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Click Fraud Can Be Costly
The Ugly Side of Paid Internet Marketing.
By Jerry Helzner, Senior Editor

Google, Inc. recently settled a lawsuit by agreeing to pay back up to $90 million to providers of goods and services who used the company's so-called "pay-per-click" form of Internet advertising. The suit charged that Google had conspired to conceal the fact that many of the "hits" on advertising links came from individuals who had their own agendas and had no intention of buying any of the goods or services offered.

In a pay-per-click system, advertisers participate in an ongoing pay-per-click bidding system that rewards the highest bidders with prime, top-of-the-list positioning on such search engines as Google and Yahoo. For example, it recently cost more than $29 per click for a refractive practice to obtain prime placement under the key search words "LASIK New York." It cost about $5 to have a prime position under the search word "LASIK." The difference in cost-per-click is that anyone typing "LASIK New York" into a search engine is believed to be actively seeking to connect with a local doctor to discuss the procedure, while an individual typing in "LASIK" can be anyone from a student doing a term paper to a resident of Guam.

In other words, a refractive practice located in New York City is willing to bid high to target a specific local base of motivated potential patients, but not very high (or not at all) to be listed under the much broader and more vague search word "LASIK."

But while it helps to be astute in selecting key search engine words and phrases that attract the best potential candidates, practices have, until now, been powerless to thwart those with their own agendas from constantly clicking on a practice link with no intention other than doing mischief. If a competitor or disgruntled ex-employee clicked on a specific practice link once a day for a month, it could cost a practice paying $29 per click almost $1,000 with nothing to show for the money spent.

System is Not for Amateurs

Those who understand how the pay-per-click advertising system works have long suspected that click fraud is rampant on the Internet. In an article in the June 2005 issue of Ophthalmology Management, David Evans, Ph.D., M.B.A., a well-respected consultant on Internet-based marketing strategies, wrote that the rate of click fraud runs as high as 20% of all the clicks generated by this form of advertising.

Dr. Evans points out that many refractive practices that use "pay per click" are unaware of the potential costs and intricacies of the system. This is now especially true of cataract surgeons who are new to marketing and who may just be beginning to use pay-per-click in an effort to attract patients for newer elective procedures such as phakic IOLs and refractive lens exchange.

Dr. Evans says that practices that intend to use "pay-per-click" advertising must set a budget limit, choose key search words that actually attract potential patients and not spread their budget thinly among too many search words.

"For example, say you are using search words such as 'LASIK' and 'LASIK San Diego' in the same pay-per-click ad campaign," notes Dr. Evans. "You will get much more traffic on the generic term 'LASIK' than you will on the much more specific 'LASIK San Diego,' but if your campaign budget becomes exhausted due to the volume of 'LASIK' hits, all of your other pay-per-click ads will be removed, including the 'LASIK San Diego' listing, where you actually have a much better chance of attracting potential LASIK candidates."

Dr. Evans cautions that any practice using pay-per-click advertising should be extremely careful in planning this type of marketing program and vigilant in monitoring it.

At times, pay-per-click advertising can get quite ugly.

For example, if you are ABC Eye Care and have a well-known and highly respected refractive practice with a strong identity in a certain area, do not be surprised if your competitor, XYZ Eye Care, also pops up if a potential patient enters "ABC Eye Care" in a search engine box.

The owner of a large refractive practice in a major metropolitan area told Ophthalmology Management that the practice was currently re-evaluating its use of pay-per-click ads.

"The cost may not be worth it if only one or two of a hundred clicks ends in a procedure," she said. "We use radio, TV, print and even billboards, but we will need to look harder at our pay-per-click costs."

GIVING BACK: Nothing Stops Dr. Mildred Olivier
She is Tireless in her Volunteer Efforts.
By Leslie Goldberg, Assistant Editor

Dr. Olivier on a mission to Jamaica.

Although government unrest has kept Mildred M.G. Olivier, M.D., F.A.C.S., from her regular volunteer missions to Haiti for the last few years, she has not taken a break from civic duty. Her continued commitment to humanitarian causes within her Chicago community and abroad has kept her busy.

A solo practitioner, Dr. Olivier has not only taken volunteerism into her life, but recruits doctors for missions every chance she gets, starting with her residents. "Every person is vital on these missions. Even the spouses that come along on the trips wind up playing important roles, such as pharmacists," says Dr. Olivier. "You need to be flexible on these missions and you need to educate, educate, educate."

Dr. Olivier, a graduate of the Loyola University of Chicago and the Finch University of Health Sciences/
The Chicago Medical School, was moved to volunteer in Haiti because her parents are both from Haiti.

"I consider myself a Haitian-American," she says.

