Patient Discussion: Dysfunctional Lens Syndrome

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5 min read

In this installment of Interventional Mindset, Dr. Waring demonstrates how to effectively communicate with presbyopic patients about dysfunctional lens syndrome.

Upon recognizing a need to better characterize the stages of the aging lens, George O. Waring IV, MD, FACS, along with colleagues Daniel S. Durrie, MD, and Jason E. Stahl, MD, proposed the terminology “dysfunctional lens syndrome” as well as a three-part staging system.1

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Overview of dysfunctional lens syndrome

Dysfunctional lens syndrome (DLS) refers to the natural aging changes that may affect the refractive properties and transparency of the crystalline lens, leading to decreased visual acuity and contrast sensitivity.2
The three stages of DLS are:3
  • Stage 1: Presbyopia
  • Stage 2: Lens aberrations and opacity
  • Stage 3: Higher-order lens aberrations with manifest opacity that impact visual acuity at both near and distance
Cumulatively at Stage 3, these DLS findings have the potential to meet the criteria for cataract surgery eligibility as outlined by Medicare guidelines.3 This video offers a peek into the exam lane, as Dr. Waring introduces the DLS concept to a plano presbyopic patient and offers refractive lens exchange as a solution.

Pearls for patient education on DLS

Through this patient conversation, we can glean four pearls for discussing DLS.

1. Build a connection.

As with any patient encounter, connecting with the individual and finding commonality helps build trust and comfort. Dr. Waring achieves this by using the shared experience of going from perfect vision to the demand for glasses, considering as aging occurs there tends to be compromised acuity impacting daily life activities.
He jokes, “You and I are not habituated to these things hanging off your neck.” Dr. Waring goes on to acknowledge that people who have always had 20/20 or above often “do not take kindly” to these changes, as it is so foreign to not be able to see clearly 100% of the time.

2. Explain dysfunctional lens syndrome in simple terms.

Along with dysfunctional lens syndrome, Dr. Waring coined the term “falling off the vision cliff” as a metaphor for the aging lens process. This embodies the concept that once vision begins to decline, it will continue to do so and at an increasingly rapid rate.
He explains to the patient that they have reached the stage of “ocular maturity,” when the lens is not functioning at full capacity and can no longer completely zoom in to focus as it did in their younger days.
Dr. Waring elaborates by explaining that refractive surgeries, such as laser in situ keratomileusis (LASIK), are intended for issues like astigmatism, which is related to the curvature of the actual structure, not just an aging lens.

3. Provide visual aids.

Using images displayed on a tablet from the patient’s advanced vision analysis, Dr. Waring explains to them that the eye uses a two-lens system. The photos demonstrate that the corneal lens of both the right and left eyes is slightly out of focus for distance.
He also provides a cross-section image to illustrate that the internal crystalline lens has become opaque, meaning they have entered the second stage of DLS. Dr. Waring offers the example of “having a slightly dirty windshield stuck in your eye.” He goes on to point out that the cloudiness is responsible for reduced distance vision.

4. Introduce treatment and its benefits.

Next, Dr. Waring presents refractive lens exchange (also known as clear lens extraction [CLE]) as an effective treatment option with three benefits.
Implantation of a crystal-clear, synthetic intraocular lens can:
  1. Restore zoom function, enabling the patient to read without glasses.
  2. Remove lens opacity, allowing for better distance vision.
  3. Prevent future cataracts, providing “anti-aging in its purest form.”

In closing

With an estimated 2.1+ billion presbyopes worldwide as of 2020,1 finding surgical solutions for DLS with longitudinal data support and a favorable safety profile should easily be top of mind for every ophthalmologist.
Taking an interventional mindset involves intervening with refractive lens exchange when an individual is in the earlier stages of DLS to ensure they might enjoy improved quality of vision and, consequently, enhanced quality of life in the long run.
  1. Waring IV GO. Dysfunctional Lens Syndrome. Cataract and Refractive Surgery Today. Published March 2020. Accessed October 19, 2023.
  2. Fernández J, Rodríguez-Vallejo M, Martínez J, et al. From Presbyopia to Cataracts: A Critical Review on Dysfunctional Lens Syndrome. J Ophthalmol. 2018;2018:4318405.
  3. Waring IV GO, Rocha KM. Characterization of the Dysfunctional Lens Syndrome and a Review of the Literature. Curr Ophthalmol Rep. 2018;6:249-255.
George O. Waring IV, MD, FACS
About George O. Waring IV, MD, FACS

George O. Waring IV, MD, FACS, is the founder and Medical Director of the Waring Vision Institute in Mt. Pleasant, SC. Dr. Waring has served as Associate Professor of Ophthalmology, the Director of Refractive Surgery at Medical University of South Carolina (MUSC), Storm Eye Institute and the Medical Director at Magill Vision Center from 2012 - 2017.

Dr. Waring also serves as Adjunct Assistant Professor of Bioengineering at the College of Engineering and Science at Clemson University. He has served as Clinical Assistant Professor of Ophthalmology at the Emory University School of Medicine, and a Staff Ophthalmologist at the Veteran’s Affairs Medical Center in Atlanta, GA. Dr. Waring IV is a diplomate of the American Board of Ophthalmology and a Fellow of the American College of Surgeons.

George O. Waring IV, MD, FACS
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