November 13, 2024 • 28 mins
The Light Adjustable Lens (LAL) has taken the refractive world by storm over the past couple of years, with an excitement that rivals the enthusaism for the latest multifocals or EDOFs to come on the market. So what's all the hype? How does this lens actually work? And even if the refractive results are impressive, do patients really want to wear UV-blocking lenses for weeks following surgery? Is the time and cost investment worth it for patietns? Dr. Ralph Chu joins the podcast.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:12):
Hey everybody, I'm Zaeo Mednick and welcome to another episode
of blind Spot. The expectations for cataract surgeons are higher
than ever. While patients have always wanted the best visual
result possible, more and more patients not only hope but
expect to be spectacle and dependent postoperatively. And while our
surgical techniques and lens calculations have improved significantly over the
(00:32):
past couple of decades, we don't always achieve the intended
refractive result. If the patient's unhappy, they might opt for
further surgery to exchange the lens or undergo Lasik to
correct the residual refraction. But what if you could change
the lens itself to fine tune the refraction after surgery,
obviating the need for these other procedures. Well, that is
what the light adjustable lens does. I'm joined today by
(00:55):
doctor Ralph Chu. Doctor Chu is the founder, CEO, and
Chief Medical Officer of Chu Vision Institute and Choose Surgery
Center in Minneapolis, Minnesota, where he specializes in cataract and
refractive surgery. In addition to a busy clinical practice, he's
built a research center of excellence participating in over one
hundred FDA clinical trials involving both therapeutics and surgical technologies,
including exemer laser cataract implants, and surgical devices. Over the
(01:18):
last twenty five years, he's become a globally recognized leader
in cataract and refractive surgery, educating thousands of surgeons around
the world and by performing live surgery in eight countries
across three continents. As a sought after expert, Doctor Chou
has been featured numerous times on national media outlets, including
appearances on The Today Show and NBC Nightly News introducing
surgical technologies and therapeutic treatments. He studied medicine at Northwestern University,
(01:42):
completed residency at Duke University, and went on to complete
a cataract, refractive, Cornea and Glaucoma fellowship in Minneapolis. All right,
doctor Ralph Cho, welcome to the podcast. Thank you so
much for joining me.
Speaker 2 (01:52):
Thank you so much for having me today.
Speaker 1 (01:55):
So you are, you're from Minnesota. I'm a Green Bay
Packers fan, so a little bit of a potential.
Speaker 2 (02:00):
Get the podcast over right there, podcast over.
Speaker 1 (02:03):
I was just as I was reading your bio, I
was like, jeez, I should I should have my I
don't have any financial disclosures, but I should have that
disclosure so.
Speaker 2 (02:11):
We can eventually from originally from Chicago. So that works.
Speaker 1 (02:14):
Yeah, it works a little bit. So we're going to
talk about the light adjustable lens, which is a really
exciting technology, which you've had a lot of experience with,
more than more than most people, probably because you've been
dealing with it for a while. And to start off,
I want to just understand, for me and for the
listeners the basic technology of how this lens and the
light apparatus work. What is the basis of this lens?
Speaker 2 (02:37):
Yeah, I think you know the way I explained it
to patients, which is probably not, you know, completely scientific,
But my understanding is there's there are polymers inside this
silicone lens that respond to UV wavelength of light. And
when these polymers are stimulated by UV light, they bond
(02:58):
and they kind of they create sort of a shift
inside the lens, right, almost like by osmosis. So where
the polymers have been bonded, the other polymers sort of
shift into place, and it causes a shape change of
the iol itself. So if there's a certain pattern of
UV light that's placed onto the lens. There's actually a
change of the shape of the lens, which actually is
what changes the refraction of the lens, and then that's
(03:21):
what helps improve the postoperative refraction for the patients.
Speaker 1 (03:25):
And pretty incredible technology to not only be able to
change the lens postoperatively, but to obviously change it in
a very very specific way in each patient to model
their refraction.
Speaker 2 (03:36):
Yeah, I think what's been amazing to us, you know,
and we've been using it the four years now ever
since the active shield had been introduced to protect the
lens from incident UV light exposure. What is the accuracy?
I mean, I find that the adjustability of the lens is,
you know, in some ways even more accurate than lasik
on the cornea. We're adjusting amounts of astigmatism and sphere
(03:59):
that are you know, in the half diopter range and
even less sometimes. So I think the accuracy is amazing.
I think that eliminating that variable of trying to predict
what the effective lens position is or you know, it's
really a mindset shift. A lot of what we do
now is shift.
Speaker 1 (04:18):
You know.
Speaker 2 (04:18):
We spend a lot of time predicting and trying our
best to predict what the post operative outcome is going
to be based on preoperative measurements. But there's a lot
of peace of mind as a surgeon to know that,
you know, we can still do our best job predicting,
and yet the variables that we don't aren't able to measure,
aren't able to control. Like essentially the healing of the
individual patient can now be effectively managed with this technology.
Speaker 1 (04:44):
What's the basic process when a patient and I imagine
the explanation you give of oph theomologist or optometrist listening
to this is pretty similar. What's the basic process? They
obviously have the surgery. You know, they wear the sunglasses
for a while, there's a couple of potential adjustments, there's
a potential lock in. How does that work? And what's
the general time frame?
Speaker 2 (05:03):
Yeah, the process you know up until the time is surgery.
It's very similar to a regular cataract surgery. So the
imp the lenses implanted like a regular intraocular lens, and
so the difference is in the post operative period. So
obviously we want to wait for the refraction to stabilize,
and so you know, it depends on the surgeon's experience
(05:23):
and judgment with their surgical technique. We typically wait about
five to six weeks after the second eye surgery before
we start adjusting. And why I say typically is we're
also measuring the patient to see how their refraction is stabilizing.
So our patients get a measurement at four weeks and
then they get another measurement on the day of the
(05:45):
adjustment one or two weeks later to just check for stability.
Some surgeons wait longer. There are some patient situations where
you wait longer. Let's say the cornea is irregular, they
have another medical condition that affects the ocular surface. All
those factors still are import and to manage, but on
a routine patient wait for the refraction to stabilize, usually
about four to six weeks after the second eye surgery,
(06:07):
and then the adjustment process, so when the patient comes
in they get their refraction measured. The lens can be
adjusted three times. Sometimes a fourth adjustment in the United
States can be done. Depends on some calculations that the
engineers that the company can perform, but three adjustments are
possible routinely. In our experience with correct targeting and a
(06:30):
little bit of experience implanting the lens, most of our patients,
I'd say sixty percent require one adjustment and then they
can start the lock in process. And the lock in
process is typically two treatments, so most patients get three treatments,
an adjustment and two lock ins, or two adjustments and
two lock ins, and each of those is typically separated
(06:51):
by about a week. Now, that can vary from clinic
to clinic, but you want at least wait forty eight
hours in between those treatments. We found that giving patients
time to kind of see what their vision is like
is also very helpful. So while medically you could wait
a shorter amount of time, it is nice to allow
the patients to psychologically and to adjust to their environment.
