Refractive surgery
Refractive surgery redefined

To prosper today many practitioners are sifting through their ophthalmic dictionaries

It’s the way of things. Just as LASIK has fit itself nicely in as the engine driving the refractive practice lexicon, change stemming from the economy and other factors is beginning to shift all that. Now practitioners must figure out how to best reshape their refractive vocabularies.
Excimer laser corneal refractive surgery really started over a decade ago, according to Richard L. Lindstrom, M.D., adjunct professor emeritus, Department of Ophthalmology, University of Minnesota, Minneapolis, and founder, Minnesota Eye Consultants, Minneapolis. “It was 1996 and over five years LASIK grew pretty rapidly and peaked at about 1.4 million procedures in the year 2,000,” he said. “Since then it has been a downward trend, especially since the economic crisis.” Dr. Lindstrom predicts that refractive surgeons will probably do less than 700,000 procedures this year.
This decline has occurred in the face of improved outcomes and technology and a relatively flat price. “That suggests to me that there is lower demand for excimer laser refractive surgery than we had anticipated,” Dr. Lindstrom said.
“For some reason we’re not targeting the right group of patients.” This perhaps requires a reexamination of demographics. “I think that most of us have been marketing to the baby boomer, but the baby boomer is now a presbyope,” Dr. Lindstrom said. “I think that our new core patient is now going to be Generation Y or the Echo-boomer. These patients are right now relatively satisfied with their glasses or contact lens wear.”
Now, Dr. Lindstrom sees it as incumbent on refractive practitioners to learn more about this group. “As refractive surgeons we actually need to understand Gen Y and the echo-boomers better,” he said. “We need to understand what their desires, goals and motivations are with regards to looking for an alternative to glasses and understand better the contact lens wearers’ transition to excimer laser refractive surgery.”
The good news is that this new group of patients is substantial. “If we generate a value proposition for that new group of people who is really in numbers the same size as the Baby Boomer population, about 78,000,000, then I think that we can see another resurgence in volume,” Dr. Lindstrom said. “Particularly as the economy recovers.”
There is also potentially room for reshaping demand by helping Baby Boomers to resolve their presbyopic and latent hyperopic issues. “We need better laser algorithms because the ones that we have don’t generate as good an outcome for a hyperope as for a myope,” Dr. Lindstrom said.
Practitioners must also seek new answers for treating presbyopia and begin to incorporate emerging technology. “The most promising options to me are the intra-corneal lenses like Acufocus (Irvine, Calif.) and ReVision Optics (Lake Forest, Calif.) and also the opportunity to improve our ability to generate multifocal optics with the excimer laser,” Dr. Lindstrom said.
This may also mean making the femtosecond laser much more prominent in the lexicon. Dr. Lindstrom points to femtosecond laser treatments, being advocated by Luis Ruiz M.D., that appear to be able to generate a multifocal cornea with the use of intrastromal patterns of small rings. “It’s a very minimally invasive procedure with a rapid visual response,” Dr. Lindstrom said. “As an aside you can also treat myopia, hyperopia and astigmatism with the femtosecond laser.” As a result, Dr. Lindstrom thinks that this may actually become the refractive laser of choice going forward.

