Crossing the Atlantic: IOLs in Europe

US surgeons are often envious of the range of IOLs available to physician colleagues abroad. However, while waiting for an indeterminate approval date, ophthalmologists should still take the time to learn about these lenses. Erik Mertens, MD, speaks with Gary Wörtz, MD, about the new IOL technologies he is working with in Belgium and shares insight into how he implements these lenses into practice.

G. Wörtz, MD: Open, outspoken. It's Ophthalmology Off the Grid, an honest look at controversial topics in the field. I'm Gary Wörtz.

Walk the floor of ESCRS or flip through CRST Europe and you'll likely be left with a wishlist of products coveted from colleagues abroad. At the top of the wishlist is bound to be an IOL, or several. It's a harsh reality that a range of IOLs regularly implanted by international ophthalmologists remains out of reach for US surgeons. Rather than sit on the sidelines and wait, we can and should take the opportunity to speak with our trusted colleagues in Europe and beyond to hear about their use of these yet-to-be-approved technologies. Then, if and hopefully when they find their way into our clinics, we will have their real-world experiences and insights to call on.

With this in mind, I decided to touch base with Dr. Erik Mertens of Antwerp, Belgium, to see which new technologies he is working with and how he is implementing them into clinical practice. Here's Erik.

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G. Wörtz, MD: Today on Ophthalmology Off the Grid, we have the pleasure of inviting one of our esteemed European colleagues, Dr. Erik Mertens, to discuss with us some of the technologies, maybe techniques and perspectives from Europe. Really excited to talk to you today, Erik, and really learn from your experience and maybe get an idea of the technologies that we might have to look forward to in the near future here in the US.

With that being said, if you don't mind, give us a little bit of an introduction about your experience, maybe some of the things you're specializing in and then we'll just go from there.

E. Mertens, MD: Okay, thank you, Gary, for having me. It's a real honor to be invited to this podcast and having, of course, the technology you are not already using in the States, I would love to give you a little bit of my insights. So I'm Erik Mertens from Antwerp, Belgium. I was trained initially as a refractive and cataract surgeon with also some experience in corneal transplants, squint surgery, and blepharoplasty and aesthetic eyelid surgery.

That being said, my premium experience is now in refractive lens exchange with premium IOLs and phakic IOLs and laser refractive surgery. Our practice is actually a multidisciplinary practice with colleagues doing glaucoma, medical retina, and so on. My private clinic also has plastic surgeons, dentists, vascular surgeons, so we are a group of doctors working together and giving a premium service to all our patients.

G. Wörtz, MD: Wonderful. That's incredible. So, it's interesting, in the United States we have this premium refractive cataract surgery model that we're able to do cataract surgery on patients and also, if they want to choose a presbyopia-correcting lens or astigmatism-correcting lens, we can actually upcharge them and we sort of dance in both of those spaces. Is that situation different in your market and is that one of the reasons you are doing a little bit more on the lens exchange and LASIK side of things? Talk to me a little bit about the market differences that you see in the US versus where you practice.

E. Mertens, MD: Yes, well, it's very interesting here in Belgium. When you have a cataract, you will get a basic reimbursement, whether you go for a monofocal IOL or a toric IOL or a premium IOL like a multifocal or whatever. The reimbursement you get is always the same. Then we can charge extra for astigmatism correction, for premium IOLs, or for femtosecond laser-assisted cataract surgery. We can upcharge to the patients, but they have to pay out of their pockets for that.

G. Wörtz, MD: I got you. So astigmatism, is that the thing you're able to charge a refractive premium for?

E. Mertens, MD: One of the reasons we can charge extras, yes.

G. Wörtz, MD: I got you, I got you. If you are doing a lot of younger patients in the lens exchange side of things, it would make me assume that you are using lenses that you feel very comfortable with, they give you a high level of patient satisfaction. Otherwise, doing a lens exchange would be a little bit of a harder sell. What lenses are you using for your younger patients who are coming in and maybe wanting a full range of vision and LASIK is not really a great option for them?

E. Mertens, MD: Well, that's a very interesting topic to talk about because we have a lot of lenses and since 2011, I started using the trifocal, the FineVision from actually a Belgium company, PhysIOL, which was amazing to see that intermediate vision added a lot to the satisfaction of the patient. That became my lens of choice for many years.

