October 2018


Practices focused on refractive

by Liz Hillman EyeWorld Senior Staff Writer

The reception area at Brinton Vision was designed to create a calm, spa-like atmosphere.

Brinton Vision’s Vision Correction Suite houses a surgical microscope, bed, four phaco systems, and five lasers, including two femtosecond and two excimer lasers.

Patients and their guests are given a private patient suite to use throughout the duration of their consultation and surgery appointments at Brinton Vision.
Source (all): Jason Brinton, MD

Practices specializing in only elective refractive procedures are seeing tremendous growth

Refractive surgery is not what it was in its heyday of the late 1990s to early 2000s—or is it? While technologies and techniques have no doubt continued to improve, there are, in addition, a whole host of new refractive procedures available, expanding options well beyond what could be offered 10 years ago. In terms of number of patients receiving refractive surgery, Richard Lindstrom, MD, Minneapolis, in the 2018 Steinert Lecture at ASCRS Refractive Day, said that as far as LASIK numbers, those have not yet recovered since their decline in the Great Recession.
However, practices focusing solely on elective refractive surgery report significant growth and success in recent years. Jason P. Brinton, MD, opened the doors of Brinton Vision in St. Louis nearly 2 years ago and has seen “tremendous growth” in terms of a patient base, which is served by 24 full-time employees and growing. “We are running as fast as we can. Last week we posted a job to hire a second surgeon,” Dr. Brinton said.
Kugler Vision, which opened in 2011 in Omaha, Nebraska, with Lance Kugler, MD, at the helm, still sees the opportunity for growth in refractive surgery. “The ground is fertile for growth, there are tremendous opportunities, and through collaboration, the growth is inevitable,” Dr. Kugler said.
Luke Rebenitsch, MD, became a partner at ClearSight LASIK, Oklahoma City, in 2015 and bought the practice outright when his partner retired earlier this year. “Since I joined the practice, our topline revenue has increased about 100%,” he said.

Why the seeming slump?

If these three ophthalmologists are having success in practices focused only on refractive surgery, why does there seem to be the perception of a so-called slump nationwide?
Dr. Kugler has some theories. “There was a downturn in LASIK volume that coincided with the recession, but there were a lot of factors that led to the downfall around that time. Some of it was financial; people had less expendable income and made other choices. But that part of it would have rebounded by now, so other factors are proving to be more of an issue than the recession,” he said.
One of those factors is fewer doctors offering refractive surgery. With the economic downturn, Dr. Kugler speculates that many ophthalmologists who once highlighted refractive surgery began focusing on cataracts. Since then, newer technologies in cataract surgery, such as the femtosecond laser and refractive IOLs, have given cataract surgery the additional opportunity for elective income.
“People who used to emphasize [refractive surgery], market it, recommend it, have lost interest in it and focused their efforts elsewhere, and that’s a huge reason it’s underappreciated today,” Dr. Kugler said.
Another factor, Dr. Kugler thinks, is changes in demographics. The baby boomers who were driving growth in refractive surgery in the 1990s and 2000s are now of an age where refractive lens exchange or cataract surgery might be better options for them. Generation X, which came after them, was a smaller group of people. However, generation Y and the millennials coming in next are a huge group, Dr. Rebenitsch said, and they’re now of the age where refractive surgery could be an option for them.
Then there was marketing. Dr. Kugler said there was a time when refractive surgery marketing focused on use of the femtosecond laser vs. blades, the latter of which might have scared off potential patients. Dr. Brinton thinks that the refractive surgery market hasn’t done itself justice on the communication front in years past.
“It’s how we talk about it and communicate the benefits of refractive surgery,” he said. “We need to do better educating our communities about the value of seeing clearly every waking moment.”
Also, with seven refractive procedures now on the market—LASIK, PRK, SMILE, ICL, refractive lens exchange, intracorneal inlays, and refractive cataract surgery—Dr. Kugler pointed out that the numbers might show fewer people getting LASIK (the procedure that has become almost synonymous with the term “refractive surgery”) because they are getting other procedures more suited to their needs.

How do refractive-only practices see success?

