoma for instance will not be suitable for multifocals. Additionally, lens replacement is not suitable for those with diabetes.
This link which has a series of 10 simple questions will guide what vision correction options are available for you.
Safety is paramount
At Centre for Sight, we are very selective about those who are eligible. Safety is our number one priority and we make our decisions based on scientific evidence, delaying (and first treating where appropriate) or declining those who might be at increased risk.
The natural crystalline lens in the eye becomes harder with advancing age and in turn fails to change shape adequately to alter focus for near. A change in shape is necessary when looking at near objects e.g. reading a book or iPad.
The natural lens functions inadequately and the condition is termed by some as “Dysfunctional Lens Syndrome” (DLS). The crystalline lens becomes progressively harder and in turn near focus deteriorates further with advancing age. Reading glasses which become progressively stronger are needed to be able to see. This condition is also called Presbyopia.
“Replacement of the poorly functioning natural lens with a high performance lens implant can result in complete spectacle independence!”
Overview of lenses for Lens Replacement surgery
Trifocal Multifocal Lens
This is the most commonly used lens at Centre for Sight with more than 90% of patients opting for this type of implant. The advantage of this lens is it reliably provides correction of distance, intermediate and near vision, in other words a full depth of focus, eliminating or reducing the need for glasses. Suitability for the lens implant is determined at consultation when numerous tests including the optical properties of the cornea and tear film are evaluated.To work well, these high performance lenses require a cornea with good optical properties as well a surface free of dryness and no streaky tear film. Expectations of how the lens performs will be provided during consultation. Patients must understand the concept of adaptation which involves the brain becoming accustomed to the new optical system and picking up new information. The lens has microscopic rings which provide near vision and as a consequence patients may well experience transient halos that disappear with adaptation.
Trifocal – PiggyBack Lens
For those who have already had cataract surgery and were not lucky enough to have a trifocal lens, there is an option of adding in a trifocal lens implant on top of the existing lens. This is also available at primary cataract surgery.For instance if someone has Diabetes or macular degeneration, they may in time have a problem with the presence of a trifocal implant and may require removal. As an add-on lens placed on top of a monofocal, the lens can easily be removed from the eye.
The single focus lens is used in the NHS and vision is geared for distance only which means recipients will in all probability require glasses for intermediate and near vision.
This is a lens that has astigmatism built in to the implant and used in those with astigmatism on their cornea of above 1.25D. For those with less astigmatism, limbal relaxing incisions are at Centre for Sight performed using the laser employed in Laser cataract surgery. Toric lenses have to be specially ordered and sometimes need to be manufactured which can increase the lead time for surgery. Toric lenses are available in combination with both Monofocal and Trifocal lenses.
At Centre for Sight a thorough preoperative consultation will be conducted by the surgeon who will carry out their procedure. The surgeon is supported by a team of highly trained technicians who perform a minimum set of investigations and measurements.
Based on initial findings, additional investigations may be required to further evaluate the eyes as necessary. During the process, the technicians and optometrists are in constant contact with and directed by the Ophthalmic Consultant. Once this has been accomplished the patient will be seen and counselled by the Consultant.
Tests done at Consultation
The consultation at Centre for Sight routinely involves evaluation of vision and refraction (eye testing), contrast sensitivity, corneal mapping, a check of the overall eye aberrations and the contribution made by the cornea and the lens within the eye.
A dry eye test (Schirmer’s test) is also performed as well as a pressure check (Tonometry) and corneal thickness evaluation (Pachymetry).
A scan of the retina and optic nerve (Ocular coherence tomography) to check the health of the back of the eye and rule out any conditions that may adversely affect the outcome of LLR.
The eyes are dilated and a wide-field retinal scan is performed followed by an evaluation by the Consultant. During the process, you will have a chance to watch schematic videos about the procedure, the lenses used and what to expect.
Additionally, you will be provided with a copy of the consent form to read, as this may generate questions which can be answered by the Consultant. The Consultant will look through all the data provided and also perform a thorough evaluation of the front and back of each eye and consider suitability of the procedure.
Your Consultant will discuss the overall findings and outline any special considerations specific to you and your eyes and if not suitable will indicate why.
Following the consultation, you will be provided a summary of the consultation, as well as the costs of the procedure for you to consider.
The procedure is typically performed under drop anaesthetic. At Centre for Sight most patients opt to have intravenous sedation which involves insertion of a venous cannula and periodic injection of sedatives to keep you well relaxed. Your pupils will be dilated with a series of eye drops and possibly with a medicine pellet under your lower lid. You will also receive strong antibiotic eye drops to kill bacteria and prevent infection.
