Soon after its FDA approval in 1998, LASIK became the most popular surgery among patients looking for a permanent means of correcting refractive error––easily eclipsing PRK as the procedure of choice. After the heady days of the initial boom, the LASIK market went bust. But, with the initial pent-up demand satisfied and a downturn in the economy in recent years, is LASIK still prominent in the hearts and minds of eye care practitioners, and their patients?
Here, your colleagues—some in private optometric practice, others in comanagement settings—offer their insights on current LASIK trends, comanagement pointers and how to best help your patients set expectations for surgical outcomes.
LASIK: Trends and Numbers
About five years ago, Scott Hauswirth, O.D., saw a decrease in both LASIK and PRK at his Minnesota Eye Consultants practice, which has 10 offices, including five located within the Twin Cities. “Patient interest in laser surgery is still there—the means to justify the expense sometimes is not,” he says. And while he says both refractive procedures have been relatively flat in recent years, he’s noticed a shift towards PRK among those who choose laser surgery, which he attributes to “a more conservative mindset in surgical approach, where we are preserving more corneal integrity.”
James Thimons, O.D., founding partner of Ophthalmic Consultants of Connecticut, concurs. “Less than five years ago, LASIK was 95% or more the market in most offices,” Dr. Thimons says. Today, almost 25% to 30% of his patients undergo PRK because it provides a safer and more predictable outcome, he says.
When
competition among refractive surgeons heated up, many turned to price
cutting—sending the entire market into a downward spiral. Those who
remained above the fray are better positioned today. Dr.
Thimons says that, because his office is based on a comanagement model,
they do no external marketing, so the cost per patient is extremely
low. While many practices chose to lower their fees to attract volume
during the lean years, Dr. Thimons says his practice chose a different
option. “We maintained fees, but made a commitment to clinical
excellence through advances in technology and patient care,” he says. As
a result, “the comanagement network and word-of-mouth referrals from
satisfied patients have allowed us to stay very competitive in a
challenging market.”
Conversely,
Dr. Thimons says many of his competitors who offered low prices for
LASIK fell by the wayside and couldn’t stay in the market when patient
volume diminished. “They wound up with financial problems because they
offered lower prices, and when volume went away they could not sustain
the model,” he says.
Dr.
Thimons also cites advances in LASIK surgery that have improved patient
outcomes and significantly broadened the patient base, including the
femtosecond laser and iris registration, which improves outcomes in
astigmatic patients. To keep current with technology requires continual
investment in capital equipment—and that can’t be sustained by a
low-price business model.
At TLC Laser Eye Center in St. Louis, the volume of LASIK surgery has remained steady, according to clinical director Eric Polk, O.D. One change, however: Dr. Polk is noticing an increasing trend of younger patients taking the plunge. “Patients who are in their late 20s and mid 30s are more interested” these days, Dr. Polk says. “These patients are aware that they have other choices besides glasses and contact lenses and are more willing to embrace new technology.”
Price Wars: The Unkindest Cut
Dr. Thimons sees this as well. “The average age of patients undergoing LASIK has decreased noticeably over the last several years. We now routinely are seeing patients five to 10 years younger than when we first began LASIK,” he says. Dr. Thimons, who estimates he and his surgical partners have comanaged 60,000 LASIK patients over the last 16 years, has also noticed another trend: more women are having LASIK surgery today. A decade ago, the vast majority of patients being treated at his practice were men. But now, Dr. Thimons says the split of men vs. women is at least 50:50.
While LASIK has remained steady for some practices, other O.D.s have not had the same experience. In 1996, Randall Fuerst, O.D., opened his first laser surgery center in Sacramento, Calif. As the business grew, he and a group of investing doctors expanded to 10 locations throughout California and Reno. Business continued to grow until the tech bubble burst in 2000, then his practice weathered the economic downturn and resumed growth until 2008. But the stock market crash that September, coupled with a pricey investment in a laser that was later recalled by the FDA, hit Dr. Fuerst’s business hard; ultimately, it could not withstand the financial loss.
Today, Dr. Fuerst is a partner in a multi-location practice in the Sacramento suburbs. Having ridden the highs and lows, he does not believe LASIK currently offers much to boost a practice’s bottom line. “LASIK in this economy continues to struggle,” he says. While it remains a revenue stream, he believes that it won’t account for more than a few patients per month.
Still, in the past six to eight months, Dr. Fuerst says he has seen a slight increase in patient interest. “We learned in LASIK to follow the consumer confidence data. If consumer confidence rose, almost invariably LASIK volume rose. Conversely, if it dropped, LASIK volume dropped. In 2009, consumer confidence fell to all-time lows,” he says.” Recently, consumer confidence levels have been trending upward, he notes.
