Cataract: Evolving
Winter 2024

by Liz Hillman
Editorial Co-Director

With its approval in late 2017, many physicians have several years of lessons learned under their belt with the Light Adjustable Lens (LAL, RxSight). And with the more recent commercial launch of the LAL+, which has a modified aspheric surface to extend depth of focus slightly, ophthalmologists have even more to talk about with this lens platform. 

EyeWorld spoke with Sumitra Khandelwal, MD, to learn how an academic center brought on the LAL, and Bryan Lee, MD, JD, Neda Shamie, MD, and Taylor Strange, DO, private practice ophthalmologists, for their diverse perspectives on and experiences with this lens. 

‘It’s a learning curve to load it’

There were a few reasons that the ophthalmologists at Baylor were interested in the LAL. 

“At Baylor, we do a lot of research in IOL calculations and various formulas, … but the results are still not perfect. … Formulas are around 75% at best, and we have outliers. I really want [LASIK-like outcomes] for our patients. We see a lot of post-refractive patients now, and their expectations are very different,” Dr. Khandelwal said. 

The academic practice didn’t join the LAL bandwagon right away, however. It was the second iteration of the lens that included ActiveShield, which reduces issues with accidental UV light exposure before lock-in, that made them more comfortable with offering the technology. But it still came with a learning curve.  

“The real questions when we started to analyze this technology were 1) how were we going to incorporate it in our practice, which is different than a private practice, and 2) is this technology going to cannibalize some of the premium technologies we already use?” she said. “Those are two questions I think everyone has to ask themselves about the Light Adjustable Lens. … I’ve been pleasantly surprised about both.”

Dr. Khandelwal said the LAL hasn’t taken away from other advanced-technology lenses, rather it’s augmented their offerings. “It’s opened up the space for patients who before maybe we didn’t think they were a great candidate for a presbyopia-correcting lens.”

From a clinic flow standpoint, Dr. Khandelwal said it’s been helpful to have their research optometrist trained in refractions and the Light Delivery Device adjustments, but the ophthalmologist is still who pushes the foot pedal. 

From a surgical standpoint, Dr. Khandelwal said the rhexis is very important with this lens. 

“The rhexis needs to be an appropriate size, covering the optic all the way around,” she said, adding later that it’s also a silicone lens, which has a bit of a learning curve. “First of all, it’s a learning curve to load it. Any scratch on the IOL has to come out, and it comes out fast from the injector.”

Dr. Khandelwal advised being careful with patients who have a lot of fluctuations with refractions, such as with OSD, which she said needs to be optimized before surgery. Finally, she offered that surgeons should guide the patients to their realistic postop goal rather than allowing patients to take the lead. 

“This is not a trifocal lens. Patients need to understand they may not get the near vision they were thinking they were going to get, and they may not get the trifocality in both eyes. I think telling them that upfront and getting them locked in in a timely manner is helpful,” she said. “Patients with decision-making challenges should be guided away from this lens.”

‘Lock in … at the end of OR days’

Dr. Lee began offering the LAL in 2019 and has found it to be his preferred lens for patients with a history of refractive surgery and those who want monovision. 

Clinic flow was one of the main adjustments his practice identified when onboarding this lens. 

“Patients may require multiple rounds of dilation, and they need refraction and discussion of the plan for each treatment as well,” he said. “I think the combination of doing so many over the years and the wonderful staff in our office has made it work. We try to spread patients out evenly between clinic days, and it is helpful to have lock-in treatments at the end of OR days. By that point, we know how long those patients take to dilate, and they do not need refraction and the same type of counseling.”

When it comes to patient selection, Dr. Lee said he’ll discuss the LAL with all patients who are candidates, even if they are not classic post-refractive or monovision patients. Many patients, he said, have specific refractive goals and are attracted to the increased accuracy offered by the LAL. Some have also decided to try monovision with the LAL and found out that they really enjoy it. “I do mention to those patients that if they don’t like monovision, they will not have full range of vision to try to make sure they aren’t surprised or disappointed,” Dr. Lee noted.

