Cataract - Light Adjustable Lens (LAL)

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stephenson

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Hi All,

Well, it's apparently "that time."

69, prior PRK (20/20 near and far for 16 years), and just this year noticed deterioration - more on left with 2+ grade (near mono vision) than on the right with 1+ grade (distance mono vision).

Optometrist believes I may get close to the original post-PRK numbers with just a clear lens - this would be pretty darn good.

So, started reading and quickly bumped into RxVision's Light Adjustable Lens product/process. Very interesting - basic summary is that a lens with macromers is inserted instead of the usual IOL, then after waiting for some stabilization/healing, a specific frequency UV light is aimed to cause the macromers to join together as polymers which allows ophthalmologist to tune the lens to adjust power and address astigmatism. After as many as three of these adjustments, the UV light is changed to a stabilizing function and it "locks" the modifications made into place. Pretty amazing.

Obviously not fully covered by Medicare and most insurance - some form of cost upper - likely not minor ...

https://rxsight.com

https://www.reviewofophthalmology.com/article/light-adjustable-lens-practice-integration

Anyone had this done and can provide insight and effects?

Thanks!
 
Yes I had the Light Adjustable Lens put in my left eye. I had had a vitrectomy in that eye and so I needed a monofocal lens. My right eye has the Vivity lens in it.

Having good intermediate computer distance vision without glasses was important to me. I was OK with reading glasses. So, I ended up doing monovision where my right eye was optimized for distance (but was good at intermediate as well since it is not a monofocal lens). For my left eye, I did 3 adjustments to get it to where it was optimized for computer distance. It worked ...fairly well. The first adjustment really did not adjust it enough and was too distance oriented. The second got me most of the way there. The third was a smaller tweak. The number of times it can be adjusted depends on how much they do each time. Some people can only have 2 adjustments, some can have 4. 3 is typical.

Almost 2 years later, I can see reasonably well at the computer with no glasses. Although if I need to switch between computer and reading something on paper (or phone) then I use reading glasses. I can get buy without reading glasses but it is a stress. My combined distance vision is 20/20 to 20/25 depending on the day which is fine.

Anyway, I think the LAL is great for people who have to have a monofocal lens (which is probably recommended for you given PRK). I was surely glad it could be adjusted. On the other hand, I absolutely love my Vivity lens in the right eye and if I could have had that for both eyes then I would have done it.

If you have any specific questions let me know. Here is the link to my cataract surgery thread where I talked a lot about the LAL.

https://www.early-retirement.org/forums/f38/another-cataract-surgery-thread-111235.html
 
Great thread, Katsmeow!

Learned a lot .... still sorting. My sense is that given my prior PRK, comfort with monovision (L short and R long), and lack of other contributing factors, I could "get away with" normal replacement lens, but they would need to "guess" a bit on any increased power.

LAL sounds like it has obvious advantages!
 
Katsmeow said:
Yes I had the Light Adjustable Lens put in my left eye. I had had a vitrectomy in that eye and so I needed a monofocal lens. My right eye has the Vivity lens in it.

Having good intermediate computer distance vision without glasses was important to me. I was OK with reading glasses. So, I ended up doing monovision where my right eye was optimized for distance (but was good at intermediate as well since it is not a monofocal lens). For my left eye, I did 3 adjustments to get it to where it was optimized for computer distance. It worked ...fairly well. The first adjustment really did not adjust it enough and was too distance oriented. The second got me most of the way there. The third was a smaller tweak. The number of times it can be adjusted depends on how much they do each time. Some people can only have 2 adjustments, some can have 4. 3 is typical.

Almost 2 years later, I can see reasonably well at the computer with no glasses. Although if I need to switch between computer and reading something on paper (or phone) then I use reading glasses. I can get buy without reading glasses but it is a stress. My combined distance vision is 20/20 to 20/25 depending on the day which is fine.

Anyway, I think the LAL is great for people who have to have a monofocal lens (which is probably recommended for you given PRK). I was surely glad it could be adjusted. On the other hand, I absolutely love my Vivity lens in the right eye and if I could have had that for both eyes then I would have done it.

