Light Adjustable Lens Experience

[psbpsbpsb]

I had started to discuss my experience with the Light Adjustable Lens in http://www.medhelp.org/posts/Eye-Care/adaptive-IOLs-outside-the-US/show/2076228 but found it was closed today.  I've just had my second adjustment and wanted to give the many interested folks in the community an update on my experience.

I had the second adjustment yesterday afternoon.  As with the first adjustment the appointment began with the optician working with me to look at where I was with my visual acuity and also getting an update on my intraocular pressures.  After being dilated and waiting an hour or so, I went in with the ophthalmologist and had the UV irradiation.  As before, they used topical anesthetic, a contact lens and eyepiece were applied, and the UV light turned on.  This time I didn't find the experience as uncomfortable.  It may be she used less irradiation this time or perhaps I still had part of the lingering washed out vision from the first adjustment still present.  After, I was essentially unable to see out of the treated eye because of a large, intense red/pink distorted area covering most of my visual field.  As the afternoon and evening went on it faded only slightly but I did seem to be able to have more sharpness with some distant objects than before, again, very hard to tell.

This morning still a lot of redness and pink hues especially noticeable when looking at white objects.Green LED lights look white.  But my acuity is returning and I feel that there was definitely an improvement with the second treatment.  The plan is for me to return in a few days for the first lock in and then the second lock in a couple days after that.  It is hard to really know just how well the lens is working at this point as I haven't recovered from the UV irradiation and I'm wearing the dark UV blocking glasses.  But I'm feeling optimistic that my intermediate vision is much better and reading vision also significantly better than my untreated presbyopic eye.  

Unless they close this forum or the moderators delete this post I'll put a couple follow ups on and some observations as I get the lock ins done.


This discussion is related to adaptive IOLs outside the US.

[KayakerNC]

Be nice if everything was in one easy to find discussion.
Reasons for choosing the LAL.
Doctor/Surgeon selection.
Initial consultations and impressions.
Surgery and adjustments results.
Thanks for keeping us updated.

[Joykat]

It would be nice to hear of others experience with the light adjustable lens.  I know it is not FDA approved so it is not available in the US, but I am sure there have been plenty of people who have traveled to Mexico for this implant.   Please tell us your story.  

[JohnHaganMD]

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[John C Hagan III, MD, FACS, FAAO]

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[flossy93]

I'm sorry they closed the prior discussion thread.  I can't figure out why.

In any event, thank you for starting the second thread on the topic and for your diligence in giving all of us an idea of what the process is like having a LAL implanted from a patient POV.  

I think this will be especially helpful not just for those who are interested in the LAL, but people who are thinking of traveling to other countries where the LAL is available.  It sounds like a lengthy stay (perhaps a month or more?) is needed to allow for the initial surgery as well as all of the follow-up appointments.  

Thank you again SO MUCH for your kindness in taking time to relay your experiences so clearly.  I look forward to hearing your next update!

[John C Hagan III, MD, FACS, FAAO]

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[psbpsbpsb]

Thanks flossy.  I'm trying to convey information that I would have liked to know before I had this done, while it is fresh in my mind.  There is quite a bit on the LAL online from the perspective of the manufacturer and ophthalmologists using this IOL, but a paucity of information from the patient point of view.  I think there is a tendency to underplay some of the difficulties in having this done and it is helpful to go in knowing as much as possible from sources besides researchers and marketing materials.  Making visits for treatment and follow up from a neighboring country has proven cumbersome and when I get the other eye done I'll be in a much better position to plan realistically.  Because of the requirements to give up your normal glasses to use the ones provided which block UV (and in my case only allowed to wear the tinted pair), and which are not prescription, and the visual after effects of the UV light treatments, you are looking at some degree of visual impairment for a good month or so from the procedure itself.

