18 EyeWorld Asia-Pacific | March 2025 CATARACT ‘Everyone had to be educated’ Dr. Shamie said her senior partner, Robert Maloney, MD, was involved in the LAL development, and her practice was involved in its clinical trials. Since then, they’ve considered it to be a paradigm shift in the way they perform cataract surgery. “The Light Adjustable Lens offers the opportunity to fine tune vision … after the lens has settled in its position, after the cornea has healed, and after the refractive outcome has stabilized. We then take that refractive outcome, plug it and the refractive target into the Light Delivery System, and adjust the lens to compensate for the refractive miss. In doing so, more than 98% of patients reach their refractive target,” Dr. Shamie said. However, there were many lessons learned in using the lens effectively in their practice. Clinic flow was the biggest hurdle. Dr. Shamie said she was doing her own adjustments initially (and she recommends those starting out with the lens do 10–20 adjustments to understand the nuances of it), but she has since trained internal ODs to perform the adjustments. Adjustments only take about 2 minutes, but the workup to prepare the patient for the light adjustment requires a discussion about target planning, then a manifest refraction and dilation. “Optometrists who are in surgical practice working closely with cataract surgeons are very well equipped with what’s required to do the light adjustments. The most difficult part is not the light adjustment but the target planning for the patient. After we decided to have our internal ODs do the light adjustments, it was a much smoother process,” she said. Dr. Shamie said it’s important to inform patients preop that light adjustment specialists will be managing adjustments after their surgery. Another lesson was the education required for the staff about the value of the lens. “Everyone had to be educated about the unique nature of this technology. We needed them to be enthusiastic about the opportunity it was adding to optimize patient outcomes and improve the quality of vision patients could achieve. They saw our cataract patients were achieving uncorrected vision of 20/20 and sometimes 20/15 and were ecstatic, so after a little while, it spoke for itself,” Dr. Shamie said. Referring doctors also had to be educated on how the postop period and co-management is different for this lens. “After empowering and educating the referring doctors and demonstrating to them the value added to their patients, they became vested in the process,” she added. Over time, Dr. Shamie said her practice changed their initial refractive targets with the lens, now targeting slightly plus to then adjust postop toward minus for a slight extended depth of focus effect. “When you treat the lens to shift toward myopic, the light treatment to change the refractive power of the lens centrally creates an extended depth of focus, similar to what you see with a monofocal plus,” she said. She also offered a few patient-specific pearls: • Advise patients with astigmatism that they’ll be living with a bit of blur for 2–3 weeks after surgery, as the lens prior to the adjustment is essentially a monofocal IOL. • Post-RK, post-hyperopic LASIK, and post-hyperopic PRK patients can take a longer time to stabilize after cataract surgery, so Dr. Shamie advised delaying adjustments by at least 5 weeks and separating light adjustment by 2 weeks. In post-myopic LASIK/PRK or eyes with no prior history of corneal-based surgery, Dr. Shamie’s practice begins light adjustments 3 weeks after surgery with eyes spaced 1 week apart. • For patients who haven’t tried monovision or don’t want to consider it, who hate glasses, and are seeking a fuller range of vision, she recommends a multifocal IOL, rather than the LAL or LAL+. • Avoid the LAL in patients who don’t dilate well and those with suboptimal vision potential, such as patients with mild to moderate AMD or with epiretinal membrane. These patients are investing time and money in the advanced technology, and if the eye’s vision potential is limited, they can get frustrated with the outcome. Overall, Dr. Shamie said the LAL and LAL+ fills a gap. “I know we have a lot of wonderful lens options out there. But when I think about my practice, my patients, not having the LAL, I think I would miss an opportunity of offering that subgroup of patients the most optimized outcome possible. Having the LAL as one of your options increases your ability to offer premium lenses to patients who otherwise would not have been good candidates for premium lenses. Prior to the LAL, our premium lens conversion was about 50%. It has increased by at least 5–10% with the addition of the LAL,” Dr. Shamie said.
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