For the surgeon who is already experienced with the LAL, Dr. Lee said a more advanced use of the lens is in cases where the capsule is not intact, such as post-YAG IOL exchange cases. “I also mention it as a back-up option for patients who prefer a different IOL as plan A but have a higher risk for intraoperative issues, such as a posterior polar cataract,” he said.

When it comes to the latest iteration, the LAL+, Dr. Lee said it has increased the number of patients considering this lens in his practice. He noted that the additional range is not the same for every patient, though this is the case with any IOL.  

“Just as important is the fact that the LAL and the LAL+ are available down to +4.0 D, which allows offering the IOL to very high myopes who appreciate that their IOL calculations are more challenging but are used to the accuracy of a contact lens,” Dr. Lee said. 

‘Everyone had to be educated’

“Patients need to understand they may not get the near vision they were thinking they were going to get, and they may not get the trifocality in both eyes. I think telling them that upfront and getting them locked in in a timely manner is helpful.”

Sumitra Khandelwal, MD

Dr. Shamie said her senior partner, Robert Maloney, MD, was involved in the LAL development, and her practice was involved in its clinical trials. Since then, they’ve considered it to be a paradigm shift in the way they perform cataract surgery.

“The Light Adjustable Lens offers the opportunity to fine tune vision … after the lens has settled in its position, after the cornea has healed, and after the refractive outcome has stabilized. We then take that refractive outcome, plug it and the refractive target into the Light Delivery System, and adjust the lens to compensate for the refractive miss. In doing so, more than 98% of patients reach their refractive target,” Dr. Shamie said. 

However, there were many lessons learned in using the lens effectively in their practice. Clinic flow was the biggest hurdle. Dr. Shamie said she was doing her own adjustments initially (and she recommends those starting out with the lens do 10–20 adjustments to understand the nuances of it), but she has since trained internal ODs to perform the adjustments. Adjustments only take about 2 minutes, but the workup to prepare the patient for the light adjustment requires a discussion about target planning, then a manifest refraction and dilation. 

“Optometrists who are in surgical practice working closely with cataract surgeons are very well equipped with what’s required to do the light adjustments. The most difficult part is not the light adjustment but the target planning for the patient. After we decided to have our internal ODs do the light adjustments, it was a much smoother process,” she said.

Dr. Shamie said it’s important to inform patients preop that light adjustment specialists will be managing adjustments after their surgery.

Another lesson was the education required for the staff about the value of the lens. 

“Everyone had to be educated about the unique nature of this technology. We needed them to be enthusiastic about the opportunity it was adding to optimize patient outcomes and improve the quality of vision patients could achieve. They saw our cataract patients were achieving uncorrected vision of 20/20 and sometimes 20/15 and were ecstatic, so after a little while, it spoke for itself,” Dr. Shamie said. Referring doctors also had to be educated on how the postop period and comanagement is different for this lens. “After empowering and educating the referring doctors and demonstrating to them the value added to their patients, … they became vested in the process,” she added. 

Over time, Dr. Shamie said her practice changed their initial refractive targets with the lens, now targeting slightly plus to then adjust postop toward minus for a slight extended depth of focus effect. “When you treat the lens to shift toward myopic, the light treatment to change the refractive power of the lens centrally creates an extended depth of focus, similar to what you see with a monofocal plus,” she said. 

She also offered a few patient-specific pearls:

• Advise patients with astigmatism that for 2–3 weeks after surgery, they’ll be living with a bit of blur as the lens prior to the adjustment is essentially a monofocal IOL. 
• Post-RK, post-hyperopic LASIK, and post-hyperopic PRK patients can take longer to stabilize after cataract surgery, so Dr. Shamie advised delaying adjustments by at least 5 weeks and separating light adjustment by 2 weeks. In post-myopic LASIK/PRK or eyes with no prior history of corneal-based surgery, Dr. Shamie’s practice begins light adjustments 3 weeks after surgery with eyes spaced 1 week apart.
• For patients who haven’t tried monovision or don’t want to consider it, who hate glasses, and are seeking a fuller range of vision, she recommends a multifocal IOL, rather than the LAL or LAL+.
• Avoid the LAL in patients who don’t dilate well and those with suboptimal vision potential, such as patients with mild to moderate AMD or with epiretinal membrane. These patients are investing time and money in the advanced technology, and if the eye’s vision potential is limited, they can get frustrated with the outcome.

