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34 | EYEWORLD DAILY NEWS | MAY 17, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING because he finds there are no refractive benefits to sequential surgery. It avoids the incon- venience of anisometropia, he added, and it cuts the time period of wearing glasses and the visits in half. One of the real benefits is to experience what your vision is like binocu- larly with different amounts of anisometropia, he said. In his first 5 months using the LAL, Dr. Chang has done 89 eyes (before having to stop because of the pandemic). Dr. Chang noted that he will usually aim a little plus in one eye and a little minus in the other so that people can see the difference when adjusting. Most will take at least mini-monovision or full monovision, he added. Editors' note: Dr. Holladay has no financial interests related to his comments. Dr. Chang has financial interests with RxSight, Perfect Lens, Johnson & Johnson Vision, and Carl Zeiss Meditec. RxSight). He first addressed barriers to greater adoption of premium refractive IOLs in 2020: inability to achieve LASIK-like outcomes, risk of side effects from diffractive lenses, surgeons lacking con- fidence in satisfying patients, patients understanding the value proposition, and lack of patient word of mouth. From the standpoint of the surgeon, he said, fees for these premium lenses come with higher expectations, and patients are unhappy if they don't get the desired result. There are also barriers to hitting the refractive target, barriers to enhancement, the problem of unwanted images and dysphotopsias, and patient miscommunication. On the patient side, there is often confusion over the value proposition because you have to have some understanding of optics, Dr. Chang said. Even after going through what the value is, there's still the dis- claimer from the surgeon that the patient may need glasses. There are extra costs involved in these premium lenses, and while some patients may not be able to afford this, others can. However, they may be less likely to want to pay the extra costs if they don't un- derstand the value of what they're getting. There is also the problem of fear, particular- ly when patients talk to friends who may be dissatisfied with a premium IOL. Often when they are happy, the role of the IOL is unclear, Dr. Chang said. Dr. Chang went on to ex- plain the way the LAL works. It's really a custom toric lens, he said. In Europe, there is also an EDOF model. Do we need this, given all the advances in formulas and diagnostics and better lenses? "They've improved the batting average; the standard devia- tion is still there," Dr. Chang said. Physicians still have to predict things like effective lens position (ELP), posteri- or corneal astigmatism, and surgically induced astigmatism (SIA), he said. You also have to add in post-refractive eyes, eyes where you don't get good biometry, unusual axial lengths and Ks, and fluctuation from the cornea. Even though we do great with astigmatism for toric lenses, there's still the issue of posterior corneal astigmatism and SIA, he said, as well as irregular corneas, the effect of AKs, and toric IOL rotation. We have the ability to enhance, he said, but many cataract surgeons don't do ker- atorefractive surgery, and from the patient standpoint, this is an unexpected procedure, and they perceive it as a complica- tion. It also delays correction of refractive error while waiting for the cornea to stabilize. With so many options, a lot of the ophthalmologist's time is spent preoperatively, Dr. Chang said, with diagnostics, counseling, IOL calculations, and setting the patient's ex- pectations. Meanwhile, postop time is often spent with those patients who are unhappy with residual refractive error, IOL performance, or unwanted images. "I think we don't think enough about how stressful that preoperative period is for the patient," Dr. Chang said. They have to decide on something they don't totally understand. Many of these patients are analytical, and there's a certain degree of fear of missing out. What's nice about the LAL, he said, is it shifts a lot of that anxiety to the postopera- tive period where counseling can be done. Patients can be shown different results with trial lenses, and they get to finalize their decision at that point. There's no need to under promise, he added, and you're opting for something that has good visual quality, so you don't have the unpredictability of whether or not the patient can tolerate decreased contrast or halos. Additionally, it is for- giving of mild maculopathy. Dr. Chang added that he has been doing bilateral same-day surgery with the LAL continued from page 32 Dr. Chang explains how the Light Adjustable Lens works. Source: David Chang, MD, screenshot from presentation

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