Eyeworld

54 | EYEWORLD | FALL 2026 R EFRACTIVE REWIND. REFRESH. REFINE. About the physicians Douglas Koch, MD Department of Ophthalmology Cullen Eye Institute Baylor College of Medicine Houston, Texas Yuri McKee, MD East Valley Ophthalmology Mesa, Arizona Beeran Meghpara, MD Director of Refractive Surgery Co-Chief of the Cornea Service Wills Eye Hospital Philadelphia, Pennsylvania by Liz Hillman Editorial Co-Director F or years, the Light Adjustable Lens (LAL, RxSight) has occupied a relatively dis- tinct role in refractive cataract surgery. Its postoperative adjustability makes it attractive for patients with prior refrac- tive surgery and in eyes where accurate refrac- tive outcomes are less predictable. Today, however, some surgeons have ex- panded their use of the LAL beyond these tradi- tionally challenging cases. While many continue to reserve the technology for post-LASIK, post- PRK, and difficult eyes, others are increasingly using it in routine cataract patients, finding that the ability to set refraction postop with patient input offers advantages. This shift raises an interesting question: Are the LAL and modern full range of vision IOLs serving fundamentally different patient popula- tions, or are they increasingly competing for the same refractive cataract surgery patient? Yuri McKee, MD, said the LAL and full range of vision lenses can—but don't always—com- pete for the same piece of the pie (that piece being patients interested in premium cataract surgery technologies). But he thinks there is a right IOL within the category of premium lenses for each patient. "If you have a variety of IOLs in your arma- mentarium, you're going to find the right one and guide the patient to the right lens for the outcome they're looking for at the price point that makes sense for them," he said. Dr. McKee also expects a "massive change" in the next 5–10 years. "We're not even going to have this conversation anymore. Full range of vision IOLs are going to be accommodating IOLs," he said, noting that there are a number of companies working on accommodating lens- es. "When these are perfected and approved, it's going to fundamentally change the entire landscape of intraocular lens surgery." LAL beyond the post-refractive patient Dr. McKee said the patient's personal refractive goals and preferences (full-time glasses, some- times glasses, almost no glasses) and the state of their eye health guide him to the appropriate lens recommendation. In his discussions with patients interested in spectacle independence, Dr. McKee shares how full range of vision IOLs have focal planes at distance, intermediate, and near to provide a broad range of vision. To achieve this, however, the refractive target must be met. "The odds of doing that in a normal eye are around 92%," he said, explaining this figure comes from the databases of Warren Hill, MD, which include hundreds of thousands of surgeries. "It's 92% with the best surgeons who do tear film tune- ups, who do the best biometry, who do the best math with modern calculation formulas. That means 8% of people are going to be half a diopter or more away from our intended target and could be unhappy and require a LASIK touch-up or lens exchange. … But then, that's the limitation with all lenses except the LAL, which has a 95–97% chance of hitting its target exactly because we're treating the lens based on the true postop outcome, not our preopera- tive measurements and mathematics, which we know have inherent error in them." Evolving roles for LAL and full range of vision IOLs LAL in a post-LASIK eye Source: Douglas Koch, MD

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