Patients from two groups, low myopes and high myopes, have been conspicuously underrepresented among the millions who've undergone refractive procedures. To help you reach these candidates and meet their needs, we've compiled advice from three surgeons who have mastered both ends of refractive surgery's widening correction range.

On the following pages:

�        Dr. Andrew Caster clues you in to the mindset of low myopes, who are more likely to achieve an excellent surgical result, and explains how to position LASIK so that it appeals to them.

�        Dr. Sylvia Norton shares how she's attained excellent results performing PRK on high myopes

�        Dr. G. Peyton Neatrour, and Mark A. Lipton, O.D., outline how they prepared their practice to offer corneal ring segments.

By considering the insights of these surgeons, you too can reach high and low for refractive surgery success.

Marketing LASIK to Low Myopes

By Andrew I. Caster, M.D., F.A.C.S.

Despite all the recent attention laser vision correction has received in the media, it's still in the very early phases of consumer adoption. Only a small percentage of the eligible candidates have chosen to undergo this type of surgery. Furthermore, low myopes as a group have been much less likely to have laser vision correction than medium or high myopes.

This is significant because the majority of myopes are in this category. A 1990 study by Health Product Research, Inc. found that 63% of the myopic population was -2D or less. A study by Dain Rauscher Wessels in 1998 had similar findings: 65% of myopes were -2.5D or below.

However, when you look at which myopes have actually had laser vision correction, a very different picture emerges. A review of more than 20,000 VISX laser vision correction treatments found that only 7% of the myopic treatments were performed on myopes -2D and below. (At the same time, the Dain Rauscher Wessels study found that a mere 2% of myopes were -6.2D or higher -- yet this group accounted for 34% of the myopes having laser vision correction in the VISX study.)

Put another way, low myopes (-2D and below) are approximately nine times less likely to have laser vision correction than their percentage of the overall myopic population might lead us to expect. Likewise, high myopes (-6D and above) are 10 to 15 times more likely to have laser vision correction than their percentage of the myopic population would suggest.

Taking a closer look

How can we explain this? First of all, two groups of low myopes aren't good candidates for laser vision correction:

�        extremely low myopes who border on emmetropia

�        presbyopes who simply take off their glasses to read.

Recruitment of these myopes will probably depend on future technological advances. Extremely low myopes may be attracted by the expectation of improved best-corrected vision, which could be possible with customized corneal treatments. Myopic presbyopes are most likely to be attracted to laser vision correction by the simultaneous availability of an easy and effective treatment for presbyopia.

However, even if we leave out these two groups, low myopes are still much less likely than high myopes to have laser vision correction. Consumer research by VISX has shed a lot of light on the reasons for this.

First and foremost, low myopes (on average) view themselves as being less handicapped by their myopia. (In fact, they are less handicapped. They wear thinner glasses and have more comfortable contact lenses, and they're able to function better without them.)

Less handicapped means less motivated. And because most low myopes have a lower sense of urgency about their vision problem, the "sales cycle" is longer; they need more time and more reassurance from patients and doctors before making a commitment. (Yes, we've all seen -1D myopes who tell us how horrible their vision is without their glasses or contact lenses, but these patients are the exceptions.)

Targeting low myopes

If you want to market to low myopes -- who comprise the majority of laser vision correction candidates -- here are some strategies that may increase the effectiveness of your message:

�        Focus on safety, precision and track record. Remember that low myopes don't see themselves as being very handicapped. For that reason, a marketing message emphasizing the removal of a handicap won't have much impact on them. "See the alarm clock without your glasses" will miss the mark.
Instead, VISX's consumer research reveals that low myopes are more concerned about safety, precision and the surgeon's record of success. This concern simply reflects human nature: The less you have to gain, the more concerned you are about what you may lose. An advertising message stressing safety and precision will address this concern.
Fortunately, low myopes are more likely to achieve an excellent surgical result. It may be a good idea to remind them of their higher likelihood of success. Stratifying outcome data could be a good way to demonstrate this.