(07:11):
And so we wait a week between adjustments and treatments.
Speaker 1 (07:15):
So that makes a lot of sense and answers a
few of the questions I already had. I had thought
that the adjustments and the lock ins occurred sooner, but
I was going to ask you, and you mentioned effective
lens position beforehand. If you were doing it a week
or so afterwards, the effective lens position could still change,
So how do you deal with that? But you answered
that if there's persistent diritis, or if there is significant
(07:35):
corneal edema. How are you going to deal with that?
Because that happens to everybody who operates. But you answered
that question by explaining by four to six weeks, and
presumably if you needed to wait longer, you can delay
so that you're making sure you've got the exact refraction
you want to be treating in those adjustments and lockins.
Speaker 2 (07:52):
Yeah, those are really great points. And when we first
started it, we had, you know, the surgical or the
practice anxiety was, Wow, how are patients going to tolerate
this two month process of having to wear protective UV
lenses while they're outside, you know, to protect the lens itself.
So we've had no patients that have had any injury
to their lens from forgetting to wear their glasses while
(08:13):
they're outside or inside. The active shield seems to be
very effective and it also helps in predictability. So our
results are like I said, the accuracy is incredible. But
you're right. I think the most important thing that you
said with your comments are this is still refractive surgery.
And so while there's a customer service component where you
want to sort of shorten the time and improve the
patient experience, we found that with right education, patients want
(08:37):
to protect their investment and they're more concerned about getting
the best outcome. So I have very little complaints about
having to wear the glasses. In fact, some people are like,
you know what, I have to go on vacation for
a week, I'm going to delay one of my treatments.
I'm happy to wear the glasses longer, you know. Whereas
you know, a surgeon was like, are you really like,
let's just get this done for you. But most of
them are very comfortable. You know. Actually, if you look
(09:00):
at the you know, Oscar ceremony, you know, one of
the producers of Oppenheimer wore his lal glasses as he
accepted the award for the Oppenheimer Best Picture. So you know,
obviously they don't seem to interfere a lot with the
lives of patients. And so with the right education, waiting
the right amount of time actually gives us a peace
(09:20):
of mind, and it really has helped helped improve our outcomes.
Speaker 1 (09:23):
I got to rewatch. I was watching the Oscars. I
love the Oscars. I got to go rewatch and see
if I can cite the site the producer who was
wearing those glasses.
Speaker 2 (09:30):
You'll see it. There's a picture online. He's holding his oscar,
you know, and he's got his lal glasses on.
Speaker 1 (09:36):
So talk to me a little bit more about the
sunglasses in the shield, because I do think that probably
is a hesitation for some people when they initially hear
about it. I know for me, when I heard about it,
I thought, who would want to wear these glasses for
so long? What is the protocol you're suggesting to a
patient wear them outside all the time? And in what
lighting conditions indoors do you need to wear them?
Speaker 2 (09:55):
Yep. So you know, you were very fortunate in Canada
to get a exposure to the early versions of the
lens before we could here in the United States. And
you know, I think those earlier versions of the lenses
were very sensitive to situations where even inside, if the
lens was exposed to instant UV light, it could cause
unwanted shape changes which would result in you know, dyspotopsias
(10:18):
or poor vision, which would require explanation of the lens
to solve that problem. And so that also made us
nervous in the initial stages, you know, of FDA approval.
The active shield was introduced about four years ago, and
it protects the lens itself from like regular UV wavelengths
like sunlight, and it requires a specific wavelength to open
(10:41):
like a gate, and that is delivered by the LEDD
light adjustment device itself, and then it delivers the wavelength
that allows the lens to sh the polymers to bond,
and the shape to change. So I think it wasn't
so much having to wear the glasses. It was the
fact that even a small of forgetting to wear the
glasses could damage the lens. Now that there's protection, the
(11:05):
FDA's requirement is recommending still inside and outside off label,
and our clinical experience has been you know, we recommend
it while they're outside, but don't require it while they're inside.
And we've had no incidents and we've done over a
thousand of these implants now to date and have had
no incidence where the lens has been damaged by incident
(11:26):
UV light or a patient forgetting One of the things
that I explained to patients that I think helps them
where the glasses religiously or diligently is we don't have
long term data about what happens to the number of
polymers in the lens as it's exposed to outside light.
So theoretically, with the active shield, you could walk around
outside without the glasses, but we don't know if we're
(11:47):
wasting polymers just by you walking around outside without the protection,
is what I tell patients. So that helps them understand, like,
protect your investment. Let's get as many adjustments as possible
that you that you've that you've paid for. And that
seems to help them understand. Yeah, I'm going to try
to wear my glasses as much as, you know, as
much as I'm told.
Speaker 1 (12:05):
Is the lesser polymers that would be there, the less
an end of adjusting you could do.
Speaker 2 (12:09):
It's right. So you might say, you know, oh, we
think we can correct this amount of a stigmatism or sphere.
But because you know, the patient wasn't good about wearing
their glasses, and now I've not seen this happens, but
this is just how I explained it to patients.
Speaker 1 (12:21):
What's your approach to torx touric LALs? Do they come
in I imagine they do come in TUX, but I.
Speaker 2 (12:28):
It's so that the lal itself is spherical. Okay, correct,
it can correct, you know the way we think of
it can correct up to four dipters of air in
one meridian, so it does two dictors at a time
in sphere or a cylinder, but you could theoretically do
four diptors of a stigmatism. Now you know, that's not
(12:50):
necessarily the ideal refraction that you want to start with,
you know, like plan zero plus four, because you're pushing
the limits. But if you think of it like you know,
that way, you can correct quite a bit of or
a factive error. And so in my experience, there's no
better lens for correcting low low degrees of astigmatism than
the LAL.
Speaker 1 (13:09):
So if somebody has three diopters of sil preoperatively, you
would just put in an aspheric lens and then you
would only treat the astigmatism once you're actually doing the adjustments.
Speaker 2 (13:21):
So yeah, it's so you're looking at the corneal stigmatism, right,
not the refram a stigmatism.
Speaker 1 (13:25):
Yeah, so the.
Speaker 2 (13:26):
LAL itself, you know, is starts out spherical, right. It's
through the adjustments that you can correct the astigmatism. And
so there are patients who you know, I think the
sweet spot to start with especially is if a patient
has about two two and a half diapters of a stigmatism.