As expected this morning the pink fuzz is a bit better but I know on Monday when I go back in for lock in number one it will be back again in spades.  So I expect to have very limited vision this week as I get, hopefully, the lock ins done.  After than I expect it will be at least a week to have most of the pink tinge and blurriness resolve and be able to finally be out of the UV sunglasses.  That will give me my best chance to really appreciate the benefit of these lenses. That said, there certainly is a big improvement between the time the lens was first put in and the two adjustments, so had I just had a normal monofocal put in I know what my baseline vision would have been and it definitely would have required me to go back to my progressives.  With the adjustments I think I may be able to function quite well glasses free, but we'll see and I'll report back.

[John C Hagan III, MD, FACS, FAAO]

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[psbpsbpsb]

Lock in one is finished and lock in two sceduled in the morning.  The lock in was not as uncomfortable as the first adjustment, again perhaps because I knew what to expect.  Same procedure - check refraction and pressures, dilate for an hour, then anesthetic drops and light exposure.  The vision blur and pink fuzzy is quite bad.  The day after I would say my vision is at 20%.  Doctor said the lockins will change the lens about -.25 diopters which is fine as I would like a little bit better near.  She seemed pleased and the lens is adjusted with an aspheric profile to give me a wider range of vision.  She said I will not end up with a strictly monocular focus.  After the final lock in and a bit of time to let my retina recover from the UV irradiation I will report back the final results.  I am so looking forward to ditching these UV glasses.

[flossy93]

Thank you for the latest post.  I think you said before your second lock-in appt would be a few days after the first, so hopefully the UV glasses are only needed for a few more days.

Thanks in advance for your final posting of results, once your second lock-in is over and your vision has recovered.  I'll be very interested to hear about the quality of your vision (halos, blurriness) as well as the clear visual range the LAL gives you with the customized adjustments.  I'm still not totally clear on how it's adjusted for multiple focal lengths (e.g. 'not strictly monocular') but I'll be very interested in your visual experience with the outcome.  

Congratulations in advance for sticking so diligently with the UV-blocking protocol.  Hopefully you will have a great visual outcome and the effort will be well worth the results!

[KayakerNC]

Looked at the other thread, and maybe I missed it, but was there any astigmatism involved in your vision?  Just wondering if it was correctable with the lens or incisions.  If you had any, of course.
So, evidently the LAL is not just an adjustable monofocal.  If the aspheric works out to give you that wider range....super exciting.
Thanks again for the updates.

[John C Hagan III, MD, FACS, FAAO]

There is a good article in Ophthalmology Management March 2014 "The Calhoun adjustable IOL breaks new ground" by Jerry Helzner that might be of interest. Likely is available on their website.

One of our surgeons is using this IOL under an experimental protocol with good results

JCH MD

[KayakerNC]

Thanks for pointing to an excellent article.
http://www.ophthalmologymanagement.com/articleviewer.aspx?articleID=110227
What I find most interesting is; "Though the most promising next-generation IOLs are still in the investigational pipeline, a more varied premium channel is expected to be available in the future."
It would be nice if the FDA process were to surpass the speed of the glaciers.

[John C Hagan III, MD, FACS, FAAO]

The "speed" of FDA approval is literally "killing us"  ''JCH MD

[psbpsbpsb]

A quick update.  Lock in two was finished Wednesday morning, 3 days ago.  Follow up will be in three weeks.  It is great to be out of the UV blocking sunglasses.  The day of the second lock in my vision was pretty bad due to the usual effect of the bright UV light.  It was better the next day and better still now.  I was told to expect several weeks of recovery.  

I cannot fairly report the final outcome yet because there has not been enough time for full recovery from the UV exposure.  My color vision is way off and there are contrast issues.  This morning I can read fairly small print with inverted colors enabled and bold text on my ipad (to decrease the contrast problem with a white background) and can also read a small scrolling banner on BBC news from a distance.  Intermediate/computer distance seems best of all.  The reading distance is not a 'crisp' vision but this may be a contrast problem.  Will give an update and summary after a bit more time goes by.

