A surgeon’s guide to undergoing refractive lens exchange

For nearly 30 years, I have confidently helped patients navigate the IOL selection process for both cataract surgery and refractive lens exchange.

Like all surgeons, I consider several factors, including patients’ ocular anatomy, age, occupation, lifestyle needs and expectations, and I make the recommendation I feel is best for them. I often found myself wondering, however, if selecting a lens for my own eyes would be more challenging. When I finally decided to undergo refractive lens exchange, the decision came easier than I expected.

Done with the compromise of contacts

With high astigmatism (about 3 D in the left eye and 2.5 D in the right eye) and thin corneas, I was a poor candidate for LASIK. I used contact lenses for a while, switching to monovision contacts when presbyopia set in. This worked temporarily, but there were a lot of compromises. I tried multifocal lenses, but they caused dysphotopsia and did not align with my active lifestyle. I also experienced symptoms of dry eye. Eventually, I found myself juggling between contact lenses for personal life and glasses in the clinic and operating room. I was frustrated and determined to find a better solution for my vision.

After many of my patients achieved remarkable outcomes with the Light Adjustable Lens (LAL, RxSight) — including my cousin, an interventional cardiologist, and my neighbor — I solidified my desire to undergo refractive lens exchange with the LAL. Around the same time, I took time off from practice before opening my own cornea, cataract and refractive center and found myself in a position to finally focus on my own eyes.

Selecting the surgeon

I reached out to Robert J. Weinstock, MD, whom I have known for many years. Rob and I share a passion for advanced technology and have similar surgical techniques. We both perform the same bimanual cataract surgery technique and routinely use the Ally robotic laser cataract system (Lensar). Its high level of accuracy, especially for astigmatism correction, has significantly improved outcomes for my patients. The laser automates crucial parts of surgery and leverages AI to enhance surgical precision and optimize the procedure through advanced imaging, automation and analysis. Naturally, I trusted the Ally system for my own eyes, too.

Rob agreed to perform my LAL surgery, and I flew to Tampa, Florida, for the procedure. We decided on a staged approach rather than immediately sequential bilateral surgery, which I preferred for comfort. The target in my left (dominant) and right eyes was –0.25 D with an LAL and –0.5 D with an LAL+, respectively. Using the Ally, Rob was able to achieve an unprecedented level of precision, which was essential in managing my high astigmatism.

The surgical experience was incredible: quick, seamless and painless. The evening of surgery, I had some blur that improved as the night wore on. By the next morning, my vision was 20/30, and it was at that moment I knew the results were going to be fantastic. Surgery in the second eye followed a similar course, and my visual recovery progressed smoothly.

My first light adjustment was performed about 2.5 weeks later. The clarity of my vision after the first adjustment was stunning. The adjustment process was quick, just a few seconds under the light, and there was no pain.

After two light adjustments and my lock-in treatments, conducted 72 hours apart, my vision is now crisp and stable. I can once again enjoy my active lifestyle and busy professional life. I can even swim in the ocean without having to worry about glasses or contact lenses. Having to wear the LAL’s UV-protective glasses was a small price to pay for the outcomes I achieved.

Technology matters

Ophthalmology is ripe with technological innovation. We are often quick to incorporate new devices and recommend them to our patients. Stepping away from the surgeon side and experiencing what we do every day as a patient gave me a new appreciation for the precision of advanced technologies like the LAL and Ally system. The latter automates the most critical steps in cataract surgery, ensuring the highest level of accuracy for things like astigmatic correction and capsulotomy and supporting a customized surgical approach.

For More Information:

Audrey R. Talley Rostov, MD, of Bellevue Precision Vision in Washington, can be reached at audreyrostov@gmail.com.

Perspective

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Given Audrey’s high astigmatism, myopia and desire to avoid dysphotopsias, the LAL was the obvious choice.

We both knew it would provide her with the flexibility she needed in both the operating room and her active, everyday life. Another critical factor for both of us was the use of the Ally system. Its precise measurements and ability to adjust for astigmatism made a huge difference in her case. The automated capsulotomy and customized treatment plan we were able to achieve were pivotal for the outcome.

Audrey stayed at my house the night before and after her surgery. Receiving real-time feedback about her postoperative experience and visual recovery was fascinating. Additionally, her enthusiasm about how her vision improved with each light adjustment was a testament to the power of the technology. Every eye heals differently, but the results Audrey experienced after her Ally-assisted LAL surgery are a reminder of why we trust advanced technologies to give patients the best possible outcomes.

Robert J. Weinstock, MD

The Eye Institute of West Florida, Largo, Florida

Disclosures: Weinstock reports consulting for Lensar.

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