Postoperative refractive changes in second-generation light adjustable lenses possibly associated with tanning bed exposure: a bilateral case report with laboratory analyses

Purpose: The Light Adjustable Lens with ActivShield™ technology (LAL 2.0; RxSight, Inc.) is an intraocular lens (IOL) that enables postoperative refractive adjustments using targeted ultraviolet (UV) light. The ActivShield was designed to enhance protection against ambient UV exposure to reduce the risk of unintentional polymerization and subsequent unintentional refractive changes. Here we report a case of bilateral LAL 2.0 implantation complicated by progressive visual decline and refractive instability despite initial reported adherence to UV protective glasses. Case: A 70-year-old woman with a history of LASIK and visually significant cataracts underwent uncomplicated bilateral LAL 2.0 implantation with intended monovision. Despite reported compliance with postoperative UV protective glasses, she developed worsening vision and varying refractions. Examination revealed central lens changes consistent with hyperpolymerization. The patient later disclosed frequent tanning bed use possibly without appropriate eye protection. Both lenses were explanted and replaced with Softport (Bausch + Lomb) IOLs. Results: Laboratory analysis of the explanted lenses showed central thickening without opacification. UV-visible spectrophotometry demonstrated ∼85% transmittance in the visible range, with a curve consistent with a lens with blue-light and UV filters. Wavefront analysis revealed irregular power distribution suggestive of unintentional macromer polymerization. Following lens exchange, best-corrected visual acuity improved to 20/20 bilaterally. Conclusions: ActivShield technology does not appear to fully prevent unintended polymerization, especially under extreme UV exposure such as tanning beds. Strict adherence to UV protective eyewear and patient education remain essential in preventing irreversible changes to the lens' structure prior to the final lock-in treatment.