CATARACT EWAP DECEMBER 2022 15 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. Dr. Fram offered the following recommendations when first beginning with the LAL. 1. Picking the IOL power: Pick on the first hyperopic side of plano so you can add in power and allow for an effective extended depth of focus by changing the spherical aberration profile centrally. In the non-dominant eye, adjust to effectively cause more negative spherical aberration and increase the depth of focus, she said. “However, if this is a post-LVC or RK eye with an already aberrated cornea, use your normal post-LASIK formulas and pick as you would to avoid big misses in refractive target and large treatments to get to plano.” 2. Higher order aberrations and expectations: Surgeons should be sure to look at Placido imaging and ablation pattern to give proper counseling of the postoperative outcome. The LAL adjustments are not wavefront guided, and if the RMS is high and/ or the Placido imaging is distorted, the patient’s best vision may be with a scleral contact lens. 3. Post-hyperopic LASIK vs. post-myopic LASIK: The hyperopic LASIK patient is challenging in that the K readings are often a moving target despite multiple measurements. This makes the ability to adjust postoperatively ideal in many ways. However, in an eye that already has negative spherical aberration on the corneal topography, it may not be ideal to add a negative spherical aberration IOL. In theory, surgeons want to place an IOL with a neutral or positive spherical aberration in these patients to counteract the negative spherical aberration of the cornea. “In our practice, we perform LAL on hyperopic LASIK patients with neutral to slightly positive spherical aberration measured by wavefront aberrometry patterns to avoid potential issues with image quality,” she said. “Alternatively, in patients with myopic LASIK ablation patterns we are comfortable using this technology as long as the ablation is centered and the Placido imaging is regular.” 4. Intraoperatively: Practice putting in three-piece IOLs, making the incision at least 2.75–3.0 mm at first to avoid Descemet’s detachments when positioning, centering the rhexis on the visual axis, 4.8–5.0 mm, cleaning the posterior capsule well to avoid delay in LAL treatment due to fibrosis of the capsule, and polishing the anterior capsule to avoid capsule contraction, placing the haptics at 6 and 12 o’clock for better IOL stability and less striae in the capsule. When first starting with the LAL technology the light adjustable device that determines when it’s time to do the lock-in treatment. However, he noted that in some cases, he’s had patients who were happy with their vision before the lock-in process. “I would love the opportunity as the surgeon to be able to bypass treatment and make the decision to lock in the patient right now if the patient is happy with their vision. Now I might have to do 1–2 small adjustments or even sham adjustments,” he said. Sometimes these small adjustments can even make patients less happy with their vision. A future option to delay adjustments several months could also be advantageous, Dr. Hoopes added. Neda Nikpoor, MD Dr. Nikpoor said that her partner, Alan Faulkner, MD, was one of the first to adopt the LAL upon launch and the first to bring the technology to Hawaii. Dr. Nikpoor started using the LAL in February 2020. Dr. Nikpoor implanted the lens in her first set of patients right before the pandemic. “During this time, we were still seeing our postops, and it gave us some time to play around with the LAL,” she said. “The timing was perfect for us to integrate something new and have time to understand it and follow those patients closely.” It’s the only lens that Dr. Nikpoor said she wants to put in post-refractive patients. “For a practice that does high-volume laser vision correction, it’s a must-have.” She added that some patients in her practice have had RK or LASIK years ago and are coming back. You want to be able to offer them the best technology designed for their eye, she said. From a practice growth perspective, it gives you a competitive edge to be first in the market, Dr. Nikpoor added. “We’ve gotten referrals from other cataract surgeons because patients are asking about it.” The LAL is also a great option for virgin eyes, she said. They did a review of their cases and found that there were high levels of spectacle independence with a mild amount of blended vision. On average across all patients, the range of vision was similar to an extended depth of focus lens. “The range and quality of vision are excellent, making LAL a great option for any patient,” Dr. Nikpoor said. One obstacle to adoption is figuring out the workflow because of the extra visits, and the visits take a while, Dr. Nikpoor said. In her practice, this involved finding time on the schedule to do adjustments twice a week and training technicians. “We would have
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