Then the trifocal, the cylindrical trifocal came along, the PhysIOL toric and the Acri.LISA toric, and surprisingly enough, I liked the PhysIOL for spheric corrections better than the trifocal Acri.LISA, but for toric corrections, because the Acri.LISA toric is a bitoric design, so the astigmatism is corrected in both optic sides of the lens, it gives me a better predictive outcome in cylindrical correction than the PhysIOL toric. That is what I found in my patients. So for the spheric corrections, I use the PhysIOL FineVision and for toric corrections on top of the trifocality, I use the Acri.LISA toric.

G. Wörtz, MD: You're making me really jealous here, Erik, because I have access to neither of these lenses. That's great perspective for us to think about what's coming down the pipe.

E. Mertens, MD: But you recently got approval for the Symfony lens.

G. Wörtz, MD: Yes, and to be honest, I have just been blown away with the happiness of my patients. I started my training in 2004 and finished my residency in 2008 and during that time, we had the first ReSTOR lens approved in the United States. It was met with a lot of fanfare by ophthalmologists, however I didn't get that same sense of fanfare from my patients in most cases. To be fair, there were a number of patients I had who were very happy but I just didn't get the sense that it was really a huge step forward.

Now, in my experience, going from the ReSTOR over to some of the lower-add multifocals, that was actually a step in the right direction, and just like you mentioned, the intermediate vision, I think, was underappreciated by industry and maybe even by doctors. Intermediate vision is so useful to patients and so when we moved into the lower-add multifocals, we started seeing a little bit more sizzle, a little bit more appreciation from our patients, really excited about that, and then now, moving into the Symfony, I'm personally seeing just a tremendous level of satisfaction in my patients.

I feel like the technology is migrating in the right direction where we really are seeing some dramatic improvements and I'd love to get your perspective, from someone who's maybe had the Symfony for a lot longer than I have. Have you been able to use it? Where do you see it in your practice? I know maybe you have your other lenses that are maybe your go-to lenses, but what are your perspectives on the Symfony?

E. Mertens, MD: Yeah. Well, besides the Symfony, I also have access to what is called the WIOL. The WIOL is a large optic correcting lens without any haptics, it's about 8.8 to 8.9 millimeters in diameter and it has a normal front surface but a hyperbolic posterior surface, which when the pupil comes down with accommodation, you get a higher degree of correction in the center of that hyperbolic posterior surface lens.

G. Wörtz, MD: Interesting.

E. Mertens, MD: I've been very impressed with the results for distance vision, intermediate, and near, and also we're doing now a multicenter European study and the counter sensitivity is really extremely good. The problems we have with the lens is actually you have to make sure that you center that lens nicely into the back and it's not always so easy. Secondly, our A-constant is not there yet, we have sometimes hyperopic surprises. Those people can see for distance and intermediate, but they complain that near vision is not good enough so we have to correct a little bit of hyperopia, so we're working on that.

Having said that and going back to the Symfony, I've used the Symfony in a lot of patients and I was also extremely impressed with distance vision, intermediate, but I was less satisfied with near vision. I know that in the States, you're working with many monovision, as you should or will call it, but what I'm doing recently is I'm implanting the Symfony in the dominant eye so they have excellent distance vision and intermediate vision but not that many issues about glare and halos at night, but I implant in the nondominant eye, the trifocal FineVision lens to have that very good near. The combination of both, they work beautifully, so they have a very good distance intermediate with the Symfony and they have the very nice small print reading capability with the fine vision in the nondominant eye.

G. Wörtz, MD: That is a really hot topic right now, talking about mixing and matching a true multifocal with a Symfony, to see if you can do that. That's something I've really been considering, I know I have some friends around the country who are doing the ... one of the lowe- add multifocals from Tecnis, sort of their intermediate version and a Symfony and mixing and matching and really having a lot of success. It sounds like that plan has worked really nicely for you. Any issues with patients not adapting to the changes because you're sort of putting different technology in either eye. Patients will always have some sort of issues, no matter what you do, there's going to be a small segment, but it sounds like you've found this to be a pretty well-accepted way to correct people's entire range of vision.