If you have any specific questions let me know. Here is the link to my cataract surgery thread where I talked a lot about the LAL.

https://www.early-retirement.org/forums/f38/another-cataract-surgery-thread-111235.html
Click to expand...
I’m due for cataract surgery. I’m interested in finding out more about LAL but having trouble getting real life experiences. I didn’t have laser or PRK.

Did you consider Panoptix?
Why do like vivity better than the LAL, why not do LAL on both?
Do you seen any sort of glare or haloing with vivity?
I was told by a doctor that mixing a monofocal and a multi focal can cause the haloing and glare in the multi focal to be more obvious. Is that the case for you?

I had scheduled to get Panoptix in both eyes but cancelled because I wanted to find out more about LAL and the potential for mini mono vision.
 
JBTX said:
Did you consider Panoptix?
Click to expand...

I had prior LASIX. Panoptix is a multi-focal lens. Both LASIX and multi-focal lenses will decrease contrast. So most surgeons either won't do Panoptix at all with someone who has had refractive surgery or they really warn you against. With Panoptix you get great multi focus range of vision but you loss a little bit of vision quality especially in low light or night settings. LASIK people can't really afford that loss.

Why do like vivity better than the LAL, why not do LAL on both?
Click to expand...

The Vivity lens is an extended focus lens. LAL is a monofocal lens. Monofocal lens give the best quality of vision and do not cause loss of contrast. Vivity to me was sort of the sweet spot between monofocal and multi-focal. In short, I was a candidate for it even with my LASIK surgery. However, my left eye had a vitrectomy due to a macular pucker. Because of that I couldn't afford any loss of contrast in my vision in that eye. So I was not a candidate for the Vivity lens in that eye. I could have saved money just getting a basic monofocal lens. However, I liked the idea of the post surgery adjustment of lens power with the LAL so I did it. I am happy I had that option.

Do you seen any sort of glare or haloing with vivity?
Click to expand...

No.


I was told by a doctor that mixing a monofocal and a multi focal can cause the haloing and glare in the multi focal to be more obvious. Is that the case for you?
Click to expand...

Well, I have an extended focus lens (the Vivity) and not a multifocal like the Panoptix so I can't speak to whether it would have been an issue if I had the Panoptix with the LAL lens.

I had scheduled to get Panoptix in both eyes but cancelled because I wanted to find out more about LAL and the potential for mini mono vision.
Click to expand...

I have read of some people with distance vision in one eye and monovision near vision in the other they can see well at all ranges. However, that is full monovision not many. Many people will be OK with seeing distance well and near well (other eye) but maybe needed computer classes for intermediate. Or, others will be OK with reading glasses but not need anything otherwise. That is basically what I have with the LAL in one eye and the Vivity in the other. You could also set up mini-monovision with the Vivity. I would have done that if I could. I probably would not have needed reading glasses if I could have. Even now, with my LAL set more for intermediate vision I can basically read almost anything without reading glasses. It is just a strain. But it is still helpful that if I go to the kitchen and need to read something on the side of a package I can read it without the reading glasses I left in the other room.

Of course, the advantage of LAL is that you can tweak your vision after surgery which you can't do with Vivity. I love my Vivity lens but I was extremely lucky in that I ended up with very clear 20/20 vision in that eye which is what I wanted. With the LAL in the left eye I had 3 adjustments to get it refined.
 
I am one of those with one eye long, and one short - was pretty normal PRK when I had it done in 2006.

I had been very astigmatic, but the PRK gave me 20/20 long and nearly perfect short ... zero glasses until the past year or do.

Optometrist said he could see no indication of the PRK and opined I might be returned to same as I had following the PRK with just lens replacement.

I'll research some more, then get a couple of consults and see what is recommended.
 
Katsmeow said:
I had prior LASIX. Panoptix is a multi-focal lens. Both LASIX and multi-focal lenses will decrease contrast. So most surgeons either won't do Panoptix at all with someone who has had refractive surgery or they really warn you against. With Panoptix you get great multi focus range of vision but you loss a little bit of vision quality especially in low light or night settings. LASIK people can't really afford that loss.