You will be brought in to the operating theatre and asked to lie down on the bed attached to the laser. The surgeon looking down a microscope will attach a suction ring to the eye, which itself will be attached to the laser. You might have a sensation of pressure. The laser portion process takes between 1 – 2 minutes and involves making an opening in the lens capsule, fragmenting the lens and in some cases making a corneal incision for the correction of astigmatism.
Once accomplished, the laser bed is rotated under another microscope and surgery continues. A sticky plastic drape is placed on the eye after the surrounding skin has been disinfected with an iodine preparation. An eyelid clip is used to keep the eyelids open and the surgeon will perform the remainder of the operation through an opening of less than 2.0mm!
The fragmented lens is removed with another sophisticated machine, followed by which the lens is implanted and once centered and the gel device removed, antibiotics are instilled to prevent infection followed by the eye being patched and a protective shield placed. The other eye is planned to be treated within a few days to a week afterwards.
Surgery on both eyes
Surgery on both eyes is sometimes performed where clinically appropriate. Patients suitable for surgery on both eyes are usually non-complex “middle of the road” cases. At Centre for Sight to ensure maximal safety, each eye is treated independently with different batch numbers of devices and medicines for each eye, as well as instruments that have had different sterilisation cycles.
If both eyes are treated on the same day, for practical reasons the eyes are not patched and instead goggles on an elastic band are placed to protect the eyes. Patients are advised to go home and keep their eyes closed and allow them to settle for at least 4 hours. Eye drops are also commenced on the same day and patients must be seen in consultation the following day.
Aftercare & Recovery
You will have some time to recover following surgery and when ready you will be served a light snack. You will be given a small toiletry bag containing your medications and instructions on their use. You will then be able to go home and we suggest you get plenty of rest that day.
The following day, you should take off your shield and patch. Preserve the shield in case you are instructed to use this at bedtime. Commence your drops as instructed remembering to close your eyes for 5 minutes by the clock before adding the next drop. You may have an appointment to be seen that day or a day or two later. If you are not seen the next day, someone from Centre for Sight will contact you to ensure you are making good progress.
The good news is visual recovery is typically very quick with many patients obtaining excellent vision the day following surgery. Sometimes vision is blurred for one or two days for a variety of reasons and this might be the case if the cataract was particularly hard.
A high-performance lens like a trifocal lens implant provides the ability to read without glasses. A monofocal lens corrected for distance vision often results in poor near vision easily remedied by a temporary pair of off the shelf reading glasses.
What to expect after Lens Replacement Surgery?
When one eye is treated at a time, often patients will report the following day that their vision in the treated eye is not quite as good as expected. This is often the case in those who were previously farsighted and can find that distance vision is blurred. This happens because the eye muscles which are trying to focus in the untreated eye, result in the implant being pushed forward making the patient short-sighted. With trifocal lenses, we emphasise preoperatively that it is only when both eyes are treated that patients get the benefit from the lenses with no comparative reference points. The eyes see similarly and vision improves rapidly each day. Previously short-sighted patients often report reading is not as good as it used to be, but with adaptation this improves. The brain is able to pick up the information that it needs and make use of this.
Visual side effects
Initially halos around headlights enough to interfere with the ability to drive comfortably affects 10% of patients, but improves in all patients with time. With adaptation, the brain is able to suppress unwanted information and patients report noticing a reduction in the size of the halos over the next 6 to 12 weeks, eventually disappearing or being just a nuisance. A few patients take longer to adapt (12 to 18 months). In the worst case scenario the implant can be replaced with a monofocal lens, which will have the consequence of reducing the depth of focus and result in the need for glasses.
We check for dry eye before surgery and this is treated if found to be significant. Those with marked tear surface abnormalities are not suitable for multifocal lenses. The abnormal surface can affect the performance of the lenses and cause fluctuation in vision. This condition can be treated in advance and once better, patients can be considered for multifocal lenses. Dry eye after surgery can occur as a result of a) no longer wearing glasses or contact lenses and being exposed to the elements or more commonly b) toxicity from the eye drops which are at a high concentration in order to penetrate and enter the eye. Preservatives in drops are also a contributory factor. Dry eye symptoms and effects do improve a few weeks after the course of eye drops has been completed.
Reading and intermediate vision
Trifocal lenses distribute light energy to three points of focus. The majority (60% or more is for distance and the remainder for intermediate and near. Also, some trifocals have more energy for near concentrated in the centre of the lens, as pupils typically constrict when one reads. However, in dim light, the pupils can dilate and thus affect reading performance, so reading menus in a dimly lit restaurant might be problematic. Using a light to illuminate the object should help. The ability to see at intermediate (computer monitors) can in some patients take time (6 to 12 weeks) and again this is to do with adaptation. The brain adapts and uses the information that is being transmitted from the retina.
