Light Adjustable Intraocular Lens for Cataract Surgery After Radial Keratotomy

Light adjustable intraocular lenses in cataract surgery: considerations

PURPOSE OF REVIEW

Light adjustable intraocular lens (LAL) is a promising concept in cataract surgery. This review explores considerations for the use of LALs.

RECENT FINDINGS

Through updates, the safety of LALs and light delivery devices have been enhanced, enabling more efficient treatment with lower ultraviolet (UV) energy. Preoperative topography and aberration are essential for understanding indications for LALs. Furthermore, when determining intraocular lens power, it is crucial to factor in potential postoperative myopia or hyperopic adjustments. This is achieved by establishing a proper postimplantation refractive target and considering potential wavefront changes. Postoperative adjustments for defocus and astigmatism have demonstrated excellent outcomes. Monovision strategy by adjustable blended vision of LALs revealed distance vision of 20/20 along with near vision of J2 in 96% of patients. However, the results of clinical studies on postrefractive cataract surgery showed contrasting outcomes at distance, indicating the need for further research results regarding its effectiveness. A new postoperative workflow needs to be designed to enable a systematic follow-up process.

SUMMARY

LALs are safe and demonstrate promising refractive outcomes. To achieve appropriate results, understanding the changes in optical characteristics associated with adjustment and constructing a new postoperative workflow are necessary.

Cataract surgery after corneal refractive surgery: preoperative considerations and management

PURPOSE OF REVIEW

Corneal refractive surgery (CRS) is one of the most popular eye procedures, with more than 40 million cases performed globally. As CRS-treated patients age and develop cataract, the number of cases that require additional preoperative considerations and management will increase around the world. Thus, we provide an up-to-date, concise overview of the considerations and outcomes of cataract surgery in eyes with previous CRS, including surface ablation, laser in-situ keratomileusis (LASIK), and small-incision lenticule extraction (SMILE).

RECENT FINDINGS

Challenges associated with accurate biometry in eyes with CRS have been mitigated recently through total keratometry, ray tracing, intraoperative aberrometry, and machine learning assisted intraocular lens (IOL) power calculation formulas to improve prediction. Emerging studies have highlighted the superior performance of ray tracing and/or total keratometry-based formulas for IOL power calculation in eyes with previous SMILE. Dry eye remains a common side effect after cataract surgery, especially in eyes with CRS, though the risk appears to be lower after SMILE than LASIK (in the short-term). Recent presbyopia-correcting IOL designs such as extended depth of focus (EDOF) IOLs may be suitable in carefully selected eyes with previous CRS.

SUMMARY

Ophthalmologists will increasingly face challenges associated with the surgical management of cataract in patients with prior CRS. Careful preoperative assessment of the ocular surface, appropriate use of IOL power calculation formulas, and strategies for presbyopia correction are key to achieve good clinical and refractive outcomes and patient satisfaction. Recent advances in CRS techniques, such as SMILE, may pose new challenges for such eyes in the future.

Cataract surgery following refractive surgery: Principles to achieve optical success and patient satisfaction

A growing number of patients with prior refractive surgery are now presenting for cataract surgery. Surgeons face a number of unique challenges in this patient population that tends to be highly motivated to retain or regain functional uncorrected acuity postoperatively. Primary challenges include recognition of the specific type of prior surgery, use of appropriate intraocular lens (IOL) power calculation formulas, matching IOL style with spherical aberration profile, the recognition of corneal imaging patterns that are and are not compatible with toric and/or presbyopia-correcting lens implantation, and surgical technique modifications, which are particularly relevant in eyes with prior radial keratotomy or phakic IOL implantation. Despite advancements in IOL power formulae, corneal imaging, and IOL options that have improved our ability to achieve targeted postoperative refractive outcomes, accuracy and predictability remain inferior to eyes that undergo cataract surgery without a history of corneal refractive surgery. Thus, preoperative evaluation of patients who will and will not be candidates for postoperative refractive surgical enhancements is also paramount. We provide an overview of the specific challenges in this population and offer evidence-based strategies and considerations for optimizing surgical outcomes.