She notes that conditions are rugged in the rural areas of Haiti. "You use what is available and need to adapt. If you don't have light, use a flashlight, if there is no flashlight, a candle will do."

Dr. Olivier recalls treating a Haitian girl with congenital glaucoma. The girl and her father had traveled 3 days by mule to meet with doctors. Dr. Olivier needed to take the girl to Port-au-Prince to operate on her. Her father told Dr. Olivier that he needed to return home to tell his wife about the operation, so he set out on his mule for the 6-day round trip. He wound up losing his mule and needed to borrow another for his return. The daughter received the operation and doctors left money for her to cover the bills for the hospital IVs, bed and food.

Dr. Olivier told the father that she wanted to see the daughter the following year. The next year, the first person Dr. Olivier saw waiting in line was the man with the mule and his daughter. "At the end of the day, you realize that this is what practicing medicine is all about," says Dr. Olivier.

Now that she is unable to enter Haiti, Dr. Olivier is constantly working with foundations and hospitals to send surgical items to the island's ophthalmology residency program. But Dr. Olivier does not limit herself to saving sight.

She recently spoke to a friend who had a mammography machine and van at his disposal, but did not know how to go about setting up a screening process or gaining additional funds to screen the women of Haiti. Dr. Olivier took it upon herself to raise funds, and with the assistance of Federal Express, has been able to initiate the program.

This year she went with ORBIS, the flying eye hospital, to Kingston, Jamaica, to perform glaucoma surgeries there for a week. "Jamaica has a very large glaucoma population," explains Dr. Olivier. "Because ORBIS is so well-organized, we were able to perform surgeries, give lectures to the local ophthalmologists, and also film and make CDs of operations, talking doctors through the procedure so that they could use the CDs as a guiding tool for future operations."

This aspect is critical because the local doctors are generalists and many times will not perform surgeries or procedures unless they are totally comfortable. It is of the utmost importance that the local doctors be able to manage the patients once the volunteer doctors have left. One of the many benefits of ORBIS, says Dr. Olivier, is that the organization sends a physician into the host country a month after the volunteer doctors have left to perform follow-up visits. This promotes both patient and local doctor compliance.

Dr. Olivier says she could not accomplish these humanitarian efforts without the help and support of individuals who do the legwork prior to her travels and those whose financial support make these missions possible.

Lenstec's Goal is U.S. IOL Market
Its Tetraflex Accommodative Lens is in Phase 3 Trials.
By John Parkinson, Associate Editor

Rendering of Lenstec's new manufacturing facility in Barbados.

Lenstec, a privately owned medical device company, is looking to break into the increasingly attractive U.S. IOL marketplace with its Tetraflex accommodative and Softec HD aspheric monofocal IOLs. The Tetraflex is currently in phase 3 clinical trials in the United States and the Softec is awaiting investigational device exemption status from the FDA.

The St. Petersburg, Fla., company has been manufacturing a variety of IOLs, capsular tension rings and viscoelastic for its own international sales as well as for other companies overseas. Lenstec says last year's CMS decision to adopt "patient-sharing" billing for presbyopia-correcting IOLs, combined with the sheer size of the U.S. market, prompted the company to seek introduction of the Tetraflex accommodative lens in the United States.   

"Currently, the United States has the only plan that allows patients to pay a premium for an intraocular lens," states Jim Simms, Lenstec vice president. He notes that this allows IOL manufacturers to charge a higher price point — as much as $900 per lens — for the presbyopia-correcting lenses.

John Clough, Lenstec president and CEO, adds that Lenstec's low-cost manufacturing system in its Barbados manufacturing plant is key to the profitability of the company's IOLs. Lenstec is planning to move into a new and larger manufacturing facility on the island later this year.

The Tetraflex was designed by Robert Kellan, M.D., a Boston ophthalmologist. It is an acrylic lens with a 5.75-mm optic whose haptics are designed with a "contoured-effect" that allows flexibility within the accommodation process. This enables the IOL to move anteriorly in the capsular bag secondary to ciliary muscle contraction.

The company also believes that monofocals will continue to be an industry standard. With this in mind, Lenstec is moving to bring its Softec HD to the U.S. market as part of an eventual "one-two" combination IOL strategy. The ability to offer surgeons the Tetraflex first, then the Softec once it gains FDA approval, is part of a plan to develop a larger customer base and greater market share for Lenstec.

Both IOLs are part of the company's Precision Series, which Lenstec says reduces variability issues by offering these lenses in smaller than currently available market increments. The Tetraflex will come in 0.20 D increments and the Softec in 0.25 D.