Overall, Dr. Shamie said the LAL and LAL+ fills a gap. “I know we have a lot of wonderful lens options out there. … But when I think about my practice, my patients, not having the LAL, I think I would miss an opportunity of offering that subgroup of patients the most optimized outcome possible. … Having the LAL as one of your options increases your ability to offer premium lenses to patients who otherwise would not have been good candidates for premium lenses. Prior to the LAL, our premium lens conversion was about 50%. It has increased by at least 5–10% with the addition of the LAL,” Dr. Shamie said.

‘Wait a month’

Dr. Strange currently performs 15+ LAL implants per week. He implemented LALs into his busy surgical practice back in 2021.

“LALs were intriguing to me because we have a lot of post-refractive patients, people who have had RK, LASIK 20+ years ago, and now they’re here for cataract surgery. It’s hard to hit the target on these patients more than 80% of the time, so I needed something that would allow me to adjust the patient’s vision after the surgery, rather than doing a lens exchange or PRK or LASIK enhancement, which is not ideal on top of prior refractive surgery,” he said. 

One lesson Dr. Strange learned early on using the LAL was to not perform the postop adjustment too early.  

“We have since learned to wait a month in order for the cornea and all the different healing factors of the eye post-surgery to get settled and not moving,” Dr. Strange said. 

Dr. Strange said he has also evolved from spacing his cataract surgery with LALs 2 weeks apart to now just a day apart so the patient’s postop light adjustments are in the same timeframe. He said he’ll do refractive lens exchanges involving the LAL on the same day. This shift reduced postoperative visits and allowed patients to get to their endpoint satisfaction faster, he explained. 

“Something else we do differently is we do YAGs early on now. I do them as early as 1 month postop because if a PCO is starting to form early, and that does happen earlier in silicone lenses like the LAL, you don’t want to be adjusting in a PCO. We YAG them early, and we found that to be better for accuracy and their adjustment period,” Dr. Strange said. 

Additional pearls from Dr. Strange are: 

• Use the regular LAL on higher aberrated corneas. If the patient has had good LASIK and aberrations are under 0.3, he is comfortable offering the LAL+ to give the patient more near vision. 
• Avoid the LAL in 16- and 32-cut RKs. “You can’t use the LAL on just any post-refractive patient,” he said. 
• Don’t use this lens in patients whose pupils dilate to less than 6 mm; it makes it harder to do adjustments. 
• A medical ophthalmologist or knowledgeable OD team can make the surgeon’s practice with the LAL more efficient.
• Have a thorough discussion with the patient to set appropriate expectations for the postop commitment with this lens (expect 3–4 extra visits).
• Have a longer discussion with high myopes who might try to get more near vision with this lens at the sacrifice of good distance vision. “In these cases, you may want to lean toward a multifocal lens with more near power,” he said. 
• Don’t feel like you have to do an adjustment just because it’s there. 
• Make sure the cornea is clear and stable before performing adjustments; outcomes can change if the ocular surface isn’t tuned up. 

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About the physicians 

Sumitra Khandelwal, MD
Professor, Department of Ophthalmology
Baylor College of Medicine
Houston, Texas 

Bryan Lee, MD, JD
Altos Eye Physicians
Los Altos, California

Neda Shamie, MD
Maloney-Shamie Vision Institute
Los Angeles, California

Taylor Strange, DO
Alliance Vision Institute
Fort Worth, Texas

Relevant disclosures

Khandelwal: None
Lee: None
Shamie: RxSight 
Strange: RxSight

Contact 

Khandelwal: Sumitra.Khandelwal@bcm.edu
Lee: bryan@bryanlee.pro
Shamie: ns@maloneyshamie.com 
Strange: tbstrange1@gmail.com