Although the economy can adversely influence those considering LASIK, motivated patients “will have the surgery done regardless of what the state of the economy is at that time,” Dr. Polk says. “These patients are willing to finance the cost of their surgery and pay for it in the next few years.”
To Refer Or Not To Refer
With LASIK in the doldrums, are optometrists still actively discussing it with patients and referring for a surgical consult?
Richard Mangan, O.D., Center Director of Whitewater Eye Centers in Indiana and Ohio, says that, generally, out of all doctors who refer to his practice, just 10% are proactive in discussing refractive surgery with their patients. “While most may have brochures in their waiting rooms promoting it, usually it takes the patient to speak up and express interest. With that said, most optometrists today are more accepting of referring out for LVC than maybe 10 years ago,” he says.
Dr. Polk advises his practice’s doctors not to wait for the patient to ask about refractive surgery. Interested patients, he believes, will have the surgery with or without the involvement of their optometrist. Some don’t ask their O.D. about LASIK because they believe the doctor does not want them to have surgery, he says. “These patients will do their own research on LASIK and may choose a provider they discovered on the Internet or heard about in an advertisement.” Dr. Polk believes the O.D. should offer surgery as an option and let the patient know that he or she can be comanaged at the optometry office. The optometrist benefits by keeping the patient in his or her office, instead of losing the individual to the ophthalmologist or laser center, he says. Secondly, it also allows the optometrist to recommend a known and trusted surgeon, he adds.
Forme fruste keratoconus need not contraindicate LASIK, if the patient is carefully screened and the condition is accounted for in the surgical approach.
Despite Dr. Fuerst’s experience, he still offers LASIK as a side-by-side option along with glasses and contact lenses. “I believe that I provide better patient care if I present all viable options to patients for their visual well being.”
Several of his partners no longer mention LASIK, instead waiting for the patient to inquire. “The rationale is that the marketplace is substantially different than it was in 1996-2000, when we began partnering with ophthalmologists in providing LASIK,” he explains. “We have much better contact lens options now—the polymers, surface coatings, dry eye treatments and multifocal contact lens designs often are better options than monovision LASIK or bilateral distance LASIK with reading glasses.” The case for LASIK is now less compelling in the face of better corrective lens options, many O.D.s believe.
Optometrists’ Role in Comanagement
Despite the ups and downs of the LASIK market, optometrists still play an integral role in comanagement. For Dr. Mangan, this includes these key steps:
• Refractive consultation. This complete exam covers all necessary testing to design a treatment plan for laser vision correction—including topography, wavefront analysis, ocular surface assessment and other presurgical testing. “If a patient is a candidate and has realistic expectations, I design a treatment plan, review the risks, benefits and alternatives, and then hand the patient off for scheduling of the procedure,” Dr. Mangan says.
• Postoperative care. The refractive surgeon reviews the clinical findings prior to surgery and will hold a meet-and-greet the day of the procedure to review any last-minute questions and provide reassurance. Dr. Mangan will then see the patient for their one-day postoperative visit. Assuming a normal outcome, the patient is then released to their optometrist for ongoing follow-up.
The process is essentially the same for patients who self-refer, although Dr. Mangan’s practice recommends a free screening first so that patients fully understand the fees. Also, the screening will permit the clinical staff to determine if the patient is indeed a surgical candidate. “We do not have this concern when a patient has already seen their optometrist. We still encourage comanagement, even if the patient bypassed their O.D. and came directly to our office,” he says.
For Dr. Thimons, the most important part of comanagement occurs before the procedure. “Patient selection is the key reason for success or failure.” Just last month, he turned down two patients interested in LASIK; other clinicians, he believes, may have given the green light. Concerns related to hyperopic correction, corneal steepness and pre-existing disease such as anterior basement membrane dystrophy, dry eye and forme fruste keratoconus, are all issues that can make or break a successful outcome. If properly managed, they pose no hindrance. But preoperative inattention to these factors can create postoperative complications and unhappy patients, he says.
At the one-day postoperative visit, Dr. Thimons checks to make sure that the LASIK flap is in the correct position, the surface epithelium is intact, the wound margins are healing and there are no underlying inflammatory issues. He also confirms that the uncorrected visual acuity meets expectations. “I am not concerned if vision is not perfect on day one, but I do want the patient to perceive the success of the procedure. This is often more of an encouragement visit for the patient.” At this time, he also reviews temporary lifestyle restrictions, such as prohibitions on swimming, gardening and heavy lifting.
