EVO ICLs versus LASIK with Dr Eric Fazio

Exciting new developments in vision correction have taken the form of EVO ICLs, or implantable collamer lens, that can provide an alternative treatment route for patients. Eric Fazio, OD, sat down with Optometry Times to discuss the pros and cons between ICL and laser-assisted in situ keratomileusis (LASIK) treatments.

Video transcript

Editor's note - This transcript has been edited for clarity.

Emily Kaiser Maharjan:

Hi everyone, I'm here with Dr Eric Fazio to talk about EVO ICL and comanagement of patients who choose this route for vision correction. Welcome, Dr Fazio glad you could be here.

Eric Fazio, OD,
Hi, how are you guys doing?

Kaiser Maharjan:
Good. So first, can you tell us a little bit about EVO ICL, like what should optometrists know about it?

Fazio:
Yeah, so it's exciting to probably talk about it. The EVO is kind of been around for a while in a prior forum called the Vizian [ICL], probably since 2008. I've been working with surgical ophthalmology my entire career. We actually did use that lens back in the day. It was a pretty difficult lens to use, because you had to do surgical [peripheral iridotomy, or] PIs, 10 and 2. The way we had to do [it was] 1 eye, then do the other, and it never really gained much traction because of how hard it was to get through the entire process, and it's a pretty expensive and timely thing.

In March of 2022, they finally launched the EVO, which put this innovative, I think it's a 360 micron hole in the center of the ones to allow aqueous flow, and that was a absolute game changer. So we immediately started using the lens like gangbusters, it's same-day surgery for both eyes. It's simple, it's quick, it's fast, it's efficient. It just made it a great option for everyone, really, to use. It's been exciting because it's really taken off pretty aggressively here in Tampa, [Florida]. That's where I'm located.

Kaiser Maharjan:
Yeah, that's fascinating. So when would you recommend EVO over contact lenses?

Fazio:
Well, you know, we're a refractive surgery practice. Probably most people that are going to use this, there going to use that in that arena where you're thinking about LASIK, you're thinking about something. I mean, LASIK's a word that's out there, so that's pretty much how you're gonna have patients come to you. But it's really an option for anyone. I mean it does have some lower dielectric limitation at minus 3 is kind of where that starts. But it could go up to 4 diopters of astigmatism, which is incredible.

But we've already done 3 of our employees here with the technologies; that speak something there. But usually it's contact lens, rejections, patients are struggling with contacts, they simply don't want to deal with them anymore. It's the typical stuff. They can be having dry eye issues, which is a thing we can hit on as well, what its advantages are for dry eye compared to LASIK. But since we do LASIK, for the Tampa Bay [Buccaneers], we're allowed to say that because we're officially affiliated with them. We are a practice that attracts LASIK candidates. It's not to be a naysayer of LASIK, but there's really significant pros and cons between LASIK and the ICL that we really need to know about, because there's times you're going to steer away from LASIK toward the ICL. I offer both options: give them the pros and cons of all that and let them decide, let the patient kind of drive the conversation.

Kaiser Maharjan:
Yeah, absolutely. So I'm also kind of curious what the surgical options means for vision progression. You know, like when the presbyopia sets in how is that handled with the EVO versus LASIK?

Fazio:
That's a great question. So, a couple of differences there we can hit on. When you do LASIK, we've all seen this as optometrists, you're just changing that cornea dramatically. You know, the big advantage EVO as is it's a small incision surgery, so it does not create a lot of dry eye because you're not really damaging a lot of nerves doing that, whether it's [photorefractive keratectomy, or] PRK even, or LASIK. They say PRK is a little bit better, you're still getting dry eye definitely, we all know that. So you're just not seen that with the EVO, which is fantastic, so that's a huge advantage. The other thing is you're not altering the cornea, so that's very important as you approach those kinds of things. They're arguing though, I've seen some studies saying it may show less progression with patients and LASIK, but that remains to be seen. I mean, it hasn't been out long enough for me to say that this distinctly, but you can always remove it. So if something gets weird, if the lens hardens, if the patient develops diabetes, or the lens changes, or something really gets funny, that thing comes out like a piece of tissue paper. It's super simple to remove, which is very cool. So that's a reversibility aspect, and that's a massive advantage it has again, not, again, trying to beat down LASIK. We're just comparing and contrast what the differences are. But they're pretty significant.

Kaiser Maharjan:
Absolutely. It's really fascinating. Can you tell me a little bit more about what the ideal patient for EVO looks like?