�        Consider a "retail" approach. Some low myopes view laser vision correction as a "technology" rather than as a medical procedure. It may be that these people view themselves as not really having a "medical" problem, so they tend to view the solution in the same context. They may respond more to a retail approach than a medical approach.

�        Appeal to contact lens dropouts. Contact lens dropouts are one of the key groups likely to have laser vision correction. An effective message might focus on:

o       the irritation or inconvenience of contacts

o       the change in lifestyle that will result from having laser vision correction

o       an overall cost comparison over a 10-year period.

�        Consider offering a discount. Because low myopes are typically less motivated to have the procedure, a few doctors have responded by charging lower fees to low myopes. This may make the procedure more attractive to these patients.
However, before discounting, you should carefully consider the degree to which price is affecting your patients' decisions (as opposed to the many other psychological factors discussed above). A lower profit margin only makes sense if it will be more than compensated for by a larger volume.
The reality is that most people don't buy the cheapest clothes, meals, cars or services available -- legal, accounting, or architectural, for example -- when the service is viewed as requiring skill and the outcome is of great importance. Besides, a discount may be resented by other patients. It may also lead to further discounting down the road.

Looking ahead

Certainly, as time goes by, laser vision correction will be seen as less novel. Also, clinical outcomes will continue to improve, which will do a lot to increase confidence in this large group of cautious potential patients. We can safely assume that low myopes will eventually have this treatment in much greater numbers.

In the meantime, using some of the strategies discussed above can help you to bring more low myopes into your practice. And that's a win-win situation for both of you.

Andrew I. Caster, M.D., is a refractive surgeon in Beverly Hills, Calif., who has performed more than 6,000 LASIK procedures. He's the author of The Eye Laser Miracle: The Complete Guide to Better Vision, published by Ballantine/Random House Books.

Treating High Myopes with PRK

By Sylvia Norton, M.D.

As you know, about 70 million people in North America are myopic. Less than 2% of these myopes have refractive error between -10 and -27 diopters. Nevertheless, this represents several hundred thousand potential patients, and these individuals make up for their small numbers with a high level of motivation. They have a tremendous amount to gain from successful refractive surgery.

Although refractive surgery on high myopes does raise concerns that are less significant for lower myopes, I've found that treating this group with photorefractive keratectomy (PRK) can produce excellent results and be highly rewarding for both the patient and the surgeon.

Here, I'd like to explain why I favor treating high myopes with PRK, and share some of what I've learned from years of working with these patients.

Why I prefer PRK

Treating high myopes using laser-assisted in situ keratomileusis (LASIK) is a questionable proposition. The amount of tissue that must be removed to correct this level of myopia can put the integrity of the cornea at risk, as well as make it difficult for the flap to reseat. In fact, the main argument that's been offered for using LASIK to treat high myopia is the supposedly greater risk of central corneal haze in PRK.

My experience disagrees. I've treated more than 100 myopes between -10D and -27D, using a VISX laser for single-stage PRK, with excellent results. I've found single-stage PRK to be highly effective and accurate, and it often has fewer complications than LASIK.

The key to avoiding and managing corneal haze, in my experience, has been controlling corneal moisture. By making this a major issue in post-PRK care, I've been able to minimize the problem. (See "Case Histories," right.)

A lot to gain

Individuals with myopia greater than -10D are highly motivated to consider laser surgery. They live with many visual inconveniences:

�        minimized images and lens edge distortions from thick spectacle lenses

�        the look of thick, "coke bottle" glasses

�        expensive spectacles and contact lenses (glasses for the correction of high myopia can cost $300 to $500 per pair)

In addition, better vision and facial appearance motivates many of these patients to wear contact lenses for as many hours a day as possible. This leads some patients to contact lens over-wear syndrome or warpage of the cornea.

For all of these reasons, the option of a safe, accurate method of eliminating both glasses and contact lenses is very attractive to the high myope.

