Eyeworld

52 | EYEWORLD | SEPTEMBER 2021 ATARACT C Contact Chang: dceye@earthlink.net Loden: lodenmd@lodenvision.com Naids: steven.naids@gmail.com Ristvedt: deborah.ristvedt@ vancethompsonvision.com LAL. It includes biometry, an OCT of the macu- la, and corneal topography. There are some patients—perfectionists and engineers, for example—who agonize preoper- atively over what specific refractive target they want, Dr. Chang said. "With the LAL, they can wait to try out their binocular pseudophakic vi- sion postoperatively and confirm or modify their refractive preference based on their daily ex- perience," he said. "This, and the fact that they won't have diffractive ring halos, dramatically relieves the anxiety for this type of patient." Learning curve and tips When starting to use the LAL, Dr. Naids said it's important to be comfortable placing a three- piece lens, and he noted that the injector system is a bit different. He suggested using an eye model to get used to it. Postoperatively, you have to reassure these patients that their vision is usually not where they want it to be at first and it won't be for a number of weeks, he said. Dr. Chang said to think of the LAL as a cus- tomizable toric IOL, and the majority of patients will end up with some amount of micro-, mini-, or full monovision. He also suggested that if you don't want to offer ISBCS, try to do the surger- ies close together. The ability to base adjust- ments on the patient's binocular, pseudophakic vision is one of the biggest advantages of this technology, Dr. Chang explained. "This is an easy implementation to pick up," Dr. Loden said. With the surgery itself, there is basically no learning curve if you're comfortable implanting a three-piece lens, he said. The only thing that requires a slight learning curve is doing the adjustments. Recent updates According to Dr. Loden, a big breakthrough is the ActivShield technology, which is a new UV protective layer built into the LAL. This new UV protective layer is automatically opened by the LDD, allowing precise lens adjustments. When the adjustments are complete, the ActivShield is automatically engaged again to protect the lens from accidental sun exposure. Dr. Loden thinks that in the near term this will increase peace of mind for patients and doctors, and in the long term may be a pathway toward removing the need for UV-blocking glasses. If you have a post-refractive eye, Dr. Loden said your workload is going to be better than doing a PRK touch-up on top of a LASIK flap. There is less overhead and faster recovery of vision, he said. But compared to a standard toric lens or standard extended depth of focus lens that you might put in, Dr. Loden said there is an in- creased workload. "It's going to take three extra visits to do adjustments and lock-ins," he added. "With the IOL's ActivShield technology, we're doing two adjustments and one final lock-in," he said. Previously, it was two adjust- ments and two lock-ins, which Dr. Loden said dramatically increased postop time, including traveling to and from the doctor's office, being dilated each visit, etc. This was a negative part of the experience for the patient, he said, so this update makes the process a little easier. Dr. Ristvedt noted that with the LAL, there is more chair time post-surgery than pre-surgery. "Postoperatively is where the real work comes in because these patients are coming back more often," she said, adding that it's usually after 3–4 weeks that manifest refraction will stabilize. "You want stability before you start to change the lens," she said, adding that it's important to make sure the patient understands his or her goals. "Once we start to adjust the lens, they're coming in every 5–7 days for a recheck," she said. "It can bog us down a little bit when it comes to doing a precise manifest refraction, checking lifestyle, and dilating enough to make sure we can get a good treatment from the Light Delivery Device (LDD)." Dr. Ristvedt added that there are usually 2–3 treatments before the lock-in occurs. "I think patients are happy because they have that great vision afterward," she said. "But it can be a little taxing." Diagnostics Dr. Loden said he doesn't do anything different in terms of diagnostics for the LAL, noting he obtains Pentacam (Oculus) and IOLMaster (Carl Zeiss Meditec) measurements on every patient. He said it's also important to know the basic corneal curvature, if the patient has regular or irregular astigmatism, and if they have a healthy retina. Similarly, Dr. Naids said his preoperative testing is the same for patients who want the continued from page 51

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