[psbpsbpsb]

Hey folks, this is the one week anniversary of my last lock in treatment.  So at one week out my eye continues to recover from the UV light used for the procedure.  My experience may be different than the average person, I don't know because few, if any, have posted on this, but in my case the after effects of the UV were pretty dramatic and still have not resolved a week later.  In dim light conditions I have definite decreased light sensitivity in the central part of the eye corresponding to the scotoma present the initial few days after the lock in and some of my color vision is changed.  For example, there is a green button for 'post a comment' on this web page and when I look at it with the left eye where my lens is, it is the color blue.  Some blue street signs are the color green!  Reds are much more pronounced and in general greens/yellows are washed out looking almost white.  I think it is gradually improving and as I read about 'blue light hazard' online I note the recovery of the retina to the phototoxic effects of light can take weeks or even months.  I hope that surgeons and the manufacturer of this IOL will discuss this more openly as a side effect and warn people in advance.  I don't see anything published about this and it needs to be researched.

On the positive side I am finding my refraction is pretty good.  Using an eye chart in less than ideal circumstances, I'm seeing at least 20/40 distance and possibly 20/30 with good light conditions, and J4 or thereabouts for reading vision.  There is definitely a 'pseudoaccomodation' phenomena at work and I am feeling as though my brain is still learning how to interpret the signals and integrate it with the other eye.  The difference in color vision and differences in the ability between each eye to see in dim light make this harder.  When I walk outside in very bright light conditions my far vision is best.  I'm able to work on the computer quite well.  I think there might be a mini-monovision effect at work here too.  With both eyes my UCVA is 20/20 distance.

So at one week out - the UV light had side effects I'm still recovering from, I'm definitely getting a benefit at different visual ranges that might be better than a standard monofocal, and there is going to be more time needed to allow my poor old brain to adjust to these changes.  If they don't close this forum topic I will try and give you an update in a few more weeks.

While I was jealous of folks who are able to go in, get a quick surgery done, get refracted and have glasses with resultant good vision all in short order with minimum cost, I am also thinking that the long term benefits of this lens and the various requirements and costs involved may be quite wortwhile.  My old progressives are sitting on my desk collecting dust and I'm able to get around quite well.  I'm optimistic but just don't feel I've gotten the full benefit of this yet and don't know for sure if I can recommend it.

[flossy93]

Thank you so much once again for the thoughtful and detailed update.  It does sound as though you are getting multi-focal vision at various distances already.  Some folks who pay for premium lenses are never free of reading glasses and the fact that you do not need your progressives is a great sign.

It's very interesting to read that the color impairment and contrast decrease aspects of the UV exposure are not fully documented and explained as a side effect.  Depending on one's profession these defects in vision could be quite problematic, even if temporary.  I can't believe you are the first patient to notice these issues, although you are probably more articulate than most patients at explaining the defects you see.  

Have you had any opportunity to evaluate your night vision with regard to halos and other typical symptoms of multifocal implants?  I was wondering since the LAL doesn't have the typical abrupt transitions from one lens 'zone' to another whether it would still generate nighttime halos and glare like some multifocals.  I'll be interested in your experience in that area when you have had a chance to observe your results.

Thank you once again for your valuable feedback.  I really hope you find that the cost, effort and inconvenience of the LAL process ultimately gives you a very satisfactory final outcome.

[psbpsbpsb]

I'm only a week out from the last lock in and I expect the UV exposure side effects to reduce and resolve over time.  How long that will take I don't know but I wanted folks to know this happens so they aren't as surprised as I was.  I'm looking forward to being able to see green leaves again especially with spring right around the corner.

My healthy right eye has good vision and minimal presbyopia so my results are going to be very influenced by that.  It has never been operated on.

[KayakerNC]

Great stuff!
Did you have any astigmatism pre-op?  If so, how did they deal with it?
Thanks again for all the updates.