You know, that is still in the sort of sweet
(13:46):
spot for having the ability to adjust that you know,
very very close to Plano. If not plano, we expect plano. Right,
So when a patient has higher amounts of a stigmatism
three three and a half in over, we are using
tors lenses, right, So toric lenses in that range still,
I think, you know, give us that flexibility. And if
the patient can have a corneal adjustment like a lasik,
(14:08):
you can still do that traditional method of toric plus.
Speaker 1 (14:11):
Lasik, but there's no light adjustable version of that touric
basically for.
Speaker 2 (14:16):
The higher degrees. I think it's sort of a case
by case like we have been successful with some high degrees,
but there is a limit to the amount that you
can adjust away. I think that's the key message. And
when you start getting over three, you know, I think
you have to start thinking about that limit of adjustability.
Speaker 1 (14:34):
Makes total sense in terms of the lens itself. I've
heard the lal is kind of described as an eat
off or maybe a monofocal plus. Where do you lie
on that spectrum in terms of your view of it
and where do you typically aim?
Speaker 2 (14:48):
Yeah, so there are two versions available in the United States.
There's the original LAL and then they recently launched the
LAL plus. And there is a slight curvad change in
the central part of the optic for the l L plus.
I may be describing it differently, maybe an asphversity change,
but it is a central change that allows for increased
(15:10):
depth of focus on the l L plus. And there's
data to show that patients who are targeted you know,
close to Plano for the l L plus have a
better smell and acuity for reading than you know, compared
site to decide within LA L. Now, there are many
things you can do with l L to achieve more
(15:32):
depth of focus, like a blended vision, you know, one
eyes offset a little bit from the distance eye. So
both are still very effective. They're both used in different situations.
And your second part of the question was targeting. So
I do think that the LA L platform, just without
the plus, has a larger depth of focus than say
a standard monofocal iol and I think it has to
(15:55):
do with the asphericity of the optic itself. It has
a little bit more negative asphericity, So people do patients
do notice an expanded range of focus. It doesn't mean
that they don't need reading glasses, but they do get
an expanded range of focus compared to a you know,
typical monofocal iol targeting. We typically like to target a
little bit hyperopia, not a lot. A little bit of
(16:17):
hyperopia plus a half when we're doing the initial implantation,
which means patients who you know might see great twenty
twenty may complain of you know, intermediate difficulty like dashboard
computer screens for that first four to six weeks. They
seem to tolerate it well because their distance vision is
(16:38):
still so good typically, but it is important to counsel
them that they may they will notice more dependence on
readers initially before the adjustments. The other targeting is dependent
on you know, the patient preference and the surgeon preference.
Some surgeons love to do a lot of blended vision
model and some surgeons like to go we just customize
to what the patient needs, so we don't come in
(16:59):
within a under saying monovision, blended vision, you know.
Speaker 1 (17:03):
And again the beauty is you have time to decide
what the patient wants and you can you can trial
a few things afterwards. If they aren't happy, I think
it's a big deal.
Speaker 2 (17:12):
I think that the confidence it gives the surgeon, the
clinical team, and the patient, like when we explain as
best we can, even if we're using trial frames to
explain blended vision or monovision or even contexts, it's totally
different for the patient, like the confidence they have and
just saying, oh, get I get to try this before
we're in there, like yep, because they try to understand,
(17:34):
but even the smartest patient just you just can't. They
can't see it. And once they see it, then you
really feel their confidence and like, yeah, no, I'm glad
I tried this. I don't really like the blended vision.
I'm just going to go distance and we're readers, or
you know, oh I like my distance, Let's try monovision.
A lot of people are like, oh, I really tolerate monovision.
Thank god we did this lens. So it's different than saying, oh,
(17:55):
I do contact lens trials on all my patients preoperatively
because we've been doing refractorve surgery twenty five years. We
do all that stuff. But somehow having the patient's experience
it themselves and be part of the decision is a
big deal.
Speaker 1 (18:09):
Which which makes sense, especially the way you describe it.
What's the dispotopsia profile for these, Like you said, it's
not a multifocal obviously, so it should be low. But
especially the LAL plus might have a bit of dispotopsia
more so than the LAL not something that you hear
too much from patients a bit, you know.
Speaker 2 (18:27):
Not at all. So the disuotopsy is like a monofocal
iol I think with that LL plus it is it
can be a little sensitive to a little bit of
myopic offset, so if somebody gets and it's patient dependent
as well, but some we've noticed some patients early on
in our experience at ilplus. We were like one of
the first few sites in the country to try it,
so when we were targeting a little bit of minus,
(18:48):
sometimes those patients noticed like a little bit of loss
of contrast. Not not not terrible, but you know when
you're talking like twenty twenty minus twenty twenty five plus
versus like a twenty twenty they some patients could notice
that we don't experience that with the standard LL So, yes,
there's a little bit of extended depth to focus on
(19:10):
the LL plus. So I always tell my colleagues be
a little bit aware of that. You know they tend
to do better plano than minus. Like, if you're going
to target plano versus minus a half or minus a quarter,
I would aim plano and then kind of see, but
the l EL plus you do minus quarter minus a half,
there's the patients tolerate that very well as well, and
you'll hear that from a lot of other surgeons who
do the l EL.
Speaker 1 (19:31):
So doctor stue, how do you pitch this to patients?
And by pitch, I don't mean advertise it to women,
say you need to do this, you should do this.
But there's so many lenses on the market, as you know,
who is the person where you're saying this is a
good lens for you off the bat. After this conversation,
I'm thinking probably if somebody really wants to be completely
glasses free, you'd be more inclined to say, well, we
(19:52):
might be more interested in talking about a true eed,
offer a multifocal lens as opposed to an LAL somebody
with a lot of astigmatism, probably a toric, and potentially
know that LASIK is there afterwards to fix any residual stigmatism.
But how are you canceling patients. Where does this fit
sort of in your algorithm?
Speaker 2 (20:11):
Yeah, I think there's two or three parts to my answer.
I think the first part to my answer is that
we recognize a need in our practice that there's many
patients and a growing percentage of patients that have had
previous cornial refractive surgery. And those patients are very they're
more difficult to have an accurate refractive outcome, even with
your best formulas, even with your best topographers. So we
(20:33):
started there saying, wow, there's these patients who had Lasik
with us fifteen years ago and now want that same
result now with their cataract surgery. And some of them
could not have further cornial surgery because some surgers will say,
we'll just do another Lasik. Well, some of those patients
have thin corneas, or now they're older, so they have
dry eyes, so they're not the greatest laser surgery candidates.
