Eyeworld

SEPTEMBER 2022 | EYEWORLD | 43 C to undergo the lengthier process. They feel like they have a say in their surgery and outcome." Dr. Hoopes noted the ActivShield advance- ment, which allows patients some flexibility with the ultraviolet glasses, but he said even before this update, he had very few cases of patients complaining about wearing them. He still recommends patients wear the glasses as much as possible. One future advancement Dr. Hoopes hopes to see is the ability for physicians to make the decision to lock a patient in. Currently, it's the software and the light adjustable device that determines when it's time to do the lock-in treatment. However, he noted that in some cas- es, he's had patients who were happy with their vision before the lock-in process. "I would love the opportunity as the surgeon to be able to bypass treatment and make the decision to lock in the patient right now if the patient is happy with their vision. Now I might have to do 1–2 small adjustments or even sham adjustments," he said. Sometimes these small adjustments can said. However, a challenge is you must pick the right patients. For example, patients' eyes must be able dilate to a certain degree, and if they can't, they are not eligible for this procedure, Dr. Hoopes said. The light adjustments are not any more difficult than doing a YAG capsulotomy, but the patient must be able to hold steady for 2 minutes. Another challenge is the potential for changes to the eye. "The promise of the lens always was that we could fine tune the results accurately and by the end of the process have patients completely corrected in their vision," Dr. Hoopes said. "The truth is there's still the possibility of having small prescriptions even at the end of light adjustment. We know people can still change 2–4 months down the road after cataract surgery just by how the capsule heals. Even the LAL doesn't prevent the possibility of more long-term changes to prescription, such as astigmatism over time." While there's no surgical learning curve, Dr. Hoopes stressed the importance of communica- tion about the treatment process. "As long as I communicate the time period with the patient, the expectation of the work needing to be done a month later, almost every LAL patient has been excited about the technology and willing continued on page 44 Though the need to remove the LAL is infre- quent, it can prove challenging, particularly if the lens has already been locked in. The LAL becomes brittle after it has been treated and locked in, Dr. Fram said. "In the previous genera- tion of the LAL without ActivShield, when trying to stabilize the lens with serrated forceps, it would break into tiny pieces." Dr. Fram suggested that the best approach is to provide counter traction with a Sinskey hook and use serrated scissors that can hold the lens while cutting. "I have also found that enlarging the main incision to 3.5 mm is helpful, as the lens is silicone and thick and may be difficult to get out of a sub-3 mm incision." Removal after lock- in is a rare occurrence with the development of the ActivShield, Dr. Fram said, "however, if you put an IOL in, you should know how to remove it safely in the circumstance that it becomes necessary." Dr. Solomon noted that he has only had to do one removal before the lens was locked in. During one of his insertions, the injector system caused inadvertent damage to the lens, and he had to explant it immediately. He mentioned that it does require attention because it's a gum- my, silicone lens. It's relatively soft at that stage, so be prepared by using good instrumentation, he said. If you have to remove the lens Dr. Fram performs the lock-in treatment with the Light Delivery Device (RxSight). Source: Nicole Fram, MD

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