EyeWorld India March 2020 Issue

EWAP MARCH 2020 11 FEATURE by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • The LAL gives patients customized vision after cataract surgery, made possible by a series of light adjustments postop. • Good candidates for the LAL are patients who will return for light adjustments, can afford the technology, and do not mind wearing glasses for a couple of weeks. • Poor candidates for the LAL are patients with small pupils, those who have a large degree of astigmatism, or who are using photosensitizing drugs. • Set up a site visit with a seasoned physician using the LAL to get a better sense of how light adjustments work and how to schedule patients post-surgery for those adjustments. Leaning in with the Light Adjustable Lens Contact information Doane: jdoane@discovervision.com Slade: sgs@visiontexas.com Waltz: kwaltz56@gmail.com Wiley: wiley@cle2020.com This article originally appeared in the December 2019 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp T he Light Adjustable Lens (LAL, RxSight) has been long awaited among cataract surgeons in the U.S., who witnessed their global colleagues using it before it became available in the States. Approved by the FDA in late 2017 for patients with preexisting astigmatism of 0.75 D or greater, initial users of the LAL are discovering best practices to maximize its potential. Here’s what some of these early practitioners have to share about how the lens works, its best candidates, and surgical pearls. How the LAL works For a patient receiving the LAL, cataract surgery is performed normally, and a standard three- piece silicone IOL is implanted. What’s different comes postoperatively. “The ‘magic’ is in the optic,” Kevin Waltz, MD, said. “Seventy percent of the optic of the IOL is polymerized, and 30% is not. You can polymerize proportionately the IOL in place and change the optic.” These polymers are activated by the Light Delivery Device to change the prescription, William Wiley, MD, explained. “This can be done 2 to 3 weeks after cataract surgery, ensuring you can achieve the patient’s visual target with a high degree of precision and accuracy,” he said. Patients can have up to three adjustments performed with the LAL, John Doane, MD, said. Vision adjustments are done in 0.25 D increments after the corneal wound has healed. Once the patient is satisfied with his or her vision, the surgeon “locks in” the vision using the Light Delivery Device. “In practice, the LAL is the most patient-customizable lens option to date and becomes analogous to a finely tailored dress or shirt,” Dr. Doane said. Dr. Doane went on to explain how the light-based technology works. “The photosensitive silicone has free macromers within the lens substrate that can migrate depending on where the light is applied over the lens,” he said. “If it’s central light, then the central part of the lens will steepen and resolve a hyperopic refractive error. If it’s peripheral light application, then peripheral thickening and central flattening with a resultant reduction in myopic refraction will occur. For astigmatism, more light is provided along one major meridian than another, creating a singular spherical focal point impinging on the central retina.” Patients receiving the LAL had uncorrected 20/20 vision or better at 6 months post- surgery at about twice the rate of patients receiving a standard IOL, according to the RxSight website. Best candidates for the LAL There are a few types of candidates who are best suited for the LAL. First, a patient must be willing to have the series of light adjustments that will help tailor their vision, Dr. Wiley said. Second, you’ll want a patient who doesn’t mind wearing glasses temporarily while their vision is fine-tuned. “Our patients really don’t seem to mind the glasses [temporarily]. This is Texas, and we’ve had several patients decorate their glasses with rhinestones,” said Stephen Slade, MD. Patients who are concerned about their quality of vision may favor the LAL, as it doesn’t have the same problems with glare, haloes, or dysphotopsias as some of the other premium IOL technology. “The lens has increased our premium lens usage since the negative and positive dysphotopsia issues are equal to a monofocal lens, which is virtually zero complaints,” Dr. Doane said. Another good candidate is someone who is a good personality match for the surgeon, because the surgeon and patient will work together closely to help achieve those visual goals, Dr. Wiley said. This can be tricky because there may be demanding patients who are not good multifocal IOL candidates but who can receive the LAL. Both parties have to be prepared to work together cooperatively. Patients also have to be ready to pay for this premium technology. The Light Adjustable Lens.