(20:53):
And so now with LAEL, now I can look at
these patients and say, we have a technology that can
give you results similar to without having to do more
surgery on your cornean. And so that was a very
downstream way to go, and those patients are so happy
We're happy because now you know, when you get that
you know, plus one refractive air after your previous lasik
(21:13):
patient that can't have more lasik, Wow, that patient's not
super happy. And doing an iowall exchange, you know, is invasive.
Some of them won't let you do further surgery because
they feel like you messed up their first one. So
lal is has been really an important technology for those patients.
The other thing is that I've learned now over the
last four years is anybody who can get a solid
(21:33):
refraction is actually a candidate for an lal Right. We
don't sell it as getting We don't actually sell any
lenses totally getting rid of glasses, because even when we're
using multifocality, you know, we find that patients like using
readers for the magnification. We find that patients sometimes even
at night, have to wear a thin pair of just
to kind of help get by, you know, with their thing.
(21:54):
It's so, you know, I don't think there's any technology
that any any of us gets, say, is completely glasses free.
You know, you might wear less glasses, you know, with
a multifocal for reading. But a lot of patients and
we kind of talk to them. It's about quality of vision.
So if somebody, you know, if we say, we have
a lens that can help you achieve a really wide
(22:14):
range of focus with the least amount of dependence on glasses,
but it has this side effect profile versus a lens
that has very few of us these discs. Autopsy has
very few night vision issues, but you might have to
wear some reading glasses more. Many patients choose the better
quality of vision, then they do say total freedom with
some risk of side effects. So that's how we kind
(22:36):
of present it, and I think that's that's important. So
that's kind of the second part was really you have
the third You have to get a good refraction. So
if you're gonna ask me, like what about fuchs what
about mac of your generation? What about glaucoma, you know
it's a monofocal EOE. Well, this is the most forgiving,
but the adjustments are dependent on a really good refraction.
So if somebody has really bad macdgen and it's really
(22:59):
like a fuzzy refract, like is it twenty twenty five,
twenty thirty, and you know, you can't really say which
is better one or two, it's going to be very
hard to decide what refraction you're going to adjust to,
which doesn't mean you can't do it, but you know,
we've sort of learned when somebody pays for something, they
need a good result, so we you know, tailor the
(23:20):
lens to that situation.
Speaker 1 (23:22):
Very very clear explanation, and I think you you've outlined
and demonstrated how you kind of frame that conversation with
the patient. The last thing I want to ask you,
which you've already kind of answered. So, but some people
might be listening to this and saying, it's a lot,
And it is a lot, the sunglasses for six weeks,
four to six weeks, the multiple procedures. Granted, you need
(23:42):
to have the right patient who cares enough to do it.
Some patients might say, yeah, if i'm a little bit off,
I don't care, and there are patients who say that,
especially at nonproactive centers. But there's somebody who might be
listening and saying, why not just say to somebody, let's
do them onnofocal and if we're off a little bit,
it will be easy to do lasik. Afterwards. You've already
addressed that that there are certain patients where you can't
do that, especially patients who've already had lasik because their
(24:05):
cornies might be a little bit too thin. And you
also even said that the degree of a stigmatism correction
is actually a little bit greater with the light adjustable
lens than it is if you were to do lasic afterwards.
So I guess I'm answering my own question, but freezing
something framing a question that I have spoken with other
people about where their initial reaction is that's a lot
(24:27):
why not just put them onnofocal and then do lasick
if you need to afterwards.
Speaker 2 (24:32):
Yeah, so I'll have two parts of that answer too.
So one thing that we've seen over the last twenty
five years is while we as doctors think that that's
an easy solution, patients are afraid to have LASIK and
another surgery on their eye, especially when they feel like
the first you know, the reviason you're doing, it's like, oh,
it's super easy to fix. It's just a little bit
of a stigmatism, a little bit of a refractive error.
(24:53):
But the reason they're seeking that is because they feel
like the first one didn't work. So sometimes regaining that
trust to do another procedure regardless of the patient's medical
condition like dry eye or thin corny or something. It's
a little bit of a hurdle, like even if we
offered that enhancement for free, we were still having that
sort of psychological barrier to overcome. So somehow with the
(25:15):
adjustment when we talk about it beforehand, the way this
works is we let the lens set on the eye
and if there's anything, you know, residual or fractive error,
like you and I talking, but if there's anything left
over that you want to see better at, we measure
it and then we can adjust. You know, we can
adjust the lens with simply a light. There's no cutting,
there's no surgery. The light just tout. They seem to
like that concept of non invasive and it's part of
(25:38):
the process. That's the first part of the answer. The
second part is, you know, you were addressing the bias
of me, of everyone, like you know, as a surgeon,
as a team, as a practice, like gosh, this is
a big burden, Like there's a lot of education, there's
a lot of change to the way the clinic has
to sort of refract the patients afterwards. This is like
you're used to seeing a categoration twice one day, one month,
(26:01):
see you later. You know, we're your glasses. But now
we're seeing them for two months, like every week, and
so it does require a little bit of a mindset change,
a little bit of a practice management change. My advice
to colleagues listening is we have the same bias like, wow,
this is a big deal, like is this going to work?
Speaker 1 (26:17):
Right?
Speaker 2 (26:18):
Patients drove this, Like the happiness of the patients is
like when LASIK first started twenty five years ago. So
there's something when you listen and feel your you know,
there's twenty twenty patients, and there's patients that you feel
that are twenty twenty that are so happy. You know,
we have husband and wife teams, we have people referring
(26:39):
like you know, their friend groups because of the quality
of vision they achieved. So we just followed the patients,
you know, like we tried it, and because of the
success with the visual outcomes, alie El sort of drove
itself and we just we just developed the practice management
around that drive. So we make sure people know about it,
that we make sure they know how much should costs,
(27:00):
and then they make a choice and then suddenly, you know,
we've all tried multifocal at Wells, and to me sometimes
the opposite was true, Like the patient is chief twenty
twenty J one vision and good intermediate vision, and yet
we never saw their wives. We never saw their friends,
you know. But now I'm like, I'm doing husband and
wives like three months apart. You know, they're like they're
(27:21):
jealous of the spouse, they're friends that they go voting with,
and they're just so it's like an LAL family out
there in my waiting room, you know, like I have
friends like you. You know, I didn't know you're getting
the LA Oh like, oh yeah, well you told me
about it at the Bridge Club. You know. Now I'm
getting it. So it's we just follow the patients.
Speaker 1 (27:37):
Yeah, and the proofs for us, ye had. The proof
is in the pudding, so to speak. And you're you're
you're generating a nice LA L family community there, Doctor
Ralph to thank you so so much for joining me.
Really really great summary on the basics as well as
some of the more advanced aspects of the light adjustable lens,
a lens that surely is going to become more popular
(27:57):
and that patients are going to be asking us about
and we need to have answers for so delighted that
you spent the time chatting with me.