Complications / Risks
As in all forms of surgery problems can occur during the operation or afterwards during the period of healing afterwards. More commonly problems are easily remedied by medication or even further surgery. Serious problems are rare but can lead to loss of vision, which can be permanent (a reduction in vision when compared to before surgery that cannot be corrected with glasses or contact lenses).
At Centre for Sight, quality standards over and above the minimal requirement by the Royal College of Ophthalmologists are collected and reported each month, which include unexpected complications during surgery, returns to the operating theatre and infections. We are pleased to report that we have complication rates that are significantly below the national average.
Loss of vision whereby vision even with glasses or contact lenses is below the standard required for driving can occur after any eye procedure and following LLR is between 1 in 500 and 1 in 1000 nationally.
The cause of this type of problem could be infection or inflammation after surgery, retinal detachment after surgery or bleeding at the time or after surgery and also posterior capsule rupture, which is where the membrane of the lens could break during surgery.
The UK rate of rupture is 1.5 to 2.0%. At Centre for Sight our rate over the last 3 years has been less than 1 in 800 (0.125%). A posterior capsule rupture may affect the ability to implant a multifocal/trifocal lens implant.
Second operations are sometimes needed and these include recentering or repositioning a lens (for instance a Toric lens used to correct astigmatism), top-up laser surgery (1% at Centre for Sight) to correct the refraction of the eye (shortsighted, farsighted or astigmatism). Those who are shortsighted are at higher risk of retinal detachments for the first few years following cataract and LLR surgery. Detached retinas are repairable by expert retinal surgeons.
The most common procedure required following LLR and Cataract surgery is a YAG laser posterior capsulotomy, where the membrane holding the lens implant becomes cloudy and impairs vision. This occurs in 5% of patients and is easily treatable at a clinic appointment.
More on YAG capsulotomy https://www.centreforsight.com/treatments/laser-cataract-surgery/yag-laser-capsulotomy
Alternative procedures to Lens Replacement
Laser vision correction
Procedures which include LASIK (Laser in situ Keratomileusis) or Photorefractive Keratectomy (PRK), work by changing the shape of the cornea and therefore do not involve a lens implant.
Phakic Intraocular Lenses
These are lens implants inserted into the eye without removal of the natural lens.
Both the above options are better for those under the age of 50, who still have clear lenses and good quality of vision with glasses or contact lenses. Both laser vision correction and Phakic intraocular lenses are able to reliably correct one point of focus and usually distance, which means those in their mid-forties might still need to wear reading glasses afterwards. There are options for extending depth of focus and providing the ability to read and include “Monovision” and in the case of laser eye surgery “Supracor Lasik”.
Monovision is a technique whereby the non-dominant eye is planned for near vision and the dominant eye for distance. This means both eyes do not see equally at distance and near, however with both eyes open a good depth of focus is achievable. This is not suitable for everyone and a contact lens trial using this scenario is advised prior to undergoing the procedure. Some may already be using this method with their contacts.
This is a Lasik procedure where the cornea is made to be multifocal. As there is a period of adjustment and adaptation, only the non-dominant eye is treated. More information on Supracor Lasik can be found https://www.centreforsight.com/treatments/laser-eye-surgery/supracor-lasik
Can I have lens replacement if I’ve had laser eye surgery previously?
Yes, but it may restrict the range of lenses available to you. We will need more information to find the most suitable option for you before booking consultation.
Will having LLR and multifocal/trifocal lenses affect my eye health in the future?
The procedure does not stop one from developing eye problems or increase the risk of eye problems. Glaucoma and age-related macular degeneration can still occur and for this reason it is important to be regularly monitored by an eye care practitioner such as a local Optometrist. It is best to continue a relationship with your current Optometrist and maintain continuity of care and also contact us at Centre for Sight if there are ever any concerns.
How soon can I expect to have good vision?
This is highly variable. Some patients obtain good vision within 24 hours and others may take a little longer. Much depends on each individual’s response to healing. If you have had High Performance Lenses (Trifocal, Polyfocal or Accommodative), implanted, there may well be a period of adaptation before you are able to see well at near.
How long should I remain off work?
Usually one or two days. You may return to work as soon as you are comfortable. Make sure you are able to take your eye drops regularly as instructed by your surgeon.
How soon after my procedure may I drive?
When your vision is clear and you are comfortable. You must be able to read a number plate at 25 meters. Your doctor will advise you if you meet the visual standards for driving.
When can I return to playing sports and other activities?
You may return to all sporting activity after TWO weeks. For contact sports, you are advised to use protective eye glasses. Polycarbonate sports glasses are recommended. For swimming, usually after 4 weeks.