E. Mertens, MD: Well, yes. We look very closely in which eye is dominant and you also know that sometimes the dominant eye is not that easy to establish. Then I'm more hesitant to implant mix and match and I would rather go for the same technology in both eyes, but when we can clearly detect the dominance in one eye, then we will go for the Symfony in the dominant eye and the FineVision in the nondominant eye because I don't ...

What I found in Belgium particularly, that monovision is not that well accepted in our patients because of our optometrists, they like to correct our patient with contact lenses for distance vision and give them reading glasses when they are 45 years or older. In contrast to the Netherlands, where the optometrists are more into monovision also in contact lens correction. So those patients are already accustomed to that monovision, which Belgium patients do not tend to have that much experience with.

G. Wörtz, MD: Isn't that interesting? Just regionally, there can be differences like that. I think you're exactly right, if someone comes to me and they have demonstrated tremendous success with monovision, I'm fairly hesitant to change them to a different technology because it's like rewiring the circuit, rewiring the brain to adapt to a new change. If someone is happy with monovision, usually in my cataract practice, I'm very comfortable simulating that for them. Do you find that to be true as well?

E. Mertens, MD: Yes, I fully agree with you. It's not one size fits all, you have to talk to the patient, you have to listen what they want, what they're accustomed to, and then you can customize your treatment to the needs of that particular patient.

G. Wörtz, MD: Right. So talk to me a little bit more about the FineVision. This sounds like a lens that you are very familiar with, you have a lot of experience, you've had a lot of success, which speaks volumes. Where is that in terms of its potential for coming to the states? Is that a topic you can talk about or have any inside information about that you can share?

E. Mertens, MD: Actually, I don't know the plans of the PhysIOL company, of doing FDA-related studies to bring the technology into the States. I don't have any clue whether they have plans in that direction.

G. Wörtz, MD: Well, it sounds like it would be a product that would be well received over here so maybe just talking about it will get some momentum in that direction. Let's switch gears just a little bit and talk about refractive surgery, because I know that's another area of expertise for you, it's an area of passion for you. We again, in the United States, it seems like recently we've been getting some approvals and it's been a very exciting time in the states, where it seems like every couple weeks, a new technology is being approved.

E. Mertens, MD: Exactly.

G. Wörtz, MD: We've gotten a couple of inlays, so we have the Raindrop approved now, we have the Kamra approved, and also SMILE has been approved. Do you have any experience with any of those three technologies and if so, I'd love to hear what your thoughts are on those?

E. Mertens, MD: Well, I have, with all three of them. Let's start with the Kamra Inlay. This is the same thing as what I've talked about with monovision, I found it hard to satisfy my patients with a reading correcting device in only one eye. They could read, they were able to read, their distance vision was good and okay, as the same thing is with Raindrop, but they said, "I'm happy, but," and I don't like the "but" in this sentence because I know they have concerns or they're not fully satisfied. As a refractive surgeon, we don't like to hear the hesitation in the voice of the patient one month after surgery.

So actually, I stopped doing the inlays because of that concern and secondly, I found in a couple of cases, even later on, nine, 10 months after surgery, late reactions in the cornea. Like getting some haze formation around the implants and for that reason I had to explant a couple of them.

Although people say it's reversible, you still end up with a little haze left in that cornea, even when you treat it with corticosteroids for a longer period of time. So in those cases, I had to take those inlays out. I was not really satisfied with the final status of the cornea.

G. Wörtz, MD: I see. Yeah.

E. Mertens, MD: That's my main concern.

G. Wörtz, MD: I see, and that's a concern I think that we all have. As ophthalmologists, we want to make sure that we're doing something that has a really high benefit profile but we know that anything we do, there are some risks. So it's really just trying to balance that to find out what is going to be most beneficial for our patients without putting them at too much risk. I think from a lot of different perspectives, surgeons have different experiences. I've heard from surgeons on the other side that say, "You know, I've really not had too much haze. I've not had that as much of an issue and we're putting them maybe a little bit deeper and our techniques have changed a little bit." Maybe that's evolving a little bit?

I think there may still be improvements and I think the space is very interesting, but I do share your concerns. I think we all have to think about that and really try to make our own mind up about what the goals are for the patients and making sure we're not putting them at too much risk. I appreciate you saying that, this podcast is really just about honest conversations and so it's important that we share those perspectives, so thank you for that.

