Refractive surgery is showing a third consecutive year¹ of high single-digit growth, according to Refractive Surgery Council (RSC), and many practices are growing much more rapidly than that — in many cases exceeding 20% year over year. That’s exciting news for a specialty that only a few years ago seemed to be stuck in the doldrums.

Even more encouraging, these numbers are only looking at laser vision correction volume and do not include the considerable growth occurring in lens refractive surgery and refractive cataract surgery.

The growth we are seeing can be attributed to several things taking place in our space, and I believe five initiatives already underway will soon precipitate even more market expansion.

1. TRAINING OPPORTUNITIES HAVE MULTIPLIED

The first thing causing refractive surgery volume to grow is an emphasis on surgeon education.² Not that long ago, ophthalmology residents with an interest in refractive surgery had a hard time getting exposure to the field and the impact they could make on patients’ lives with the expanding toolbox of refractive surgery procedures. In fact, the Accreditation Council for Graduate Medical Education’s ophthalmology residency requirements have only required a minimum number of observing or assisting in at least six keratorefractive surgeries,³ many of which are simply observing limbal relaxing incisions being done during cataract surgery, rather than the traditionally defined procedures of refractive surgery such as LASIK, PRK and SMILE.

Fortunately, an expanding list of private fellowships around the country that have a singular focus on refractive surgery are now available. This has occurred organically, and coordination and certification via the Refractive Surgery Alliance (RSA) is underway.⁴

Comprehensive, focused refractive surgery fellowships include a requirement to perform hundreds of refractive surgery procedures spanning the whole gamut of the modern procedures of refractive surgery: from laser vision correction, such as LASIK, PRK and SMILE, to lens refractive surgery, including phakic IOLs, toric IOLs, presbyopic lenses and corneal crosslinking.

2. FORGET COMPETITION — TEAMWORK IS BETTER

The second phenomenon causing growth in refractive surgery is collaboration among refractive surgeons, rather than competition between them. Because refractive surgery exists in a growth market, not a fixed one, a more effective strategy to trigger category growth is to message broadly about the benefits of the procedures, rather than confusing the market by having multiple surgeons claim their version of LASIK is superior to someone else’s version of LASIK.

Fear-based messaging, such as “We are the only place in town that offers XYZ-femto LASIK. The other guys use blades” or “Come to us because we do minimally invasive SMILE, and they do laser vision correction from the past,” only causes patients to retreat to the temporary solutions they have used historically. Since we know that no two eyes are exactly alike and that different refractive errors and anatomies are better suited for different procedures, positive messaging about a life of clear, crisp vision without glasses and contact lenses in general causes interest in the category to increase.

Two years ago, the RSA published marketing guidelines that require its members to message based on patient benefit rather than particular technologies, and to eliminate teaser rates and “bait and switch” tactics of corporate centers that have failed in the past.⁵

Further collaboration is needed not only between ophthalmologists and refractive surgeons, but also between ophthalmologists and optometrists. Interesting forces in the retail market are impacting traditional optical models and are catalyzing refractive surgery growth as a result. Large box stores and online opticals such as 1-800 Contacts and Warby Parker are making it difficult to compete in the marketplace if your bread and butter is retail brick and mortar. So, optometry is re-inventing itself and transitioning from a primarily retail profession to a medical model of providing services and clinical care such as cataract and refractive surgery comanagement.

And this is appropriate. The population demographics dictate that more doctors are needed to serve the medical, triage and clinical care of patients, defining ideal roles for ocular disease-focused optometrists, ophthalmologists and refractive surgeons to thrive via collaboration. Models of collaborative care and comanagement are increasingly common,⁶ and old myths about refractive surgery are being re-examined based on facts and the modern peer-reviewed literature [See “MythBusters: Refractive surgery edition”, page 57].

3. HELP THEM DO THE MATH

The third important initiative underway is changing the economic model whereby patients can access refractive surgery. One of the biggest hurdles for young patients to access the procedures in the past has been the large upfront cost. Patient financing solves that problem. I believe the economic benefit to patients who have refractive surgery at a young age may be the single most compelling reason that refractive surgery will eventually become the default solution for refractive error — just like automobiles replaced horses and buggies and cell phones replaced land lines.

I would like to offer a computational exercise to demonstrate the math. Let’s say that (like most people) your axial length and refractive development stabilizes at the time of full-grown adulthood (by age 20). Let’s also say that you wear daily disposable contact lenses for your myopia and buy a set of frames to wear at night every few years. Extended-wear daily soft contact lenses cost an average of $25 per box. Because most people are risk takers with their contact lenses⁷ and don’t actually change them on time, we will assume you go through 10 boxes a year.

So, $25/box × 10 boxes = $250/year for 25 years is $6,250 in contact lenses.

For purposes of our computation, let’s also assume you buy a pair of prescription glasses at around $400, conservatively every four years. This would cost about $2,500 over 25 years, for a grand total of nearly $9,000. And that’s before you start needing prescription bifocals and progressives in your middle forties, where prosthetic eyewear costs escalate much further.

