April 2016




Refractive editors corner of the world

LASIK worldwide

by Ellen Stodola EyeWorld Senior Staff Writer



It is no surprise to anyone in ophthalmology that LASIK volumes have not recovered from the early 2000s high. But why havent they? Is this a global or market-specific phenomenon? In this months Refractive editors corner of the world, experts from around the globe assess root causes of the decline in adoption and provide recommendations on how we can potentially reenergize this life-changing procedure. Technology has advanced, patient satisfaction is at an all-time high, and accessibility is nearly 100% global; meta analyses have demonstrated the overall exceptional outcomes. This months column provides unique insights into the current state and provides powerful recommendations on what it will take to change the tide for laser vision correction.

Steven Schallhorn, MD, refractive editor


Eyes of patients undergoing LASIK. The procedure has been used for more than 20 years in millions of patients around the world. Source: Boruch Len

Surgeons practicing in different areas around the world comment on LASIK

Over the years, LASIK has become a popular and reliable procedure around the world. Arthur Cummings, MD, Wellington Eye Clinic, Dublin, John Chang, MD, Hong Kong, and John Kanellopoulos, MD, medical director, LaserVision.GR Institute, Athens, Greece, and clinical professor of ophthalmology, New York University Medical School, New York, commented on trends they see in LASIK around the world.

Penetration of LASIK worldwide

LASIK has been around for more than 20 years, and more than 40 million procedures have been performed since 1991, Dr. Chang said. In most countries, LASIK is now a mature market, having enjoyed a rapid growth in the first 10 years and now leveling out, he said. He said that there are 3 kinds of patients: those who rapidly adapt and accept new technology and have their surgery performed in the first 510 years; those who wait and have surgery in a mature market; and those who would never choose to have LASIK. LASIK seems to have peaked almost 10 years ago, and this was about 10 years since it was clinically introduced internationally, Dr. Kanellopoulos said. There are several speculations as to why this has happened. One is that the economy has not fully recovered from the downturn that started in 2008 and led people to feel that their disposable income couldnt go toward an elective procedure such as LASIK.

Another reason is that LASIK has become a very universal procedure, he said. It is practiced by many low-cost centers, and it may be viewed by patients as a procedure that carries less allure. A third reason Dr. Kanellopoulos cited is that some of the serious LASIK complications have been broadly advertised, and people are aware that ectasia, infection, and dry eye may be associated with LASIK. Nevertheless, it remains the mainstay of refractive surgery for myopia, astigmatism, and/or hyperopia, he said. Technology has evolved, and I think LASIK penetration, although in lower numbers than the peak era of 2001 to 2004, is relatively stable globally. Dr. Cummings thinks LASIK is seen in about 2.2 people per 1,000, based on a market review recently done in Ireland. The data came from both U.S. and European analysis, he said.

Where is it growing?

LASIK may be growing in markets where it has been around for awhile, Dr. Cummings said. For instance, children of parents who had LASIK may now have it on their parents advice. Numbers also seem to be growing where small incision lenticule extraction (SMILE) is offered and where the clinic provides more than just laser eye surgery, he added. Now we are treating young patients who become eligible for surgery in their late teens and early 20s, Dr. Chang said, adding that another group that is growing is those with presbyopia. Patients who have enjoyed good vision without glasses are fed up with reading glasses and now wish for spectacle freedom, he said. Therefore, presbyopia is another incentive for having surgery. With worsening weather conditions and pollution, many are becoming intolerant of contacts lenses, Dr. Chang added.

Dr. Kanellopoulos thinks that specialized LASIK procedures are growing. The use of topography- guided technology appears to offer superior results clinically as far as visual acuity, quality of vision, and retaining asphericity of the eye, he said.

Where is it declining?

The fact that LASIK has become so commercialized and is offered almost as a commodity is a reason that Dr. Kanellopoulos thinks LASIK may be declining. This is probably perceived by the general public as a product that is not desirable and not a top priority. Dr. Cummings sees a decline in areas where the predominant providers are high street based and added that false and aggressive advertising and unrealistic promises undermine the value of LASIK.

Because of the declining economy, the procedure is performed less frequently at present, Dr. Chang said, adding that LASIK is usually considered as a disposable income consumer product. Most LASIK procedures go along with the local financial index, he said. When the financial index is high, patients have more disposable income, and LASIK is one of the procedures they often choose to have performed. Recent negative publicity in Asia about the procedure may be having an adverse impact, Dr. Chang said. Another possible explanation is an increase in patient acceptance of the SMILE procedure; Dr. Chang thinks this may be causing some decline in LASIK.

What can be done

LASIK should only be performed in offices and premises of consultant ophthalmologists, according to Dr. Cummings. The only indications are matching the patient needs with the most appropriate procedure, ensuring all inclusion criteria are met, and there should be no hard sell, he said. Although some people think laser eye surgery is a commodity, it is a surgical procedure that is being performed on healthy people with healthy eyes whose goal is to improve their vision and enjoy a glasses-free life. There is no room for error, Dr. Cummings said. There is no room for commercial pressure on the patients suitability for the procedure. If and when LASIK is provided in this environment and context, it will grow, he said. It is a remarkable procedure with an incredible safety and efficacy record when properly and appropriately delivered. Dr. Kanellopoulos sees the primary difference between people who wish they had LASIK done and those who had it done as fear rather than finances. Creating public awareness that this is an extremely safe procedureperhaps safer than wearing contact lenseswill increase the number of LASIK cases performed, he said.

It still amazes me that patients wear everyday contact lenses, and they are very casual about it in regard to how old their lenses are and the hygiene that they use, he said. They may sleep with their lenses in but then balk at the idea of having surgery on their eyes. I think that we as an ophthalmic community need to propagate the data and the truth, he said. I have personally taken the road of being very honest with my patients, speaking openly about complications, and not trying to sell the procedure, and I think this has helped me to have a tremendous turnaround in my patients in regard to how many of them decide to have surgery. Dr. Kanellopoulos thinks that people are far more educated today than 20 years ago. I think we are past the era of testimonials and more into the era of real science, educating our patients, and having them decide what the best solution is, Dr. Kanellopoulos said. Dr. Chang thinks that good patient education and understanding of the misconceptions as well as good marketing techniques will help increase LASIK in areas where it may have declined. Ultimately, good patient experience, low complication rates, and excellent results [are] the recipe for patients referring their friends and relatives, he said.

Editors note: Dr. Chang has no financial interests related to this article. Dr. Cummings has financial interests with Alcon (Fort Worth, Texas). Dr. Kanellopoulos has financial interests with Alcon, Allergan (Dublin), Kera- Med (Orange, California), Optovue (Fremont, California), i-Optics (The Hague, the Netherlands), and Carl Zeiss Meditec (Jena, Germany).

Contact information

: johnchang@hksh.com
Cummings: abc@wellingtoneyeclinic.com
Kanellopoulos: ajk@brilliantvision.com

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