The Vivity lens is an extended focus lens. LAL is a monofocal lens. Monofocal lens give the best quality of vision and do not cause loss of contrast. Vivity to me was sort of the sweet spot between monofocal and multi-focal. In short, I was a candidate for it even with my LASIK surgery. However, my left eye had a vitrectomy due to a macular pucker. Because of that I couldn't afford any loss of contrast in my vision in that eye. So I was not a candidate for the Vivity lens in that eye. I could have saved money just getting a basic monofocal lens. However, I liked the idea of the post surgery adjustment of lens power with the LAL so I did it. I am happy I had that option.



No.




Well, I have an extended focus lens (the Vivity) and not a multifocal like the Panoptix so I can't speak to whether it would have been an issue if I had the Panoptix with the LAL lens.



I have read of some people with distance vision in one eye and monovision near vision in the other they can see well at all ranges. However, that is full monovision not many. Many people will be OK with seeing distance well and near well (other eye) but maybe needed computer classes for intermediate. Or, others will be OK with reading glasses but not need anything otherwise. That is basically what I have with the LAL in one eye and the Vivity in the other. You could also set up mini-monovision with the Vivity. I would have done that if I could. I probably would not have needed reading glasses if I could have. Even now, with my LAL set more for intermediate vision I can basically read almost anything without reading glasses. It is just a strain. But it is still helpful that if I go to the kitchen and need to read something on the side of a package I can read it without the reading glasses I left in the other room.

Of course, the advantage of LAL is that you can tweak your vision after surgery which you can't do with Vivity. I love my Vivity lens but I was extremely lucky in that I ended up with very clear 20/20 vision in that eye which is what I wanted. With the LAL in the left eye I had 3 adjustments to get it refined.
Click to expand...
Thank you for your thorough answers. They are helpful.

I had the impression that even though LAL was single pt of focus, due to the adjustment process you could effectively get something similar to extended depth of focus - is that true?

I’m not sure you will be able to answer this, but if you would have been eligible for panoptix would you have gone that route, or do you think you are happier with what you ended up with, or would you have gone with 2 vivity with occasional use of reading glasses?

I’m kind of circling back around to Panoptix. I wear glasses all the time now, but I’m not big on the idea of having to put readers on and off a hundred times a day when I look at my phone. If I knew I’d have good night vision with Panoptix then I think I’d be sold.
 
Here's a link to a company that collects tech for optometrists and ophthalmologists into a product catalog - haven't sorted completely, but some good information ...

https://www.beye.com/about
 
JBTX said:
Thank you for your thorough answers. They are helpful.

I had the impression that even though LAL was single pt of focus, due to the adjustment process you could effectively get something similar to extended depth of focus - is that true?

I’m not sure you will be able to answer this, but if you would have been eligible for panoptix would you have gone that route, or do you think you are happier with what you ended up with, or would you have gone with 2 vivity with occasional use of reading glasses?

I’m kind of circling back around to Panoptix. I wear glasses all the time now, but I’m not big on the idea of having to put readers on and off a hundred times a day when I look at my phone. If I knew I’d have good night vision with Panoptix then I think I’d be sold.
Click to expand...

On the LAL being monofocus, basically what they are able to do through the adjustment process is fine tune the monovision to what you want. So lets say you have adjusted one lens to be exactly 20/20 on distance vision. Basically to be plano. (In my case my Vivity lens happily gave me this when implanted)

And then you with the other lens have them adjust it to what you want. My LAL lens started out as a little farsighted actually. So in each adjustment they went the other way. So, they gave me a prescription for distance glasses afterwards in case I wanted sharp clear vision in both eyes at night. They stressed I did not need these glasses but could get if I wanted. The right lens on the glasses has no correction at all. The left lens is corrected to -1.25. For me when I look at distance with both eye I usually test at 20/20 occasionally 20/25. If I think about it I know that my left eye vision is not nearly as sharp as my right. But I don't think about it. (Some people can't adjust to monovision. I had no problem with it).