Speaker 2 (28:03):
Well, thanks for inviting me. I enjoyed our talk.
Speaker 1 (28:06):
Thank you everybody for listening to another episode of blind Spot.
Have a great day.
Hey everybody, I'm Zaeo Mednick and welcome to another episode
of blind Spot. The expectations for cataract surgeons are higher
than ever. While patients have always wanted the best visual
result possible, more and more patients not only hope but
expect to be spectacle and dependent postoperatively. And while our
surgical techniques and lens calculations have improved significantly over the
(00:32):
past couple of decades, we don't always achieve the intended
refractive result. If the patient's unhappy, they might opt for
further surgery to exchange the lens or undergo Lasik to
correct the residual refraction. But what if you could change
the lens itself to fine tune the refraction after surgery,
obviating the need for these other procedures. Well, that is
what the light adjustable lens does. I'm joined today by
(00:55):
doctor Ralph Chu. Doctor Chu is the founder, CEO, and
Chief Medical Officer of Chu Vision Institute and Choose Surgery
Center in Minneapolis, Minnesota, where he specializes in cataract and
refractive surgery. In addition to a busy clinical practice, he's
built a research center of excellence participating in over one
hundred FDA clinical trials involving both therapeutics and surgical technologies,
including exemer laser cataract implants, and surgical devices. Over the
(01:18):
last twenty five years, he's become a globally recognized leader
in cataract and refractive surgery, educating thousands of surgeons around
the world and by performing live surgery in eight countries
across three continents. As a sought after expert, Doctor Chou
has been featured numerous times on national media outlets, including
appearances on The Today Show and NBC Nightly News introducing
surgical technologies and therapeutic treatments. He studied medicine at Northwestern University,
(01:42):
completed residency at Duke University, and went on to complete
a cataract, refractive, Cornea and Glaucoma fellowship in Minneapolis. All right,
doctor Ralph Cho, welcome to the podcast. Thank you so
much for joining me.
Speaker 2 (01:52):
Thank you so much for having me today.
Speaker 1 (01:55):
So you are, you're from Minnesota. I'm a Green Bay
Packers fan, so a little bit of a potential.
Speaker 2 (02:00):
Get the podcast over right there, podcast over.
Speaker 1 (02:03):
I was just as I was reading your bio, I
was like, jeez, I should I should have my I
don't have any financial disclosures, but I should have that
disclosure so.
Speaker 2 (02:11):
We can eventually from originally from Chicago. So that works.
Speaker 1 (02:14):
Yeah, it works a little bit. So we're going to
talk about the light adjustable lens, which is a really
exciting technology, which you've had a lot of experience with,
more than more than most people, probably because you've been
dealing with it for a while. And to start off,
I want to just understand, for me and for the
listeners the basic technology of how this lens and the
light apparatus work. What is the basis of this lens?
Speaker 2 (02:37):
Yeah, I think you know the way I explained it
to patients, which is probably not, you know, completely scientific,
But my understanding is there's there are polymers inside this
silicone lens that respond to UV wavelength of light. And
when these polymers are stimulated by UV light, they bond
(02:58):
and they kind of they create sort of a shift
inside the lens, right, almost like by osmosis. So where
the polymers have been bonded, the other polymers sort of
shift into place, and it causes a shape change of
the iol itself. So if there's a certain pattern of
UV light that's placed onto the lens. There's actually a
change of the shape of the lens, which actually is
what changes the refraction of the lens, and then that's
(03:21):
what helps improve the postoperative refraction for the patients.
Speaker 1 (03:25):
And pretty incredible technology to not only be able to
change the lens postoperatively, but to obviously change it in
a very very specific way in each patient to model
their refraction.
Speaker 2 (03:36):
Yeah, I think what's been amazing to us, you know,
and we've been using it the four years now ever
since the active shield had been introduced to protect the
lens from incident UV light exposure. What is the accuracy?
I mean, I find that the adjustability of the lens is,
you know, in some ways even more accurate than lasik
on the cornea. We're adjusting amounts of astigmatism and sphere
(03:59):
that are you know, in the half diopter range and
even less sometimes. So I think the accuracy is amazing.
I think that eliminating that variable of trying to predict
what the effective lens position is or you know, it's
really a mindset shift. A lot of what we do
now is shift.
Speaker 1 (04:18):
You know.
Speaker 2 (04:18):
We spend a lot of time predicting and trying our
best to predict what the post operative outcome is going
to be based on preoperative measurements. But there's a lot
of peace of mind as a surgeon to know that,
you know, we can still do our best job predicting,
and yet the variables that we don't aren't able to measure,
aren't able to control. Like essentially the healing of the
individual patient can now be effectively managed with this technology.
Speaker 1 (04:44):
What's the basic process when a patient and I imagine
the explanation you give of oph theomologist or optometrist listening
to this is pretty similar. What's the basic process? They
obviously have the surgery. You know, they wear the sunglasses
for a while, there's a couple of potential adjustments, there's
a potential lock in. How does that work? And what's
the general time frame?
Speaker 2 (05:03):
Yeah, the process you know up until the time is surgery.
It's very similar to a regular cataract surgery. So the
imp the lenses implanted like a regular intraocular lens, and
so the difference is in the post operative period. So
obviously we want to wait for the refraction to stabilize,
and so you know, it depends on the surgeon's experience
(05:23):
and judgment with their surgical technique. We typically wait about
five to six weeks after the second eye surgery before
we start adjusting. And why I say typically is we're
also measuring the patient to see how their refraction is stabilizing.
So our patients get a measurement at four weeks and
then they get another measurement on the day of the
(05:45):
adjustment one or two weeks later to just check for stability.
Some surgeons wait longer. There are some patient situations where
you wait longer. Let's say the cornea is irregular, they
have another medical condition that affects the ocular surface. All
those factors still are import and to manage, but on
a routine patient wait for the refraction to stabilize, usually
about four to six weeks after the second eye surgery,
(06:07):
and then the adjustment process, so when the patient comes
in they get their refraction measured. The lens can be
adjusted three times. Sometimes a fourth adjustment in the United
States can be done. Depends on some calculations that the
engineers that the company can perform, but three adjustments are
possible routinely. In our experience with correct targeting and a
(06:30):
little bit of experience implanting the lens, most of our patients,
I'd say sixty percent require one adjustment and then they
can start the lock in process. And the lock in
process is typically two treatments, so most patients get three treatments,
an adjustment and two lock ins, or two adjustments and
two lock ins, and each of those is typically separated
(06:51):
by about a week. Now, that can vary from clinic
to clinic, but you want at least wait forty eight
hours in between those treatments. We found that giving patients
time to kind of see what their vision is like
is also very helpful. So while medically you could wait
a shorter amount of time, it is nice to allow
the patients to psychologically and to adjust to their environment.
