According to projections, the market valuation of refractive surgery devices is expected to increase at a compound annual growth rate (CAGR) of 3.9% from 2024 to 2034, offering an absolute dollar opportunity of $312.3 million worldwide by the end of that period.1 The growing prevalence of myopia, in particular, is driving this growth.2
So how can refractive surgeons capitalize on the market growth? I believe the answer is by offering a variety of procedures, including laser and lens-based options such LASIK, photorefractive keratectomy (PRK), small incision lenticule extraction (SMILE), implantable collamer lens (ICL) surgery and refractive lens exchange (RLE). A comprehensive and inclusive strategy to refractive correction ensures you can treat a broader range of patients and help them achieve their vision goals.
Growth Potential
The growing demand for refractive surgery is multifaceted, with driving factors including prevalence of eye diseases and disorders (eg, myopia, hyperopia, astigmatism, presbyopia, and dry eye disease [DED]), lifestyle changes, increased patient awareness, technological advancements and high success rates.
This article, however, focuses on myopia prevalence and its subsequent growth potential. Myopia is the leading cause of visual impairment globally.3 In the United States, about 4% of the population (13 million people) have myopia.4 In addition to genetics, factors such as increased near work activities5,6 and focusing on digital screens7 for long periods without breaks have been linked to the onset and progression of myopia. Urbanization, educational pressure and socioeconomic factors also affect myopia progression. Lastly, the enduring effects of the post-COVID era, where remote work has become the norm, contribute significantly to this trend.
Capitalizing on the growth of the refractive surgery market requires not only recognition of the evolving needs of patients but also a reframing of refractive surgery as a component of holistic wellness, aligning with the trend of self-care and preventive health measures. In my experience, patients respond well when I explain that contact lenses, even with perfect contact lens hygiene, deprive the eye of oxygen. I say, “Your eyes are going to thank you, and this is the best thing you can do for your cornea in the long run.”
Diversify Procedure Offerings
Offering a diverse range of procedures and positioning them appropriately is paramount to helping patients make an educated decision. LASIK, PRK and SMILE remain cornerstones, particularly for patients with moderate to high myopia and hyperopia. The advent of lens-based options such as phakic IOLs and RLE, however, offers compelling options that can be tailored to specific patient profiles and preferences. Patients with -3.00 to -10.00 D of myopia typically are a candidate for any of these procedures. Some of these patients come in knowing what procedure they want, whereas others need more extensive counseling (see Patient Education below). I have them share with me what they know about refractive surgery options going into the consultation, and then we discuss what I think is best for them. How we position each type of procedure, along with patient selection, is detailed below.
Laser vision correction
Traditionally, laser vision correction (LVC) procedures such as LASIK, PRK, and SMILE may be a good option for patients with moderate to high myopia and hyperopia. The long-term stability of LVC is excellent, but some patients require an enhancement due to regression over time.
Typically, I only perform PRK for patients who have mild keratoconus. I combine the procedure with corneal cross-linking performed on the same day to stabilize the cornea. I reserve LASIK for hyperopia and low myopia (typically less than -2.00 D). For the remainder of prescriptions, I discuss SMILE and EVO ICL.
My approach to educating patients about LVC depends on their previous level of understanding. Typically, I mention that SMILE is the latest technology of all the options and has the lowest risk of DED. If a patient has not heard of the procedure, I share it has been commonly performed in Europe since 2008, was approved by the FDA in 2018, and I trained with the creator of the procedure in London. I talk about outcomes and potential complications. Occasionally, a patient with a very low myopic prescription (eg, -1.50 D) insists on SMILE after a friend had excellent results. I am wary of performing SMILE in low prescriptions, however, because of the difficulty of dissecting and removing a smaller lenticule. I steer the patient in the direction of the LVC procedure I think is best for them.
I do not mention cost routinely. If a patient asks, I may answer the question generally but explain that our surgical coordinator will answer all logistical questions regarding scheduling and payments. I sometimes mention patients may use their FSA accounts and/or a payment plan for the cost of any LVC procedure.
ICLs
Evolving research and clinical insights8 highlight the efficacy of the EVO ICL (STAAR Surgical) as an excellent option for a broad range of refractive errors. Most patients in my practice either undergo SMILE or ICL surgery. The latter offers a high degree of correction, often beyond the limits of LVC. It also preserves corneal integrity, mitigates the DED concerns associated with LVC, and provides predictable and stable visual outcomes.9 Patients like the idea that phakic IOLs can be removed or replaced if necessary.
In the past, I considered the EVO ICL mainly for individuals with moderate to severe refractive errors. Now, however, I offer it across a broader spectrum of refractive errors, even in the -6.00 to -8.00 D range. I tell patients they get to 20/20 with both LVC and ICL surgery, but there is less incidence of higher-order aberrations with the latter.10,11 In my opinion, ICL is a great procedure regardless of the refraction; if it’s great in a -9.00 D myope, why wouldn't it be great in a -6.00 D or even a -3.00 D myope?
