What’s ahead for 2009
Global ophthalmic trendsetting for 2009

Practitioners look around the globe at shifting ophthalmic sands

Source: Mark Packer, M.D.

As we hurtle into 2009 the world of ophthalmology continues to spin ever faster with new trends arising on all fronts. We looked here to zero in on the key changes happening around the globe.
In the refractive arena the United States is on a different axis from the rest of the world, according to Daniel S. Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park, Kansas. “If we look globally the U.S. is having a little bit different effect in the area of refractive surgery then the rest of the world because a lot of refractive surgery matured here a little earlier,” he said. “We saw the spike in growth in 1999 and 2000, which the rest of the world was not seeing at that point in time when the lasers were matured.”
This has left the U.S. ophthalmology world with a little less leeway during the economic downturn. “As the economy started affecting it, it’s almost like there was a little bit of a housing bubble in that there was more of a drop here,” Dr. Durrie said. So, the toll that recent stock market woes have taken, vary depending upon the locale. “Some people think that there’s a 30% drop others think that there’s up to a 50% drop in the elective laser surgery market—but it’s not dropping that much in Europe or in other countries where the adoption curve has been a little slower to take off.”
Dr. Durrie sees some of this as the result of medical advertising effort which was not permissible in some quarters. “Medical advertising in the United States was much more heavily done than in other places in the world—so, the word got out earlier,” Dr. Durrie said. “I think that in order to achieve refractive surgery growth you have to convince surgeons that it’s time to do refractive surgery and that was delayed in certain areas.”
Asia for example is now seeing a huge surge in refractive procedures. “If you see where the boom is going on now in Asia, where’s there’s a huge growth, there wasn’t any refractive surgery being done there 15 years ago,” Dr. Durrie said. “You look at these growth curves and they go from country to country.” As a result, economic problems in the area may not be as apparent. “They may be having a time where there’s an economic downturn but it’s still rising because acceptance of refractive surgery is growing in that general part of the world,” Dr. Durrie said.

Shifting refractive population

Ophthalmologists in the United States are also seeing trends towards a different type of refractive patient. “In the U.S. we definitely kind of had a bubble a few years ago,” Dr. Durrie said. “Some of the innovators had surgery quite a few years ago and now the patients who are having surgery are more conservative—they’re more in the later-adopter stage and the tale end of the early adoptors.” These patients tend to be more conservative and are looking more closely to see if the technology is right for them. When they get their questions answered these patients will be electing refractive surgery, Dr. Durrie believes. The economy will also be a factor in refractive resurgence. “There will be continued growth as the economy recovers in all areas of the world, but it will vary around the world depending upon how far the adoption curve has progressed,” Dr. Durrie said.
In the United States in the upcoming year he sees increased interest in select areas. “I think we’ll see a growth in the high-end advanced technology,” he said. “I don’t think that there will be a lot of growth in the lowest price lowest technology.” Most LASIK bargain hunters have already had their day, Dr. Durrie believes. “I think that a lot of those people might have had surgery already that wanted to go for the $299 special,” he said. “I think that they’re now more looking at a high definition TV instead of a regular TV.”
Those now investing in refractive surgery are willing to pay but want to get their money’s worth. “They’re still going to look for value but they’re not going to try to go on the cheap,” Dr. Durrie said. “So, most surgeons are realizing that if they haven’t invested in femtosecond technology they probably need to in 2009.”
Dr. Durrie also sees a trend towards a new generation of refractive patient. “The real growth area is in the 18 to 24 year olds whose parents had surgery, or who have been asking their parents ever since they got their first contact lenses, ‘When can I have surgery,’” he said. “That group is maturing.” This group also appears to be a large one. “The Millennium generation, generation Y, is larger than the Baby Boomer generation,” Dr. Durrie said. “That area of our practice has grown from 7 to 14% over the last couple of years.”
In addition, the Baby Boomers are now looking to refractive lens exchange. “We’re now having another big bump where the Baby Boomers are now getting in their late fifties,” Dr. Durrie said. These non-severe cataract patients are opting to replace their lenses far earlier than their parents did, thanks to premium IOLs. “In our practice the average age that somebody has their lens removed is 54, where as two years ago it was 65,” Dr. Durrie said. Patient now believe that if presbyopia is inevitable they would rather act sooner than later, he finds.

Lens appeal

These premium IOLs are going to be an important part of refractive practice. “Premium IOLs are definitely being evaluated very closely by the surgeons and patients and I think we’ll see some trends for new lenses to come out and new use of existing lenses with a lot of mix and match lenses,” Dr. Durrie said.
Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., likewise thinks that premium IOLs will continue to drive growth. Despite the recent economic downturn he has found that his practice has continued to thrive by keeping the emphasis on quality.
“Our practice is in a unique position where we’re about at the same place as we were last year,” he said. “Actually the total number of cataract surgeries is down, by about 5% and the proportion of people that are opting for premium lenses is stable at about 30%.”
This is a much higher number, however, than at most other practices currently. “We are a practice that has always valued quality so we have a higher percentage [of premium lenses] in general,” he said. “Nationwide about 7% of implants are premiums.” Many of these patients are established and are in a better position financially than younger patients who might have to worry about credit for refractive procedures. “I would have to say that probably on a national level the economy is reducing the number of people who can borrow to have refractive procedures, or premium IOLs,” Dr. Packer said. “People who are going to do it with cash, they’re OK. These are people in their 50’s or 60’s and have it in the bank.”
He sees lenses such as the Tecnis multifocal (Advanced Medical Optics, Santa Ana, Calif.), which is on the verge of Food and Drug Administration (FDA) approval, as likely to generate a lot of excitement. “That will be in the U.S. certainly in ‘09 and it’s going to have an impact on the numbers for presbyopia lenses because it will create a lot of enthusiasm,” Dr. Packer said. “I’m sure that that will increase the adoption of premium channel lenses.”
On a global level he also sees cataract surgery in general as entering a period of rapid growth. “If you look at what’s happening in China and India, there are huge numbers of people who are rising into this new middle class who are going to suddenly use there eyes for reading, using computers, and driving who are going to notice deterioration in their vision much earlier,” Dr. Packer said. “If they had just worked in agriculture they may never have had cataract surgery.”
In the U.S. there should also soon be a rise in cataract surgery with demographics as the engine. “The demographics of cataract surgery are that there is going to be a lot more of it in the short term five to ten year future, because of the growth of the Baby Boom generation,” Dr. Packer said. “So, cataract surgery on the whole and then specifically as a refractive procedure are both tremendous growth opportunities on what I call a short to mid-term horizon.”