Success synonyms

Also of course the economy is on the lips of every refractive surgeon these days. In addition to the shifting demographics, John B. Pinto, medical practice management consultant, J. Pinto & Associates, San Diego, sees this as the other great mega trend. “LASIK figures have really cratered internationally,” he said. “It is just macroeconomics and the great recession.” All practitioners need do is take a peek at the consumer confidence index on the conference boards Web site (www.conference-board.org). “LASIK leads, consultations and cases have always been following in lock step with the American consumer confidence figure,” Mr. Pinto said. “Whenever that figure is high leads consults and cases rise and the contrary is also true.”
Right now if Mr. Pinto had to put a word on where the confidence index stands it would be “trough.” Although, he is quick to point out that the index has begun to climb slightly in recent months. This has already begun to impact practices. “I’m seeing two effects in the last few months—there is a cohort of refractive surgery practices that have kind of stuck to the knitting, most have kept up their promotional activities and have said I’m durably going to be in this category in good times and bad,” Mr. Pinto said. “I’m noting that their numbers are starting to rebound at the same time that the consumer confidence figures are starting to come back and we all have the drum beat in the popular culture, the green shoots in the economy and the expectation that the last two quarters of this year are going to be GDP [gross domestic product] positive.”
Meanwhile, Mr. Pinto finds that another group of clients is in a different position. “I have another cohort of clients who for very good reasons in most cases saw the great recession as a good driver for shuffling their service portfolio, shifting to more geriatric disease management,” he said. “As a result, they’re caught a little bit flat during this mild resurgence that we are expecting to see.”
However, he emphasizes that he doesn’t see pulling back from refractive surgery as such a bad thing. “Empirically in most cases such practices that have shuffled their portfolios and increased have been able to much more than make up for their drop in LASIK,” Mr. Pinto said. “I have had clients in the last two years who have been devolving out of refractive surgery and recommitting to geriatric care who have growth their senior segments by double digits in the midst of the recession—some of them even working in the midst of the rust belt, where manufacturing jobs have melted away.” He points to one client in particular, a Detroit-based, solo-practitioner who has built his practice about 30% in the last two years.
Steven J. Dell, M.D., director of refractive and corneal surgery, Texan Eye, Austin, Texas, and medical director, Dell Laser Consultants, Austin, thinks that it will be very difficult for practices that are purely laser refractive to prosper. “I don’t see large numbers of doctors doing purely laser refractive correction,” he said. “I think that you will see practices place a little bit more emphasis on Baby Boomer and senior populations; lens based technology as opposed to pure laser refractive.”
Dr. Dell’s own practice has always been a mix of IOL’s and laser refractive services, something that has stood him in good stead. “Toward the end of last year we started seeing a contraction in the laser refractive side . This has recovered somewhat lately but is still down from normal levels,” he said. “But IOLs are through the roof and we have more cataract patients than we can service.”
Dr. Lindstrom finds that many leading refractive surgeons are taking this route, deciding how to best incorporate lens implants for cataract or refractive lens exchange into the practice. Some are now revisiting skills acquired in residency that have lain dormant. “There are some pretty prominent people on that list who are “learning” how to do phacoemulsification and put lens implants in from Tom Tooma [M.D.] to Robert Maloney [M.D.] to Vance Thompson [M.D.]” he said. “The other option and this is what Dan Durrie [M.D.] has done, is to hire an associate to do that surgery.”
Bruce S. Maller, president, BSM Consulting, Incline Village, Nev., likewise finds that practices that formerly did higher volumes of LASIK surgery that once may have been in the hundreds per month have diversified to other ophthalmic surgical procedures. “They have refreshed their skills and are doing either more cataract and/or refractive cataract surgery or are doing other purely refractive surgical procedures other than just LASIK,” he said.
On the low volume side, practices that are doing a handful of LASIK patients a month, are also reevaluating the mix. Many are deciding whether it is worthwhile for them to even remain in refractive surgery. “Many of those practices are having a hard time surviving because their volumes have gone from maybe five or ten patients to one or two per month,” Mr. Maller said. “The surgeons look at this and ask, “Do I even want to stay actively involved?” This is particularly vexing for those who own their equipment. “You’re not that anxious to say that I’m no longer going to do this because you feel badly that you have got five or six hundred thousand dollars invested in equipment let alone any changes you made to upgrade your facility,” Mr. Maller said.

In a word: marketing

For those who want to remain in refractive surgery Mr. Maller recommends remaining visible. “You need to keep your name and your brand top of mind with customers,” he said. “It’s not like customers are not still seeking information; they continue to assimilate information about something whether or not they are ready to buy.”
In addition, he suggests further optimizing visibility with the help of social networking sites. “Perhaps maintain some type of social networking function, whether you have You Tube videos on your website, or if you have a practice account with Twitter, or if you are blogging off of your website, there are many different ways for you to carry on a conversation with prospective patients about the fact that you’re still in the game,” Mr. Maller said.
LASIK practitioners also need to have a competitive price point. “As long as it’s going to cost me $4000 or maybe $4500 for bilateral LASIK, I’m going to look and compare that to another pair of glasses that will tide me over, or I’ll just continue with my contact lenses for a period of time, because in the near term it’s much more cost effective,” he said. “To the extent that you can narrow the gap between other vision correction options and refractive surgery you make my decision [to have LASIK] a little bit easier.”
He recommends offering coupons and other special discounts to make it more affordable for patients right now without permanently lowering the price. “Even if you charge $1200 or $1,300 an eye if your laser is already paid for, you’ll have some variable costs, some supply costs and maybe a royalty payment, but you’ll still contribute money towards fixed overhead,” he said. “Why wouldn’t you do that?”
He also suggests perhaps including a calculator on the website so that potential patients can see for themselves how quickly the surgery will pay for itself compared to continuing to re-up on glasses and contact lenses.
Going forward, Dr. Dell urges practitioners to remain confident. “I think that it bears keeping in mind that we’re not going to run out of people who are myopic or hyperopic and who want laser vision correction,” he said. “We have a product that delivers a result that is better than almost anything else in any other specialty in medicine.”
Practitioners need to reframe LASIK and remind prospective patients about what they are really offering. “When you look at the value proposition of spending money on LASIK that benefit’s a patient every waking moment of their lives for the rest of their lives I think that that compares very favorably with anything else on which they can spend their money,” Dr. Dell said. “There are people who will spend $4000 on a vacation that is gone in a week, but they don’t have 4,000 to perfect their vision for a lifetime, or who spend $100 on a haircut every six weeks—that‘s beyond my ability to comprehend.”

Editors’ note: Dr. Lindstrom has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.), among others. Mr. Pinto has no financial interests related to his comments. Dr. Dell has financial interests with AMO, Allergan (Irvine, Calif.), and Bausch & Lomb. Mr. Maller has no financial interests related to his comments.

Contact information

Dell: 512-327-7000, sdell@austin.rr.com
Lindstrom: 612-813-3633, rllindstrom@mneye.com
Maller: 775-832-0600, bmaller@bsmconsulting.com
Pinto: 619-223-2233, pintoinc@aol.com