9 EyeWorld Asia-Pacific | December 2024 FEATURE Pathways to Precision and Perfection – Light Adjustable Lens (LAL) vs. IOL Formulae essentially find the sweet spot where they can meet critical needs at near (e.g. reading their mobile device without glasses) while blurring their distance vision as little as possible. With contact lens fittings, presbyopic patients take advantage of refractive adjustability in one or both eyes all the time. Indeed, in our practice, our optometrists handle much of the postoperative decision-making with the LAL by simulating different outcomes with trial lenses – just as they do with mini-monovision contact lens fittings. So, this isn’t simply a question of whether the LAL outperforms modern biometry/formulae in hitting a refractive target. The problem is that we often don’t know preoperatively what the best target is. Having to choose preoperatively between competing IOL designs and refractive targets that they cannot preview or later easily reverse can be very stressful. It is challenging for preoperative patients to comprehend the difference between being plano or -1.00, the difference between having 0.75 D of astigmatism versus none, and the difference of 1 versus 1.5 diopters of intentional anisometropia. After making these lifelong decisions and finally selecting a refractive objective, we then add the disclaimer that we cannot guarantee their desired refractive outcome. We all know that taking away too much of someone’s preoperative functional myopia is risky. Discovering that they’ve lost their ability to read their phone, read in bed, or apply makeup, is a major source of “buyer’s remorse” for many patients who fancied good distance vision. This is why the ability to change the refractive target or IOL type in the second eye based on the patient’s experience with the first eye is the most important benefit of delayed sequential bilateral cataract surgery (DSBCS). This becomes a moot point with the LAL, and I therefore offer every bilateral LAL patient the option of immediate sequential bilateral cataract surgery (ISBCS). Thanks to adjusting both eyes simultaneously postoperatively, my LAL patients typically make the same total number of trips to the office/surgery center as if they had undergone DSBCS with traditional IOLs. More than 90% of my bilateral LAL patients have chosen the option of ISBCS. Although LALs can be used for anyone, it is particularly well-suited for our most challenging refractive IOL patients. These include post-keratorefractive or refractive lens exchange (RLE) patients, those with inconsistent keratometry (e.g., dry or abnormal ocular surface), uncompromising personalities demanding a specific outcome (e.g., no distance or no reading glasses), and those who’ve never worn eyeglasses thanks to rigid contact lens monovision and expect this to continue. Thanks to greater refractive precision and optimal quality of day and nighttime vision with LALs, we finally have an excellent IOL technology to reliably satisfy most RLE patients. I recently performed bilateral same day RLE on my own wife with LAL Plus. Fortunately, I am still married! I believe that as ophthalmologists gain more experience with the LAL, they will perform more RLE with this platform. The resulting word of mouth will increase interest and demand among presbyopic patients in their 60s who don’t have any cataract. The older published literature pertains to early versions of the LAL used in the first clinical trials. The LAL platform first introduced in several European and Canadian investigational centers could not correct astigmatism, explaining the muted enthusiasm for that first iteration. Because the FDA has not approved low power toric IOLs in the US, the LAL is the only IOL in the US that can correct as little as 0.5 D of astigmatism. Another LAL advance is Active Shield (RxSight), which theoretically eliminates the need for constant UV protection postoperatively. Since this became available 3 years ago, I stopped having my patients wear UV glasses indoors. This has significantly improved the patient’s experience and decreased the urgency to get the LALs locked in as early as possible. I continue to use all the multifocal, extended depth of focus, and monofocal IOL models available to me in the US. However, for a growing subset of patients, some of whom are among the most difficult to satisfy, it has been wonderful to have this game-changing technology as an option.
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