Clear Lens Phacoemulsification for Correction of High Myopia

The article by Pucci et al.1 on the treatment of high myopia with clear lens phacoemulsification demonstrates that clear lens extraction with intraocular lens (IOL) implantation can be an effective treatment option for high myopia. This is particularly applicable in places such as Hong Kong, where there is a high prevalence of high myopia that may go beyond the treatment limits of more widely used refractive procedures such as photorefractive keratectomy and laser in situ keratomileusis (LASIK). We would like to discuss a few particulars in the study. The first is about the postoperative refractive status. While we agree that highly myopic patients would prefer a slightly myopic postoperative refractive status,2 we would like to know the rationale behind choosing the postoperative target refraction of −3.0 diopters (D). Many LASIK surgeons would choose the monovision approach for presbyopic patients, aiming to correct 1 eye to plano and the other eye to −1.0 D to −1.5 D. Most patients in the study were at early presbyopic age (mean age 41.6 years ± 7.2 [SD]), and 7 of 16 patients received unilateral surgery with presumably some accommodative amplitude left in the unoperated eye. The monovision approach may make these patients less spectacle dependent. Second, poly(methyl methacrylate) (PMMA) IOLs were used for implantation. Five of the 20 operated eyes developed significant posterior capsule opacification (PCO) that required neodymium:YAG (Nd:YAG) laser capsulotomy. Although the percentage is comparable to what is generally reported,3 attempts to further reduce the risk of significant PCO are desirable because Nd:YAG capsulotomy increases the risk of complications such as retinal detachment, especially in highly myopic eyes.4 New acrylic soft IOLs, eg, the AcrySof® IOL (Alcon Laboratories), have a lower rate of PCO than the PMMA lenses.5 To our knowledge, Alcon now also produces lower-power AcrySof IOLs, manufactured in 1.0 D steps, with lens power ranging from +5.0 D to −5.0 D (model MA60MA). These foldable IOLs require a smaller wound for insertion and allow sutureless surgery. The overall integrity of the eye could be better preserved. Finally, we believe that lidocaine 2% jelly (Astra) represents a significant improvement over lidocaine 4% eyedrops for anesthesia in phacoemulsification.6 The jelly lengthens the contact time and obviates the need for multiple applications during the surgery. We have used the jelly for topical phacoemulsification in our centers for more than 2 years with excellent results. We commend Dr. Pucci and coauthors for their well-conducted study and clearly written article. We hope that our suggestions on the choice of target refraction, IOL, and anesthetic agent will broaden the discussion and enhance the overall results. Joan S.K. Ng FRCS Helios T.C. Leung OD, PhD Dennis S.C. Lam FRCS, FRCOphth aHong Kong, People's Republic of China