Achieving a new level of refractive precision: Surgical strategies

Even the most experienced cataract surgeons—armed with advanced diagnostic technologies, modern IOL power calculation formulas, and a meticulous surgical technique—encounter patients whose vision does not reach the intended refraction. A prospective analysis of about 9000 routine cataract surgeries showed that 62% and 89% of eyes achieved a refractive outcome within ±0.50 D and ±1.00 D of the target, respectively.¹ Although a residual refractive error is often small, it may still be enough to require glasses or an enhancement. In our practice, historically, about 5% of patients are outside of the ±0.50-D window.

The Light Adjustable Lens (LAL; RxSight) is a compelling technology to close the gap between intended target and postoperative refractive outcome. It provides an opportunity to fine-tune the lens power once the eye has healed after surgery and the patient provides their feedback, thereby reducing the risk of an unhappy patient due to refractive surprise. One way to further reduce the risk is by incorporating femtosecond laser assistance with a robotic cataract laser platform (Ally; Lensar, Inc).

The laser aligns a precisely sized and centered capsulotomy with the optical center of the lens rather than the pupil, which helps ensure a more predictable effective lens position and reduces the risk of a late myopic shift. Additionally, laser arcuate incisions may be used for astigmatism management. This combination provides a stronger foundation for refractive accuracy even before the postoperative fine-tuning process with the LAL.

A versatile combination

The LAL has been shown to deliver precise refractive outcomes.In a cohort of 34 eyes, most were within ±0.25 D (91%) or ±0.50 D (97%) of the manifest spherical equivalent target. The average patient satisfaction score was
8.8 of 10, and monocular contrast sensitivity was equivalent to that of a normal population aged 50 to 60 years. There was no reported loss of best-corrected distance visual acuity, and no safety concerns were noted.²

The LAL may be especially beneficial in post–refractive surgery eyes. A study of 94 eyes of 77 patients with a history of 4-, 6-, 8-, and 16-cut radial keratotomy (RK) showed 98%, 88%, and 69% of eyes were within
±1.00 D, ±0.50 D, and ±0.25 D of the intended refraction, respectively. In the 4-cut RK group, 73% of eyes achieved 20/20 or better uncorrected distance visual acuity (UDVA). In the 6- and 8-cut groups, 75% reached 20/20 or better UDVA, and in the 16-cut group, 80% reached 20/20 or better UDVA. After the postoperative light treatments, refractive precision within ±0.50 D and ±0.13 D improved from 44% to 88% and 16% to 46%, respectively.³

Another study showed LAL performance may be more effective in achieving a target refraction and improving UDVA compared with a standard monofocal IOL.⁴ In 40 patients with preexisting astigmatism, 28 received an LAL and 12 received a monofocal IOL. The mean cylinder after lock-in with the LAL was –0.34 ±0.34 D compared with –1.00 ±0.32 D 17 to 21 days after monofocal IOL implantation. Additionally, 79% of the LAL group and 33% of the control group achieved a UDVA of 20/20 or better.

Pairing the LAL with robotic laser cataract surgery is a strong foundation for meeting surgical expectations. It allows me to control centration and astigmatism management better than those who perform LAL cases without robotic laser assistance. I use the robotic cataract laser system to create a 5.1-mm capsulotomy to ensure better effective lens position and consistent centration. Rather than centering the capsulotomy on the pupil axis, the robotic cataract laser system centers it on the patient’s visual axis, mitigating late myopic shift. This versatile combination reduces the need for extensive LAL adjustments postoperatively.

Additionally, a laser arcuate keratotomy helps debulk cylinder at the corneal plane during cataract surgery, whereas postoperative LAL adjustments may be used to optimize the refractive end point. In my hands, this 2-stage strategy reduces reliance on toric IOLs, provides efficiency in complex corneas, and delivers sharper outcomes for patients with high expectations for spectacle independence. It also expands the pool of candidates for premium IOLs to include those with somewhat irregular corneas.

Postoperatively, patients who receive the LAL consistently describe 2 themes:

• A sense of ownership in achieving their visual end point. Almost unanimously, patients appreciate having input in their visual outcomes.
• A feeling that they are seeing better after surgery than ever. In many cases, patients achieve vision even beyond their expectations, which aligns with the findings of published studies.²

Clinical workflow

The LAL procedure requires a longer postoperative process for patients and eye care clinicians. This involves an adapted appointment scheduling system that accounts for light adjustments and the final lock-in procedures.

Patients perceive the extra postoperative visits as part of the premium experience rather than a burden. Additionally, a low enhancement rate saves me valuable chair time and frees my schedule to focus on surgical consultations and procedures. Although LAL patients require additional counseling on the front end, including explaining the procedure and postoperative requirements, such as the need to wear UV-blocking glasses until their lock-in is complete to prevent inadvertent polymerization of the lens, the postoperative visits are usually abridged as patients are engaged in fine-tuning their vision.

Lastly, combining LAL with a robotic cataract surgery technique involves a short learning curve. Precise capsulotomy, IOL centration, and astigmatic planning are crucial to minimizing the adjustment burden on clinic and patients alike. I have found it only takes a few cases before the workflow feels natural.

Conclusion

Combining the LAL with the robotic cataract laser system helped me achieve a new level of precision with refractive cataract surgery and patient collaboration. Fine-tuning the refractive result and achieving 20/20 UDVA is easier than ever, and the procedure has broad applicability, even in complex cases such as post–refractive surgery eyes.

Additionally, a high level of patient satisfaction underscores the procedure’s potential. For surgeons contemplating adopting the use of robotic laser cataract surgery with the LAL, focusing on the following areas will set them up for success:

• Careful patient selection and expectation management
• A meticulous surgical technique, including the use of optical centration
• A plan for addressing astigmatism aggressively at the time of cataract surgery
• Thoughtful workflow management
• Honest and realistic patient counseling about the process and benefits of adjustable lens technologies

Mujahid A. Hines, MD

E: [email protected]

Hines practices at NVISION Eye Center in Roseville and Folsom, California. He did not acknowledge any financial interest.

References

1. Brogan K, Diaper CJM, Rotchford AP. Cataract surgery refractive outcomes: representative standards in a National Health Service setting.
   Br J Ophthalmol. 2019;103(4):539-543. doi:10.1136/bjophthalmol-2018-312209

2. Ichikawa K, Sakai Y, Toda H, Kato Y, Ichikawa K. Visual outcomes after cataract surgery with the light adjustable lens in Japanese patients with and without prior corneal refractive surgery. J Refract Surg. 2024;40(11):e854-e862. doi:10.3928/1081597X-20241002-03

3. Webster M, Baartman B, Jones M, et al. Light-adjustable lens in eyes with a history of radial keratotomy. J Cataract Refract Surg. 2025;51(3):243-248. doi:10.1097/j.jcrs.0000000000001596

4. Moshirfar M, Wagner WD, Linn SH, et al. Astigmatic correction with implantation of a light adjustable vs monofocal lens: a single site analysis of a randomized controlled trial. Int J Ophthalmol. 2019;12(7):1101-1107. doi:10.18240/ijo.2019.07.08