The penetration of refractive and excimer laser surgery in Belgium is very low. Only 2% of ametropes undergo refractive surgery, compared with 94% who wear spectacles and 4% who wear contact lenses. Each year, approximately 16,000 people—from a population of 10.5 million—undergo an excimer laser procedure in Belgium. Since 2005, these numbers are stagnating.

Similar to the status in France, all Belgian laser centers are in the hands of ophthalmologists: No person outside of our profession has input into any laser center's daily activities. All centers are found in small (one to five) or large (20 to 25) ophthalmologist groups. There are 20 excimer lasers in Belgium (Table 1), only 17 of which are active. There is also still one roll-on, roll-off laser active in Belgium: This is a quasi-unique solution comparable with some in eastern European countries. The number of lasers has not increased in the last 2 years to 3 years.

Unlike other countries, including the United States, there is nearly no press coverage of excimer laser surgery—or generally speaking of refractive surgery—in Belgium. Usually, only three to four minor articles are published each year.

WAVEFRONT-GUIDED VERSUS OPTIMIZED
Some lasers need a wavefront-guided treatment to improve outcomes, whereas others such as the MEL 80 (Carl Zeiss Meditec AG, Jena, Germany) and the Allegretto Wave Eye-Q (WaveLight AG, Erlangen, Germany) use an optimized ablation profile to obtain similar results. The hype of wavefront has passed; it is now used as a primary treatment in cases with higher-order aberrations and in most retreatment cases.

SURFACE VERSUS INTRASTROMAL
Surface ablation—PRK, LASIK, and Epi-LASIK—has become more popular since 2005; what used to account for 30% of treatments now accounts for up to 40% of treatments. LASIK never became popular in the southern part of Belgium, as 95% to 100% of treatments have always been PRK or LASEK. Overall, however, the majority of excimer laser surgeons in Belgium are performing LASIK, because the recuperation time of BCVA is dramatically different from surface ablation.

Although we are more aware of the minimal risk of iatrogenic keratectasia, recent surveys demonstrate that the risk is less than feared and that these cases are probably incipient keratoconus cases that were not previously diagnosed. Surface ablation is preferred in (1) the presence of corneal irregularities that signify keratoconus, (2) cases with a thin cornea (ie, less than 500 µm for -3.00 D and up), or (3) patients practicing contact sports. The second choice is Epi-LASIK, using a separation device such as the Amadeus II (Advanced Medical Optics, Inc., Santa Ana, California), the Hansatome (Bausch & Lomb, Rochester, New York), or the M2 (Moria, Antony, France). This is more elegant (ie, produces a nicer flap) is less toxic (ie, no alcohol), and results in less pain and discomfort in the healing period.

In Belgium, the standard of care for surface ablation includes the use of ice water before and immediately after treatment. For ablations of more than 80 µm, 0.02% mitomycin C is used for 20 seconds following treatment to avoid haze formation.

PHAKIC IOLs
Anterior and posterior chamber iris-fixated IOLs. As the limits for excimer laser surgery were brought down between -8 to -10, we moved toward phakic IOL implantation. Our favorite choices are the Veriflex/Verisyse (Advanced Medical Optics, Inc.), or the Artisan/Artiflex (Ophtec, Groningen, the Netherlands), as marketed in Europe. Introduction of the foldable Veriflex revolutionized this technology, as it tremendously decreased the recuperation time. Patients with phakic IOLs, similar to those with posterior chamber IOLs, regain BCVA nearly instantly.

The spherical and toric versions of the STAAR ICL (STAAR Surgical, Monrovia, California) and the PRL (Carl Zeiss Meditec AG), a phakic refractive lens, are also popular in Belgium. We prefer the Artiflex, because we are convinced that it is safer for the eye in the end. We also have experience performing cataract surgery in eyes with a Verisyse IOL. Surgeries were uneventful; first, we phacoemulsified the cataract and implanted the new IOL lens, and then we performed IOL removal.

Concerning the Veriflex/Verisyse and Artisan/Artiflex lenses, in 2006, 8% of patients received a phakic hyperopic IOL, and 92% received a myopic. Of the myopic IOLs, 70% received the foldable Artiflex and 30% received the old Artisan. The mean diopter value of implanted phakic myopic IOLs was -10.00 D, although 10% were -5.00 D or less.