So, if I close my right eye, my left eye is sharp at about 36". It remains sharp to about 12". Close than that, it loses sharpness. I just looked on my phone at a Kindle book page and I could read with it as close as 4". It is blurry at that but I can do it. I could read at 12" without reading glasses if I did not have vision distortion due to my macular pucker (my vitrectomy helped my visual acuity but I still have some wavy distortion. Beyond 36" or so my vision with the LAL is blurry if only looking through that eye. So the area of focus is really about that 24" from 36" out and 12" out.

With the Vivity lens I have a much larger area of focus. I can see very well from distance to about 36". As it gets closer than 36" it gets blurry. 12" is more blurry with that eye than with the left eye (but I don't have the distortion).

So let's say my right eye was a LAL optimized for distance vision and my left eye was optimized to 36" vision. I think the vision on the right eye would drop off in acuity well before 36". The left eye would get blurry past 36". So I don't know how I would like it at say 10'. But, since I only have 1 LAL I don't know if it would have been an issue. Of course, the beauty of LAL is that through the adjustment phase you can finetune that. At my surgeon's office, the surgeon does the actual adjustment at the machine. But, the optometrist's set the target for the machine based upon their exam o you and talking with you. The optometrist commented to me that he had just had someone come in that day for a LAL adjustment and he wanted to adjust because he had monovision but didn't like it that his fellow choir members looked blurry to him. So we wanted to adjust so that distance would be sharp. It is all very individual.

If I had not LASIK and could have had PanOptix I think I would have gone for it. That said, the Vivity lens has been much better than I expected and I think that 2 Vivity lenses would likely have worked well for me with having one lens a little monovision and I would have had the risk of the PanOptix. Still I might have gone for it if I could have.

One thing that the surgeons office did tell me. Up to about 3 months after surgery they can usually go in and switch out lenses. They don't love doing it but they can do it. Online I have come across some people who did get their lens switched post surgery. It was good to know I had that fallback...
 
Katsmeow said:
On the LAL being monofocus, basically what they are able to do through the adjustment process is fine tune the monovision to what you want. So lets say you have adjusted one lens to be exactly 20/20 on distance vision. Basically to be plano. (In my case my Vivity lens happily gave me this when implanted)

And then you with the other lens have them adjust it to what you want. My LAL lens started out as a little farsighted actually. So in each adjustment they went the other way. So, they gave me a prescription for distance glasses afterwards in case I wanted sharp clear vision in both eyes at night. They stressed I did not need these glasses but could get if I wanted. The right lens on the glasses has no correction at all. The left lens is corrected to -1.25. For me when I look at distance with both eye I usually test at 20/20 occasionally 20/25. If I think about it I know that my left eye vision is not nearly as sharp as my right. But I don't think about it. (Some people can't adjust to monovision. I had no problem with it).

So, if I close my right eye, my left eye is sharp at about 36". It remains sharp to about 12". Close than that, it loses sharpness. I just looked on my phone at a Kindle book page and I could read with it as close as 4". It is blurry at that but I can do it. I could read at 12" without reading glasses if I did not have vision distortion due to my macular pucker (my vitrectomy helped my visual acuity but I still have some wavy distortion. Beyond 36" or so my vision with the LAL is blurry if only looking through that eye. So the area of focus is really about that 24" from 36" out and 12" out.

With the Vivity lens I have a much larger area of focus. I can see very well from distance to about 36". As it gets closer than 36" it gets blurry. 12" is more blurry with that eye than with the left eye (but I don't have the distortion).

So let's say my right eye was a LAL optimized for distance vision and my left eye was optimized to 36" vision. I think the vision on the right eye would drop off in acuity well before 36". The left eye would get blurry past 36". So I don't know how I would like it at say 10'. But, since I only have 1 LAL I don't know if it would have been an issue. Of course, the beauty of LAL is that through the adjustment phase you can finetune that. At my surgeon's office, the surgeon does the actual adjustment at the machine. But, the optometrist's set the target for the machine based upon their exam o you and talking with you. The optometrist commented to me that he had just had someone come in that day for a LAL adjustment and he wanted to adjust because he had monovision but didn't like it that his fellow choir members looked blurry to him. So we wanted to adjust so that distance would be sharp. It is all very individual.