Getting off to a good start

The first step to successfully using PRK to treat high myopes is careful patient selection. Make sure you:

�        Take a thorough medical history. Exclude any high myopes with contraindications to PRK.

�        Educate the patient. The patient must be fully aware of the risks (and benefits) of using PRK to correct high myopia. In particular, counseling patients about the long postoperative healing of the cornea is necessary to ensure compliance.

�        Get informed consent. This is essential, not only for your legal protection, but to ensure a successful outcome.

Maintaining a stable eye before surgery

During my years of experience treating this unique group, I've noted a number of factors that increase the likelihood of achieving the intended result. Making sure the eye is stable before surgery is crucial. To ensure this:

�        Discontinue contact lenses. Contact lenses must not be worn for at least 2 to 3 weeks prior to the evaluation (a minimum of 2 weeks for soft lenses, 3 weeks if the lenses are hard or gas permeable). Lenses must remain out until after surgery.

�        Check corneal topography and refractions on the day of surgery. This allows you to detect any changes due to corneal warpage or because the patient failed to follow instructions and completely discontinue contact lenses prior to the surgery.

�        Check for progressive or unstable myopia. These patients must be excluded.

�        Check for dry eye. I've found dry eye syndrome in 62% of the highly myopic eyes I've treated. Also, about 60% of our PRK candidates present with acne rosacea, known to be associated with unstable tears due to meibomian gland dysfunction. You should treat patients with either condition with punctal occlusion using silicone plugs prior to PRK.

�        Educate patients about pre- and post-op PRK complications. The patient may notice a symptom that would otherwise go undetected.

Postoperative healing and complication management

Complications encountered with PRK treatment of eyes between -10 and -27D include central islands, transient haze, dry eyes and need for secondary treatments. Postoperative steroid treatment and control of corneal moisture is critical to corneal wound healing, and essential to achieving superior results. In fact, by focusing on these concerns, we've been able to manage complications without any loss of visual acuity.

Generally, we prescribe topical steroids, which are slowly tapered (dropping back a step about every 6 weeks). We have the patient continue steroids if haze develops. We also prescribe medication for pain control and sedation, if necessary, and advise the patient to rest and avoid work for 48 hours. (These patients usually expect their eyes to heal without any special effort on their part. In fact, their eyes heal much better -- and they complain less about pain --if they rest.)

�        Dry eye control. Postoperative healing is greatly enhanced by careful control of ocular surface lubrication. We insert punctal plugs for increased tear film stability, and tell patients to instill tears every 1 to 2 hours.
We also advise patients to:

o       avoid dry environments. A dry environment will have a significant impact on the healing of all PRK patients. We recommend humidifying the work and home environ- ments, and we warn patients about the dangers of wood stoves, heaters, fans and air conditioners.

o       avoid dehydrating medications. Antihistamines, decongestants and diuretic medica- tion can undermine corneal healing post-PRK.

o       wear nocturnal moisture retention goggles to conserve ocular moisture. Incomplete blinking and nocturnal lagophthalmos are evident in many contact lens wearers. Use of moisture goggles post-PRK decreases tear film evaporation from corneal exposure.

�        Central islands. We reinsert bandage lenses for 1 month or more if central islands occur. (All central islands that we've encountered have resolved with this therapy.)

�        Transient haze. Haze resolves if tear film stability is enhanced with artificial tears, punctal plugging and nocturnal moisture goggles, as well as slowly tapering steroid therapy over a period of 6 to 7 months. (See chart above, left.)

In the final analysis . . .

Many high myopes don't achieve their final, stable visual outcome until a year or more after surgery, even though good functional vision can be obtained within the first month. By the 1-year postoperative visit, about 60% of our high myopes, with or without astigmatism, had achieved 20/15 uncorrected acuity. The intended correction versus the actual correction achieved shows a very close correlation at 12 months post-PRK (see "Intended vs. Actual Correction," above, right.)

