Refractive Lens Exchange: Outcomes in Myopes vs Hyperopes, Retinal Risk, and Patient Satisfaction

Our companion guide to refractive lens exchange covers what the procedure involves and who is a candidate. This post goes further, reviewing the published evidence on how refractive lens exchange outcomes differ between myopes and hyperopes, the retinal risks specific to myopic eyes, posterior capsule opacification rates in this younger patient population, and what patients actually report about their satisfaction. It is written for both patients considering RLE and for referring optometrists and GPs, with full literature citations throughout.

How do RLE outcomes differ between myopes and hyperopes?

Hyperopes are considered the ideal RLE candidates and consistently achieve excellent visual outcomes and high satisfaction. Myopes achieve comparable visual acuity outcomes but report slightly lower satisfaction rates and face meaningfully higher risks of vitreoretinal complications.

Brenner et al. (Br J Ophthalmol, 2023) studied 35,206 eyes implanted with a trifocal IOL, of which 23.4 percent were myopic (mean spherical equivalent -3.62D, mean age 53). Compared with the emmetropic and hyperopic groups, there were no significant differences in uncorrected distance visual acuity, binocular uncorrected distance visual acuity, or binocular uncorrected near visual acuity between groups. Enhancement surgery was required in 12 to 20 percent of eyes depending on which biometry formula was used.

Llovet Rausell et al. (Indian J Ophthalmol, 2026), a retrospective comparative series using the RayOne Trifocal IOL in myopic, hyperopic, and emmetropic presbyopes, found comparable visual acuity outcomes across all three groups. However, patient-reported outcome measures showed high satisfaction and spectacle independence at all distances overall, with worse results in myopes compared with hyperopes and emmetropes.

Hannan et al. (Ophthalmology, 2023) reported on 34,660 eyes from the United Kingdom, predominantly low hypermetropes, with multifocal IOLs used in 83.2 percent of eyes. Of these, 86.2 percent achieved a refractive outcome within 0.5D of the intended target. Only 42.9 percent achieved a postoperative uncorrected distance visual acuity equal to or better than their preoperative corrected distance visual acuity, an important counselling point discussed further below.

Djodeyre et al. (J Refract Surg, 2021) studied 133 young high hypermetropes (mean spherical equivalent +6.29D, mean age 36.94 years) implanted with a multifocal IOL. 92 percent were within 0.5D of target, 89 percent achieved postoperative uncorrected distance visual acuity equal to or better than their preoperative corrected distance visual acuity, 97 percent were satisfied, and 100 percent reported spectacle independence at all distances.

For patients: the Hannan et al. finding that only 42.9 percent of eyes achieved uncorrected distance vision at least as good as their preoperative corrected vision is worth discussing at consultation. This does not mean vision is worse overall after surgery. It reflects that some patients still require glasses for specific tasks even after a generally successful RLE, and it is a useful figure for setting realistic expectations rather than a cause for alarm.

What is the risk of retinal detachment after refractive lens exchange?

Retinal detachment is the most serious vitreoretinal complication of RLE and the primary reason for caution in myopic eyes. The overall risk inferred from cataract surgery data is between 0.36 and 2.9 percent at 10 years, approximately ten times the general population risk.

Qureshi and Steel (Eye, 2020) conducted a comprehensive review of retinal detachment following cataract phacoemulsification, reporting an overall 10-year incidence of 0.36 to 2.9 percent. Thylefors et al. (Acta Ophthalmol, 2022), using the Swedish National Cataract Register across 58,624 surgeries with a mean follow-up of 4.67 years, found an overall retinal detachment rate of 0.51 percent. The mean time to retinal detachment was 1.83 years after surgery, longer than the follow-up period of most published RLE studies, a point returned to below. Key risk factors identified were increasing axial length, younger age, vitreous loss, and male sex. In patients under 60 with axial length above 25mm, the incidence during the study period was 6.40 percent, rising to 9.46 percent in males specifically.

Morano et al., an IRIS Registry analysis (Ophthalmol Sci, 2023), identified additional risk factors including lattice degeneration (multivariable odds ratio 10.53) and new-onset posterior vitreous detachment following surgery (odds ratio 1.24). Chan and Varma (Eye, 2025), in an editorial summarising the current evidence, conclude that RLE in pre-presbyopic myopes without confirmed PVD should be approached with caution, noting that RLE may improve uncorrected vision but can introduce vitreoretinal pathology, sometimes years later.