At the two-week visit, Dr. Thimons evaluates corneal health and checks the refraction. If everything is on point, the patient is scheduled for a three-month follow-up. If not, he or she comes back in two weeks to be rechecked.
Fortunately, today’s advanced, all-laser procedures have reduced the demand for subsequent retreatments. The need for enhancement procedures when using the Intralase (Abbott Medical Optics) femtosecond laser for flap creation has gone down to 1% to 5%, depending on refractive correction, Dr. Thimons says. Additionally, careful patient selection and realistic postoperative expectations also should diminish the need for enhancements.
At the two-week visit, Dr. Thimons spends time talking about the visual outcome. “We discuss what they can do now that wasn’t possible before, such as driving without glasses, seeing the alarm clock in the morning and not worrying about contact lens care. This is an opportunity to teach patients about the process of laser vision correction. “There is some cheerleading involved, but it is mostly informative,” he says. “Hopefully, they will talk to others about what a great experience it was.”
At the three-month visit, he stresses that the cornea has changed, but not the retina or optic nerve. “I remind the patient they need to be seen on a yearly basis to assess the aspects of their ocular health that are related to their preoperative myopia.”
Dr.
Fuerst begins by letting the patient know he will do everything in his
power to take good care of his or her vision and eye health “for many
years to come,” not just during a lone surgical procedure. “From this
long-term perspective, I am more closely aligned with the patient’s
interests.” The high cost of acquiring an excimer and a femtosecond
laser, plus their maintenance costs and expenses for staffing and
marketing “can create enormous pressure to continually bring patients in
to ‘feed the laser,’” he says. Now,
no longer working in that environment, Dr. Fuerst says he can counsel a
patient as to what their expectations can and should be. “I do not mind
telling patients who have realistic expectations for distance and near
vision that they will be delighted with LASIK. If we are discussing
monovision with a patient who is on the computer eight to 10 hours per
day, I discuss and/or demonstrate what this means via the use of
monovision contact lenses. Finally, having comanaged more than 2,500
patients in the past 17 years, I can speak with knowledge and
understanding as to how LASIK can impact the patient’s world.”
At
Dr. Mangan’s practice, patients first fill out a questionnaire and
watch a video about LASIK. These educational tools give the patient an
opportunity to write down any questions that they may have. “The most
important thing, however, is simply the dialogue between patient and
doctor,” Dr. Mangan says. “It doesn’t take very long for an astute
clinician to determine whether a patient has realistic expectations or
not. I have on more than one occasion said to a patient: “If you need a
100% guarantee that you will be free from glasses after surgery, you
should not have the surgery. I prefer to under-promise and
over-deliver.” Dr. Polk
stresses the importance of personalizing the patient expectations. The
presbyope needs a different consent than the patient who’s under age 40,
and the patient who has a high prescription needs a different consent
than one with a low prescription, he says. Presbyopes should be given
the option of monovision or partial monovision, he adds. “However, I
tell patients that presbyopia is a dynamic process—even if we get it
right, they will eventually need readers for some things as they age.
Many patients do not realize this and have an expectation that their
monovision will be perfect for all distances for the rest of their
lives.” Patients with a low to moderate prescription can expect a good refractive outcome.
Comanagement 101
Carefully setting patient expectations is a key part of comanagement, of course.
To the Future
Many promising advances in technology may impact the LASIK market in the near future. Dr. Thimons cites these four breakthroughs on the horizon that may change the landscape of refractive surgery:
• LASIK has been limited in its ability to provide near-point correction, Dr. Thimons says. One new technology in clinical trials that addresses this is an inlay with pinholes called Kamra (AcuFocus) that’s implanted under the LASIK flap. “This would be a major step forward. A number of patients decline LASIK because of limits in near-vision correction.”
• Collagen crosslinking, which strengthens the cornea up to 200x its pretreatment level, effectively removing the risks of ectasia in patients with thin corneas or early keratoconus.
• Currently, IOL technology is evolving faster than LASIK. There may come a point when younger patients will more routinely opt for clear lens extraction and IOL implantation instead of LASIK, since it addresses both distance and near vision, Dr. Thimons says. New technologies may allow doctors to routinely reduce the age for lens replacement surgery to into the fourth and fifth decades to address the onset of presbyopia.
• Topography-guided laser vision systems, now under FDA review, would allow surgeons to design an ablation profile completely unique to the patient, improving results for patients with irregular corneas and other surface abnormalities. This technology may be on the market as early as 2014.
Despite the downturn in the economy, LASIK can still remain an important part of an optometric practice. With the advent of new technology, refractive surgery may yet reach the pinnacle it once enjoyed in the culture and in the clinic.
