Eyeworld

53 EW FEATURE September 2018 • Products that could change how you practice between being plano or –1.00? Or if they want to read without glass- es, how can they decide between wanting –2.00 or –3.00? "Adjustable IOLs will allow patients to use trial lenses or even trial soft contact lenses to make this decision post- operatively," Dr. Chang said. "We all know that mini-monovision is extremely popular for contact lens wearing presbyopes, largely because the anisometropia can be adjust- ed and can be reversed if it is not tolerated." He added that adjustable IOLs will give patients the ability to try out different amounts of pseu- dophakic anisometropia before the cataract surgeon delivers this result with confidence. "For patients, so much of the stressful preoperative decision making will shift to the postoperative period, when an optometrist can explain and demon- strate the options instead of the cat- aract surgeon," he said. "I think that patients, their referring optometrist, and their cataract surgeon will all be happier with this arrangement." EW References 1. Lundstrom M, et al. Risk factors for refrac- tive error after cataract surgery: analysis of 282,811 cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2018:44;447–452. 2. Inoue Y, et al. Axis misalignment of toric intraocular lens: placement error and postoperative rotation. Ophthalmology. 2017;124:1424–1425. 3. Lee BS, Chang DF. Comparison of the rota- tional stability of two toric intraocular lenses in 1273 consecutive eyes. Ophthalmology. March 2018. Epub ahead of print. Editors' note: Dr. Chang and Dr. Maloney have financial interests with RxSight. Dr. Waltz and Dr. Doane have no financial interests related to their comments. Contact information Chang: dceye@earthlink.net Doane: jdoane@discovervision.com Maloney: info@maloneyvision.com Waltz: kwaltz56@gmail.com For the future, the LAL can do as many corrections as there are patterns of light. At present, Dr. Doane said that +/–2 D of sphere and 0.75–2 D of astigmatism are approved in the U.S. Outside the U.S., the treatments can be done to 3 D of sphere (plus or minus) and 3 D of astigmatism. Looking ahead, he said that any pattern could be possible. "My guess is that an extended depth of focus or multifocal pattern to resolve presbyopic complaints would be the next order of interest from surgeons and the company," he said. The FDA approval was for postoperative adjustment of sphere and cylinder, Dr. Chang said. "This means that the [LAL] should become the ideal toric IOL for low to moderate astigmatism in my opinion," he said. "Although we get excellent results currently, we still must estimate posterior corneal astigmatism and surgically induced astigmatism." He added that low power toric IOLs are not available in the U.S. A study by Inoue et al. showed that 28% of the net mean toric IOL axis misalignment at 1 year was from surgical misalign- ment. 2 Dr. Chang added that even when using digital surgical align- ment, a study from his practice showed that postop rotation of more than 5 degrees occurs between 8–18% of the time, depending on the IOL model. 3 Correcting the astigmatism after several weeks post- operatively circumvents all of these issues, he said. Dr. Chang thinks this new tech- nology will help change the patient experience. "We will all welcome the improvement in refractive accu- racy," he said. "However, the biggest benefit will be the ability for pa- tients to 'try' different pseudophakic refractive options postoperatively as a better way to decide what they want." Having to decide whether they want better uncorrected distance, mid-range, or near vision preop- eratively is confusing and stressful for patients, he said. Without an IOL already in their eye, how can patients understand the difference they looked at +/–0.25 D, which is one level more accurate than corne- al laser vision correction. Dr. Waltz said that he has found the LAL to be "shockingly accurate." He added that the trial included patients with only certain amounts of astigmatism. He said the results of the trial were the best trial results he has seen. "In a typical U.S. trial, you'll have about 40–50% of the patients be 20/20 uncorrected," he said. "In this trial, which was more difficult because you had to be astigmatic, LAL eyes achieved 20/20 or better uncorrected vision in more than 70% of eyes, which was approxi- mately two times the rate of the control group. Additionally, approx- imately a third of the LAL patients were 20/16 or better." Since distance was so good, it improved the intermediate and near as well, Dr. Waltz said. He added that the process for the LAL is a bit more complex, requiring multiple light treatments before it's locked in. This technolo- gy also comes with an extra fee for the work that is involved, which Dr. Waltz estimated could be $5,000– 8,000 per eye. Correction permanence Dr. Maloney said that after the adjustment of the lens is completed, it is locked in to ensure that the lens doesn't change in the future. "Humans are living biological tissue, so living tissue can change," Dr. Doane said. "From everything we can tell with long-term results, in our centers and long-term data outside the U.S., the IOL remains stable." He added that the cornea can change its astigmatism over time, and this will likely be what could change and alter the patients' un- aided vision. "My contention is that if the cornea doesn't change then the result will be stable long term," he said. Approved corrections Currently in the U.S., the LAL is ap- proved for myopia, hyperopia, and astigmatism, alone or in combina- tion, up to 2 D, Dr. Maloney said. axis localization, an ophthalmol- ogist right out of residency should achieve better refractive outcomes with an adjustable IOL than I cur- rently do using all of these technol- ogies for my toric monofocals," he said. Adjusting implant with light versus PRK or LASIK Dr. Doane said after 22 years in practice, he would rather adjust the IOL than the cornea. "Involving the cornea adds another layer of healing and tissue biology that we can avoid when we deal with the lens and light adjustment," he said. "The old- er the patient, the more important this concept is to understand." Dr. Maloney said he thinks pa- tients would much rather have the implant adjusted than have corneal adjustment with PRK or LASIK. "We think of refractive surgery as no big deal," he said. "No matter how we explain it, patients think of LASIK and PRK as having their eye sliced and zapped." Dr. Waltz, who implanted the first lens in the FDA PMA trial, said that either option would work, but he thinks the LAL can give better results than PRK or LASIK. He added that patients also have variability in how their epithelium and stroma heal. There's not much variability in how the LAL heals, he said, so you don't get the surprises that you get with other technologies. "I think if you knew you had to do it, most ev- eryone who could afford it would do the light adjustable lens," he said. "The cost would be a negative, but the quality will be better with the light adjustable." Accuracy of the LAL Dr. Maloney said that 92% of LAL eyes are within 0.5 D of target. "The best number for every other lens is about 70%," he said. "That doesn't include astigmatism correction, which is better with the [LAL] also." Dr. Doane added that this is the "most accurate refractive procedure I have been involved in" with respect to outcomes with +/–0.25 and +/–0.5 D. He added that since such a high percentage of eyes were +/–0.5 D,

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