Light adjustable lens (LAL) technology continues to evolve, expanding clinical applications and refining postoperative refractive outcomes. In this Q&A conversation, the Eye Care Network caught up with P. Dee G. Stephenson, MD, FACS, founder and chief executive officer of Stephenson Eye Associates in Venice, Florida, to learn more about recent advances in LAL technology, challenges in adoption, and the role of ocular surface optimization in achieving accurate, repeatable surgical results. She also discusses diagnostic tools and treatment protocols for managing ocular surface disease (OSD) before and after cataract surgery.

Note: Transcript edited lightly for clarity and length.

What are the most significant improvements in LAL technology in recent years, and how have they enhanced patient outcomes?

P. Dee G. Stephenson, MD, FACS: The technology [is] constantly improving, so the advantages that drew us to LAL [technology] are better than ever, and the pool of candidates is larger. LALs give us more predictable outcomes than we can achieve with a fixed lens because they allow us to correct for a host of variables postoperatively. For example, we can correct for post-refractive corneal issues, preoperative measurements skewed by ocular surface problems, and changes that occur during postoperative healing, such as capsulotomy constriction leading to a shift ineffective lens position.

Recently, the range of lens powers for LALs has expanded. With more powers, more patients are good candidates for LAL technology and have access to all the LAL advantages. We’ve also seen the introduction of a built-in UV shield, which reduces the variability of depending on patients to use UV-filtering glasses. The light adjustment device is more efficient as well.

Improvements to the lenses themselves are not the only advancement that improves outcomes. The LAL system now analyzes our outcomes data and shows us we are getting good results, which gives me a confidence boost and makes me feel like I am accomplishing something important for my patients.

How have advancements in light-adjustment techniques and materials impacted the precision and safety of post-implantation adjustments?

Stephenson: With previous LALs, there was always a chance that bright sunlight could alter the implant, so patients who received earlier version LALs had to wear special UV glasses all the time until the adjustments and lock-ins were done. RxSight introduced a UV light filter called ActivShield that is built into the lens. Patients do not need to wear special sunglasses for weeks—a big improvement in their experience—and we no longer need to worry about patients’ noncompliance with the glasses potentially affecting their outcome.

Can you discuss the role of new light delivery systems in improving the efficiency and accuracy of adjustments in light adjustable IOLs?

Stephenson: Since LALs were introduced, there have been upgrades in the light delivery system hardware and software. Every update makes the process more efficient—a little less time, a little less challenging. The software can now leverage years’ worth of outcomes data to help us make adjustments, speeding both decision-making and the treatment itself.

The system detects a barcode on the implant, which populates the database with the patient’s name, refraction, and refractive goal. It updates the data every time we do an adjustment or lock-in treatment. After putting a contact lens on the patient, I only need to use the laser for a few minutes, which is shorter than previous versions.

What are the current challenges or limitations in the adoption of light adjustable IOL technology, and how are recent advancements addressing these issues?

Stephenson: Although the LAL experience has improved with more efficient adjustments and no more need to wear special sunglasses, it is still a journey to better vision, rather than an instant result. In my practice, we do about 92% premium lenses, so we are good at setting expectations to avoid surprises or frustrations. With LAL lenses, that means educating patients so they can weigh the advantages against the prospect of going through an 8 to 10 week process.

I make sure my patients understand that I want to take my time to get their vision as perfect as possible, customized for their lifestyles. I explain as I go, so they understand we are methodically getting their distance eye to 20/20, working on the near eye, taking care of astigmatism, and so on. They know the timetable up front, and they are happy to be part of this process—especially when they start seeing the results.

What are the best practices for preparing patients for surgery and post-surgical care with this premium IOL option?

Stephenson: In addition to the education I mentioned, I think that all patients deserve to start surgery with a healthy cornea. We typically treat the ocular surface for 2 to 3 weeks before preoperative testing. After surgery, they need to continue dry eye therapy in addition to their postoperative medications. I emphasize that if they get complacent and stop treating their dry eye, it will affect their ability to accurately make the assessments they need to so we can adjust their IOL.

What are the most effective diagnostic tools currently available for assessing the health of the ocular surface, and how do they compare in terms of accuracy and patient comfort?

