Tracking refractive trends in practice

Practitioner studies how procedures are evolving

ASCRS Trends in Refractive Surgery Survey reveals trends similar to Dr. Durrie’s findings
Source: Richard J. Duffey, M.D., and David Leaming, M.D.

There has been a shift in refractive surgery, with a much younger demographic looking to undergo the procedure, according to Daniel S. Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park. Dr. Durrie decided to take a look at emerging trends in his practice after facing repeated questions from colleagues about how often he was using different technologies.
“I decided the best way to do that was to go back and look at 200 consecutive patients that came in and see what we suggested that they have done,” Dr. Durrie said.
There were several surprises in the study, he found. One unexpected result that really jumped out for him was that the second most popular procedure, just behind SBK thin flap LASIK with IntraLase (Advanced Medical Optics, Santa Ana, Calif.), was refractive lens exchange. “We found that the rate was about 16%,” Dr. Durrie said. “If we had done this study two years ago it would have been about 0.5%.” Also, when he combined those results with the 4% of patients who he determined were receiving phakic IOLs, he was surprised to see how many were receiving implants. “It meant that for 20% of everyone who walked in thinking about having LASIK, we suggested that he should have an implant in his eye,” he said.
Unlike when new technology is presented to patients, here was a shift that seemed to evolve on its own. “We started looking at why,” Dr. Durrie said. “We found some real changes in what we’re seeing from patients on the demand side.”

The millennium perspective

When he looked closer at this, Dr. Durrie found that two big trends were emerging. The first involved the age at which people were undergoing LASIK or PRK, which had taken a large dip. “For the 30 years that I have been involved in refractive surgery the average age has always been 38 years old,” Dr. Durrie said. Now, instead of dipping down just a few years, he finds the age has dropped down all the way to 18 years.
This shift is being powered by interest in refractive surgery from a new population—the millennium generation. Unlike those before who only turned to refractive surgery after their contact lenses or glasses failed, the ‘millenniumers’ see the procedure as a rite of passage. “They’ve had lasers available since their first contact lenses and pair of glasses, and they’ve been asking their parents when they can have this done,” Dr. Durrie said. “The standard for when people can have it done is 18.”
These younger patients see the financial advantage of refractive surgery. “They’re coming in saying, ‘Why do I want to pay for glasses and contacts the rest of my life when I could just fix it; the earlier I fix it the more money I save,’” Dr. Durrie said.
The millennium generation also sees refractive surgery as a safer option, he believes. “They’ve heard about the risk of contact lenses and acanthamoeba and the Fusarium infections, and they don’t want to have that,” he said. “Also, modern advanced IntraLase (SBK) with the best lasers and tracking and alignment systems has made it so that most statistics will say that it is as safe, if not safer in selected cases, than wearing contact lenses.”
However, it may take awhile for this trend toward younger refractive surgery to become clear. “It’s going to take awhile because organized ophthalmology and optometry is not thinking about this as a replacement [for contacts and glasses] yet,” Dr. Durrie said. “But if the statistics and the demand keep going this way, I think we’ll see a significant trend. The hump will jump to the earlier stage as it ends up being a rite of passage like orthodontics, where people get this done because their parents are still paying for it.”

Baby boomer effect

Another interesting trend that Dr. Durrie has discovered has to do with lens replacement, also with younger people expressing interest. “If you had asked people years ago when the cataracts get bad enough to take out it was in the 70s [age range],” Dr. Durrie said. “The average age in 2007 that we replaced lenses was 54.” Again this is a generational shift. “What has happened is the baby boomers arrived,” Dr. Durrie said. “They do not want to get older and they do not mind investing in the future.” Many of these patients have realized that if they change their lens they can prevent presbyopia and cataracts.
“They’re looking at this on a proactive basis and are saying, ‘I can have surgery and stop the downward spiral, and if I do a multifocal lens, an accommodative IOL, or mini monovision I can have near vision and it’s permanent,’” Dr. Durrie said. “So they’re driving this from their side and they don’t mind paying for it.”
It is this second trend that explains why so many of Dr. Durrie’s patients are now receiving IOLs instead of undergoing LASIK. “Now when someone comes in to our office who is 53 and thinking about LASIK, we look at him carefully and see how much nuclear sclerosis he has, and try to predict when he is going to get cataracts,” he said. “We say, ‘Instead of doing LASIK, we can skip that and replace your lens.’”
Despite these trends, laser surgery still of course tops the list. Dr. Durrie also took a closer look at what he was doing here comparing when he used wavefront-guided with wavefront-optimized surgery. “I was always a big wavefront-guided person,” Dr. Durrie said. “Then I did a clinical study and found that the majority of patients were getting better results with wavefront-guided surgery.”
When he looked closer at who were the best candidates for each approach, he found a simple way to decide. “You can look at their topography, whether they have astigmatism or not. If it’s symmetrical, you can just use conventional surgery with optimized and get fabulous results,” he said. “However, if someone on his topography has a descended apex or asymmetric astigmatism or a lot of spherical aberration, then I find I need to use wavefront-guided correction.” This he finds occurs in only about 10% of cases.
Overall, Dr. Durrie believes that younger patients are going to continue to be a driving force in both lens and refractive surgery. “We’re going to be putting lenses in people’s eyes at a younger age, and we’re going to be doing refractive surgery younger,” he said. There will also be more of a push for phakic IOLs with even those in their 20s clamoring for the removable lenses, he predicts.

Editors’ note: Dr. Durrie has financial interests with Advanced Medical Optics (Santa Ana, Calif.).

Contact information

Durrie: 913-491-3737, Ddurrie@Durrievision.com