Developing a Presbyopic Business Model
NearVision CK can be a cornerstone in serving the aging patient population.
BY DANIEL S. DURRIE, M.D.

NearVision Conductive Keratoplasty (CK, Refractec, Irvine, Calif.) has found its "sweet spot" as a treatment for patients with presbyopic emmetropia and low hyperopia — those who see well at distance but do not like wearing reading glasses. In the 3 years that CK has been on the market, even physicians who were initially skeptical must acknowledge that it works well for this patient population.

By now, early practitioners of CK have worked out most of the technical "bugs" with the treatment, established best practices for patient selection and developed technique modifications, such as LightTouch (Refractec), that make a tremendous difference in success rates and consistency of outcomes.

What remains a challenge is figuring out how to make presbyopic, anti-aging treatments like NearVision CK fit into the typical practice's business model. About 40% of the adult population (based on data from the Baltimore Eye Survey) falls into the plano presbyope category. With LASIK, we have created another 10 million patients with emmetropia who will eventually develop presbyopia. Cataract surgery has become so accurate that most patients with pseudophakia effectively have plano presbyopia, as well. Given that CK is a market-tested, FDA-approved procedure with high patient satisfaction, it should be one of the highest volume surgical treatments performed in ophthalmology. So why is it not? In my opinion, the answer is that most ophthalmologists, unless they were already performing Botox (Allergan) or other cosmetic treatments, simply do not know how to succeed in the anti-aging business. Now that CK is being joined in the marketplace by other approved presbyopic solutions, such as multifocal and accommodating IOLs, it may be time for a new perspective.

Playing the Anti-Aging Game

Earlier generations, by and large, wore dentures, let their hair go gray and wore reading glasses when they needed them. Today's aging baby boomers are a different demographic group. They (we) have decided it is worthwhile to spend the money to stave off the signs and symptoms of aging — not only to look and feel younger, but to continue to live active and productive lives. For these patients, price is not a major factor in their choice of a physician. They are looking for an ophthalmologist who will be with them over the long term as they age and face not only worsening near vision, but also cataracts, AMD and other aging-related problems such as dry eye.

These patients present ophthalmic practices with an opportunity to create an anti-aging niche. I position NearVision CK as the first line of defense against the aging of the eye, but I also tell all my patients who choose CK that more surgery will be required as they continue to age. I explain that CK is the minimum amount of treatment that will "turn back the clock" and help them get rid of their reading glasses, but that we will leave room for more CK treatment, if necessary, down the road. Moreover, I also inform patients that new IOLs exist that can replace the "zoom feature" in their eyes, and that we may want to consider these IOLs at a later date. As a result, some patients are interested in skipping ahead and going straight to an accommodating IOL.

Even though our office performs many refractive lensectomies, I do not recommend this procedure for patients with plano presbyopia who are good candidates for NearVision CK. I use the analogy that if you want to get rid of a wrinkle, you may start with Botox, and then go on to a little tuck, but you do not start off with a full facelift. I counsel patients to save the more invasive, higher-risk options for when they are really needed. Patients with emmetropia who have had good vision all their lives tend to be rather risk averse anyway, and appreciate this cautious approach.

I find that even patients who have had successful LASIK and develop presbyopia are attracted to the idea of a bladeless, relatively simple radiofrequency treatment. For example, I recently performed five back-to-back NearVision CK treatments on patients who had successful LASIK 5 to 10 years ago and have since developed presbyopia. While anecdotal, this reinforces the fact that even if patients have had highly successful LASIK surgery, they would rather have CK over another LASIK procedure for presbyopia.

It is not LASIK

CK is not LASIK, and to market or price it as if it were is a big mistake. LASIK corrects congenital defects in the eye: myopia, hyperopia, astigmatism and higher-order aberrations. Once those defects are successfully corrected, the problem does not recur. Presbyopia, however, is a dynamic condition, that progressively worsens with age. We know from studies that have been performed and from our own experience over 7 years of performing CK that regression of the CK effect — while it does sometimes happen — is not the real issue. The primary reason for enhancement is simply the continuation of the aging process. When I explain it this way to patients, staff and referring doctors, I find that they easily grasp that there can be no "lifetime guarantees" for a natural part of the aging process.

The traditional model of free or low-cost enhancements does not work in the anti-aging business. Cataract surgeons are accustomed to removing a cataract, inserting an IOL and being essentially done, except perhaps for providing a pair of reading glasses or performing a YAG capsulotomy. Modern LASIK surgeons with good technology are reporting enhancement rates of 2-5%, so they are essentially finished with most patients after the laser procedure, as well. Offering free or low-cost enhancements for these patients makes sense because few require retreatments. However, cosmetic surgeons or dentists would never offer free enhancements for the rest of the patient's life — and the presbyopia surgeon cannot either.

The classic cataract surgery or LASIK surgery business model requires a constant inflow of patients requiring these services. Expensive and complex marketing and comanagement programs are needed to maintain patient demand. With a well structured anti-aging surgery program, patients will stay in a practice, helping it grow.

Build in Future Surgeries

As I noted earlier, I openly state to my patients that 100% of those who undergo NearVision CK will require an enhancement in the future. That enhancement may be a CK touchup, cataract surgery, a refractive lensectomy or some other procedure that is still in the development stages. In this way, I build in the expectation for future surgeries from the beginning of the consultation. I tell all my patients that they will receive a discount on their second CK treatment, whether it is needed in 6 to 12 months, or in 3 years. I also tell patients they will receive a discount on a refractive lensectomy or other refractive procedure if they choose to have them performed in our practice, essentially bundling three surgeries into one procedure.

Patients do not expect to receive enhancement surgery for free and they respond well to the strategy that I have outlined above. This also encourages them to return to our practice for their vision and eyecare needs for many years to come. With the approach I have described, I now perform up to 50 NearVision CK treatments per month, and CK volume, as well as other elements of our anti-aging practice, continues to grow. OM

Dr. Durrie is in private practice at Durrie Vision in Overland Park, Kan., and is a consultant for Refractec. He can be reached by e-mail at ddurrie@durrievision.com.