Stephenson: I use advanced diagnostic platforms such as iTrace (Tracey Technologies) and Cassini, both of which provide dry eye evaluation capabilities. These tools allow me to assess corneal topography, tear film quality, and meibomian gland function, helping me determine the most effective therapies while also educating patients. With iTrace, I can demonstrate dysfunctional lens syndrome, showing how corneal and lens aberrations combine to impair vision. I also use Tearcheck (ESW Vision) to analyze tear breakup and ocular surface inflammation. By capturing detailed images, I am able to illustrate how quickly a patient’s tear film evaporates, making the problem visible and easier to understand.

How have recent developments in ocular surface treatment protocols improved the preoperative management of conditions like dry eye disease and meibomian gland dysfunction (MGD)?

Stephenson: Today, we have a wide range of effective options for improving the tear film and reducing inflammation prior to surgery. My standard protocol for most patients includes oral supplementation, preservative-free artificial tears, eyelid hygiene, and a prescription drop tailored to the patient’s diagnosis.

I typically begin by recommending a clinically validated oral supplement containing GLA and omega-3 fatty acids (EPA and DHA) along with other active ingredients (HydroEye; ScienceBased Health) that enhance the tear film and help reduce ocular surface inflammation.¹ I encourage patients to continue this long term as part of their ongoing dry eye management.

For lubrication, I recommend a preservative-free artificial tear used as needed. Those with convenient multidose bottles—such as Systane Complete PF (Alcon); Retaine MGD PF (OCuSOFT); or Retaine CMC PF (OCuSOFT)—have made it easier for patients to maintain regular use without relying on single-use vials.

Eyelid hygiene is another key step for optimizing the ocular surface and lowering bacterial load before surgery. I instruct patients to use a hypochlorous acid spray (Avenova or OCuSOFT) twice daily, either sprayed directly onto closed eyelids or applied with a clean pad. For patients with Demodex blepharitis, I initiate a 6-week course of lotilaner ophthalmic solution 0.25% (Xdemvy; Tarsus Pharmaceuticals).

Most preoperative patients with OSD also benefit from a prescription medication. For MGD, I often prescribe perfluorohexyloctane ophthalmic solution (Miebo; Bausch and Lomb), which reduces tear evaporation, works relatively quickly, and is preservative-free, making it a strong preoperative choice. To boost tear production and reduce inflammation, I frequently prescribe cyclosporine-based therapies, such as Cequa (Sun); Restasis (AbbVie); or Vevye (Harrow). If inflammation is more prominent, I turn to lifitegrast ophthalmic solution (Xiidra; Bausch and Lomb), and in select cases, add a short course of topical steroids like loteprednol to help quiet the ocular surface before surgery.

Can you discuss the importance of a comprehensive ocular surface assessment before surgical procedures, such as cataract or refractive surgery, and how it influences surgical outcomes?

Stephenson: In cataract surgery, we strive to control every variable possible, and the ocular surface is the single biggest variable. That is why I make it a priority to obtain a complete picture of each patient’s ocular surface and treat any issues aggressively.

For the best outcomes, we need accurate and repeatable preoperative measurements. These measurements capture a single moment in time, so at that moment, the cornea must be optimized, with dry eye disease well controlled—particularly for patients receiving LAL or presbyopia-correcting lenses. In addition, the ocular surface must be prepared to tolerate the challenges of surgery itself, as well as the weeks of postoperative topical medications that follow.

If OSD is not identified and treated beforehand, patients may experience poor outcomes increased astigmatism and mistakenly attribute their discomfort to the surgery, rather than their preexisting condition. Fortunately, most patients begin seeing results from dry eye therapy within a few weeks, at which point they are ready for biometry and surgical planning.

It is equally important to emphasize that ocular surface therapy must continue after surgery for patients to maintain comfort and achieve the best vision. This is especially critical for LAL patients, who require a clear and stable tear film to provide accurate feedback during postoperative adjustments and ultimately achieve their best possible vision.

P. Dee G. Stephenson, MD, FACS
E: [email protected]
Stephenson is founder and chief executive officer of Stephenson Eye Associates in Venice, Florida.

The thoughts and opinions expressed are those of Stephenson and do not necessarily represent the opinions of this publication.

Reference

1. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c