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Quality data important to attract younger patients to LASIK
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I have been involved with corneal refractive surgery since 1981, when as a young assistant professor and director of the Cornea Service at the University of Minnesota Department of Ophthalmology, I was invited by my friend George O. Waring III, MD, to participate as a surgeon on the so-called PERK study.
In 1988, I acquired one of the first 10 excimer lasers in the U.S. and participated in multiple clinical trials that continue to date as laser corneal refractive surgery technology evolves and improves. I continued with radial and astigmatic keratotomy, pioneering and teaching mini-RK and the ARC-T system of corneal relaxing incisions for astigmatism until 1995-1996, when the first two excimer lasers, Summit and Visx, were approved by the U.S. Food and Drug Administration. I then abandoned the mini-RK procedure for myopia in favor of laser corneal refractive surgery and limited my use of ARC-T incisions to my refractive cataract surgery practice.
While I started with PRK, I adopted microkeratome LASIK and then femtosecond LASIK early and with my associates, particularly David Hardten, MD, helped train many of America’s current corneal refractive surgeons. Minneapolis/St. Paul and the 50-mile surround are a good barometer of the LASIK market in the U.S.
We launched LASIK/PRK in our practice in 1996, and our volume of cases doubled every year, reaching a peak of just more than 7,000 eyes in 2000 with four refractive surgeons. The same occurred in the U.S. as a whole, with a peak just more than 1.4 million eyes per year in 2000/2001. In 2014, with six refractive surgeons in our group, we performed just more than 3,000 LASIK/PRK procedures, about 40% of the volume we generated more than 10 years ago.
Nationwide, a similar reduction in LASIK/PRK has occurred, with a likely U.S. volume of less than 700,000 eyes in 2014 vs. 1.4 million in 2000/2001. During this same time period, cataract surgery in our practice and in the U.S. approximately tripled.
This collapse of the LASIK/PRK market was not anticipated or predicted by anyone. The reasons are multifactorial and still under debate, but I will share my thoughts.
Certainly, the Sept. 11 tragedy in the U.S. was a trigger, with a significant recession from late 2001 into 2004 and then the Great Recession from 2008 to 2011. So, economic decline has played a role.
Still, the other alternative to spectacles, contact lens wear, has enjoyed steady growth of 3% to 4% per year over the past decade while LASIK has collapsed. I believe patient demographics play a significant role. The average age of a contact lens wearer is 31 years, and the average age a patient opts for LASIK/PRK is 39 years. These numbers have stayed steady as we have transitioned from the 78 million baby boomers as the most common patient for both these modalities to Gen X and now especially Gen Y/Millennials.
Most patients start with glasses until they are in their teens and then, if unhappy with spectacles, advance to contact lens wear. Most LASIK/PRK patients come from people unhappy or frustrated with contact lens wear for one reason or another, and this does not usually occur until the 30s. The baby boomers are now all presbyopic, so LASIK/PRK is less attractive, and we are seeing growth in refractive lens exchange for the so-called “dysfunctional lens syndrome.” The anticipated approval of the AcuFocus Kamra inlay for presbyopia in the U.S. may bring some of the younger boomers back into our offices for LASIK/PRK combined with a presbyopia-correcting corneal inlay, and I project the impact of this technology will grow the market as much as 10% to 20%.
The key potential patient for LASIK/PRK today, however, is definitely the Millennial. Depending on one’s definition, Millennials are approximately 16 to 36 years old with a mean age of 26 years. There are a lot of them, approximately 100 million, and they are wearing contact lenses at a similar to slightly higher percentage than their baby boomer parents. We who do corneal refractive surgery are seeing them and the Gen X patient replace the baby boomer as our typical patient, but we are far from seeing strong growth in our surgical volumes. Again, the reasons are several.
First, the Millennial is still doing well with contact lenses at the mean age of 26 years.
Second, Millennials are struggling financially with a high unemployment and underemployment rate and, in many cases, the burden of debt accumulated during their secondary education. Contact lenses cost on average less than $500 per year, while LASIK/PRK carries an average price tag of $4,000. It can certainly be argued that in 8 years the savings from eliminating the annual cost of contact lenses could pay for LASIK/PRK, but many Millennials just cannot come up with the money. We do see many parents and grandparents gifting the procedure, but on their own, few Millennials can write a check for $4,000. Payment plans and the like help, but just staying in glasses or contact lenses is attractive to most.
Third, we have suffered from bad press regarding LASIK/PRK, and many patients fear the procedure. Most of us who are committed refractive surgeons with significant experience consider this fear of LASIK/PRK to be out of balance with the facts. Carefully performed, credible studies such as PROWL-1 and PROWL-2 confirm over and over again the excellent safety and efficacy profile of LASIK/PRK. While spectacles provide an extraordinary safety profile, for the patient seeking an alternative to glasses, it is easy to argue that the lifelong cost is lower and the safety profile, quality of vision and quality of life superior with LASIK/PRK when compared with contact lens wear, especially when the higher-risk extended wear contact lenses are selected.
The future for growth in LASIK/PRK volume is, in my opinion, good, as the current technology in an experienced surgeon’s hands generates an amazing visual outcome with a low risk, and our industry continues to invest to make the procedure even better.
To see a strong recovery, the Millennial patient population in the U.S. needs to get a little older, with better jobs and less debt. Second, the inappropriate fear of LASIK/PRK needs to be mitigated with an honest sharing of the facts. Third, a treatment for presbyopia such as the Kamra needs to become available. Finally, collagen cross-linking may expand the pool of eligible patients.
While contact lenses continue to improve, there remains a significant number of patients who will become contact lens intolerant, usually in their 30s, numbering as many as 3 million per year in the U.S. alone. These Millennial patients with contact lens intolerance can, in my opinion, create accelerating growth in the LASIK/PRK market beginning now and continuing for 20 years.
It is important that quality data and information sources be available so that patients can be properly educated as to the risks, benefits and opportunities that modern LASIK/PRK offers. PROWL-1 and PROWL-2 will be helpful in this task, and the FDA, National Eye Institute, military and private practice surgeons that participated in these studies are to be thanked for these excellent and highly credible studies.