How light adjustable lenses improve cataract surgery outcomes for patients with Dr. Jack Chapman

Post-operative care for cataract surgery patients that are fitted with the light adjustable lens (LAL) has gotten easier since 2018 thanks to ActivShield, according to Jack M Chapman, MD, of North Georgia Eye Associates, an EyeSouth Partners affiliate practice. He told Optometry Times in an exclusive interview that patients don't mind the extra follow-ups because they appreciate the flexibility LALs give them to find what is comfortable for their eyes.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Jordana Joy:

Hi everyone. I'm here today with Dr. Jack Chapman, managing partner and ophthalmologist at North Georgia Eye Associates. He's here to chat about the light adjustable lens, the only post-surgery customizable cataract lens on the market. Welcome, it's great to have you today.

Jack M Chapman, MD:

Hello to you, too. I’m happy to be here.

Joy:

North Georgia Eye Associates just recently reopened at the beginning of this year. Could you give us an overview of what went into the decision to integrate LALs into the practice with the reopening, and what that process was like for you guys?

Chapman:

It’s (LALs) been approved since 2018, but recently they had the approval of the newer version, which had ActivShield in it, which made the post-operative portion a lot easier. The fact that you can adjust the lens or customize it or allow the patient to test drive it, as we say, after surgery was big for us.

One of the things that we deal with, both us and our co-managing doctors out there, is the fact that we have a good surgery, we put the lens in, patient sees well for a week, and then their vision changes and then they're not seeing as well as they were. And so what happens in that regard is the lens enters into this thing we call ELP, or effective lens position, where the cataract is that big, the implants that big, and as the bag shrinks around the implant, it can nudge the lens a little bit and change its effective lens position, and thus induce a refractive error that wasn't there previously and gives the patient not the quite as good a vision as they had at the time. This is the part that is challenging for us because neither of us has any control over it.It's the tissues that are doing the work on that regard from affecting the vision.

The other item we deal with nowadays is we have a lot of people that are in that age range that have had LASIK done, and so they had LASIK to get rid of their glasses. LASIK was approved in 1995 and came aboard on 1996, so all those people from 96 on had LASIK and so we've got hundreds of them out there. Now, they're coming to cataract age. Well, they've been many years without glasses, that's why they had the LASIK to start with, and so now they're going to have a cataract. The cataract has caused their vision to go down, and a lot of times,they'll come in and say, ‘Oh, I think my LASIK is worn offand I need LASIK again.’ And we examineand say, ‘No it’s your cataracts that have grown,’ so we have to work on the cataract process. When they go through cataract, they haven't had glasses, so they are not real thrilled about going back into glasses. In order to be able to pretty much help them get to where they can be the best afterwards and to handle this effective lens positionor this refractive error that can occur after cataract surgery, is to have a lens like light adjustable lens, where we can put the lens in, have them heal up, get over the post-op period, and then start adjusting the lens, customizing it for that patient to dial them in. A lot of times, we tell them it's like going to have a dress fitted. If you're going to have a custom fit dress, you have togo through several fittings. You have a custom fit suit, you got to go through several fittings, same way with a light adjustable lens. We use that period to be able to dial them in so we can get them to as spectacle-free as we can, similar to the way they were pre-cataract after their LASIK.

Joy:

With those additional fittings that are required or possible with LALs, how have they been received by patients that have received them so far?

Chapman:

The patients so far have really taken to it. They like the idea of having the lens customized and they're willing to commit to going through the process, just like they were going to have clothing customized. They got to go through the process, and so we explained it to them on the front end, that it's going to take three or four visits to do the adjustments on them, to get them dialed in. Then, they'll be able to go home, try them, test it out, test their vision, and then come back. If we need to do an additional adjustment, we'll do that for them. They like the idea that they're in control of their vision, that they can go home and then come back and tell us, ‘Oh, this is what I like, this is what I don't like. This is where I'd like to be.’ And then we show them how we can get them there through customizing and doing the adjustment. As far as results go with the light adjustable lens, 96% of patients are willing to go out and tell their friends and family how much they like it, so patients are very satisfied with this process.

Joy:

Besides those additional visits, how has post-operative care changed for those patients receiving LALs?

Chapman:

You go through the normal post-op care like we would with anyone afterwards. We treat them and manage them appropriately, and use the appropriate eye drops to prevent infection, prevent inflammation. Once they get through the period, – 17 days is required minimum, but we do three weeks because it works out well — so that's 21 days that we go through, allowing time to make sure that the eye is healed and everything's settled down. There's none of the normal things that happen after cataract surgery. No residual corneal edema, no residual swelling of the macula, which sometimes we can see. But if those things do occur with the light adjustable lens, no problem. We just keep them using the UV protection lenses and wait till that resolves. There's no limit on time when you have to do it. You don't have to do it at that three-week period. You only start it if the patient is stable, but it gives us time to manage all that. Once that's quiet, then we come in and start the process.

Joy:

Given this updated technology, what should optometrists keep in mind when they're referring their patients for cataract surgery?

Chapman:

The optometrist – we co-manage with a lot of optometrists out there– is able to talk to the patient and to gage what their aspirations are, where they want to be after surgery. And then whether they're a type of person that it’s okay to wear glasses or the type person who’s had LASIK previously, doesn't want to wear glasses again. This is how they can get there with that process and being able to assure as best we can that their vision is going to be able to be dialed in after surgery.

Joy:

Was there anything else that you wanted to add that we haven’t touched on yet?

Chapman:

One of the issues with having to have something that's customizable after surgery, not only as previous people had LASIK and the effective lens position, but is the fact that your intraocular lenses come from the manufacturer only in half-diopter steps. With that half-diopter step, and then a little bit of parameter on either side, if you put in a lens, this doesn't necessarily mean that lens is going to put you right on the spot because of the half-diopter steps. To be able to compensate that with a light adjustable lens is very helpful.

We work together hand in hand with our optometrist to help do the adjustments after surgery, and this is where optometry shines because optometry is very, very good at doing refractions, being able to nail down, get that refraction right where it needs to be. When you're doing the adjustments, the very first adjustment is very much key. The lens is only adjustable from -2 to +2, so that's the range that you're working with. As far as the cylinder goes, it's adjustable for -75 up to -2 diopters of cylinder, and so those are the parameters that you're dealing with. As far as doing the near part in this, many of our patients want to have near as well as distance, and so we work with them on doing a mini monovision. We start out with a mini monovision, and then sometimes we have to do more of a monovision with the light adjustable lens. They have an LAL plus lens that is out now, which is what we're using, that gives a little bit of near on top of that. It's a type of change to the lens, and so we do not have to do as much of a correction on the up close part to get what we need so that way the disparity between the distance eye and the near eye is not as much. We're able to do that mini monovision, or do a monovision, adjusting it or customized for that patient and works very well. Of course, the dominant eye is the distance eye and the non-dominant eye is the near eye, but the good thing about the light adjustable lens, we do that, patient goes home and tries it doesn't like it, we can adjust it.

Joy:

Absolutely, that’s all very vital information. Well, thank you very much, Dr. Chapman. I appreciate the time today.

Chapman:

Thank you so much.