The bottom line? Despite some surgeons' reservations, PRK is very effective for treating high myopia, and the risks are relatively low when compared to those encountered with more invasive refractive procedures. Long-term visual outcomes are excellent. And paying more attention to maintaining corneal moisture has minimized the problem of corneal haze.

Given these patients' high level of motivation, treating them with PRK makes sense. And the results will generate a lot of personal satisfaction for both you and your patients.

Case Histories: Two High Myopes Treated with PRK

Two patients (one younger, one older) illustrate the typical postoperative course for high myopes. Although long healing is to be expected, the results of the highest myope treated (Case One) show how rapid and clear visual results can be with PRK.

Case One: Male, age 27

Refractive errors:

OD -23.00 -1.00 x 121 20/40 +2

OS -27.00 -1.00 x 029 20/30 -1

History: Patient had dry eye syndrome with incomplete blinking (Marfans syndrome). Artificial tears, preoperative silicone punctal plugs and nocturnal moisture retention goggles were used to address this problem.

Results:

POST-OP VISIT	UCVA RIGHT EYE	UCVA LEFT EYE
first day	20/400	20/60
second day	20/70	20/50
third day	20/40 -2	20/40
1 week	20/20	20/25
8 months	20/20	20/25

 

This patient showed two Snellen lines of improvement above his best corrected preoperative vision for the right eye.

Case Two: Female, age 57

Refractive errors:

OD -10.75 -1.00 x 089 20/25

OS -12.50 -0.25 x 178 20/20

History: Dry eye syndrome

Results:

����������� POST-OP VISIT	UCVA RIGHT EYE	UCVA LEFT EYE
first day	20/100	20/200
second day	20/30	20/70
third day	20/40	20/50
1 week	20/30	20/30
4 months	20/25 +2	20/15

 

Both eyes achieved better than the previous best corrected spectacle acuity.

Dr. Sylvia Norton is a cornea and refractive surgery specialist and director of the Jerva Eye Laser Center in Syracuse, N.Y. Dr. Norton is also an adjunct professor at the University of Ottawa Eye Institute. She was an FDA principal investigator for PRK from 1991 to 1996 and has studied dry eye for 20 years.

The Corneal Ring Segment Alternative

By G. Peyton Neatrour, M.D., and Mark A. Lipton, O.D.

Despite the growing popularity of refractive surgery and the large number of myopes in this country, treating low myopes can be a challenge. Many surgeons aren't comfortable using laser surgery for very low ranges of myopia. At the same time, low myopes have less to gain and more to lose by subjecting their eyes to a procedure that entails risks. As a result, low myopes are often more cautious and less willing to undergo laser surgery than higher myopes.

Corneal ring segments (CRS) are an attractive alternative to laser surgery that can help you bring these potential patients into your practice. They offer low myopes a low-risk way to achieve freedom from glasses and contacts, with excellent visual acuity. More important, refractive correction using CRS is reversible, unlike correction done using LASIK or PRK.

Currently, Intacs from KeraVision are the only CRS available in the marketplace. And although the FDA-approved range for Intacs is limited at the moment -- 1D to 3D of myopia and 1D or less of astigmatism -- an enormous number of adults fall within this range. A marketing study conducted for KeraVision by the A. D. Little Research Group indicates that about 15 million people are currently eligible for Intacs, and about half of them are interested in undergoing refractive surgery to correct their vision.

Advantages of corneal ring segments

Many of the points listed below can help you to convince reluctant low myopes to come to you for correction.

Corneal ring segments are:

�        Quick and easy. Implanting Intacs requires no special equipment. The procedure can be done in a standard minor procedure room and only takes 10 to 15 minutes per eye.

�        Safe. The safety of Intacs has been demonstrated in clinical trials. (See below for potential complications.)