ICL adoption is straightforward for cataract surgeons, especially those who have embraced a refractive mindset. Incorporating this technology can augment your service offerings and help you cater to a broader patient base while not requiring you to offer corneal refractive surgery. I also think it is important to have some knowledge of refractive surgery, even if you don’t offer other refractive procedures. In my opinion, ICL is the easiest refractive surgery to learn if you've never done any refractive surgery.
Refractive lens exchange
This procedure is a great option for patients with presbyopia or significant refractive errors. I perform a lot of premium cataract surgery. For patients with a history of LASIK or another laser-based procedure, unfortunately, their lens options are limited. Typically, they cannot achieve a true extended depth of field. It can be hard for a 25- or 30-year-old to consider the ramifications of LVC, but patients in their 40s who present for a refractive surgery evaluation are more cautious. RLE is a great option for this population. For high myopia, however, I tend to lean toward the ICL procedure because the lens sits more anteriorly in the eye. In my hands, this decreases the risk of retinal complications like a tear, hole or detachment compared to RLE.
Patient Education
I take a tailored approach to patient education. If a patient looks overwhelmed by the number of options and asks for my advice, I'll guide them toward what I consider the best option for them. If a patient is very astute and wants as much information as possible, I go through all of the surgical options and discuss the pros and cons of each.
Most patients are familiar with LASIK but might not have heard about SMILE or phakic IOLs. I spend time explaining that both procedures are just as safe and effective and offer all the benefits of LASIK. In some cases, one of these procedures can be a better option for their eye due to anatomy or lifestyle. With ICL surgery, I explain that the cornea is untouched, which leaves them with more options down the line when they need cataract surgery.
Conclusion
Ultimately, capitalizing on the growth potential of refractive surgery hinges on embracing an array of procedures, challenging conventional mindsets and prioritizing patient-centered care. Engaging in comprehensive discussions to elucidate the pros and cons of each procedure for patients and tailoring your recommendations accordingly empowers patients to make an educated decision on the best surgical procedure for them. OM
References
1. Future Market Insights. Refractive surgery device Market Outlook from 2024 to 2034. www.futuremarketinsights.com/reports/refractive-surgery-devices-market. Accessed Dec. 4, 2024.
2. Myopia and Presbyopia Treatment Market Share, Size, Trends, Industry Analysis Report, By Myopia Treatment Type (Corrective, Surgical, Drugs), By Presbyopia Treatment Type (Prescription Lenses, Contact Lenses, Intraocular Lenses, Refractive Surgery); By Region; Segment Forecast, 2022–2030. www.polarismarketresearch.com/industry-analysis/myopia-presbyopia-treatment-market. Accessed Dec. 4, 2024.
3. Banashefski B, Rhee MK, Lema GMC. High myopia prevalence across racial groups in the United States: A Systematic scoping review. J Clin Med. 2023;12(8):3045. Published Apr. 21, 2023.
4. Flaxman SR, Bourne RRA, Resnikoff S, et al. Global causes of blindness and distance vision impairment 1990-2020: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(12):e1221-e1234.
5. Huang HM, Chang DS, Wu PC. The association between near work activities and myopia in children — A systematic review and meta-analysis. PLoS One. 2015;10(10):e0140419. Published Oct. 20, 2015.
6. Dutheil F, Oueslati T, Delamarre L, et al. Myopia and near work: A systematic review and meta-analysis. Int J Environ Res Public Health. 2023;20(1):875. Published Jan. 3, 2023.
7. Foreman J, Salim AT, Praveen A, et al. Association between digital smart device use and myopia: a systematic review and meta-analysis. Lancet Digit Health. 2021;3(12):e806-e818.
8. Albo C, Nasser T, Szynkarski DT, et al. A Comprehensive Retrospective Analysis of EVO/EVO+ Implantable Collamer Lens: Evaluating Refractive Outcomes in the Largest Single Center Study of ICL Patients in the United States. Clin Ophthalmol. 2024;18:69-78. Published Jan. 9, 2024.
9. Parkhurst GD. A prospective comparison of phakic collamer lenses and wavefront-optimized laser-assisted in situ keratomileusis for correction of myopia. Clin Ophthalmol. 2016;10:1209-1215. Published Jun. 29, 2016.
10. Jiang Z, Wang H, Luo DQ, Chen J. Optical and visual quality comparison of implantable collamer lens and femtosecond laser assisted laser in situ keratomileusis for high myopia correction. Int J Ophthalmol. 2021;14(5):737-743. Published May 18, 2021.
11. Zhao W, Zhao J, Han T, et al. A comprehensive investigation of contrast sensitivity and disk halo in high myopia treated with SMILE and EVO implantable collamer lens implantation. Transl Vis Sci Technol. 2022;11(4):23.