The proposed mechanism is that pseudophakia alters vitreous protein composition, accelerating vitreous syneresis and the development of PVD (Jakobsson et al., Invest Ophthalmol Vis Sci, 2015). Removing the lens also reduces lens volume, which draws the anterior hyaloid forward and increases traction at the vitreous base, a recognised mechanism for creating retinal breaks.

In myopic RLE candidates, I specifically assess axial length, age, PVD status, and the presence of peripheral retinal pathology including lattice degeneration. High myopes under 55 without confirmed PVD require very careful counselling, and in many cases a phakic IOL is a safer alternative that preserves the natural lens while still correcting the refractive error. For patients for whom laser vision correction is not suitable and a phakic IOL may be relevant, more detail is available at drmacintyre.com/laser-vision-correction.

How is PVD status assessed before RLE in myopes?

Accurate pre-operative assessment of posterior vitreous detachment status is one of the most important steps in evaluating a myopic RLE candidate, as confirmed PVD substantially reduces, though does not eliminate, retinal detachment risk.

Kicova et al. (Acta Ophthalmol, 2012) compared techniques for identifying complete PVD and found B-scan ultrasonography performed by an experienced operator to be the most accurate, at 83 percent, compared with 76 percent for clinical examination alone. Hwang et al. (Ophthalmol Retina, 2020) found macular OCT useful for ruling out PVD when an attached posterior hyaloid is directly visualised, but the absence of a visible hyaloid on macular OCT does not, on its own, confirm complete peripheral PVD. Momenaei et al. (Ophthalmol Retina, 2024) further demonstrated that even vitrectomised eyes can develop retinal detachment after lens surgery, underlining that confirmed PVD reduces but does not eliminate risk entirely.

The ESCRS MYOPRED study is an ongoing five-year prospective study specifically investigating the influence of PVD on retinal detachment after lens surgery in myopic eyes, and its results are awaited as the most robust prospective data on this question to date.

I use B-scan ultrasonography as part of my pre-operative assessment in high myopes being evaluated for RLE. Macular OCT alone is insufficient for this purpose, since a negative macular OCT does not confirm peripheral PVD. In patients where PVD status remains uncertain after assessment, I treat this as a significant factor weighing against proceeding with RLE in favour of alternatives.

What are PCO rates after refractive lens exchange and why do they matter?

Posterior capsule opacification occurs at higher rates in younger RLE patients than in the older cataract surgery population. This matters clinically because YAG laser capsulotomy in high myopes carries an additional, small, but real risk of precipitating retinal detachment, discussed further in our guide to YAG capsulotomy and posterior capsule opacification.

Ursell et al. (Eye, 2020), a five-year real-world study of 20,763 eyes with monofocal IOLs, found an overall YAG capsulotomy rate of 11.9 percent at five years. Donachie et al. (Eye, 2023), using the Royal College of Ophthalmologists' national database, identified younger age as a significant independent risk factor for PCO, directly relevant given the younger age profile of the RLE population compared with typical cataract surgery patients. Djodeyre et al. (J Refract Surg, 2021) reported a 7.89 percent PCO rate in young hyperopic RLE patients at a mean age of 36.94 years, notably higher than rates typically seen in older cataract populations.

Chan and Varma (Eye, 2025) note that high myopes appear to have increased rates of post-capsulotomy retinal detachment, since YAG laser treatment creates disruption of the anterior hyaloid face and delivers acoustic trauma to the vitreous base. The younger age at which RLE is performed means a longer expected lifetime of pseudophakia, and therefore more opportunity for PCO to develop over the patient's lifetime. Modern square-edge IOL platforms, such as the Clareon platform, have lower PCO rates than older round-edge designs, which is one reason for preferring modern premium IOL platforms in RLE patients specifically.

I counsel all RLE patients that YAG capsulotomy may be required in the years following surgery. In myopic RLE patients, I specifically explain the additional context that YAG carries a small but real additional risk of retinal detachment, and that they should seek urgent assessment if they notice a sudden increase in floaters or any curtain or shadow in their peripheral vision after YAG treatment.

What do patients report about their satisfaction after RLE?

Overall patient satisfaction after RLE is high, particularly in hyperopes. Spectacle independence rates consistently exceed 80 to 90 percent in well-selected patients with appropriate IOL choice, though a small but meaningful minority experience significant dysphotopsia.