�        Effective. Currently, Intacs are available in three sizes: 0.25 mm (to correct -1D to -1.5D), 0.30 mm (-1.75D to
-2.25 D), and 0.35 mm (-2.50D to -3.00 D). In a U.S. premarket approval cohort study conducted by KeraVision, 74% of patients implanted with CRS achieved 20/20 UCVA or better; 55% achieved 20/16.
We're conducting an ongoing study at our own clinic comparing visual outcomes following LASIK and Intacs implantation. So far, comparing 100 eyes in each group, the Intacs eyes have achieved a greater percentage of 20/20 and 20/15 vision than the LASIK eyes. (We plan to report the complete results of the study at the American Society of Cataract and Refractive Surgery meeting this month.)

�        Reversible. Inserting the corneal ring segments flattens the corneal surface, gently stretching the tissue and eliminating excess curvature. No tissue is removed from the central optical zone of the cornea; natural, positive corneal asphericity is maintained. Because neither the structure nor the function of the eye is permanently changed, refractive surgery with CRS is fully reversible.

�        Adjustable. A less-than-optimal correction can easily be adjusted by replacing the implant with another of the three available sizes. (In our experience, this is seldom necessary.)

�        Adaptable. If the patient's vision changes over time, CRS can be replaced to match the patient's current needs. Patients who may soon develop presbyopia, for example, will have the option of switching to monovision. Younger patients who are likely to have a change in prescription will know that their CRS can be adjusted accordingly.

In addition to these benefits, CRS can be used as a follow-up to prior vision correction methods. For example, they can be used to correct low residual myopia after LASIK if further corneal reduction isn't appropriate.

Managing complications

During the first 10 months we offered Intacs, we implanted them in 140 patients. The few complications we encountered are described below.

�        Overcorrection (<1%). One 52-year-old patient was overcorrected. We removed the CRS and plan to perform LASIK. (Another alternative would be to implant 0.21 mm CRS as part of an FDA-approved study, or whenever they become available.)

�        Undercorrection (4%). We exchanged CRS successfully in two patients and plan to correct the remaining four patients by exchanging their current CRS for 0.4 mm or
0.45 mm CRS, as part of an FDA-approved study.

�        Induced astigmatism (5%). The few cases of induced astigmatism we encountered had two different causes:

o       Incision-related (1%): Two eyes in different patients without initial sutures healed with gaping, causing against-the-rule astigmatism. A suture enhancement resolved the astigmatism. However, a suture wasn't sufficient to resolve the astigmatism in three other eyes, when gapes weren't noticed at the slit lamp.

o       CRS-related (4%): In 5 eyes, intolerable against-the-rule astigmatism (greater than 1.00D) developed between week 1 and week 12, necessitating CRS removal. The astigmatism resolved in 1 week, and the myopia has returned to within 0.75D or less of
preoperative refraction.

Help getting started

Because corneal ring segments are unique and still relatively new, KeraVision has developed an optional 10-step program to help you integrate Intacs into your practice. We took advantage of this program and were able to incorporate Intacs into our armamentarium within 3 months. (Note: Whether or not you choose to participate in this program, certification in implantation of Intacs is required by KeraVision.)

These are the 10 steps in the KeraVision program, which cover the key aspects of incorporating almost any new technology into a practice:

�        Introduction. Before we received any formal training in the surgical procedure, a representative from KeraVision introduced us to the product, the procedure and the results of clinical studies. He helped us explore the potential market for Intacs in our area and determine whether we needed any additional dedicated staff. (Because our practice already had several refractive coordinators, we didn't need any additional staff.)

�        Training. Our surgeons, surgical technicians and refractive surgery coordinators attended training sessions, which are held periodically at central locations. Although some surgeons are resistant to the idea of mandatory training, inserting Intacs is a unique procedure. It involves the use of an unusual marking system, and you'll need to use three instruments at once at one point during the surgery (a suction ring, a pocket guide and a tunneler). We found the training, which includes wet lab experience using eye bank eyes and lectures on theory and technique, very helpful.

