Eyeworld

40 | EYEWORLD | SUMMER 2025 R EFRACTIVE Relevant disclosures Lobanoff: Alcon, Bausch + Lomb, Ziemer Loden: None Thompson: Alcon, Bausch + Lomb, BVI, Johnson & Johnson Vision, Rayner, RxSight, Zeiss Williamson: None an accurate refraction to treat with the LDD and need to figure out if the patient has dry eye or epithelial irregularity that needs to be taken care of first. You should optimize the optical system and have a stable refractive endpoint be- fore you start your refractive adjustments." For a virgin cornea, Dr. Thompson typically waits a month to start adjustments, but for a post-LASIK patient, he recommended waiting 6–8 weeks and for post-RK patients, 2–3 months. Targeting at the LDD is also important. For a distance eye, Dr. Thompson likes to take into account the difference of a plano refraction in a short exam lane by either targeting +0.25 D sphere with the LDD or double checking the refraction outside of the lane. While a few pa- tients do like a little myopia in both eyes, most will want excellent distance vision. The amount of myopia needed to deliver excellent interme- diate and near vision is also relatively small, typically 0.5–0.75 D with the LAL+ and less than 1 D with the LAL. "Once you have figured out that the refrac- tive error is stable, the refractive endpoint is sharp, and the refractive goals are clear, it's time for the light adjustment. That's where you want to use all the tools this technology has, includ- ing the align assist function, which helps you keep the approximately 5.5 mm treatment beam centered on the 6 mm optic," he said. Dr. Lobanoff said talking to patients about the lens is also important. "I tell patients, 'We think this is the best lens for you. This is amaz- ing technology, and here's how it works. But there's a small percentage of patients who have some difficulty with it. There is a small chance that we're going to have to switch this out for a different lens.' If you prepare patients for that scenario ahead of time, they're usually on board with you." Dr. Williamson agreed this is a great lens, but it's important for ophthalmologists to under- stand patient selection. Talking about potential issues in advance with patients is crucial. The lens works for many difficult scenarios, but is- sues can still occur occasionally in these scenari- os and sometimes in virgin corneas, he said. While an explant is unlikely, Dr. Williamson said it's worth mentioning because he has found that the most frustrated patients are those who are surprised when they have an issue. "I think it's worth telling patients that there's a chance that we'll have to remove this after the lock-in. I understand all the negatives for doing that and introducing that negative mindset preopera- tively. I just think if they're spending that much time and money, patients need to know that this possibility exists," he said. Dr. Lobanoff said he will wait to make sure that an explant is the right decision. "We want to wait for complete healing. We've usually done at least two treatments, sometimes three in these patients, and we want to eliminate all the normal things." You want to be sure the tear film is good, check for PCO, and any other prob- lems. "Don't be too quick to do the YAG. Don't be too quick to blame the posterior capsule," he said. This can make an explantation more difficult and limit future options. However, Dr. Loden did note that you can put an LAL in after doing a vitrectomy. Leave the haptics in the sulcus and pop the optic through the anterior capsule, so you don't have to abort and go back to a standard three-piece monofocal lens. Dr. Thompson said he rarely does an ex- plant for the LAL, noting the reported explant rate is similar to other monofocal IOLs at approximately 0.2%. While he is very comfort- able doing an early YAG laser capsulotomy if he is worried about the refractive endpoint, he agreed that an open capsule makes an explant more challenging. Dr. Lobanoff has worked with RxSight regarding some cases of unsatisfied patients. He approached company leadership to discuss some isolated problems and try to find a solu- tion. "The company is there. They stand behind it. They know it's an important product for us," he said. Dr. Williamson said he has been working with the RxSight medical affairs team and is gathering his preoperative OPD-Scan III (Nidek) data as well as data from after surgery in order to have more information for when issues occur post lock-in. Dr. Loden said when dealing with advanced optics, it's important to talk to experts who understand what's going on. Some of the new research by RxSight is showing that a lack of good centration and cornea striae during the lock-in may affect the final visual outcome. continued from page 39 Contact Lobanoff: mlobanoff@gmail.com Loden: lodenmd@icloud.com Thompson: vance.thompson@ vancethompsonvision.com Williamson: blakewilliamson@weceye.com

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