CATARACT 14 EWAP DECEMBER 2022 adjustment capabilities. However, it does not fully counteract these aberrated corneas to achieve better quality of vision.” She added that the EDOF version will be interesting, if it does not increase the dysphotopsia profile. Phillip Hoopes Jr., MD Dr. Hoopes has been using the LAL technology for 8–9 years, from the FDA trial through its launch, giving him a unique perspective. Hoopes Vision has a research center, he said, so it’s able to get involved in a lot of industry research and studies, including the LAL FDA study. Once the product was approved in 2019, his practice began using it. Dr. Hoopes said the LAL involves a change from the usual mindset. With traditional implant technology, most of the work is done before surgery. You make your measurements, you put the implant in, and you’re stuck with the results. “The Light Adjustable Lens is a crossover into the idea of refractive cataract surgery.” He said physicians who have done refractive surgery likely don’t have to change their routine too much in order to incorporate the LAL. Postop patients wear UV- protective glasses for up to 5 weeks, Dr. Hoopes said. The process begins by sitting down with the patient over multiple visits, anywhere from three to five extra visits. Traditionally, Dr. Hoopes sees cataract patients at 1 day, 1 week, and 1 month postop, but with the LAL, the work starts at 1 month postop. Patients must be informed preop about the extra visits and that they must come in several times a week, he said. “The promise of the LAL is to have a product where a month after surgery you can fine tune and personalize results to the patient,” he said. However, a challenge is you must pick the right patients. For example, patients’ eyes must be able to dilate to a certain degree, and if they can’t, they are not eligible for this procedure, Dr. Hoopes said. The light adjustments are not any more difficult than doing a YAG capsulotomy, but the patient must be able to hold steady for 2 minutes. Another challenge is the potential for changes to the eye. “The promise of the lens always was that we could fine tune the results accurately and by the end of the process have patients completely corrected in their vision,” Dr. Hoopes said. “The truth is there’s still the possibility of having small prescriptions even at the end of light adjustment. We know people can still change 2–4 months down the road after cataract surgery just by how the capsule heals. Even the LAL doesn’t prevent the possibility of more long-term changes to prescription, such as astigmatism over time.” While there’s no surgical learning curve, Dr. Hoopes stressed the importance of communication about the treatment process. “As long as I communicate the time period with the patient, the expectation of the work needing to be done a month later, almost every LAL patient has been excited about the technology and willing to undergo the lengthier process. They feel like they have a say in their surgery and outcome.” Dr. Hoopes noted the ActivShield advancement, which allows patients some flexibility with the ultraviolet glasses, but he said even before this update, he had very few cases of patients complaining about wearing them. He still recommends patients wear the glasses as much as possible. One future advancement Dr. Hoopes hopes to see is the ability for physicians to make the decision to lock a patient in. Currently, it’s the software and Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Though the need to remove the LAL is infrequent, it can prove challenging, particularly if the lens has already been locked in. The LAL becomes brittle after it has been treated and locked in, Dr. Fram said. “In the previous generation of the LAL without ActivShield, when trying to stabilize the lens with serrated forceps, it would break into tiny pieces.” Dr. Fram suggested that the best approach is to provide counter traction with a Sinskey hook and use serrated scissors that can hold the lens while cutting. “I have also found that enlarging the main incision to 3.5 mm is helpful, as the lens is silicone and thick and may be difficult to get out of a sub-3 mm incision.” Removal after lock-in is a rare occurrence with the development of the ActivShield, Dr. Fram said, “however, if you put an IOL in, you should know how to remove it safely in the circumstance that it becomes necessary.” Dr. Solomon noted that he has only had to do one removal before the lens was locked in. During one of his insertions, the injector system caused inadvertent damage to the lens, and he had to explant it immediately. He mentioned that it does require attention because it’s a gummy, silicone lens. It’s relatively soft at that stage, so be prepared by using good instrumentation, he said. If you have to remove the lens
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