Eyeworld

42 | EYEWORLD | SEPTEMBER 2022 ATARACT C About the physicians Nicole Fram, MD Advanced Vision Care Los Angeles, California Phillip Hoopes Jr., MD Hoopes Vision Draper, Utah Neda Nikpoor, MD Aloha Laser Vision Honolulu, Hawaii Jonathan Solomon, MD Director Solomon Eye Physicians & Surgeons Bowie, Maryland by Ellen Stodola Editorial Co-Director may allow for some accommodation. Dr. Fram explains to patients that the LAL technology can more effectively hit targets and customize vision, particularly in the post-corneal refractive surgery population. Dr. Fram noted there is not currently an IOL that exactly counterbalances the higher order aberrations of the cornea and/or accom- modates. "This is the missing advancement in the world of lens replacement," she said. "This technology may solve the effective lens position issue by providing postoperative adjustment ca- pabilities. However, it does not fully counteract these aberrated corneas to achieve better qual- ity of vision." She added that the EDOF version will be interesting, if it does not increase the dysphotopsia profile. Phillip Hoopes Jr., MD Dr. Hoopes has been using the LAL technolo- gy for 8–9 years, from the FDA trial through its launch, giving him a unique perspective. Hoopes Vision has a research center, he said, so it's able to get involved in a lot of industry research and studies, including the LAL FDA study. Once the product was approved in 2019, his practice began using it. Dr. Hoopes said the LAL involves a change from the usual mindset. With traditional im- plant technology, most of the work is done be- fore surgery. You make your measurements, you put the implant in, and you're stuck with the results. "The Light Adjustable Lens is a cross- over into the idea of refractive cataract surgery." He said physicians who have done refractive surgery likely don't have to change their routine too much in order to incorporate the LAL. Postop patients wear UV-protective glasses for up to 5 weeks, Dr. Hoopes said. The pro- cess begins by sitting down with the patient over multiple visits, anywhere from three to five extra visits. Traditionally, Dr. Hoopes sees cataract patients at 1 day, 1 week, and 1 month postop, but with the LAL, the work starts at 1 month postop. Patients must be informed preop about the extra visits and that they must come in several times a week, he said. "The promise of the LAL is to have a prod- uct where a month after surgery you can fine tune and personalize results to the patient," he Adopting the Light Adjustable Lens: implementation and personal experiences T he Light Adjustable Lens (LAL, RxSight) is still a relatively new IOL technology, offering the ability to adjust the refractive settings of the lens after implantation with "lock-in" treatments. In this article, several physicians discussed their decision to bring it into practice, implementation considerations, and overall impressions. Nicole Fram, MD Dr. Fram decided to bring the LAL into her prac- tice when she realized she had a more than 20% post-LASIK/PRK patient population needing cataract surgery. Even the best formulas reach a refractive target +/–0.50 D 69–79% of the time, she noted. 1–5 "The promise of a technol- ogy that we could adjust after surgery to meet the refractive goals was exciting," she said. "In addition, our primary strategy for independence from glasses in this patient population was mini-monovision, as the EDOFs and multifo- cals on the market at the time had significant diffractive dysphotopsia." Dr. Fram said workflow adjustments to accommodate the LAL were relatively easy. The patients had all appointments scheduled from the start and understood how long they would need to be in the office. It is important to explain upfront that this technology is not for all patients, particularly if they are from out of town or have a low threshold for wait times. Dr. Fram said she had no reservations about implementation, except that prior to the ActivShield technology, she had one patient develop a central zone and poor vision due to non-compliance with the protective glasses. "Fortunately, the development of ActivShield has decreased this risk, and we have not seen a single case since its implementation." It's important to tell the patient that the strategy for more spectacle independence is blended monovision. "They need to understand the 80/20 rule—80% of what they do on a day-to-day basis will be spectacle-free. Howev- er, this is still monovision, and when driving at night or reading a medicine bottle, they may need glasses." Monovision in the pseudophake is different than monovision with LASIK/PRK or contacts, as their natural crystalline lens

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