Fazio:
Probably the same thing you're looking at for any LASIK patient. It's someone that wants to get out of glasses, tired of contacts, maybe contact lenses are irritating them, active patients. I mean, the company's actively seeking testimonial-like patients, many of them are athletes. So you're gonna start seeing those, a basketball player has been already done that's got a high profile, Justin Bieber's a guy that's all over the place currently with the lens, and I guess we know who he is. They're just going to be targeting active lifestyle patients probably in the typical age range again, they're not really targeting presbyopes right now. Personally, I had a good friend of mine do the EVO recently who is a presbyopes, because he's 20/15, he was a high myope and wanted options. I said, "This is the way to do to do it," and this guy is so happy. He's become a testimonial patient for the practice, but he's a good friend of mine as well. That's off label, like on label, you're really looking at 45 and under. Kinda of like with LASIK, I mean, can you do it older? You can, you just got to be very verbal about how you do it. Are you looking at monovision? What's the stability of it gonna be? You can't guarantee stability with either of those technologies, so there's conversation that has to be had.

Kaiser Maharjan:
Absolutely. When it comes down to comanagement of patients who choose EVO, what should optometrists be ready for?

Fazio:
So it's different. It's probably very similar because, again, optometrists know LASIK. It's kind of like a LASIK pre-op, anyways, when you're doing that, we'll talk briefly about that. You're going to do like a LASIK pre-op on the exam. The difference is, there's some scans that need to be done for sizing. So the sizing on the original Vizian was done on the Orbscan, and it's really a white-to-white measurement you're looking at, and you're looking at an anterior chamber depth issue, when you're looking at ordering it. So that's what you got to be looking at. But in the immediate post-op, what's different with LASIK is because it's interoptic surgery, you're looking for pressure spikes, so you're gonna want to do that one hour check of the pressure. That's totally different, and very importantly, you're looking at something called the vault, you want to make sure that the lens isn't over-vaulted, and giving, essentially, the patient a type of angle issue. Now, that's pretty rare. I have not seen that, but it is something you do. the viscoelastic or the kind of gel that the surgeon is used to inject is called OcuCoat. It's a little different than others and they can cause that 35 kind of pressure and you got to be comfortable with what you got to do with that, which is usually not a lot. You typically will prescribe Brimonidine or something mild to kind of get him for a couple days, or nothing, depending on where it goes. But you gotta have a good relationship with your surgeon if the pressure gets high. That's probably the main difference.

Other than that, it's actually a little easier, because you're not dealing with the typical dry eye issues, and we're all very, very comfortable with [inaudible] comanagement, or at least most of us are. Typically, a 1 day, 1 week, you don't really probably need a month, you probably do a 3 month and done, and you're back to yearly. That's kind of what we're doing. We're very comfortable with it. We haven't been doing that one month. It's a long answer.

Kaiser Maharjan:
And that's okay. Are there any comorbidities or other existing conditions that would preclude a patient from getting this procedure? You know, you mentioned potentially taking out the lens if a patient develops diabetes and stuff like that.

Fazio:
Yeah, so again, comparing and contrasting probably to LASIK, which is the biggest procedure we have, is probably a bit the opposite. So when you look at patients that are poor candidates for LASIK, you got a thin cornea, you may have a patient who has a dystrophy and you really want to try to help them out, they've just been excluded from LASIK, perhaps, because their prescriptions -15, which talks about what the lens can do, you can go from minus 3 to minus 20. It can do 4 diopters of astigmatism. An example of that is a local optometrist, who was a -15 with 3 diopters to cylinder that we did, and is the happiest patient you'll ever meet and sends us like a zillion of patients. So there's that, so we'd actually do more than what LASIK can do, but probably the biggest things you're looking for is anatomy. If the chamber depth is under 3 millimeters, it's off label. Now surgeons will do it under that, by the way, we will as well, down to about 2.8 millimeters of internal anterior chamber. That's an important differentiation, so you got to exclude the cornea.

Then the size is if it's over 13 millimeters, or a microphthalmia, like a very small eye, that won't work either. So there's 5 sizes; it has quite a few, probably more than you need. The majority of the patients go within the central 3 sizes. It's very rare that you need the small one, or the really big one. It fits most eyes that you're gonna see. Those are probably the 2 considerations that is different than LASIK.

Kaiser Maharjan:
Yeah, absolutely. Well, thank you so much. Is there anything else that you'd like to add that we haven't touched on?

Fazio:
Nothing really, I think it's just an exciting new offering. It's finally something new and innovative that's coming out. I mean, I've been involved with LASIK and ICLs again for a long time, but LASIK longer. LASIK came out in, you know, the '90s, early 90s, so it's been around forever. I trained in Canada, so it's it was out there even earlier. So that's there, but you don't see a lot of new tech. I'm involved in a lot of research, you don't see a lot of new tech in LASIK, so it's kind of fun to see something new coming down the refractive reader that has distinct differences and advantages. I think it's really exciting to be involved with this product and its launch and I think we're gonna see a big explosion of growth with the ICL in the future.

Kaiser Maharjan:

Well, thank you so much for chatting today. It's been a pleasure. It's been really informative. So thank you so much, Dr Fazio.

Fazio:
Thank you.