Brenner et al. (Br J Ophthalmol, 2023), in their series of 17,603 patients with a trifocal IOL, reported high overall satisfaction. Djodeyre et al. (J Refract Surg, 2021) found 97 percent satisfaction and 100 percent spectacle independence at all distances in young high hypermetropes with a multifocal IOL. Yim et al. (Ophthalmol Ther, 2023), studying 39 RLE patients with a PanOptix trifocal IOL, found 77 percent achieved complete spectacle independence, 87 percent were satisfied with their vision, and 90 percent would recommend the procedure, with starbursts the most frequently reported visual symptom.

Schallhorn et al. (Clin Ophthalmol, 2017), stratifying outcomes across age groups from 45 to 65 years, found 91 to 94 percent of patients achieved 20/20 uncorrected distance vision bilaterally across all age groups, with no significant difference in satisfaction by age group. Llovet Rausell et al. (Indian J Ophthalmol, 2026) found myopes had worse patient-reported outcome measures than hyperopes and emmetropes despite comparable objective visual acuity outcomes, suggesting satisfaction is influenced by factors beyond visual acuity alone, including dysphotopsia, neuroadaptation, and pre-operative expectations.

The gap between objective visual acuity outcomes, which are similar across myopes and hyperopes, and subjective satisfaction outcomes, which are better in hyperopes, highlights the importance of pre-operative counselling and expectation management, particularly in myopic patients considering RLE.

Who is and is not a suitable candidate for RLE based on this evidence?

Candidate selection for RLE requires integrating multiple factors: refraction, age, axial length, PVD status, peripheral retinal health, and patient expectations. The evidence supports a more conservative approach in myopes than in hyperopes.

Strong RLE candidates include presbyopic hypermetropes with a high prescription of +4D or above outside the laser refractive range, patients over 50 with confirmed or likely PVD, patients with early lens changes suggesting a cataract is imminent regardless (since lens surgery becomes inevitable in any case), and patients whose primary motivation is spectacle independence at all distances.

Patients who warrant caution, or for whom alternatives should be considered, include myopes under 50 without confirmed PVD, for whom a phakic IOL is generally safer since it preserves the natural lens; high myopes with axial length above 25mm at any age, given the substantially elevated retinal detachment risk; males under 60 with high myopia specifically, given the 9.46 percent risk observed in the Swedish data during the follow-up period; patients with lattice degeneration, given the tenfold odds ratio for retinal detachment in the IRIS registry data; and pre-presbyopic patients who still accommodate, since RLE causes a permanent loss of accommodation that cannot be reversed.

Phakic intraocular lenses are a viable alternative for younger myopes who are not suitable for laser refractive surgery. They correct the refractive error without removing the natural lens and do not carry the same vitreoretinal risk profile as RLE.

What are the limitations of the current RLE evidence base?

Chan and Varma (Eye, 2025) note that most RLE outcome data comes from retrospective series rather than prospective randomised controlled trials, and that ethical considerations prevent comparative allocation of patients between RLE and observation in high ametropia, meaning a definitive randomised comparison is unlikely ever to be conducted.

Most published RLE series have a follow-up period shorter than the mean time to retinal detachment identified in the Swedish population data, 1.83 years. This means retinal detachment risk may be systematically underestimated in published RLE outcome series, since many studies simply have not followed patients long enough to capture events that occur, on average, well beyond their study period. Patient-reported outcomes in RLE are also underreported relative to visual acuity data, and much of what is known about patient satisfaction comes from a smaller number of dedicated studies rather than being routinely captured across the literature.

The ESCRS MYOPRED study is expected to provide the most robust prospective data on retinal detachment risk in myopic lens surgery once complete, and its results are awaited. In the meantime, the prevailing view in the literature is that it remains reasonable to extrapolate IOL outcome data from cataract surgery to RLE (Rosen et al., J Cataract Refract Surg, 2016), while recognising that RLE patients are younger, have higher visual expectations, and require longer follow-up periods than typical cataract surgery patients to fully capture their risk profile.

Dr Ross MacIntyre completed subspecialty fellowship training in cornea, complex cataract, and refractive surgery at the Wilmer Eye Institute, Johns Hopkins University, and applies this evidence base to individualised pre-operative counselling for every RLE patient, with particular attention to the retinal risk factors discussed above in myopic candidates. For patients considering cataract surgery using the same phacoemulsification technique used in RLE, our general guide covers the procedure itself in detail. For patients with a history of, or risk factors for, macular complications, our guide to macular oedema after cataract surgery covers the related vitreoretinal inflammatory pathway in more depth.

