Eyeworld

38 | EYEWORLD | SUMMER 2025 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Mark Lobanoff, MD OVO LASIK + LENS Minneapolis, Minnesota James Loden, MD Loden Vision Centers Nashville, Tennessee Vance Thompson, MD Vance Thompson Vision Sioux Falls, South Dakota Blake Williamson, MD Williamson Eye Center Baton Rouge, Louisiana S ince its approval, the Light Adjustable Lens (LAL, RxSight) has become well known for the successful outcomes that it can provide for patients. Mark Lobanoff, MD, James Loden, MD, Blake Williamson, MD, and Vance Thompson, MD, discussed their experience with the product and what they've learned about limitations, how to work through some challenges, and factors to consider in order to ensure success with both routine and unusual or challenging clinical cases. Dr. Lobanoff said the Light Adjustable Lens is "one of the most amazing technologies we've developed in ophthalmology, and it is an incred- ibly valuable resource." "We came out of the gate at our practice using it quite heavily, in part because we have a large refractive patient population who've undergone RK, LASIK, or PRK in the past. We were excited to use it," he said. "As we began using it heavily over the course of about 2 years, especially in this population, we began to collect a few patients who weren't making sense to us." There were some patients who had been target- ed for plano sphere but were complaining about vision quality. Dr. Lobanoff noted that there are some things that physicians can do to limit the num- ber of patients who may struggle with this lens, the first being just "understanding that it's not magic." The lens can currently correct sphere and cylinder. For post-LASIK patients, where there is difficulty with modern formulas nailing down the power, this is going to save them, he said. However, something that he learned early on in his experience with the LAL is that it does not yet treat most higher order aberrations. "You can't expect the technology to correct for very abnormal higher order aberrations on the corneal surface," he said. Dr. Lobanoff said you also need to be care- ful with astigmatism. Often we're looking at numerical indications of astigmatism (the mag- nitude, the axis), he said. You get your printout from the IOLMaster (Zeiss), from the Lenstar (Haag-Streit), but what it doesn't tell you is if that astigmatism is symmetrical or regular. When you do the UV treatment, it treats it as if the astigmatism is regular and symmetric, so you need to be sure you're asking the lens to do something that is within its capability to do. Dr. Thompson noted that while only a pinhole lens is currently indicated to reduce negative optical effects from highly aberrated corneas, there are still advantages to the LAL in such cases. "Since the doctor and patient select the magnitude and axis of astigmatism correction based on the postop manifest, they can often find a refraction that works better than one that is based on difficult to interpret preoperative keratometric measurements. For cases of mild corneal irregular astigmatism, this can be an excellent solution that still allows light to enter through a standard 6 mm optical zone," he said. Dr. Lobanoff also said to pay attention to lens centration during surgery and Light Delivery Device (LDD, RxSight) pattern cen- tration during light treatments. Both the LAL and LAL+ have negative spherical aberration, while the LAL+ has a subtle central feature for enhanced depth of focus. "If you put an aspher- ic lens more than approximately 0.5 mm off the visual axis, especially one that has fairly signifi- cant negative spherical aberration, you're going to get reduced benefits and potentially problems with your optics." It's important to take the extra step, using technology to make sure that the lens is centered as close to the visual access as you can get and that the light pattern is not persistently decentered, which the LDD will warn you about during the procedure. Dr. Loden said the LAL+ is not a lens implant that should be used for some irregular corneas, and ophthalmologists should be con- scious of patient selection. Dr. Lobanoff said when you do a high hy- peropic or RK, you're creating a cornea that has a lot of negative spherical aberration. Then you take a lens that has negative spherical aberra- tion in it, so if you do have a post-hyperopic pa- tient, limit it to lower levels of post-hyperopia. Dr. Lobanoff said it's also important to try to understand ahead of time if the patient will tolerate monovision. "If the patient has not tol- erated monovision in the past, our experience is they're not going to tolerate it with this either." Nuances of the Light Adjustable Lens in specific patient populations

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