�        Strategic planning. We developed a 90-day strategic marketing/integration plan that:

o       assigned responsibilities

o       detailed financing options for patients

o       recommended staff incentives for communicating the features and benefits of Intacs to candidates

o       provided material for advertising campaigns

o       arranged for ongoing staff training

o       arranged special training in technical issues as well as sales, pricing, marketing and patient consultation for a dedicated Vision Correction Coordinator (VCC). Front desk staff were trained to field phone calls and route them to the VCC.
The representative also made sure that all required instrumentation was put in place and checked, and helped us to equip vision correction consultation rooms for patient orientation and education about CRS.

�        Proctoring. Within 30 days of the training, we began performing Intacs procedures, with assistance from a proctor assigned by the company. The proctor created detailed reports on our first few patients' preoperative and postoperative status, with follow-up at 1 week and 1 month post-implantation.

�        Staff training. After our first proctored surgeries reached 1 month post-op, the representative helped us implement the strategic plan. He lead a series of training meetings designed to clarify staff and patient expectations and reinforce our staff's commitment to offering Intacs. The meetings covered all aspects of integrating Intacs into our practice, including:

o       background information about Intacs and KeraVision

o       the procedure's indications, benefits, restrictions and contraindications

o       helpful information about phone skills, marketing, advertising and sales programs.

�        �Implementing marketing programs. We also fine-tuned our target market concept, finalized our individualized marketing plan and began advertising the procedure in our area.

�        Training for patient consultations. During the second month of the 90-day strategic plan, our staff was trained to guide the prospective patient from the consult phase through to the decision to have Intacs implantation. This training, which involves the surgeon, the VCC and someone posing as a potential patient, focused strongly on role playing (using video techniques) and patient education.

�        Patient seminars. KeraVision can help you provide seminars for patient education -- usually 1 hour long (or less) -- using computer-projected slides. For our practice, the VCC, with help from company representatives, developed standardized patient information displays that we show to patient candidates in the vision correction consulting room.
KeraVision provides an information packet for prospects which includes a booklet containing:

o       background information on eye function and myopia

o       a description of how Intacs work

o       the benefits and risks of the procedure

o       major package insert information, including contra-indications, warnings and precautions

o       instructions on preparing for the procedure

o       information about post-surgical care and restrictions

o       a self-test to reinforce the learning experience.

�        O.D. seminars. Once we collected positive 90-day follow-up data on the first 10 eyes treated, our representative helped us start a seminar-based outreach, education, and incentive program aimed at O.D.s. The program was designed to make O.D.s aware that we offer this procedure, and to encourage them to refer prospective candidates. (A track record of acceptable outcomes was essential because O.D.s want to see favorable results before referring patients.)

�        Evaluation and refinement. Finally, we underwent periodic reviews designed to:

o       analyze the initial and follow-up data from each surgery

o       address any surgical problems that arose

o       make sure that equipment was restocked as needed

o       review marketing and business plans

o       assess pricing to make sure we remained competitive

o       identify new challenges, opportunities and goals and add them to our strategic business plan

o       offer refresher training as required.

Everybody wins

CRS offer low myopes a relatively risk-free way to permanently but reversibly correct refractive problems. In fact, this is the first corrective procedure ideally designed to reach this untapped segment of the refractive market.

The addition of this non-laser alternative has helped to separate our vision correction practice from others and has given our patients another option for vision correction that has unparalleled future versatility. If you choose to offer Intacs and take advantage of the comprehensive program described above, you too will be able to attract and treat a wider pool of patients, offer more options and greater flexibility to your existing patients, and expand your practice.

Dr. Neatrour has been performing vision correction procedures since 1993. His practice is 80% refractive, offering LASIK, Intacs and AK. He's been recognized as a VISX star surgeon (top 5% by procedure volume in the U.S.) for the past 2 years. He's committed to giving his patients the best vision correction alternatives and has undergone LASIK himself. Dr Lipton has co-managed several thousand cases of LASIK, Intacs, RK and AK since 1992. He's practiced with Dr. Neatrour since 1996. Dr. Neatrour performed LASIK on Dr. Lipton in 1997 .