If I had not LASIK and could have had PanOptix I think I would have gone for it. That said, the Vivity lens has been much better than I expected and I think that 2 Vivity lenses would likely have worked well for me with having one lens a little monovision and I would have had the risk of the PanOptix. Still I might have gone for it if I could have.

One thing that the surgeons office did tell me. Up to about 3 months after surgery they can usually go in and switch out lenses. They don't love doing it but they can do it. Online I have come across some people who did get their lens switched post surgery. It was good to know I had that fallback...
Click to expand...
Thanks. I found a website where people talk about their cataract surgeries.

https://patient.info/forums/discuss/browse/cataract-386

Lot of interesting perspectives. The downside of it is it seems to be mostly people who have had issues and are searching for help so it gives a distorted negative view of things.

On one thread there were three people who did a Vivity / Panoptix combo and were very happy about it. (It’s hard to find 3 people happy about anything on that site). I may inquire about that.
 
stephenson said:
Hi All,

Well, it's apparently "that time."

69, prior PRK (20/20 near and far for 16 years), and just this year noticed deterioration - more on left with 2+ grade (near mono vision) than on the right with 1+ grade (distance mono vision).

Optometrist believes I may get close to the original post-PRK numbers with just a clear lens - this would be pretty darn good.

So, started reading and quickly bumped into RxVision's Light Adjustable Lens product/process. Very interesting - basic summary is that a lens with macromers is inserted instead of the usual IOL, then after waiting for some stabilization/healing, a specific frequency UV light is aimed to cause the macromers to join together as polymers which allows ophthalmologist to tune the lens to adjust power and address astigmatism. After as many as three of these adjustments, the UV light is changed to a stabilizing function and it "locks" the modifications made into place. Pretty amazing.

Obviously not fully covered by Medicare and most insurance - some form of cost upper - likely not minor ...

https://rxsight.com

https://www.reviewofophthalmology.com/article/light-adjustable-lens-practice-integration

Anyone had this done and can provide insight and effects?

Thanks!
Click to expand...

Question on the Medicare coverage. You said:
“ Obviously not fully covered by Medicare and most insurance - some form of cost upper - likely not minor ...”

I understand that Medicare will not pay for any premium lens. Will they pay the minimum leaving us to pay the balance or do they pay nothing if you select a premium lens such as the light adjustable lens? Thanks.
 
Maximus said:
Question on the Medicare coverage. You said:
“ Obviously not fully covered by Medicare and most insurance - some form of cost upper - likely not minor ...”

I understand that Medicare will not pay for any premium lens. Will they pay the minimum leaving us to pay the balance or do they pay nothing if you select a premium lens such as the light adjustable lens? Thanks.
Click to expand...

Medicare will pay for the surgery itself and the basic lens. You pay the upcharge for the premium lens. Also, I had laser cataract surgery and Medicare doesn't pay the extra cost for that. I chose to pay it.
 
Katsmeow said:
Medicare will pay for the surgery itself and the basic lens. You pay the upcharge for the premium lens. Also, I had laser cataract surgery and Medicare doesn't pay the extra cost for that. I chose to pay it.
Click to expand...

Thanks for the info. So by up charge do you mean the amount above $1431 or $2263 depending where the procedure is done.

According to Medicare.gov, having cataract surgery at an ambulatory surgical center costs about $1,789 ($750 in doctor fees and $1,039 in facility fees). Medicare pays $1,431 of that total, which means the patient pays $357. (Ambulatory surgical centers are non-hospital facilities for patients who don’t need more than 24 hours of care.)

Having cataract surgery with a hospital’s outpatient department, on the other hand, costs $2,829 ($750 in doctor fees and $2,079 in facility fees). Medicare pays $2,263 of that total, so the patient pays $565. These estimates vary based on where you live and the complexity of your cataracts.
 
Maximus said:
Thanks for the info. So by up charge do you mean the amount above $1431 or $2263 depending where the procedure is done.

