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Continued economic downturn affecting LASIK, PRK volumes
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 Richard L. Lindstrom |
The volume of LASIK/PRK performed each year in the United States has fallen significantly during the current economic slowdown, from about 1.2 million procedures a year to about 750,000 projected for 2011.
This is the second time surgical volumes have fallen significantly in the face of an economic contraction. The first time was immediately after the Sept. 11 attacks. In that contraction, LASIK volumes fell for approximately 2 years before experiencing a 4-year period of growth from 2004 to 2008. Now, we are in the third year of an economic contraction, and LASIK volumes have fallen again significantly. Because laser refractive corneal surgery is a consumer discretionary spend, its volumes follow the rises and falls in the economy and consumer confidence adjusted by the seasonality quite closely. A small recovery in consumer confidence appeared to be working its magic for LASIK/PRK volumes earlier this year, but now the economy is slowing again and consumer confidence is falling, suggesting that we will not see a meaningful recovery in LASIK/PRK surgical volumes any time soon.
Two indices surgeons can follow that appear to correlate quite well with elective surgery demand are the Luxury Consumption Index and the seasonally adjusted Consumer Confidence Index. Both currently suggest that we will continue to experience weak demand for LASIK/PRK in the next 6 months. Patient surveys reveal that the number of patients desiring laser corneal refractive surgery remains strong, but the poor economy and the current population demographics are discouraging to me.
The baby boomers have passed into the presbyopic age group, reducing their demand until we have a good solution for presbyopia. I am impressed that the Kamra corneal inlay (AcuFocus) holds great promise to strengthen demand in the patient with presbyopia alone or combined myopia or hyperopia, astigmatism and presbyopia, but we are likely 2 or more years away from U.S. Food and Drug Administration approval. Generation X represents a smaller opportunity, and Generation Y, or the echo boomers, is in general too young and still doing well with contact lenses to seek LASIK/PRK in high numbers. So, a strong return to LASIK/PRK volumes approaching the 1.4 million procedures performed at its peak of demand will likely not occur until a good solution for presbyopia, a strong economy and some aging of the echo boomers occur. Unfortunately, these three factors may not align until late in this decade.
In regards to choice of procedure, LASIK continues to dominate in the U.S. at more than 85% of laser refractive corneal surgery. This is primarily related to the rapid visual recovery and lack of discomfort, which is appreciated by the LASIK patient. Good data support the conclusion that both LASIK and PRK generate good outcomes at 4 to 6 months postoperative, but visual recovery is much slower after surface ablation. Microkeratome flaps have been replaced in the majority of surgeries by femtosecond laser flaps, but many experienced surgeons continue to deliver good outcomes with the modern microkeratome. In our practice, despite great experience with mechanical microkeratomes numbering more than 50,000 procedures, our six surgeons found better visual acuities, a lower complication rate and a reduced enhancement rate with femtosecond laser-generated LASIK flaps. We have therefore abandoned the microkeratome in favor of the femtosecond laser.
Research is under way to develop a new generation of contact lenses that would allow rapid visual recovery and reduced pain with surface ablation, and if this technology succeeds, I would predict significant growth in PRK volume. Absent such a technology advance, I expect LASIK will continue to dominate in the U.S. Outside the U.S., there are countries in which PRK dominates, such as Italy, but this dominance is primarily driven by the issue of cost.
LASIK/PRK remains the second most common surgical procedure performed by the anterior segment ophthalmic surgeon, projected to number just more than 750,000 this year. These 750,000 procedures are performed by about 2,000 to 2,500 corneal refractive surgeons, for an average volume of 300 to 350 per surgeon. Both of these numbers are dwarfed by the 3.2 million cataract surgeries projected to be performed by about four times as many surgeons, with slightly higher average volume per surgeon of 350 to 400 procedures per year.
Most corneal refractive surgeons also perform cataract surgery, including refractive cataract surgery. Combined, cataract surgery, refractive cataract surgery and refractive corneal surgery offer the American anterior segment surgeon a nice combination of third-party pay and direct-patient pay, buffering somewhat the continuing pressure on reimbursement. In the long run, the economy and consumer confidence will rebound, accelerating demand for LASIK/PRK, so I believe the American anterior segment surgeon can look forward to growing surgical volumes.
The surgeon who is well trained in both refractive corneal surgery and refractive cataract surgery appears to me to be well positioned to survive the current economic environment and prosper in the future when we hopefully experience a stronger economic recovery, along with aging of the baby boomers and echo boomers and advances in technology for the treatment of presbyopia. I encourage all young anterior segment surgeons, which I define as anyone intending to practice for 10 or more years, to learn the skills required to offer both laser corneal surgery and laser refractive cataract surgery to their patients. For those who do, the future will be bright.
- Disclosure: Dr. Lindstrom is a consultant and an investor for AcuFocus.