There are no restrictions and you may return to general activities like housework, shopping and gardening the following day. You must keep away from smoky and dusty environments and do not forget to wash your hands before using your eye drops.
|Consultation – reduced price for payment in advance of consultation||£295.00|
|Laser Monofocal Premium Package||£2,975 per eye (from £94 per month)*|
|Laser Monofocal Toric Premium Package||£3,575 per eye (from £113 per month)*|
|Laser Multifocal Premium Package||£3,950 per eye (from £110 per month)*|
|Laser Multifocal Toric Premium Package||£4,250 per eye (from £110 per month)*|
*per eye with 0% interest finance option payable over 24 months. Deposits will apply.
For laser vision correction consultations, we request the payment to be completed at the time of booking consultation.
The prices are an indication of usual charges.
The information here is not complete and may be subject to change.
Please read in conjunction with the Centre for Sight Terms and Conditions.
Since Toric lens is ordered specifically for each eye, a deposit is required. The deposit is included in the final price and is non-refundable.
Laser Lens Replacement (LLR) / Lens Replacement surgery packages are inclusive of:
- 90 days of postoperative care
- Correction of astigmatism up to 1.25D. (For higher levels, toric lenses will be required)
- High Precision VICTUS Femtosecond Laser
- Laser vision correction enhancement if required postoperatively
- YAG posterior capsulotomy if deemed necessary within 6 months of the procedure
Financing Options for Self-Pay Cataract Surgery
Centre for Sight has partnered with V12 Finance, to make the cost of cataract surgery and remarkable care affordable.
Our attractive 0% APR (representative) repayment option is available over 24, 18 and 12 months, subject to application.
A deposit payment will be required. If you wish to pay a larger deposit, even lower monthly finance rates are available, all interest-free.
Centre for Sight is an Introducer Appointed Representative of V12 Retail Finance Limited. Registered in England and Wales 4585692. Correspondence address: 20 Neptune Court, Vanguard Way, Cardiff, CF24 5PJ. Registered Office: One Arleston Way, Solihull, B90 4LH. V12 Retail Finance Limited act as a credit broker and introduces to one or more lenders, for which they will receive a commission.
V12 Retail Finance is a trading name of Secure Trust Bank PLC. Both are authorised and regulated by the Financial Conduct Authority. Centre for Sight will not receive a commission for making introductions to V12.
Credit acceptance is subject to application and status. Other terms and conditions apply and will be advised upon acceptance.
Sources & References
1. Refractive Lens Exchange. Patient Information from the Royal College of Ophthalmologists. Revised April 2017. RCOphth
2. Corneal inlay implantation for correction of presbyopia. Interventional procedures guidance [IPG455] Published date: April 2013 NICE
3. Daya SM, Nanavaty MA, Espinosa-Lagana MM. Translenticular hydrodissection, lens fragmentation, and influence on ultrasound power in femtosecond laser-assisted cataract surgery and refractive lens exchange. Journal of Cataract and Refractive Surgery. 2014 Jan;40(1):37-43. doi: 10.1016/j.jcrs.2013.07.040. Epub 2013 Nov 22. PubMed
4. Alió JL, Grzybowski A, Romaniuk D. Refractive lens exchange in modern practice: when and when not to do it? Eye and Vision. 2014;1:10. doi:10.1186/s40662-014-0010-2. PMC
5. Nanavaty MA, Daya SM. Refractive lens exchange versus Phakic intraocular lenses. Current Opinion in Ophthalmology. 2012 Jan;23(1):54-61. doi: 10.1097/ICU.0b013e32834cd5d1. PubMed
6. Minassian DC, Reidy A. Future Sight Loss UK (2): An epidemiologic and economic model for sight loss in the decade 2010-20. [Internet]. [cited 2014 Jan 6]. RNIB
7. Montés-Micó R, Ferrer-Blasco T, Charman WN, Cerviño A, Alfonso JF, Fernández-Vega L. Optical quality of the eye after lens replacement with a pseudo accommodating intraocular lens. Journal of Cataract and Refractive Surgery. 2008 May;34(5):763-8. doi: 10.1016/j.jcrs.2008.01.017. PubMed
Natural Lens Replacement also known as Laser Lens Replacement and branded by some as Clarivu™ or NuVu is a process where the natural lens of the eye is replaced with a high performance lens implant to correct vision. Use of these lenses such as the Trifocal lens, provides patients with spectacle independence*.
*Note those who have Diabetes may not be suitable for permanent Trifocal lenses, however a there is an option now available for a trifocal easily removable piggy back lens Your consultant at Centre for Sight will discuss these options in more detail with you at consultation.
Authored by Sheraz Daya MD FACP FACS FRCS(Ed) FRCOphth
Mr Daya is the Medical Director of Centre for Sight and listed amongst the 100 most influential ophthalmologists in the world ( https://theophthalmologist.com/power-list/2018/sheraz-daya/).
Next review due January 2020.