(07:11):
And so we wait a week between adjustments and treatments.
Speaker 1 (07:15):
So that makes a lot of sense and answers a
few of the questions I already had. I had thought
that the adjustments and the lock ins occurred sooner, but
I was going to ask you, and you mentioned effective
lens position beforehand. If you were doing it a week
or so afterwards, the effective lens position could still change,
So how do you deal with that? But you answered
that if there's persistent diritis, or if there is significant
(07:35):
corneal edema. How are you going to deal with that?
Because that happens to everybody who operates. But you answered
that question by explaining by four to six weeks, and
presumably if you needed to wait longer, you can delay
so that you're making sure you've got the exact refraction
you want to be treating in those adjustments and lockins.
Speaker 2 (07:52):
Yeah, those are really great points. And when we first
started it, we had, you know, the surgical or the
practice anxiety was, Wow, how are patients going to tolerate
this two month process of having to wear protective UV
lenses while they're outside, you know, to protect the lens itself.
So we've had no patients that have had any injury
to their lens from forgetting to wear their glasses while
(08:13):
they're outside or inside. The active shield seems to be
very effective and it also helps in predictability. So our
results are like I said, the accuracy is incredible. But
you're right. I think the most important thing that you
said with your comments are this is still refractive surgery.
And so while there's a customer service component where you
want to sort of shorten the time and improve the
patient experience, we found that with right education, patients want
(08:37):
to protect their investment and they're more concerned about getting
the best outcome. So I have very little complaints about
having to wear the glasses. In fact, some people are like,
you know what, I have to go on vacation for
a week, I'm going to delay one of my treatments.
I'm happy to wear the glasses longer, you know. Whereas
you know, a surgeon was like, are you really like,
let's just get this done for you. But most of
them are very comfortable. You know. Actually, if you look
(09:00):
at the you know, Oscar ceremony, you know, one of
the producers of Oppenheimer wore his lal glasses as he
accepted the award for the Oppenheimer Best Picture. So you know,
obviously they don't seem to interfere a lot with the
lives of patients. And so with the right education, waiting
the right amount of time actually gives us a peace
(09:20):
of mind, and it really has helped helped improve our outcomes.
Speaker 1 (09:23):
I got to rewatch. I was watching the Oscars. I
love the Oscars. I got to go rewatch and see
if I can cite the site the producer who was
wearing those glasses.
Speaker 2 (09:30):
You'll see it. There's a picture online. He's holding his oscar,
you know, and he's got his lal glasses on.
Speaker 1 (09:36):
So talk to me a little bit more about the
sunglasses in the shield, because I do think that probably
is a hesitation for some people when they initially hear
about it. I know for me, when I heard about it,
I thought, who would want to wear these glasses for
so long? What is the protocol you're suggesting to a
patient wear them outside all the time? And in what
lighting conditions indoors do you need to wear them?
Speaker 2 (09:55):
Yep. So you know, you were very fortunate in Canada
to get a exposure to the early versions of the
lens before we could here in the United States. And
you know, I think those earlier versions of the lenses
were very sensitive to situations where even inside, if the
lens was exposed to instant UV light, it could cause
unwanted shape changes which would result in you know, dyspotopsias
(10:18):
or poor vision, which would require explanation of the lens
to solve that problem. And so that also made us
nervous in the initial stages, you know, of FDA approval.
The active shield was introduced about four years ago, and
it protects the lens itself from like regular UV wavelengths
like sunlight, and it requires a specific wavelength to open
(10:41):
like a gate, and that is delivered by the LEDD
light adjustment device itself, and then it delivers the wavelength
that allows the lens to sh the polymers to bond,
and the shape to change. So I think it wasn't
so much having to wear the glasses. It was the
fact that even a small of forgetting to wear the
glasses could damage the lens. Now that there's protection, the
(11:05):
FDA's requirement is recommending still inside and outside off label,
and our clinical experience has been you know, we recommend
it while they're outside, but don't require it while they're inside.
And we've had no incidents and we've done over a
thousand of these implants now to date and have had
no incidence where the lens has been damaged by incident
(11:26):
UV light or a patient forgetting One of the things
that I explained to patients that I think helps them
where the glasses religiously or diligently is we don't have
long term data about what happens to the number of
polymers in the lens as it's exposed to outside light.
So theoretically, with the active shield, you could walk around
outside without the glasses, but we don't know if we're
(11:47):
wasting polymers just by you walking around outside without the protection,
is what I tell patients. So that helps them understand, like,
protect your investment. Let's get as many adjustments as possible
that you that you've that you've paid for. And that
seems to help them understand. Yeah, I'm going to try
to wear my glasses as much as, you know, as
much as I'm told.
Speaker 1 (12:05):
Is the lesser polymers that would be there, the less
an end of adjusting you could do.
Speaker 2 (12:09):
It's right. So you might say, you know, oh, we
think we can correct this amount of a stigmatism or sphere.
But because you know, the patient wasn't good about wearing
their glasses, and now I've not seen this happens, but
this is just how I explained it to patients.
Speaker 1 (12:21):
What's your approach to torx touric LALs? Do they come
in I imagine they do come in TUX, but I.
Speaker 2 (12:28):
It's so that the lal itself is spherical. Okay, correct,
it can correct, you know the way we think of
it can correct up to four dipters of air in
one meridian, so it does two dictors at a time
in sphere or a cylinder, but you could theoretically do
four diptors of a stigmatism. Now you know, that's not
(12:50):
necessarily the ideal refraction that you want to start with,
you know, like plan zero plus four, because you're pushing
the limits. But if you think of it like you know,
that way, you can correct quite a bit of or
a factive error. And so in my experience, there's no
better lens for correcting low low degrees of astigmatism than
the LAL.
Speaker 1 (13:09):
So if somebody has three diopters of sil preoperatively, you
would just put in an aspheric lens and then you
would only treat the astigmatism once you're actually doing the adjustments.
Speaker 2 (13:21):
So yeah, it's so you're looking at the corneal stigmatism, right,
not the refram a stigmatism.
Speaker 1 (13:25):
Yeah, so the.
Speaker 2 (13:26):
LAL itself, you know, is starts out spherical, right. It's
through the adjustments that you can correct the astigmatism. And
so there are patients who you know, I think the
sweet spot to start with especially is if a patient
has about two two and a half diapters of a stigmatism.
You know, that is still in the sort of sweet
(13:46):
spot for having the ability to adjust that you know,
very very close to Plano. If not plano, we expect plano. Right,
So when a patient has higher amounts of a stigmatism
three three and a half in over, we are using
tors lenses, right, So toric lenses in that range still,
I think, you know, give us that flexibility. And if
the patient can have a corneal adjustment like a lasik,
(14:08):
you can still do that traditional method of toric plus.