Shifting glaucoma sands

In the glaucoma arena likewise new trends are emerging. Michael S. Berlin, M.D., director, Glaucoma Institute of Beverly Hills, Los Angeles, and professor of clinical ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, sees glaucoma as becoming a greater concern for two major reasons. “Number one we have a population shift into an older population, which is more likely to have glaucoma,” he said. “Number two we have better diagnostics and a better understanding of diagnostic principles of glaucoma such that we can find it earlier and want to do something about its devastating consequences earlier.” This leads to a much larger market share of patients who could benefit from improved techniques to control the disease and even perhaps cure it, he believes.
Internationally, where excimer laser trabeculostomy (ELT) is available, Dr. Berlin sees resources for combating glaucoma as being better than in the United States. “Subsequent to the [2008] ESCRS meeting, I attended several sites that have been using the technology for over five years and the results have been astounding,” he said. “Many of the patients require no medication or certainly far less medications and no longer have to be concerned about the consequences of elevated IOP because their pressures have been normalized.”
Dr. Berlin sees a potential boom with the ELT technology. He compares this emerging glaucoma technology under development by EyeLight Inc. (Los Angeles) to advanced LASIK. “LASIK originally was difficult to perform and only done by expert cataract surgeons because it really required a lot of physician/patient communication,” Dr. Berlin said. “When trackers were developed no longer did the surgeon’s input matter—then anybody could do it and that’s what happened.”
This rapidly evolving ELT technology is not yet available in the United States. “The original technology is a proven technology,” Dr. Berlin said. “The second generation device is in development and as soon as it’s ready will certainly be under application for FDA review and use in this country.”
Another technology being used by the European contingent is eye stents (Glaukos, Laguna Hills, Calif.). These are inserted into the trabecular meshwork to bypass outflow obstructions, according to Dr. Berlin. “Those will certainly be advantageous—we just don’t have long-term results,” he said. “We don’t know what’s going to happen to foreign bodies in trabecular meshwork over the long term.”
In the United States the recent economic climate together with technological advances may well begin to forge change in glaucoma treatment patterns. “The ongoing therapy regimens in the U.S. have been for years drugs first, then maybe lasers, and then as a last resort trabeculectomy or in rare cases non-penetrating surgery,” Dr. Berlin said. “The reason pharma was so strong is that the profit margin on drugs is phenomenal and there’s a lot of money spent both to patients in periodicals and to the physicians themselves to promote one drug over another.”
The surgical approach has been viewed as a last resort. “Surgery has been in the back pocket because of the problems with the surgical procedure, the amount of follow-up time and hands on care needed with these procedures, and the often devastating long term results for the patient,” Dr. Berlin said. “But with newer procedures we can give patients the benefits of surgical pressure lowering without the need for medications and without the long term downsides of the older surgeries.”
Given the long-term cost of drugs these may become far less prevalent. “Today’s surgical procedures are paid for by two years of drop use,” Dr. Berlin said. With many patients diagnosed in their 40s and 50s, who will likely live until about age 80, that offers a steep incentive to opt for surgery. “That two year cost difference is phenomenal for the third party payers that have to look for a two year versus a 20 year cost,” Dr. Berlin said. “Downsides now with the newer procedures are now almost eliminated.”
Dr. Berlin sees this as a new era for glaucoma. He compares it to the gamut run by both cataract and refractive surgery. “In the old days of cataract surgery there was a large incision, patients were hospitalized for days and vision rehabilitation was weeks,” he said. “Now cataract surgery is done in a much shorter time and the patient is rehabilitated within a week.” Likewise, refractive surgery which didn’t even exist 25 years ago, can now be done by most practitioners thanks to tracking systems. “With glaucoma surgery, we didn’t have these tools before, but we’re getting them as we speak,” he said. “This will make glaucoma surgery much more beneficial to many patients.” h

Editors’ note: Dr. Durrie has financial interests with Advanced Medical Optics (Santa Ana, Calif.) and Alcon (Fort Worth, Texas). Dr. Packer has no financial interests related to his comments. Dr. Berlin has financial interests with Alcon, Merck (Whitehouse Station, N.J.), and Santen (Napa, Calif.).

Contact information:

Berlin: 310-855-1112, Berlin@ucla.edu
Durrie: 913-491-3330, ddurrie@durrievision.com
Packer: 541-687-2110, mpacker@finemd.com