CATARACT 16 EWAP DECEMBER 2022 a specific tech who was good at assessing dilation, getting patients dilated, programming, being with us for the treatments, etc.,” she said. “We have patients coming in clusters of three, so we have three patients getting refracted close to each other and getting dilated together, and we found that to be useful.” Dr. Nikpoor said the LAL is an “easy sell” with post-refractive patients. “I explain to them that even with all the measurements we take, we’re still going to be off 10–20% of the time,” she said. “I show them their scans, and I show them why their RK or LASIK makes it challenging to determine the correct lens power.” For other patients, Dr. Nikpoor will still explain how it’s necessary to enhance any diffractive or premium lens 10–15% of the time. Then she explains the alternative of putting a lens into the eye where all the adjustments are built into part of the process and any fine tuning can be done without an additional surgery. She added that the LAL is a desirable option for some patients who don’t know what they want and find it stressful to commit. Dr. Nikpoor said the ActivShield technology has been a helpful advancement. Though she noted that she’s only had one patient who was not compliant with the glasses before ActivShield, she did have to end up exchanging that patient because of stray UV light. It was a difficult case, Dr. Nikpoor said, but when she did the exchange, the ActivShield technology was available, so this was one of her first patients with the update. Dr. Nikpoor is eager to see the ability to add or remove extended depth of focus in the future. “Even though it’s a monofocal, it gives you a little more extended depth of focus than a typical monofocal, and when you do the first adjustment in a myopic direction with a myopic target, on the near eye, you get even more extended depth of focus,” she said. “But I think they will figure out a way to induce even more and give us the ability to induce it or take away if we want to.” Another exciting future advancement is the potential for the company to create a custom light adjustment profile that would help offset some corneal aberrations, Dr. Nikpoor said. Jonathan Solomon, MD Dr. Solomon was aware of the LAL technology for a number of years before deciding to use it in his practice. “I was eager to get my hands on the technology with the idea that it would T he light adjustable lens (LAL, RxSight) has been around for many years and is undergoing a resurgence in the United States. Drs. Fram, Hoopes, Nikpoor, and Solomon are to be congratulated for exploring this technology and using it in their practices. Dr. Fram rightly points out that 20% of her cataract patients these days have had prior LASIK or PRK. This is very similar in my practice and I’m sure it is the same in many practices in Asia. These are demanding patients but also quite motivated and I find them a pleasure to deal with because they have often been very happy with their previous corneal refractive surgery and want to revisit good unaided vision after cataract surgery. The first thing to note is that not all post LASIK patients are the same and each cornea needs to be assessed on its merits. The authors highlight the logistic challenges in their practices of multiple visits and chair time in explaining the value of the light adjustable lens. They also lament the fact that it is only available in a monofocal type lens at present. It is clearly an evolving technology. Dr. Hoopes rightly concedes “the truth is there is still a possibility of having small prescription errors at the end of light adjustment”. So it is not a perfect technology and cannot be promised as such. It seems to me that the light adjustable lens is a United States phenomenon and has not achieved significant traction outside the United States. Why would this be so? • One issue is cost; it is an expensive lens and there are good alternatives. • The second is accuracy of current cataract surgery. Modern biometry with ocular surface optimization and improved formulae have improved our ability to hit the target in normal eyes and also in post refractive eyes. • We also have good technology to enhance post cataract refractive errors with either PRK or LASIK. Often these are very small adjustments and PRK is quite easy to perform and does not induce further corneal aberrations. In many parts of the world, there is also the option of a secondary sulcus placed intraocular lens, such as the Rayner Sulcoflex. This is my preferred option when there is a post cataract refractive error, if corneal laser is not appropriate. These have a long track record, are easy to perform as a secondary procedure some months after the original cataract surgery, and have an excellent accuracy and safety profile. My personal view is that the light adjustable lens will remain a United States phenomenon and its value to surgeons and patients will decrease when a good quality secondary sulcus intraocular lens is available in the United States. This may be some time away. Of course, the light adjustable lens technology may evolve to provide an EDOF or multifocal type optic and it may eventually be possible to reverse aberrations by adjusting the light adjustable lens. If so, the LAL may have a role beyond a niche procedure in the USA. Editors’ note: Dr. Lawless is a consultant for Alcon and Carl Zeiss. Michael LAWLESS, MD Associate Professor, Vision Eye Institute, Sydney 4/270 Victoria Ave., Chatswood, Australia michael.lawless@vei.com.au ASIA-PACIFIC PERSPECTIVES
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