[psbpsbpsb]

I did have astigmatism addressed with the lens adjustment.  The ophthalmologist told me she left a 'little bit' intact as it would be of some optic benefit.  I've found using cheap over the counter reading glasses from the drug store helpful for very fine print close up without any distortion of the image, in the past I found that due to the astigmatism in the eye those weren't as beneficial as now.  I drove yesterday in bright light conditions without glasses and without problem.  I'm typing this on my computer without eyeglasses.  Every day I feel as though I'm doing better with this lens, there is definitely an adjustment period. Still with major green/blue discrimination problems but some of the other color issues seem better with improvement in the pink/red tinge issue.

[psbpsbpsb]

An update.  So color vision has slowly improved.  Traffic lights now look green instead of white.  Looking at trees and vegetation still looks white and washed out and I do have some differentiation issues between certain shades of blue and green.  I'm still not using glasses and think I can get around pretty well without them.  I used a distant eye chart and think I'm about 20/30 with optimal conditions on the LAL side.  Reading is probably around a J4-5 again with optimal conditions.  Contrast and lighting play a big part in how well I'm able to see.  Improvement has been a gradual process and I believe there is a neuroadaptation that must take place.  The way I focus on objects on the LAL side is different than how I focus on the unoperated on eye.  There is a bit of 'latency' when I focus on the left, as though my brain somehow has to figure out what I'm trying to focus on.  My guess is that this is a part of the increased depth of focus and aspheric quality to my visual system.  On a good day with sunlight and in the morning, sitting outside with my wife having a coffee, I'm absolutely delighted with how well I can see.  I'm also really happy to be able to do my work on the computer without much problem.  Driving - all depends on lighting conditions.  I don't think I'd be comfortable driving at night, at least not yet.  I may end up getting some driving glasses for optimal vision particularly at night.  Another issue - I was a Lasik patient many years ago and I think I have issues with dry eye, apparently this gets better as the cornea heals for some weeks after cataract surgery.  It isn't a huge problem but dry eyes and eyelid inflammation really make a dramatic difference in the quality of my vision.  So I'm still not at my final endpoint yet, the healing process and adjustment process with this lens takes some time.  Overall the trend has been consistent improvement.

[flossy93]

Great to hear the update and that you are continuing to do well with the LAL.  

It's really a surprise how long the altered color and contrast perception persists.  Although I've only read a little about the LAL procedure, your posts are the first I've heard about it.  It's very good that your color perception is continuing to improve; hopefully the trend will continue!

Thank you again so much for the informative posts and the work you have put in so we can all understand the LAL process from the patient's perspective.  It is greatly appreciated!

[KayakerNC]

Great update.  Keep 'em coming!
I don't know when you'll need the other (right) eye done, but is the LAL still in consideration?

[psbpsbpsb]

Thanks kindly.  My hope is I continue on this trend and my postings will come to an end. :-)

I definitely would consider the LAL for the right eye when that time comes, but I'll also probably want to hold out as long as I can because of how complicated it was to get this done and the long process.  The country in Europe I'm residing does not have this available and while it is only an hour flight to Berlin, that still is a pretty big hassle.  I'll be flying out next week for a checkup.

I took a color test to see just how bad my vision had been impacted by the UV.  I set up a blog with the results and here it is  www.lightadjustablelens.blogspot.com/

[psbpsbpsb]

This may be my last post on this topic.  I'm now several months out from the procedure.  My color vision in the blue/green spectrum is close to normal although it continues to recover and is not 100%.  I went in for refraction while I was on a trip to the US to get some driving glasses last week.  The LAL eye is about 20/50 distance and pretty good for reading without glasses.  My prescription is -100 = -50 x 180 with +175 add.  Since my non operated on eye is plano, I'm able to get around without glasses.  

When the time does come for the other eye I'll probably elect to get an LAL again.  The question for me will be, would that eye be a candidate for a multifocal IOL and will there be good templates for the LAL to be set multifocal for that eye?  It is a very cool technology and you can see how they could use this to tremendous advantage for multifocals.

[boldandfunny]

20/50 is a bit on a low side? Do I understand correctly your target correction was for intermediate (computer work)?
Is this the reason your distance is not so great (uncorrected)?
If you wear distance glasses - what your corrected acuity is? Surely much closer to 20/20?