Speaker 1 (14:11):
Lasik, but there's no light adjustable version of that touric
basically for.
Speaker 2 (14:16):
The higher degrees. I think it's sort of a case
by case like we have been successful with some high degrees,
but there is a limit to the amount that you
can adjust away. I think that's the key message. And
when you start getting over three, you know, I think
you have to start thinking about that limit of adjustability.
Speaker 1 (14:34):
Makes total sense in terms of the lens itself. I've
heard the lal is kind of described as an eat
off or maybe a monofocal plus. Where do you lie
on that spectrum in terms of your view of it
and where do you typically aim?
Speaker 2 (14:48):
Yeah, so there are two versions available in the United States.
There's the original LAL and then they recently launched the
LAL plus. And there is a slight curvad change in
the central part of the optic for the l L plus.
I may be describing it differently, maybe an asphversity change,
but it is a central change that allows for increased
(15:10):
depth of focus on the l L plus. And there's
data to show that patients who are targeted you know,
close to Plano for the l L plus have a
better smell and acuity for reading than you know, compared
site to decide within LA L. Now, there are many
things you can do with l L to achieve more
(15:32):
depth of focus, like a blended vision, you know, one
eyes offset a little bit from the distance eye. So
both are still very effective. They're both used in different situations.
And your second part of the question was targeting. So
I do think that the LA L platform, just without
the plus, has a larger depth of focus than say
a standard monofocal iol and I think it has to
(15:55):
do with the asphericity of the optic itself. It has
a little bit more negative asphericity, So people do patients
do notice an expanded range of focus. It doesn't mean
that they don't need reading glasses, but they do get
an expanded range of focus compared to a you know,
typical monofocal iol targeting. We typically like to target a
little bit hyperopia, not a lot. A little bit of
(16:17):
hyperopia plus a half when we're doing the initial implantation,
which means patients who you know might see great twenty
twenty may complain of you know, intermediate difficulty like dashboard
computer screens for that first four to six weeks. They
seem to tolerate it well because their distance vision is
(16:38):
still so good typically, but it is important to counsel
them that they may they will notice more dependence on
readers initially before the adjustments. The other targeting is dependent
on you know, the patient preference and the surgeon preference.
Some surgeons love to do a lot of blended vision
model and some surgeons like to go we just customize
to what the patient needs, so we don't come in
(16:59):
within a under saying monovision, blended vision, you know.
Speaker 1 (17:03):
And again the beauty is you have time to decide
what the patient wants and you can you can trial
a few things afterwards. If they aren't happy, I think
it's a big deal.
Speaker 2 (17:12):
I think that the confidence it gives the surgeon, the
clinical team, and the patient, like when we explain as
best we can, even if we're using trial frames to
explain blended vision or monovision or even contexts, it's totally
different for the patient, like the confidence they have and
just saying, oh, get I get to try this before
we're in there, like yep, because they try to understand,
(17:34):
but even the smartest patient just you just can't. They
can't see it. And once they see it, then you
really feel their confidence and like, yeah, no, I'm glad
I tried this. I don't really like the blended vision.
I'm just going to go distance and we're readers, or
you know, oh I like my distance, Let's try monovision.
A lot of people are like, oh, I really tolerate monovision.
Thank god we did this lens. So it's different than saying, oh,
(17:55):
I do contact lens trials on all my patients preoperatively
because we've been doing refractorve surgery twenty five years. We
do all that stuff. But somehow having the patient's experience
it themselves and be part of the decision is a
big deal.
Speaker 1 (18:09):
Which which makes sense, especially the way you describe it.
What's the dispotopsia profile for these, Like you said, it's
not a multifocal obviously, so it should be low. But
especially the LAL plus might have a bit of dispotopsia
more so than the LAL not something that you hear
too much from patients a bit, you know.
Speaker 2 (18:27):
Not at all. So the disuotopsy is like a monofocal
iol I think with that LL plus it is it
can be a little sensitive to a little bit of
myopic offset, so if somebody gets and it's patient dependent
as well, but some we've noticed some patients early on
in our experience at ilplus. We were like one of
the first few sites in the country to try it,
so when we were targeting a little bit of minus,
(18:48):
sometimes those patients noticed like a little bit of loss
of contrast. Not not not terrible, but you know when
you're talking like twenty twenty minus twenty twenty five plus
versus like a twenty twenty they some patients could notice
that we don't experience that with the standard LL So, yes,
there's a little bit of extended depth to focus on
(19:10):
the LL plus. So I always tell my colleagues be
a little bit aware of that. You know they tend
to do better plano than minus. Like, if you're going
to target plano versus minus a half or minus a quarter,
I would aim plano and then kind of see, but
the l EL plus you do minus quarter minus a half,
there's the patients tolerate that very well as well, and
you'll hear that from a lot of other surgeons who
do the l EL.
Speaker 1 (19:31):
So doctor stue, how do you pitch this to patients?
And by pitch, I don't mean advertise it to women,
say you need to do this, you should do this.
But there's so many lenses on the market, as you know,
who is the person where you're saying this is a
good lens for you off the bat. After this conversation,
I'm thinking probably if somebody really wants to be completely
glasses free, you'd be more inclined to say, well, we
(19:52):
might be more interested in talking about a true eed,
offer a multifocal lens as opposed to an LAL somebody
with a lot of astigmatism, probably a toric, and potentially
know that LASIK is there afterwards to fix any residual stigmatism.
But how are you canceling patients. Where does this fit
sort of in your algorithm?
Speaker 2 (20:11):
Yeah, I think there's two or three parts to my answer.
I think the first part to my answer is that
we recognize a need in our practice that there's many
patients and a growing percentage of patients that have had
previous cornial refractive surgery. And those patients are very they're
more difficult to have an accurate refractive outcome, even with
your best formulas, even with your best topographers. So we
(20:33):
started there saying, wow, there's these patients who had Lasik
with us fifteen years ago and now want that same
result now with their cataract surgery. And some of them
could not have further cornial surgery because some surgers will say,
we'll just do another Lasik. Well, some of those patients
have thin corneas, or now they're older, so they have
dry eyes, so they're not the greatest laser surgery candidates.
(20:53):
And so now with LAEL, now I can look at
these patients and say, we have a technology that can
give you results similar to without having to do more
surgery on your cornean. And so that was a very
downstream way to go, and those patients are so happy
We're happy because now you know, when you get that
you know, plus one refractive air after your previous lasik
(21:13):
patient that can't have more lasik, Wow, that patient's not
super happy. And doing an iowall exchange, you know, is invasive.