In Belgium, the foldable toric Artiflex is expected to receive a Conformité-Européenne (CE) mark in early 2008. The STAAR ICL has also enjoyed success; its market share of LASIK procedures was 5%. Additionally, there is a trend to implant this lens in eyes with moderate-to-low myopia. The Zeiss PRL has ±1% of the LASIK market share.

OTHER PROCEDURES/TECHNOLOGIES
Thermal procedures/conductive keratoplasty. Optical thermal procedures are a niche sector. We have personal experience with conductive keratoplasty: We know that the effect regresses, although slower than after laser thermokeratoplasty, and that there are several indications for its use including presbyopia, touching up hyperopic refractive overshoots after previous refractive surgery, or astigmatism treatment after previous refractive or cataract surgery.

There are seven conductive keratoplasty units in Belgium, four of which are regularly active and used on approximately 100 patients each year. The trend of conductive keratoplasty is slightly growing.

Femtosecond lasers. As of yet, there are no femtosecond lasers in Belgium. This technology certainly improves predictability and safety through (1) consistent flap cuts, (2) thinner and more regular flaps, and (3) a more homogenous bed. Femtosecond lenticule extraction (FLEX) technology, introduced by Walter Sekundo, MD, of Mainz, Germany, with the VisuMax femtosecond laser (Carl Zeiss Meditec AG) eliminates the need of an excimer laser. This technique may revolutionize refractive laser surgery in the near future—if preliminary results are confirmed.

HYPEROPIA
The limit for excimer laser refractive surgery in hyperopic patients is 4.00 D to 5.00 D, however, most surgeons would not use the excimer laser on an eye with more than 4.50 D. In those instances, a phakic anterior chamber IOL—when the anterior chamber depth allows it—should be used. Alternatively, a posterior chamber phakic IOL could be inserted. Refractive lensectomy using a monofocal or multifocal IOL would be the ideal solution.

Multifocal and accommodating IOLs. The Crystalens IOL (Eyeonics, Aliso Viejo, California) was introduced to Belgium in 2001. Because outcomes were different in Belgium and Europe than in the United States—and unrealistic expectations were created—the use of this IOL dropped sharply and disappeared in Belgium. On the contrary, the use of multifocal IOLs is growing. The Restor (Alcon Laboratories, Inc., Fort Worth, Texas), using apodized technology of 3M (Saint Paul, Minnesota) was first introduced to Belgium in 2004. Advanced Medical Optics, Inc. introduced the diffractive Tecnis Multifocal in 2005. We have personal experience using the Tecnis lens with prolate anterior surface-enhancing contrast sensitivity in more than 350 eyes and are extremely pleased with the results.

There is a trend toward a higher penetration of multifocal IOLs in Belgium. Approximately 10% of IOLs are multifocal; 1 year ago, this number was 7.5%. There is also a trend toward mixing and matching diffractive (eg, Tecnis, Restor) and refractive (eg, ReZoom) IOLs.

Together with Advanced Medical Optics, Inc., we started the Happy Patients Project. Its intention was to increase better patient selection so that side effects (eg, halos that are present in 5% of patients) would be avoided or minimized.

FUTURE TRENDS
I. Howard Fine, MD, of Eugene, Oregon, phrased it nicely at the American Society of Cataract and Refractive Surgery opening session when he said that US surgeons are switching from high-volume low-cost to high-quality personalized patient paid care. We expect a similar change in our country. The market of refractive surgery in Belgium will continue to grow, due to a combination of new technologies such as bladeless LASIK and phakic and multifocal IOLs.

At the end of 2006, IntraLase (IntraLase Corp., Irvine, California) held 30% of the procedural market share in LASIK in the United States. It may be a little too early to tell if femtosecond laser technology will grow, but with the right improvements and advancements in technology, it may become the gold standard.

Frank J. Goes, MD, is Medical Director of the Goes Eye Centre, in Antwerp, Belgium. Dr. Goes states that Advanced Medical Optics, Inc., Alcon Laboratories, Inc., Bausch & Lomb, Ophtec, STAAR Surgical, and Carl Zeiss Meditec AG provided data for this article. He also states that he receives travel compensation from Advanced Medical Optics, Inc., and Carl Zeiss Meditec AG. Dr. Goes may be reached at tel: +32.3.2198491; fax: +32.3.2196667; or frank@goes.be.