E. Mertens, MD: Absolutely, and Kamra and Raindrop, they work beautifully, but in very well-selected cases. The surgeon has to look into that, talk to the patient, and go in-depth on what can happen and what they can expect. And in selected cases, they work very well.

G. Wörtz, MD: Nice. Well, let's talk a little bit about SMILE. Again, that technique and the laser was approved for correction of myopia in the United States very recently. Tell me about what your experience has been like with SMILE. Maybe how do you select patients for SMILE versus LASIK and where you see it fitting in your market.

E. Mertens, MD: I have not done that many cases, but I can tell you my small experience with SMILE. SMILE is of course very appealing to patients, an all laser, no blades surgery with only a small incision in the cornea. Although it looks very appealing, it ... I had to go through a ... steep learning curve, it was a learning curve. In the beginning, you're not used to follow the curvature of the cornea with your instruments. You have to be very careful that you take out the whole disc that the femtosecond just prepared for you in the cornea.

G. Wörtz, MD: Right, you don't want to leave any behind, do you?

E. Mertens, MD: Exactly, that's one ... when you end up in that situation and you cannot always recognize it, you only see it postoperatively when doing a corneal topography or imaging device. Then you notice it and it's very difficult to repair that. The second issue I find is that when you need to do a touch-up, first you say to the patient, "Okay, we do a very elegant procedure, very small incision," and now you need to do a touch-up with a PRK. A lot of pain for a couple of days and it will take 10 days before your vision returns to 20/25 or 20/20.

That's difficult to me to talk to the patient and say, "This is the high ... It is a high-end surgery. When everything goes well, it's beautiful." But it's in its early stages of development, as we've seen. I started doing PRK in 1991. We saw a lot of haze with the broad beam lasers, their predictability was not good, we had to give a lot of steroids for a longer period of time. That's the same thing with SMILE. When we can develop this technique and get it much finer technology with less concerns, then it will work beautifully. For the moment, I'm very selective in my patients and I'm not using it as a high-volume procedure for the moment in my practice.

G. Wörtz, MD: Well, I think you've said that very elegantly. We see the promise of this technology, we see the promise of a small incision, laser-only procedure, just like we see the promise of the corneal inlays, like the Kamra and the Raindrop. It may be that these technologies might evolve simultaneously and maybe synergistically, where down the road we're seeing even more reasons to maybe do SMILE with a Raindrop or SMILE with an AcuFocus device.

It is really interesting and the reality is LASIK is so good it's really hard to compete with it with a procedure that is just so well established and so refined.

E. Mertens, MD: Exactly, I fully agree. LASIK, of course, has a 20-year track record and LASIK is so good and SMILE is of course, very appealing and it will improve for sure. As you said, SMILE in combination with inlays, that would be great. There's still a lot of work to do but we ain't seen nothing yet, for the moment.

G. Wörtz, MD: I love it, I love it. Well, Erik, I really appreciate you just coming on and talking about your experiences. It sounds like there's a lot of things in Europe that we may have to look forward to. The FineVision IOL sounds very appealing, along with the Acri.LISA toric, and we all are just cheering on the people who are out trying to develop new technologies and helping give us new tools to treat our patients with. Any parting thoughts, before we wrap this up?

E. Mertens, MD: Well, yeah, I want to say few words about the ICL and the evolution which is going on with the ICL.

G. Wörtz, MD: Sure, absolutely.

E. Mertens, MD: You know they had a rebranding and they call it now EVO, from evolution, and EVO+ for the larger optic diameter ICL, which since I've been using the AquaPORT technology since four years now, almost five I think, I've seen a tremendous growth of my amount of ICL patients in respect to laser vision correction, and that in many ways.

First of all with the AquaPORT, you do not need iridectomy anymore, which was, let's be honest, the most bothersome part of the surgery for the surgeon and for the patient. Although we try to do a very good job, once in awhile you ended up with a high eye pressure and you had to come to the clinic in the middle of the night and deal with that, so you do not want to see these in young patients. I haven't in more than 1,500 AquaPORT cases I've never seen a pressurize.

G. Wörtz, MD: Wow.

E. Mertens, MD: Yeah, that is a really amazing technology. Secondly, because of the flow of aqueous, which is forced between the ICL and the crystalline lens before entering in the anterior chamber, also in the four year period, I haven't seen a case of opacities, anterior opacities in the lens, and haven't seen any cataract cases.