Your total spend before the age of presbyopia is nearly double what you likely would have paid to have your myopia and astigmatism corrected when you were eligible. If you account for the prescription progressive lenses and bifocals needed during the years after presbyopia, instead of cheap drug-store readers, you are literally saving tens of thousands of dollars by having your myopia corrected when young.

Patient financing is what allows young people to access the benefits of refractive surgery in such a way that the monthly spend on glasses and contact lenses is basically in parity with what they will spend monthly to have their vision corrected.

The obvious patient benefit is that the cycle of throwing good money at bad vision every month stops after a few short years with refractive surgery.

4. NO PATIENT LEFT BEHIND

Essential to building trust in refractive surgery, and thus fostering market expansion, is patient outreach. The sad reality is that some patients have had complications from refractive surgery procedures and have felt abandoned. One of the major initiatives of the RSA is to reach out to these patients and offer free consultations at centers that have access to things like topography-guided procedures and/or crosslinking, which in many instances can help. In other instances, nonsurgical therapies such as scleral lenses are indicated.

And sometimes these patients only need simple reassurance and demonstration of compassion. We believe everyone should have access to clear vision, and it is incumbent upon us to reach out to these patients and help them.

5. CAPITAL EQUIPMENT REFORM

The final initiative underway to help grow the refractive surgery market is changing the way refractive surgeons access capital equipment. The old model of a high cost to invest in a certain laser, with click fees every time it is used, should change to a monthly lease fee that comes with unlimited upgrades in software and unlimited usage. This is not to say that the monthly lease fee should necessarily be low — manufacturers must be profitable or else they would have no incentive to innovate.

What needs to change is the capital equipment business model, because patient interests, surgeon interests and manufacturer interests have not been aligned in the past. A change to a lease model stimulates innovation so that more patients have access to the procedures and surgeons are not economically penalized by offering procedures and enhancements to all patients who might benefit from the category (including those who may have undergone cataract surgery).

It will also ensure that more patients have access to the latest innovations sooner, because surgeons will not be economically motivated to get maximum use-time out of older lasers they had invested heavily in years earlier. It’s encouraging that some vendors and manufacturers of laser systems are already looking at ways to innovate around their platforms and the economic models whereby they provide technology to their surgeon customers.

IN SUMMARY

The refractive market is growing because of several phenomena taking place. The opportunity is to engage by seeking out formalized fellowship training and joining the initiatives that are underway to build trust and deliver significant value to our patients.

It is truly an exciting time to be a refractive surgeon. I sincerely hope you’ll join us. OM

REFERENCES

1. Laser vision correction market growth continues for third straight year, the refractive surgery council reports. Refractive Surgery Council. Feb. 7, 2019. https://americanrefractivesurgerycouncil.org/wp-content/uploads/2019/02/FINAL-RSC-Laser-Vision-Correction-Volume-Report-for-2018-Announcement.pdf . Accessed March 26, 2019.
2. RSA Fellowship Network. http://rsafellow.com . Accessed March 26, 2019.
3. Required minimum number of procedures for graduating residents in ophthalmology. Review Committee for Ophthalmology. 2013 Accreditation Council for Graduate Medical Education (ACGME). https://acgme.org/Portals/0/PFAssets/ProgramResources/240_Oph_Minimum_Numbers.pdf?ver=2015-11-06-120652-043 . Accessed April 8, 2019.
4. Refractive Surgery Fellowship network. Refractive Surgery Alliance. http://rsafellow.com . Accessed March 26, 2019.
5. RSA Marketing Guidelines. http://www.refractivealliance.com/marketingguidelines/ . Accessed March 26, 2019.
6. Stahl S. The comanagement conundrum. Ophthalmology Management. 2012:16;27-30. https://www.ophthalmologymanagement.com/issues/2012/march-2012/the-comanagement-conundrum . Accessed March 27, 2019.
7. Risk behaviors for contact lens-related infections among adults and adolescents – United States, 2016. Centers for Disease Control and Prevention. Aug. 18, 2017: 66(32);841-845. https://www.cdc.gov/mmwr/volumes/66/wr/mm6632a2.htm?s_cid=mm6632a2_e Accessed April 8, 2019.
8. Price MO, Price DA, Bucci FA Jr, Durrie DS, et al. Three-year longitudinal survey comparing visual satisfaction with LASIK and contact lenses. Ophthalmology. 2016 Aug;123:1659-1666. Epub 2016 May 18. https://www.ncbi.nlm.nih.gov/pubmed/27208981 . Accessed March 27, 2019.

About the Author

Greg Parkhurst, MD, is the physician-CEO at Parkhurst NuVision, an ophthalmic-optometric integrated eye-care delivery system in San Antonio, Texas. He is the past president of the Refractive Surgery Alliance.