What is the RLE surgery process like?

How can something that sounds as intense as “refractive lens exchange” be a such a simple process? Well for starters, there’s no embarrassing hospital gown.

Joel Hunter, MD
Joel Hunter, MD
Refractive Surgeon, Hunter Vision Updated 10/31/18 11:37 AM

RLE is an initialism for Refractive Lens Exchange. I found out a while back that if the initials spell something, then it’s an acronym. If they are just letters and don’t spell a word, it’s an initialism. For instance, LASIK would be an acronym, but my Compulsion to Explain Initialisms (CTEI) is an initialism. And an inconvenient one at that, because it makes for a long, unnecessary start to a blog on the RLE process. And that’s what we’re here to talk about today. What happens in RLE surgery?

Since RLE is generally performed on a crowd about two decades younger than cataract surgery, most patients are in good health. That’s great news for them because it allows RLE to be performed in an overall less “surgical” setting. It’s possible to perform a sterile procedure under exceptionally rigorous standards for safety and precision without making it feel like a major surgery. One of the qualms I’ve had when performing cataract surgery at a hospital or ambulatory surgery center (ASC…another initialism!) is how a patient undergoing a minor procedure is walked through the same process they would have for heart surgery. Gowns and rolling hospital beds and IV poles—the whole set up creates an opportunity for anxiety at a level wildly incommensurate with a procedure that only requires eye drops for anesthesia.

People in good health without major medical problems don’t have to go through that with RLE. There’s no purpose to it when it’s just as safe to wear normal clothes instead of a gown and your own shoes instead of those little hospital footies. You walk into the procedure room and lay down on a bed for the surgery, then 20 or 45 minutes later (depending on if you have one or both eyes done) you can stand up and walk out. There’s no more need to be rolled around in a hospital bed than there would be for LASIK. Your legs are fine! Plus, since you don’t have anesthesiologists knocking you unconscious, you can use them (your legs) without falling over when you leave—just like when you walked in. During the procedure, since you’re still on planet Earth, we can chat if you want. Or I can be quiet if you’d like to drift off for a brief nap as some folks choose to do.

This brings us to the worry people have about being conscious during a procedure like this. It’s understandable—and common—to feel like being knocked out would be easier. Truthfully, if it was easier, we would do RLE that way. But let me explain why it isn’t. Going under general or even light anesthesia is more difficult than having RLE. For the former, you get an IV placed and have a fast trip into the nether realm and a very slow trip out of it for the next several hours. Also, you can’t eat anything after midnight the night before, and sometimes the idea behind that—vomiting when you don’t want to—becomes a reality. For RLE, you have to look at a bright light. I’m not even leaving out a bunch of details so the contrast will be more impressive. It’s exceptionally anticlimactic. You’ll get a valium to help take the edge off, but having been through RLE with countless people who didn’t want even the valium, I can assure you there’s not much edge that needs to be taken off.

The reason all this is true is due to how sensation works for the eye. You may wonder how a procedure performed on the eye—the same organ that can feel like a whole rock is in there if a tiny piece of sand touches it—could be anticlimactic. The same feature that makes the eye so incredibly sensitive to the slightest irritation, also makes it incredibly easy to put it into a totally painless, irritation-free state. All those very sensitive nerves are unmyelinated (naked) and right next to the surface of the eye. A single drop of anesthetic makes them go completely silent and numb. Now, there’s no harm in a little over-protectiveness, so we give a bunch of those drops. But in any event, there is zero sensation of pain during the procedure. It’s a bright light. That is annoying because it’s bright, but that’s it.

In closing, the RLE process from start to finish doesn’t have a lot of ups and downs. It’s a walk through a very predictable, purposefully unexciting process. The greatest effort of the day is getting up from the big leather chair you sit in while you get your pre-operative drops to walk into the procedure room and lay down. The complex and detailed parts of the procedure are handled by people who like it because it’s their job. And because of that, the whole process ends up feeling the way it should on your side of things. It just feels simple. When you take away all the anxiety-provoking components of hospital gear and the possibility of pain, you end up with the great relief—even if it’s somewhat boring—of an anticlimactic experience that has the ability to change the rest of your life.

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