[JohnHaganMD]

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[kenhart]

Short version: I have had cataract surgery at the Codet Vision Institute in Tijuana, Mexico, where I had a  Calhoun Light Adjustable Lens implanted into my right eye.

I will need to  break this post into 3 pieces to fit within the character limits. Hope they stay together.

Long version Part I:
I'm a 56 year old male with cataracts. I've not worn glasses except for reading glasses (about +1.5 diopters), however I have had a prescription for corrective lenses since approximately age 48, (I didn't wear these glasses, as I couldn't tell a net benefit except for the lower reading portion.) In the prescription my right and left eye have from - 0.25 to - 0.50 Spherical and Cylindrical correction.

I work as an engineer, with lots of time on the computer, dealing with reading material and occasional close-up inspections and probing of live circuits.

It was about 10 years ago that I started having presbyopia and began dealing with multiple pairs of (different powers of) reading glasses for differing purposes. Then about 4-5 years ago, I started getting cataracts.

My symptoms of that were a feeling of looking through fog, or through a dirty windshield. The brighter the day, the thicker the fog. In addition to that, I had multiple, slightly misaligned images in each eye. The two main images in each were not very far apart angularly, but enough that it was hard to discern, say, "1' from "11". Reading glasses corrected this for close distances. Both eyes seemed to have very similar symptoms, but were slightly different; and the right eye had notably more fog.

Driving became difficult, especially in areas I was unfamiliar with, and especially at night. By the time I could read the signs, it was too late to make use of the information. I believe I instinctively found some workarounds - like finding a way to get some accommodation, with effort,  for short periods, or learning to use my hands or arms to shade my eyes from the direct sun when needed.  But on occasion I couldn't do that. On a motorcycle I turned into the low sun in the evening and both hands were busy; I felt basically blind in the right eye, and nearly blind in the left.

Oddly, when tested by an optometrist, they always test me in a dark room that minimize the symptoms. And as mentioned above, I seemed to  learn to do something that tended to focus the images somewhat, with significant effort (possibly I still had some accommodation? - however, I could not tell that the pupils got smaller when doing this). The results are they would tell me,with both eyes together, I had 20/20 vision.

I have been looking the last few years at options. I was hoping for an accommodating lens to be proven to work, and to be approved in the U.S. where I live. The Synchrony lens seemed to be the most promising option, but it doesn't appear that it has actually lived up to expectations.  (see previous posts from Anomalychick including Mar 17, 2013 for some details about that - apparently there was non-accommodation in perhaps 30% of the cases - (she went with the Synchrony lens regardless, and as I recall, there was some other issue with her results.)

The MultiFocal lenses had too many drawbacks for me (mainly issues with night driving 'artifacts'). However, there was a trifocal called FineVision that had some appeal available outside the US.

However, I decided to go with the Light-Adjustable Lens even though there is no accommodation at all with this fixed-focus lens. (see a previous (and later) post from brzez on Apr 02, 2013 for some details on this lens; as he went with the light adjustable lens (LAL) from Calhoun Vision). The benefit here is that the lens is adjusted AFTER the lens has been implanted and some healing of the eye has occurred. This makes it highly likely that you will not need glasses (or Lasik as a corrective second procedure), for at least at the distance you select (in my case, far distance). There are other interesting things that can also be done with the LAL, but I didn't entertain these, though I might do so with the 2nd eye in the future. My intent was to do one eye only at the current time.

The closest/least expensive option for me was to travel from my home in Virginia (U.S.) to Tijuana, Mexico to the Codet Vision Institute for surgery by Dr. Arturo Chayet. The process to get the lens is expensive ($3900/eye) and a bit troublesome (for those not living near the surgeon, they have things organized so that you can do it in two trips; 3 days minimum are required to get a consultation, surgery, and post-op check, and a full Monday-Saturday is required after a 2-week healing period for adjustments), but the potential advantages in accuracy following eye-healing made the trouble worth it to me.