Refractive
Summer 2025

by Ellen Stodola
Editorial Co-Director

Since 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 incredibly 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 targeted for plano sphere but were complaining about vision quality.

Dr. Lobanoff noted that there are some things that physicians can do to limit the number 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 careful with astigmatism. Often we’re looking at numerical indications of astigmatism (the magnitude, 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 centration 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 aspheric lens more than approximately 0.5 mm off the visual axis, especially one that has fairly significant 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 conscious of patient selection.

Dr. Lobanoff said when you do a high hyperopic or RK, you’re creating a cornea that has a lot of negative spherical aberration. Then you take a lens that has negative spherical aberration in it, so if you do have a post-hyperopic patient, 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 tolerated monovision in the past, our experience is they’re not going to tolerate it with this either.”

Dr. Loden agreed that you want to be careful with the approach to monovision in this lens. You can’t adjust for near vision and if they don’t like it, adjust 1.75 D back for distance vision without inducing the risk of aberrations. You have to pick a goal, stick with it, and do as few adjustments as you can. “We’re trying to push our adjustments off a little more. One of the things we used to do was if we missed the IOL power calculation, we would do a quick adjustment at 10–14 days out, an off-label adjustment early, to get them where they could see and be functioning,” he said. But he’s trying not to do that now unless it’s completely necessary. “We’re trying to wait longer for the adjustments. We never do a third adjustment. We would rather come back and do a laser procedure or a piggyback lens than a third adjustment,” he said. “But I think that no matter what you do, you’re going to have a rare lens that’s not going to perform exactly as you think it is, and you may have to intervene.”

Dr. Thompson, who has been part of the FDA studies for the LAL from the beginning, sees more and more uses for both the LAL and LAL+. “Because these are the only lenses that can be adjusted after refractive error has occurred, they are the most accurate, demonstrating both better uncorrected and best corrected vision than monofocal control lenses in two FDA trials,” he said. “We can combine this accuracy with the broadened depth of focus to provide our patients with an excellent visual solution. Most patients, even those who have not tried blended vision before surgery, will find it a great way to achieve both high quality and range of vision, generally with small differences between the two eyes,” he said.

He also noted some factors to pay attention to, particularly for physicians who are new to adopting this lens. He generally recommends getting familiar with insertion and light treatments with the LAL before moving on to the LAL+.

Dr. Thompson said the technology is much more forgiving than excimer surgery, since it allows multiple non-invasive treatments, but doctors still need to treat it like refractive surgery. This includes making sure the refraction is stable and accurate and that the LDD targets for each eye are appropriate.

“You want a crisp refractive endpoint,” he said. “If it’s not 20/20 crisp, we may not have 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 before 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 patients do like a little myopia in both eyes, most will want excellent distance vision. The amount of myopia needed to deliver excellent intermediate 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 refractive 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, including 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 amazing 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 understand patient selection. Talking about potential issues in advance with patients is crucial. The lens works for many difficult scenarios, but issues can still occur occasionally in these scenarios 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 preoperatively. 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 problems. “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 explant for the LAL, noting the reported explant rate is similar to other monofocal IOLs at approximately 0.2%. While he is very comfortable 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 solution. “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.

Dr. Thompson noted that if a physician has questions or concerns about a result, the company is able to review the case and give feedback. While the system is very robust, two factors that are important to keep in mind are pupil dilation and LDD treatment centration, both of which are now monitored by the device. “This technology has greatly expanded our premium practice. Like any new and actively developing tool, we must continue to refine our skills and knowledge for patients to benefit the most from its technical and clinical advantages,” he said.

There is a huge need for this product, Dr. Lobanoff said, but it’s important that you’re using it in the right patient population. “I think understanding there’s going to be limitations to any technology is important,” he said.

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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

Relevant disclosures

Lobanoff: Alcon, Bausch + Lomb, Ziemer
Loden: None
Thompson: Alcon, Bausch + Lomb, BVI, Johnson & Johnson Vision, Rayner, RxSight, Zeiss
Williamson: None

Contact

Lobanoff: mlobanoff@gmail.com
Loden: lodenmd@icloud.com
Thompson: vance.thompson@vancethompsonvision.com
Williamson: blakewilliamson@weceye.com