The short answer to this question is specialization and customer service, according to Drs. Brinton, Kugler, and Rebenitsch.
Dr. Brinton sees refractive surgery as a subspecialty of ophthalmology like glaucoma, retina, and pediatrics. “With rapidly advancing technology and new procedures, there are increased benefits to pursuing subspecialty fellowship training and focusing on the field of refractive surgery. The technology involved with LASIK and the modern vision correction procedures we perform today is increasingly complex. Practitioners who specialize in our field and offer the full range of refractive procedures are seeing a great deal of growth.
“There is so much more that we can do now. For the previous generation of refractive surgeons, LASIK was the only option, and for those who offer only LASIK upward of 90% of patients presenting for vision correction surgery may be considered candidates. For us that number is 42%—a majority of patients coming to our office for LASIK are having their eyes corrected with one of the other options,” Dr. Brinton said. “I think these additional procedures have given refractive surgery a shot in the arm, particularly for the presbyopic population looking to live without reading glasses and bifocals. Now we have multiple effective treatments.”
For those interested in pursuing a career in refractive surgery, Dr. Brinton recommends a dedicated refractive surgery fellowship.
“Most cornea-based fellowships focus on pathology and provide more limited exposure to refractive surgery beyond LASIK. There are about a dozen fellowships like ours that give broad-based refractive surgery training and provide fellows with extensive experience doing LASIK, SMILE, ICL, and inlay procedures as part of their training,” he said.
The availability of presbyopia- correcting treatments has been a major driver of practice success, Drs. Brinton and Rebenitsch said. Dr. Brinton said that as of 2018, more than half of refractive patients presenting to his office are seeking presbyopia correction. These patients are presbyopic but are still years out from cataract development (cataract cases called into his office are referred elsewhere). Dr. Rebenitsch estimated that about 40% of his practice’s revenue is from presbyopia treatments.
“While laser vision correction is growing, it’s not growing at quite the same rate as presbyopia,” Dr. Rebenitsch said.
Another thing that sets their practices apart is creating a concierge or boutique feel.
“When we opened our practice, my wife and I started by making a list of the ways our current medical system is impersonal and falls short of patient expectations,” Dr. Brinton said. “It was long. We began by agreeing not to do any of those things on the list.”
For example, instead of a traditional check-in counter, patients are attended to at what looks like a concierge desk at a hotel. When they sit down at a couch in the waiting room, there is a menu, which they can use to request a drink or snack. Tablets are provided for patients to use throughout the process, but in general, Dr. Brinton said that there is minimal waiting. “After diagnostic testing is complete we sit down for 20–30 minutes to discuss refractive surgery options and go over their questions. Our consultation fee includes a second visit if desired to go over further questions. We have hours that make sense for patient schedules, rather than traditional medicine hours,” Dr. Brinton said. “I think we have to stop seeing this as an extension of traditional medicine; these services need to be provided in a way that is accessible to this generation.”
Similarly, patients to Dr. Rebenitsch’s practice are offered water, soda, or coffee upon arriving, phones are answered with what he called a “ClearSight smile,” and technicians are encouraged to get to know patients on a personal basis. He also said the practice employs seven members of counseling staff who devote a significant amount of time to each patient. After procedures are completed, Dr. Rebenitsch offers his personal cell phone number.
“Our goal is to create a relationship before, during, and after the procedure, and to create excitement after the procedure to help drive word-of-mouth referrals as well,” he said.

Atmosphere ripe for growth

Research (based on data from 1999 to 2004) in the U.S. population ages 12–54 years old found myopia prevalence was 41.6%.1
“Just myopia in the United States is about 30–50% of the population. Of that, 80% or higher is eligible for refractive surgery, so the addressable market is enormous,” Dr. Kugler said. “If you include those who have hyperopia and presbyopia … now it’s close to 100% of the population who can benefit from refractive surgery, yet only 4% have had refractive surgery.”
What about the financial aspect of these elective procedures?
“We need to make the economic argument that refractive surgery is valuable and saves money over a lifetime vis-à-vis glasses and contacts,” Dr. Brinton said.
“Early on our staff agreed not to do ‘free exams’ or go the route of coupons, discounts, and special deals. Everyone pays the same amount for a given procedure. Pricing integrity is an important component of the trust we have with our patients.” Patients pay a consultation fee when they book their LASIK consult, and a typical LASIK procedure runs $6,400. LASIK and other refractive procedures present an attractive alternative to those who are spending hundreds and sometimes thousands a year on glasses and contacts. Dr. Brinton said they have seen a significant increase in the number of patients in their 20s coming in for laser vision correction. “Patients in this age range are seeing that they have more years to enjoy their eyesight and the most to gain by having their vision corrected in their early adult years.”
While the patient can benefit from what he called “life-changing procedures,” Dr. Brinton said the practice approach is simpler as well. “Not contracting with insurance companies frees our staff up to focus on patient care,” he explained.
All three doctors said word of mouth has become their most powerful form of marketing. Yet the population, in general, doesn’t have any idea that there is more to refractive surgery now than LASIK, Drs. Kugler and Rebenitsch said.
“We still have a good portion of our patients who have never heard of most of our refractive options. Once that awareness is created, I don’t know how we’ll keep up,” Dr. Rebenitsch said.
“The opportunities are almost limitless,” Dr. Kugler said. “Every year, there are more than 2 million children in the United States who become eligible for refractive surgery, so we’re not even close to maintaining the inflow of new myopes. Even if we just did LASIK and not all the other procedures, we’re not keeping up with the influx of people who have that as an option.”


1. Vitale S, et al. Increased prevalence of myopia in the United States between 1971–1972 and 1999–2004. Arch Ophthalmol. 2009;127:1632–9.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

: jbrinton@brintonvision.com
Kugler: lkugler@kuglervision.com
Rebenitsch: lrebenitsch@gmail.com

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