Arranging an assessment

If you are considering refractive lens exchange, particularly if you are myopic or have risk factors discussed above, a comprehensive pre-operative assessment including PVD evaluation is an appropriate first step. I consult at Northern Eye Consultants, Northpark Private Hospital, Bundoora, and at Bass Coast Eye Centre, Wonthaggi. A referral from your GP or optometrist is required.

Contact Northern Eye Consultants to arrange an appointment. For referral information for GPs and optometrists, visit the Northern Eye Consultants for-referrers page. For our overview of who is suitable for RLE and how it differs from cataract surgery, see our companion guide to refractive lens exchange in Melbourne.

References

1. Chan E, Varma S. Refractive lens exchange: the evidence behind the practise. Eye. 2025;39:208-209.
2. Hannan SJ, Schallhorn SC, Venter JA, Teenan D, Schallhorn JM. Immediate sequential bilateral surgery in refractive lens exchange patients: clinical outcomes and adverse events. Ophthalmology. 2023;130(9):924-936.
3. Brenner LF, Nistad K, Schonbeck U. Rethinking presbyopia: results of bilateral refractive lens exchange with trifocal intraocular lens in 17,603 patients. Br J Ophthalmol. 2023;107:912-919.
4. Djodeyre MR, Ortega-Usobiaga J, Beltran J, et al. Bilateral refractive lens exchange with trifocal intraocular lens for hyperopia in patients younger than 40 years: a case-control study. J Refract Surg. 2021;37:524-531.
5. Thylefors J, Jakobsson G, Zetterberg M, Sheikh R. Retinal detachment after cataract surgery: a population-based study. Acta Ophthalmol. 2022;100:e1595-e1599.
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7. Morano MJ, Khan MA, Zhang Q, et al. Incidence and risk factors for retinal detachment and retinal tear after cataract surgery: IRIS Registry analysis. Ophthalmol Sci. 2023;3:100314.
8. Jakobsson G, Sundelin K, Zetterberg H, Zetterberg M. Increased levels of inflammatory immune mediators in vitreous from pseudophakic eyes. Invest Ophthalmol Vis Sci. 2015;56:3407-3414.
9. Kicova N, Bertelmann T, Irle S, Sekundo W, Mennel S. Evaluation of a posterior vitreous detachment: a comparison of biomicroscopy, B-scan ultrasonography and optical coherence tomography to surgical findings with chromodissection. Acta Ophthalmol. 2012;90:e264-e268.
10. Hwang ES, Kraker JA, Griffin KJ, et al. Accuracy of spectral-domain OCT of the macula for detection of complete posterior vitreous detachment. Ophthalmol Retina. 2020;4:148-153.
11. Momenaei B, Wakabayashi T, Kazan AS, et al. Incidence and outcomes of recurrent retinal detachment after cataract surgery in eyes with prior retinal detachment repair. Ophthalmol Retina. 2024;8:447-455.
12. Ursell PG, Dhariwal M, O'Boyle D, Khan J, Venerus A. 5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a real-world evidence study of 20,763 eyes. Eye. 2020;34:960-968.
13. Donachie PHJ, Barnes BL, Olaitan M, Sparrow JM, Buchan JC. The Royal College of Ophthalmologists' national ophthalmology database study of cataract surgery: report 9, risk factors for posterior capsule opacification. Eye. 2023;37:1633-1639.
14. Rosen E, Alio JL, Dick HB, Dell S, Slade S. Efficacy and safety of multifocal intraocular lenses following cataract and refractive lens exchange: meta-analysis of peer-reviewed publications. J Cataract Refract Surg. 2016;42:310-328.
15. Llovet Rausell A, Ortega Usobiaga J, Fernández García JL, Beltrán Sanz J, Navalón-Tolosa J, Llovet Osuna F. Visual outcomes and patient satisfaction in refractive lens exchange with trifocal intraocular lens in presbyopic hyperopia, emmetropia, and myopia. Indian J Ophthalmol. 2026;74(Suppl 1):S33-S39.
16. Yim CK, Dave A, Strawn A, Chan J, Zhou I, Zhu DC. Visual outcomes and patient satisfaction after bilateral refractive lens exchange with a trifocal intraocular lens in patients with presbyopia. Ophthalmol Ther. 2023;12(3):1757-1773.
17. Schallhorn SC, Schallhorn JM, Hannan S, Teenan D. Refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes. Clin Ophthalmol. 2017;11:1309-1320.
18. European Society of Cataract and Refractive Surgeons. MYOPRED study: influence of posterior vitreous detachment on retinal detachment after lens surgery in myopic eyes. escrs.org.