New tools, presbyopic IOLs driving rapid changes in refractive surgery

With an array of technological advances at their disposal, refractive surgeons should consider shifting from a “catch and release” model of treating patients to an “acquire and hold” model.

A note from the editors:

In this installment of reports from the annual Ocular Surgery News Section Editor Summit in Las Vegas, Refractive Surgery Section Editor Daniel S. Durrie, MD, speaks about how technological advances are driving dramatic changes in the subspecialty.

Over the past 15 years, technology has been driving the growth of refractive surgery. While the growth is starting to stabilize, the advances are beginning to have a major impact on how we practice.

One major change is that phoropter-driven conventional laser surgery is becoming out-of-date. Some are hanging on to this, but I think we’re headed to a premium product with premium pricing, whether it will be wavefront-optimized, wavefront-driven or topography-driven.

Ultimately, whichever is the best procedure will win, and people will adapt. But I think that no matter which laser you use, we should be steering the conversation to better premium treatments; otherwise, we just risk confusing patients.

Progress has moved quickly. Laser keratomes have gone from 1% of the U.S. market to 25% of the market in the past 3 years. As a result, blade keratomes have improved significantly to compete. The entire industry responds to these types of changes.

We now have the IntraLase 60 kHz, which is used by only a few people in the country right now. But they are saying that the machine has improved, and not just in terms of speed.

My flaps take about 17 seconds now, so the speed is comparable to a microkeratome. Beyond that, if you look at the eyes 1 day postop they look like they are a couple of weeks out already.

I predict that we’re going to start customizing the flap for the individual eye. We should not be using the same thickness or diameter parameters for every patient. Eyes are different sizes, and corneas have different thicknesses.

Another major change is that PRK is back in fashion after it was considered undesirable for a while. Ophthalmologists are doing roughly 20% to 30% PRK now. This is a positive change, in that it gives the pharmaceutical company incentive to work on better drugs and it does really help patients.

Corneal presbyopia surgery is an interesting area right now. Conductive keratoplasty is demonstrating a longer-term effect, and people are starting to take notice.

The complicated lens

Accommodation is much more complicated that we thought. During accommodation, the lens changes its shape, spherical aberration and thickness. There is a lot happening to our lens to complicate our optics as we get older.

Daniel S. Durrie

I believe the lens is the key to refractive surgery procedures of the future. Refractive surgeons often do not think about the lens, but I believe they will be thinking much more about it now.

What we are looking toward now is a “four-in-one” lens-based procedure. This considers improving distance and near vision, as well as the future need for cataract surgery and maintaining stable vision.

The question remains, Who should have this surgery? Currently we think it should be cataract patients who can afford it. But why should we only consider patients who already have a cataract? This is going to be a major point of discussion for refractive surgeons in the future.

Less than 3% of the presbyopic population has billable cataracts. Out of this group, about 25% to 30% is willing to pay for premium IOL prices. Most patients who have a cataract want Medicare to pay for it, and they are satisfied with whatever IOL you offer them.

We need to think about the 99% of the population that could benefit from premium IOLs. Otherwise, in effect, industry is spending a lot of money to get FDA approval for presbyopic IOLs for just 1% of the population.

If it was worthwhile to go after this 1%, then it is worthwhile to go after the other 99%.

Changing business practices

Presbyopic IOLs are changing our practice, in that we choose our patients differently for refractive surgery. We have modified the way we do the diagnostic workup, and this gets to the core of our practice’s structure.

These IOLs are also changing the discussions we have with patients, the relationships with referral doctors and our business models in general. They are affecting the value of refractive surgery practices in a way that might be a major driver for people to incorporate them into their practices.

Refractive surgery is now viewed as a continuum of care with at least three stages. First we correct congenital defects of the eye, then we perform a bridging scleral corneal procedure, and finally we implant an IOL.

Since within each stage you have upgrades of category, every patient can undergo as many as six, and sometimes more, refractive procedures in a lifetime.

Our refractive surgery dynamics are changing with more and more young people wanting surgery. Generation Y has never known a world without LASIK, the Internet or debit cards.

This generation trusts and values its parents, so we also market to our 55-year-old patients who can influence their children or purchase them surgery as a present.

This same group of young patients will also embrace IOLs; they won’t put up with presbyopia or cataracts. So the rosy future for this industry lies with this generation of patients and consumers.

Diagnostic, educational tools

Changes in the lens are shaping which diagnostic equipment we use. We have at our disposal digital slit-lamp photography, Oculus Pentacam, anterior segment optical coherence topography visiometrics and the Optical Quality Analysis System, a new device that measures optical quality and scatter.

We now need new educational tools, including integrated information systems, that enable us to show patients everything going on with their eyes at once, without having to show them the diagnostic equipment.

With these types of education tools, in conjunction with the advanced diagnostic tests, you are more likely to be able to show patients if they need cataract surgery as well as refractive surgery. In effect, you can sell cataract surgery via these diagnostic instruments because the patient can see right there what is going on with the lens.

Acquire and hold

We made a significant change over the past few years when we realized that our best asset is our previous patient. This prompted us to move from the “catch and release” model to the “acquire and hold” model, a shift that represented a major change in our practice. The patient base you already have can be a tremendous value to your practice.

What we are finding is that there are good models to grow our business based on the patients we have already operated on.

Specialists in glaucoma, retina and oculoplastics already operate under this model, but LASIK and cataract surgeons do not.

These subspecialties differ in starter procedures, business models and re-treatment rates. Glaucoma surgeons, for example, do not start treating a patient with a trabeculectomy but rather go through stages before performing surgery. Likewise, retina surgeons don’t always do a buckle or a vitrectomy on every patient but begin with something else and then progress to that if the patient needs it. Certainly, the plastic surgeon performs a sequence of procedures, including injections, upper-eyelid surgery, forehead lift and so on.

By contrast, LASIK and cataract surgeons do not have a “pre-procedure,” so we are not accustomed to working that way.

Nowadays, however, refractive surgeons are going to be seeing multiple re-treatments, so they need to be thinking about how this will fit into their long-term business model. All previous refractive surgery patients are now great candidates for additional surgery. We are upgrading to more advanced lasers, and we can correct their higher-order aberrations, perform corneal presbyopia surgery or implant an advanced IOL.

We also do comprehensive ocular wellness exams now. I want to see every patient 2 years after surgery to perform an ocular wellness exam, called “advanced ocular analysis.” This is an advanced exam that goes above and beyond what an optometrist or anyone else can do. We also do nutritional analysis and education, both of which the patients love. We are looking after their long-term care.

For more information:

• Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 200, Overland Park, KS 66211; 913-491-3737; fax: 913-491-9650; e-mail: ddurrie@durrievision.com.