According to Medicare.gov, having cataract surgery at an ambulatory surgical center costs about $1,789 ($750 in doctor fees and $1,039 in facility fees). Medicare pays $1,431 of that total, which means the patient pays $357. (Ambulatory surgical centers are non-hospital facilities for patients who don’t need more than 24 hours of care.)

Having cataract surgery with a hospital’s outpatient department, on the other hand, costs $2,829 ($750 in doctor fees and $2,079 in facility fees). Medicare pays $2,263 of that total, so the patient pays $565. These estimates vary based on where you live and the complexity of your cataracts.
Click to expand...

The amount above whatever Medicare would pay if you weren't getting a premium lens. So if Medicare would pay $X to the provider if you were getting a basic monofocal lens and you get a premium lens that costs $2000 more then you pay $2000. If you were getting a premium lens that costs $2000 more and you get laser surgery that costs $1000 more then you pay $3000.

DH and I both had cataract surgery from different providers. With both providers they made it super clear what the exact additional costs would be for different options. This was all known in advance.
 
Just had my first consult today.

Had PRK 16 years ago, and I am not willing to go back to wearing glasses - so, I'll orobably opt for the Vivity lens which should provide more mid range than my PRK mono vision dud, and on the short eye, more mid and perhaps some long. Vivity is an EDOF lens - Extended Field of Vision.

I was and am still considering LAL.
 
stephenson said:
Just had my first consult today.

Had PRK 16 years ago, and I am not willing to go back to wearing glasses - so, I'll orobably opt for the Vivity lens which should provide more mid range than my PRK mono vision dud, and on the short eye, more mid and perhaps some long. Vivity is an EDOF lens - Extended Field of Vision.

I was and am still considering LAL.
Click to expand...

As you know I have Vivity on one eye and LAL on the other. I was very, very lucky with my Vivity lens I have great vision for all except very close reading. I can even read almost everything with the Vivity lens but it is a strain for close reading. I think I could the absolute best possible outcome for the Vivity lens. Of course, that doesn't always happen.

The beauty of the LAL is being able to adjust the prescription after the lens is implanted.
 
Update.

Decided not to have two Vivity lenses ... changed ophthamologists to one that could do LAL. He was very surprised the first had immediately chosen two Vivity lenses for a post PRK patient.

Following full work up, the new doc and I discussed, at length, options. LAL was his recommendation. He noted RxSight is delivering by the end of the year a new lens called LAL Plus which will provide an EDOF like capability. I'm going to wait for that for the non-dominant eye.

Targets: OD Plano, and OS -0.75.
 
Sue J said:
Extended Depth of Focus is my guess.
Click to expand...

Yes, one of the many terms that describe various designs that attempt to provide additional ranges of vision.

Like all designs, there are pros and cons.
 
stephenson said:
Update.

Decided not to have two Vivity lenses ... changed ophthamologists to one that could do LAL. He was very surprised the first had immediately chosen two Vivity lenses for a post PRK patient.

Following full work up, the new doc and I discussed, at length, options. LAL was his recommendation. He noted RxSight is delivering by the end of the year a new lens called LAL Plus which will provide an EDOF like capability. I'm going to wait for that for the non-dominant eye.

Targets: OD Plano, and OS -0.75.
Click to expand...

Good luck with the EDOF. There was a forum I went to that talked about the LAL EDOF. There was a clinic in Mexico doing trials for it and I think someone had a thread about it. I would have done a LAL with EDOF if it had been available when I had surgery but it wasn't. I did have Vivity on one eye after LASIK and have had perfect results from it. Of course, the advantage of LAL is being able to adjust the prescription after surgery which is a great comfort to have thatn option.
 
Katsmeow said:
Good luck with the EDOF. There was a forum I went to that talked about the LAL EDOF. There was a clinic in Mexico doing trials for it and I think someone had a thread about it. I would have done a LAL with EDOF if it had been available when I had surgery but it wasn't. I did have Vivity on one eye after LASIK and have had perfect results from it. Of course, the advantage of LAL is being able to adjust the prescription after surgery which is a great comfort to have thatn option.
Click to expand...

Hi Kay. Can you please link to the forum discussion on the LAL EDOF? I have an evaluation in May.
 
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