Eyeworld

SPRING 2026 | EYEWORLD | 99 G Contact Larsen: cllarsen@mneye.com Ristvedt: deborah.ristvedt@ vancethompsonvision.com Relevant disclosures Larsen: AbbVie, Alcon, Glaukos, Iantrek, iSTAR Medical, New World Medical, Thea Ristvedt: AbbVie, Alcon, BVI, Glaukos, Osheru, Rayner, Sight Sciences • Patients unable to comply with strict UV-blocking eyewear prior to lock-in • Those unable to attend multiple postop visits required for adjustments • Eyes with significant zonular weakness or pseudoexfoliation, where IOL centration may be less predictable Dr. Ristvedt also noted some patients to avoid or those where precautions are needed. "For patients with pseudoexfoliation, I ensure adequate dilation for postop adjustments," she said. "In cases of severe glaucoma with central vision loss, the difficulty in obtaining accurate treatments (as the patient must fixate straight ahead) and the necessity of additional appoint- ments must be carefully considered." She added that being a silicone lens, it is necessary to con- sider alternative IOLs if additional procedures that involve intraocular gas are anticipated. Combined MIGS and LAL Dr. Ristvedt said the LAL can also be a good op- tion when doing a combined cataract and MIGS procedure. "I am passionate about intervention- al glaucoma and find that the LAL is a suitable choice when combining it with MIGS," she said. Dr. Larsen agreed that the LAL can be com- bined with MIGS, and she said this has become increasingly common in clinical practice. "Pro- cedures such as the iStent [Glaukos], Hydrus [Alcon], or goniotomy-based MIGS generally do not preclude LAL use," she said. However, Dr. Larsen said that timing and expectations are important considerations. "MIGS-related changes in IOP and the reduction in topical medication burden can subtly affect refractive outcomes in the early postop period," she said, adding that the LAL's adjustability can be advantageous because it allows refractive refinement after IOP has stabilized. "That said, surgeons should be cautious with more invasive glaucoma procedures that may induce greater postop inflammation or an- atomical change, as this could delay or compli- cate the adjustment process," Dr. Larsen said. Other considerations Dr. Ristvedt noted that when implanting the LAL, complete capsular overlap is always ideal. "I ensure the capsulorhexis is centered on the Purkinje images, measuring 5.0–5.5 mm in diameter," she said. "I often combine MIGS with the cataract procedure, not only to prevent further visual field loss but also to help patients get off topical drops." Dr. Ristvedt said minimiz- ing the need for drops supports a good ocular surface, which is essential for obtaining a sharp manifest refraction and maximizing the preci- sion of the LAL adjustment. Dr. Larsen also shared some of her pearls for nuances with the LAL: • IOP stability: Dr. Larsen ensures the IOP is stable before initiating light adjustments, particularly in patients undergoing combined surgery. • Steroid response: Glaucoma patients are more likely to be steroid responders. "Careful monitoring and tailored steroid regimens are important during the adjustment period." • Pupil dilation: Adequate dilation is essential for successful adjustments, which may be more challenging in patients on chronic miot- ics (less common in current practice) or with pseudoexfoliation. • Patient counseling: "I spend extra time preop explaining the timeline, UV precautions, and need for multiple visits, as adherence is criti- cal to success," Dr. Larsen said. The LAL is a meaningful advancement in refractive cataract surgery, Dr. Larsen said, adding that glaucoma should not be viewed as an absolute contraindication. The key is patient selection and expectation management. "For the right glaucoma patient—particular- ly those with stable disease, good visual poten- tial, and a desire for refractive precision—the LAL can deliver outstanding outcomes," she said. "As with all premium technologies, success depends on thoughtful counseling, careful sur- gical planning, and close postop follow-up." "The LAL provides a vital missing link, enabling us to fully optimize visual outcomes and allow individualized care for patients, even those with pathology that historically deterred the use of advanced-technology IOLs," Dr. Ristvedt said. "It truly puts the patient in the driver's seat regarding their final vision."

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