G. Wörtz, MD: That's incredible.

E. Mertens, MD: Yeah, that's incredible, so that was a criticism for the ICL for many years, and I think they solved that problem now for good. The only issue in my opinion, the only issue which is still remaining is the sizing issue. We sometimes get, although we do UBM, although we do caliper measurements and we try to choose the right length of the ICL, sometimes we end up with a low vault or a high vault and this is the only remaining issue with the ICL. Because in the end, I'm not touching the cornea, so by not touching the cornea or by not altering the curvature of the cornea, you will not get dry eye.

And also, later on in life because let's be honest, ICL surgery is only the step before we do a refractive lens exchange or a cataract surgery later on in life, those patients who are willing to see without glasses will be also asking the eye surgeons of the future to have a premium IOL because they do not want to wear reading glasses. When you've done laser refractive surgery, it's much more difficult, as we know, to pick the right power of the IOL and also because of the different asphericity of the cornea, implanting a multifocal IOL at present days, the quality of vision is even less than in a virgin cornea. You don't have those issues with the ICL.

I know that STAAR Surgical is really working with the FDA and they will make the commitment to bring that technology to the States. Of course it will take some time, but that I know for sure they want to bring this technology to the States as well.

G. Wörtz, MD: Well, Erik, the AquaPORT really sounds like it is solving multiple problems all at once.

E. Mertens, MD: Exactly, yes, at the same time.

G. Wörtz, MD: That's something that we would love to see here in the US. Walk me through a little bit, what patients are you trying to steer towards an ICL versus what patients would you say, "No, I think you're going to do better with LASIK"? What is your conversation, what's your criteria look like?

E. Mertens, MD: Yes, well actually, I'm going to make a bold statement. For me, every patient is a good candidate for the ICL unless there are contraindications. What many surgeons still do and what I did also four or five years ago is telling my patients, "You are not a good LASIK candidate or a SMILE candidate, so we have another option for you." Then you scare them away because then they think, "Hmm, it can be a dangerous procedure."

G. Wörtz, MD: Yeah, "this other thing must not be so good".

E. Mertens, MD: Yes. So now I tell them, "Okay, we have multiple options. We have laser vision correction side and we can do laser vision correction on the surface, under a flap, or directly in the cornea, or we can implant an extra lens and we leave your own crystalline lens in the eye. These are the four options we have. We going to do an examination and after examination, I will tell you which one I think is the best for you."

Whether we find a little bit of ... We do a lot of work on dry eyes and the one thing you do not want is a 20/20 uncorrected patient one month post op and complaining about dry eyes. That's the nightmare, I think, of the refractive surgeon. We are very keen on that and also now with the AquaPORT technology, we implant even 50 years old with the ICL, which I did not do before I had the AquaPORT technology available.

G. Wörtz, MD: That's very interesting. I like the way that you position the ICL at the very beginning, because then it doesn't sound like it's an afterthought or some riskier alternative to LASIK if you can't qualify. I think that's a really nice pearl, that presenting it from the very beginning as a very good option equal to the other options depending on the patient's own exam. That probably sets that up in their mind on a different level.

E. Mertens, MD: Yes. As a different procedure, but an equal procedure.

G. Wörtz, MD: Right.

E. Mertens, MD: Not an exception.

G. Wörtz, MD: Right, exactly, exactly. And that's a great pearl, I think we can apply that to even other things in our positioning of technology. That's just great. Well, Erik, thanks again for sharing your time, your perspectives. I always enjoy listening to you speak and reading your articles and I look forward to connecting with you in the future.

E. Mertens, MD: Thank you, Gary, for having me.

G. Wörtz, MD: Absolutely. This has been Ophthalmology Off the Grid. Has your wishlist grown? Mine has. But instead of feeling like that kid on Christmas who didn't get this year's it toy, let's be proactive. Let's listen to our European colleagues research these innovations, consider how they might fit into our practices, and just maybe, have a little faith that they'll make their way across the Atlantic.

This has been Ophthalmology Off the Grid. Be sure to rate, review, and subscribe. If you've got a question or idea, I'm all ears. This is Dr. Gary Wörtz, thanks for tuning in.

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