Visual Outcomes of a Second-Generation, Enhanced UV Protected Light Adjustable Lens in Cataract Patients with Previous LASIK and/or PRK

Purpose

To report on the visual outcomes of the second-generation (ActivShieldTM) Light Adjustable Lens (LAL) used in cataract surgery for patients with a history of laser refractive surgery (LASIK and/or photorefractive keratectomy [PRK]) using a co-managed, open-access methodology.

Patients and Methods

This retrospective case series of consecutive patients with history of laser refractive surgery implanted with the second-generation LAL with an emmetropic target were included in the study. Following surgery, all patients received their ultraviolet (UV) light treatments at a separate open-access facility through a co-managed arrangement. Uncorrected distance visual acuity (UDVA), spherical equivalent (SE), and residual cylinder for eyes with an emmetropic refractive target were the primary outcome measures as documented at the patient's final, stable, refractive postoperative exam.

Results

Thirty-three patients (34 eyes) with a history of laser refractive surgery were included in the study and implanted with the second-generation LAL with a postoperative emmetropic refractive target. Twenty-eight (82.4%) saw 20/20 or better and 9 (26.5%) saw 20/15 or better. The mean SE was 0.01 ± 0.31 D and 33 (97.1%) were within ±0.50 D SE of plano. The mean residual cylinder was -0.28 ± 0.32 D and 30 (88.2%) were within ±0.50 D.

Conclusion

Use of the second-generation LAL was efficacious in cataract surgical patients with a history of LASIK and/or PRK using a co-managed, open-access methodology.

Light adjustable intraocular lenses: an updated platform for cataract surgery

PURPOSE OF REVIEW

Light adjustable intraocular lenses (LALs) are a relatively new platform for cataract surgery that is shifting the paradigm for intraocular lens placement following cataract removal.

RECENT FINDINGS

LALs may have additional utility in patients with prior refractive surgery and complex ocular conditions, as they give the surgeon greater latitude in preoperative intraocular power calculations to meet postoperative refractive goals.

SUMMARY

Further study of best candidates for LALs is warranted. Current best candidates are patients who can comply with treatment and have decreased accuracy in calculating the preoperative intraocular power requirement.

Visual Outcomes of an Enhanced UV Protected Light Adjustable Lens Using a Novel Co-Managed, Open-Access Methodology

Purpose

To report on the safety and visual acuity (VA) outcomes using a co-managed, open-access methodology with a second-generation (ActivShield^TM) Light Adjustable Lens (LAL 2.0).

Patients and Methods

This retrospective observational case series of consecutive patients implanted with the LAL 2.0 choosing an emmetropic target in at least one eye were included in the study. All patients were co-managed with light treatments occurring at an open-access facility. Exclusion criteria included pathology of the macula and/or cornea with reduced best corrected visual acuity (BCVA). The primary outcome measures were uncorrected distance visual acuity (UDVA), spherical equivalent (SE), and residual cylinder for emmetropic goal eyes at the final 3- to 9-month postoperative visit.

Results

Thirty-three patients (62 eyes) were included in the study and implanted with the LAL 2.0. Thirty-three (53.2%) eyes had previous corneal refractive treatment(s) with 22 (66.7%) having no original historical refractive records available. Thirty-six (58.1%) total eyes and 20 (32.3%) postrefractive eyes had an emmetropic refractive target. Of all the emmetropic goal eyes, 35 (97.2%) saw 20/20 or better and 36 (100%) were within ±0.50 D SE of plano and had a mean cylinder of −0.15 ± 0.26 D. Of the postrefractive emmetropic goal eyes, 19 (95%) saw 20/20 or better, 20 (100%) were within ±0.50 D SE of plano and had a mean cylinder of −0.17 ± 0.28 D.

Conclusion

A co-managed, open-access methodology using the LAL 2.0 was safe and efficacious even in challenging postrefractive clinical scenarios.