Lenstec was founded by Clough in 1993 and personally financed by him, beginning as a technology-transfer company selling turnkey laboratories designed to manufacture PMMA IOLs. After building several facilities internationally, Clough decided to build his own manufacturing plant on the aforementioned Barbados property. Today, Lenstec also has a satellite office in England.

Previously, Clough founded another company, Suncoast IOL. A mechanical engineer by training, his professional background includes a stint with a contact lens company where he was leader of a design team that developed the first computer-controlled contact lens lathe.

The company is hoping for a second quarter 2008 launch for the Tetraflex, provided everything goes according to schedule. Lenstec is estimating a similar timeframe for introduction of the Softec. Further down the pipeline, the company is also considering other IOLs, such as a toric, another accommodative, a telescopic IOL for AMD and a device to eliminate posterior capsular opacification.

Treating Fusarium Keratitis
The Recent Outbreak Requires New Patterns of Care.
By Eric D. Donnenfeld, M.D.

The significance of the outbreak in fusarium keratitis linked to a specific contact lens solution is that clinicians need to rethink the management of patients who are wearing contact lenses and present with an active keratitis.

In the past, therapy has been primarily directed toward bacterial disease, especially in areas outside of the extreme southern United States. This new outbreak produces a need for clinicians to rethink patterns of care and modify therapeutic intervention until federal agencies can identify the root cause of the current case activity.

In recent years we have moved away from culturing, scraping and plating due to the development of an effective range of antibiotics now available to treat bacterial keratitis. In the FDA Preliminary Public Health Advisory Report published April 10, 2006, it is recommended that "if a patient presents with a microbial keratitis, consider that a fungal infection may be involved and obtain a specimen for laboratory analysis". The appropriate protocol for this procedure is to scrape the tissue for fungal analysis with a stain such as Gomori-Methenamine Silver (fusarium can be identified by cellular analysis in minutes vs. culturing which may take weeks). Additionally, if you suspect and/or identify a case of fungal keratitis in a contact lens wearer, you should report the event to the FDA.

Because the initial presentation of most fungal keratitis cannot be differentiated from bacterial disease in the early phases, the need for laboratory analysis is critical. Some clinicians are recommending dual initial therapy of fourth-generation fluoroquinolones and topical anti-fungals (Amphotericin B) until the cellular analysis is available. Do not initiate steroid treatment before the condition has been identified, as fungal disease feeds on the immunosuppression produced by steroids.

There is evidence in the literature that many patients with contact lens intolerance and ocular surface inflammation may benefit from topical cyclosporine (Restasis). Restasis improves tear quality and quantity while reducing inflammatory ocular surface disease. Another benefit of cyclosporine that is relevant to the current outbreak is that it is also an anti-fungal agent.

IN THE NEWS

►Visian toric. STAAR Surgical Company has submitted a Pre-Market Approval (PMA) supplement to the FDA for the Visian TICL, its toric implantable Collamer lens designed to treat both myopia and astigmatism.

STAAR submitted the Visian TICL application as a supplement to the PMA for its Visian ICL, which the FDA approved in December for use in correction of myopia in adults and which is now available to patients in the United States.

The Visian TICL supplemental filing supports an indication for use in adults 21 to 45 years of age for the correction of myopia ranging from -3 D to -20 D with astigmatism of 1 D to 4 D.

►New WaveLight approval. WaveLight, Inc. said it has received approval from the FDA to treat mixed astigmatism with the wavefront-optimized Allegretto Wave excimer laser system. The indication includes the reduction or elimination of naturally occurring mixed astigmatism of up to
6 D at the spectacle plane.

Three month follow-up data for 142 eyes demonstrated that 68% of eyes achieved 20/20 vision and 95.8% achieved at least 20/40 vision postoperatively. For sphere, 94% of eyes were within 0.5 D of targeted correction and 99% were within 1 D of targeted correction. Astigmatic results for 77% of eyes were within 0.5 D of target and 95% of eyes were within 1 D of target.

►Allergan Foundation gift. The University of California, Irvine has received a $2 million gift from The Allergan Foundation, the philanthropic arm of Allergan, Inc., to the department of ophthalmology. The gift, the largest donation ever to ophthalmology, will further strengthen the department's research agenda and clinical care.

►Avastin impacts Macugen sales. OSI Pharmaceuticals reported that U.S. sales of its Macugen treatment for wet AMD dropped from approximately $59 million in the last 3 months of 2005 to just under $51 million in the first quarter of 2006. OSI CEO Colin Goddard, Ph.D., said the drop was due to increased use of off-label Avastin.

Dr. Goddard said that OSI was tracking the wet AMD marketplace and expecting the launch of Genentech's Lucentis therapy for wet AMD.

"If we got it wrong (on Macugen), we will not allow this to be dragged out," Dr. Goddard noted.