June 2019


Device Focus
Incorporating the Light Adjustable Lens into a practice

by Michelle Stephenson EyeWorld Contributing Writer

“In the U.S., approximately 25% of patients choose moderate monovision, and the LAL will allow surgeons to hit the target exactly where the patient wants it.”
—Richard Lindstrom, MD


The Light Adjustable Lens (LAL, RxSight) has been FDA approved for more than a year but has not yet come to the marketplace. Surgeons are anxiously awaiting its availability, as it will offer a new level of customization for cataract surgery patients.
According to Richard Lindstrom, MD, the LAL will create a premium monovision channel. “The LAL will allow for premium monovision, which I think will be popular. In the U.S., approximately 25% of patients choose moderate monovision, and the LAL will allow surgeons to hit the target exactly where the patient wants it,” he said.
He said there will also be the opportunity for a select group of patients to achieve perfect distance vision as well. “If you’re an airline pilot, a golfer, or an elite athlete who is willing to pay extra to have perfect vision in both eyes, there will be that opportunity. I would rather not have to do a laser corneal refractive surgery procedure if I could do an adjustment in the intraocular lens,” Dr. Lindstrom said.

Precise outcomes

According to John Berdahl, MD, the LAL makes very precise outcomes accessible to every surgeon. “We are not changing human tissue; we’re changing silicone, which is much more predictable. We can make changes after the eye has healed, so we won’t have surprises in effective lens position, in surgically induced astigmatism, or in posterior corneal astigmatism. The outcome will be primarily dictated by how good of a manifest refraction the surgeon can do,” he said.
The other advantage is that patients will be able to see what their final visual result will be before locking it in, Dr. Berdahl said.

Incorporating the LAL

According to Kevin Waltz, MD, it is important to prepare your staff for incorporating the LAL into your practice. “When you start talking about charging $3,000 per eye or more extra for surgery, the staff has to get comfortable with that because that’s a huge number for them,” he said.
If you are planning to add LALs to your armamentarium, Dr. Waltz recommended beginning to implant toric lenses now. “This gives you and your staff an entry point to get comfortable,” he said.
Once the lens is available, there will be a specific protocol for training surgeons, said Kevin M. Miller, MD. “It’s a significant commitment of time for surgeons who want to implant these lenses. Patients will get implanted, wear UV-protecting glasses for the next 3 to 3.5 weeks indoors and outdoors, then undergo one or two light adjustments, followed by one lock-in treatments. There are many patient visits,” he said.
Dr. Miller said that in the clinical trial, LAL patients were targeted for hyperopia so that they could be adjusted toward emmetropia. “It’s easier to adjust these lenses from the hyperopic direction because you’re treating the center of the lens with the ultraviolet light. It’s a little harder to treat from the myopic direction, where you have to treat the periphery of the lens. One of the most frustrating aspects of treating these patients is they have to dilate to larger than the diameter of the lens, which is 6 mm. You may find that after a patient has been consistently dilated numerous times, he or she undergoes a sort of pupil dilation fatigue. For the last few treatments, the pupil may not dilate beyond the edge of the lens implant,” he said.
Robert Maloney, MD, agreed with targeting for hyperopia. “We typically target between +0.50 and +0.75 in the distance eye. If we are doing monovision, we target about –1.50 in the near eye. The technology allows patients considering monovision to experience different amounts of anisometropia, after the cataracts have been removed, using trial frames or temporary contacts. It offers a level of customization that’s never been possible before,” Dr. Maloney said.
Dr. Berdahl added, “It won’t replace every lens on the market, but I think it will be one of the most important tools in our toolkit of lenses to help achieve spectacle independence.”

The future

According to Dr. Miller, the FDA approval letter came with strings attached. “The company is required to do a post-market study that is almost as involved as, if not even more involved than, the premarket approval clinical trial,” he said.
Dr. Maloney thinks the LAL will be the lens of choice for the next 10 to 15 years. “After that, we will have electro-optical lenses with adjustable sphere and cylinder that also accommodate,” he said.

About the doctors

John Berdahl, MD
Vance Thompson Vision
Sioux Falls, South Dakota

Richard Lindstrom, MD
Minnesota Eye Consultants

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles

Kevin M. Miller, MD
Kolokotrones Chair in Ophthalmology
David Geffen School of Medicine
University of California, Los Angeles

Kevin Waltz, MD
Eye Surgeons of Indiana Indianapolis

Financial interests

: RxSight
Lindstrom: RxSight
Maloney: RxSight
Miller: None
Waltz: None

Contact information

Berdahl: john.berdahl@vancethompsonvision.com
Lindstrom: rllindstrom@mneye.com
Maloney: rm@maloneyvision.com
Miller: kmiller@ucla.edu
Waltz: kwaltz56@gmail.com
Incorporating the Light Adjustable Lens into a practice Incorporating the Light Adjustable Lens into a practice
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