Advancements to cataract surgery have increasingly helped surgeons and patients to anticipate optimal outcomes. The advent of laser assistance, enhanced lens technology and improved formulas and techniques have all brought better vision and more independence from wearing glasses. But one variable has always been difficult, if not impossible, to overcome: “where the refractive outcome ultimately lands,” says Neda Shamie, MD, a cataract, LASIK and corneal surgeon and partner at the Maloney-Shamie Vision Institute in Los Angeles.

“Our hands have always been tied,” she says. “Depending on how the corneal wound heals or where the lens settles into position in the eye, that vision outcome may or may not be on target.”

For patients seeking refined surgical outcomes without any post-surgery surprises, the Light Adjustable Lens (LAL, RxSight) allows for more fine-tuning of their vision. The first lens that is fully adjustable post-surgery, the LAL can be adjusted non-invasively through a series of ultraviolet (UV) light-based treatments. Errors of up to 2 D of myopic, hyperopic and astigmatic correction can be adjusted, and astigmatism can be corrected down to 0.5 D of cylinder, the lowest level approved to be treated.

Surgeons who are involved in the overall management of their clinics say that certain protocols, such as patient scheduling and a coordinated effort with other members of the care team, can guide workflows.

ADJUSTING TO ADJUSTMENTS

With the LAL, the ability to perform post-surgical modifications has gone from potential luxury to clinical certainty. Due to the nature of the product, patients require at least two (and as many as five) follow-up visits. The lens consists of polymers — light-responsive particles that respond to specific UV light. The polymers require treatment with light adjustments to become stabilized post-surgery. As UV light is directed to a specific area of the lens, macromers form and a highly predictable change in lens curvature occurs, allowing for the new shape to match selected prescriptions.

“You have to make adjustments in all of these surgeries,” Dr. Shamie says. “It’s a given because the lens is flexible and needs to be locked into the final power desired. The lens implanted is chosen based on preoperative measurements, but there is often room for refinement.”

Follow-up visits consist of a manifest refraction, dilation and light adjustment, which is typically no longer than 90 seconds. Still, developing a scheduling strategy is essential to Dr. Shamie’s practice, where she says approximately 30% of surgical patients receive this lens. “We schedule surgery for each eye 1 week apart, Dr. Shamie says. “We then begin light adjustments 2 weeks from the second eye.” The adjustments are not scheduled in blocks and are spread throughout the day.

Dr. Shamie adds that most patients average two to four adjustments, but those who land further from the refractive target or are unsure about where they want their target refraction to be could require more adjustments. Also, for patients with higher amounts of astigmatism or with unstable corneas, such as seen in post-radial keratotomy, more adjustments or delayed treatments could be necessary.

At Summit Eye Care in Wauwatosa and Menomonee Falls, Wis., John Vukich, MD, follows a similar template. “The fundamental question about the use of this lens is the additional patient pressure on your schedule,” says Dr. Vukich, founder and medical director at Summit. “Most patients go through at least two adjustments. And part of that expectation is the way that we have begun to practice with this lens.”

At the first adjustment, patients are brought as close to plano vision in both eyes to optimize for distance, essentially bringing them to zero, says Dr. Vukich.

“Commonly, with that first adjustment we will achieve macular potential or tear film limited potential. It is not uncommon to have uncorrected acuities of 20/15 after the first treatment. About 70% of patients will want more near vision, and what we will do is take the non-dominant eye and bring them to about -0.75 at the second adjustment.”

STAFF COLLABORATION & PATIENT EDUCATION

Implantation of the lens is essentially no different than any three-piece lens, but both Dr. Vukich and Dr. Shamie agree that the best approach is to involve various members of the clinical and administrative teams because the main learning curve is in working through postoperative management. Delegating the adjustment appointments to their clinic’s optometrists has been the preferred approach for both.

“That has been an absolute game-changer,” Dr. Shamie says. “Our optometrists manage target planning and light delivery. Having optometrists who understand the technology, appreciate the advanced approach and offer patients continuity of care has been seamless.”

One week after the first adjustment, doctor and patient meet to assess how much closer to target they are.

“If the patient is at target, the locking procedure begins, which is similar to the adjustment treatment but with a different pattern of light that treats the entire lens,” Dr. Shamie says. “If the patient is not at target, they will see that doctor for a second adjustment,” after which she says they are typically on target and can have their final treatment or “lock-in.”

Dr. Shamie emphasizes informing any referring optometrists about the multiple visits required and engaging them to assist with target planning. “They know their patients better than surgeons do,” she says. “And they’re the ones who can really help to decide the target refraction.”

Involving other staff is also a fixture in her practice. “The phone team and front desk staff need to be informed about what this lens offers so that they can help to manage office traffic. Our technicians are knowledgeable about the advantages of the lens and can present information to patients when they’re being worked up for surgery. Patients want access to information at every level, so we have to think about all touch points.”

According to Dr. Vukich, caseload management could also soon be assisted on at outsourced basis with various trials underway to test the feasibility of conducting refractions and adjustments through service organizations. “This could be the key to a more straightforward way of adding this functionality to your practice,” he says.

As an out-of-pocket expense for patients, this modality would not impact reimbursement. “This lens is in the premium package category, as with all premium cataract surgeries,” says Dr. Shamie. “We’ve decided that this lens requires more relative value units, clinic time and effort. Therefore, we felt it was justifiable to be more expensive than other premium lens offerings.”

OPTIMAL CANDIDATES

Approved for patients with an existing cataract, corneal astigmatism of at least 0.75 D and no macular disease, the lens does not face many exclusions, says Dr. Vukich. “If you believe placing a single-vision lens is appropriate, this is essentially a single-vision lens that offers fine-tune ability. It’s ideal for patients who have dry macular degeneration but still have some macular potential. This lens also gives the ability to fine-tune a functional endpoint for patients who have other compromises, such as visual field, without introducing other aberrations.”

According to RxSight officials, contraindications include:

• Systemic medications that could increase sensitivity to UV light;
• Systemic medications considered toxic to the retina;
• History of ocular herpes simplex virus;
• Nystagmus; and
• Refusal to wear UV protective eyewear post-surgery.

Dr. Shamie says there are other exclusions she considers. “The most common reason that I cannot offer the lens would be if the pupil doesn’t dilate more than 6.5 mm, because pupil dilation impacts the ability to treat the entirety of the lens optic.”

Dr. Vukich also advises the use of the lens among LASIK or corneal refractive surgery patients. “This lens works really well for patients who have atypical corneas,” he says. “It gives you that soft landing zone. And the results speak for themselves for patients who have otherwise normal anatomy and potential for maximum vision.” OM