Some of them won't let you do further surgery because
they feel like you messed up their first one. So
lal is has been really an important technology for those patients.
The other thing is that I've learned now over the
last four years is anybody who can get a solid
(21:33):
refraction is actually a candidate for an lal Right. We
don't sell it as getting We don't actually sell any
lenses totally getting rid of glasses, because even when we're
using multifocality, you know, we find that patients like using
readers for the magnification. We find that patients sometimes even
at night, have to wear a thin pair of just
to kind of help get by, you know, with their thing.
(21:54):
It's so, you know, I don't think there's any technology
that any any of us gets, say, is completely glasses free.
You know, you might wear less glasses, you know, with
a multifocal for reading. But a lot of patients and
we kind of talk to them. It's about quality of vision.
So if somebody, you know, if we say, we have
a lens that can help you achieve a really wide
(22:14):
range of focus with the least amount of dependence on glasses,
but it has this side effect profile versus a lens
that has very few of us these discs. Autopsy has
very few night vision issues, but you might have to
wear some reading glasses more. Many patients choose the better
quality of vision, then they do say total freedom with
some risk of side effects. So that's how we kind
(22:36):
of present it, and I think that's that's important. So
that's kind of the second part was really you have
the third You have to get a good refraction. So
if you're gonna ask me, like what about fuchs what
about mac of your generation? What about glaucoma, you know
it's a monofocal EOE. Well, this is the most forgiving,
but the adjustments are dependent on a really good refraction.
So if somebody has really bad macdgen and it's really
(22:59):
like a fuzzy refract, like is it twenty twenty five,
twenty thirty, and you know, you can't really say which
is better one or two, it's going to be very
hard to decide what refraction you're going to adjust to,
which doesn't mean you can't do it, but you know,
we've sort of learned when somebody pays for something, they
need a good result, so we you know, tailor the
(23:20):
lens to that situation.
Speaker 1 (23:22):
Very very clear explanation, and I think you you've outlined
and demonstrated how you kind of frame that conversation with
the patient. The last thing I want to ask you,
which you've already kind of answered. So, but some people
might be listening to this and saying, it's a lot,
And it is a lot, the sunglasses for six weeks,
four to six weeks, the multiple procedures. Granted, you need
(23:42):
to have the right patient who cares enough to do it.
Some patients might say, yeah, if i'm a little bit off,
I don't care, and there are patients who say that,
especially at nonproactive centers. But there's somebody who might be
listening and saying, why not just say to somebody, let's
do them onnofocal and if we're off a little bit,
it will be easy to do lasik. Afterwards. You've already
addressed that that there are certain patients where you can't
do that, especially patients who've already had lasik because their
(24:05):
cornies might be a little bit too thin. And you
also even said that the degree of a stigmatism correction
is actually a little bit greater with the light adjustable
lens than it is if you were to do lasic afterwards.
So I guess I'm answering my own question, but freezing
something framing a question that I have spoken with other
people about where their initial reaction is that's a lot
(24:27):
why not just put them onnofocal and then do lasick
if you need to afterwards.
Speaker 2 (24:32):
Yeah, so I'll have two parts of that answer too.
So one thing that we've seen over the last twenty
five years is while we as doctors think that that's
an easy solution, patients are afraid to have LASIK and
another surgery on their eye, especially when they feel like
the first you know, the reviason you're doing, it's like, oh,
it's super easy to fix. It's just a little bit
of a stigmatism, a little bit of a refractive error.
(24:53):
But the reason they're seeking that is because they feel
like the first one didn't work. So sometimes regaining that
trust to do another procedure regardless of the patient's medical
condition like dry eye or thin corny or something. It's
a little bit of a hurdle, like even if we
offered that enhancement for free, we were still having that
sort of psychological barrier to overcome. So somehow with the
(25:15):
adjustment when we talk about it beforehand, the way this
works is we let the lens set on the eye
and if there's anything, you know, residual or fractive error,
like you and I talking, but if there's anything left
over that you want to see better at, we measure
it and then we can adjust. You know, we can
adjust the lens with simply a light. There's no cutting,
there's no surgery. The light just tout. They seem to
like that concept of non invasive and it's part of
(25:38):
the process. That's the first part of the answer. The
second part is, you know, you were addressing the bias
of me, of everyone, like you know, as a surgeon,
as a team, as a practice, like gosh, this is
a big burden, Like there's a lot of education, there's
a lot of change to the way the clinic has
to sort of refract the patients afterwards. This is like
you're used to seeing a categoration twice one day, one month,
(26:01):
see you later. You know, we're your glasses. But now
we're seeing them for two months, like every week, and
so it does require a little bit of a mindset change,
a little bit of a practice management change. My advice
to colleagues listening is we have the same bias like, wow,
this is a big deal, like is this going to work?
Speaker 1 (26:17):
Right?
Speaker 2 (26:18):
Patients drove this, Like the happiness of the patients is
like when LASIK first started twenty five years ago. So
there's something when you listen and feel your you know,
there's twenty twenty patients, and there's patients that you feel
that are twenty twenty that are so happy. You know,
we have husband and wife teams, we have people referring
(26:39):
like you know, their friend groups because of the quality
of vision they achieved. So we just followed the patients,
you know, like we tried it, and because of the
success with the visual outcomes, alie El sort of drove
itself and we just we just developed the practice management
around that drive. So we make sure people know about it,
that we make sure they know how much should costs,
(27:00):
and then they make a choice and then suddenly, you know,
we've all tried multifocal at Wells, and to me sometimes
the opposite was true, Like the patient is chief twenty
twenty J one vision and good intermediate vision, and yet
we never saw their wives. We never saw their friends,
you know. But now I'm like, I'm doing husband and
wives like three months apart. You know, they're like they're
(27:21):
jealous of the spouse, they're friends that they go voting with,
and they're just so it's like an LAL family out
there in my waiting room, you know, like I have
friends like you. You know, I didn't know you're getting
the LA Oh like, oh yeah, well you told me
about it at the Bridge Club. You know. Now I'm
getting it. So it's we just follow the patients.
Speaker 1 (27:37):
Yeah, and the proofs for us, ye had. The proof
is in the pudding, so to speak. And you're you're
you're generating a nice LA L family community there, Doctor
Ralph to thank you so so much for joining me.
Really really great summary on the basics as well as
some of the more advanced aspects of the light adjustable lens,
a lens that surely is going to become more popular
(27:57):
and that patients are going to be asking us about
and we need to have answers for so delighted that
you spent the time chatting with me.
Speaker 2 (28:03):
Well, thanks for inviting me. I enjoyed our talk.
Speaker 1 (28:06):
Thank you everybody for listening to another episode of blind Spot.
Have a great day.
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