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Slow but steady growth expected for all areas of refractive surgery
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I classify refractive surgery into refractive corneal surgery and refractive cataract surgery, although not all patients who undergo lens-based refractive surgery have a cataract as typically defined. Refractive corneal surgery for me includes LASIK, PRK, SMILE, incisional procedures such as RK and corneal or limbal relaxing incisions, which today can be done with a diamond knife or a femtosecond laser, collagen cross-linking, Intacs, conductive keratoplasty and intracorneal implants for presbyopia.
Most refractive corneal surgeons also perform lens-based refractive surgery, which I categorize as refractive cataract surgery. Arguably all lens-based surgery is refractive surgery, as all patients have a preferred refractive target. I include here cases in which I simply try to minimize induced lower- and higher-order aberrations in patients who present near emmetropia and correct pre-existing visually significant astigmatism and presbyopia. For me, commonly performed procedures include selecting a lens implant with the ideal asphericity, utilizing a toric IOL to treat astigmatism and reducing the handicap of presbyopia with monovision, a multifocal, an extended depth of focus or an accommodating IOL. A small number of extreme myopes, about 4,000 per year in the U.S., undergo a phakic IOL implant. The new technologies that have become available to us over the last decade or two are nothing short of amazing and, for many, somewhat intimidating as we are challenged to develop ever more skills to meet the needs of our ever more demanding patients.
A few thoughts and observations on the field of refractive surgery. Of the about 18,000 U.S. ophthalmologists, only about 2,000 perform refractive corneal surgery frequently. The most common procedure is LASIK, which represents about 85% of the 650,000 procedures performed each year in the U.S. The second most common procedure is PRK. SMILE is just being launched, as are intracorneal lenses for presbyopia. In general, refractive corneal surgery has not seen meaningful procedure growth in the past decade despite the fact that outcomes are excellent and continue to improve, and we have more FDA-approved procedures available every year.
It is likely that demographics explain to some extent this lack of growth in procedure volume, as the next best group of candidates for myopia, astigmatism and hyperopia are the millennials who range in age from 16 to 36 years, with a mean age near 26. Most patients in this age group do well with contact lenses and have not yet looked in serious numbers for a surgical alternative. In addition, many millennials remain underemployed with significant college debt. I expect these patients to seek refractive corneal surgery in increasing numbers as more move into their 30s. Thus, starting around 2020, I anticipate growth in LASIK, PRK and/or SMILE volume.
We can also anticipate slow but steady growth in the surgical treatment of presbyopia with intracorneal lenses and refractive cataract surgery. Collagen cross-linking might also prove to be a very safe and minimally invasive way to treat low levels of refractive error. Refractive cataract surgery is performed by about two-thirds of the 9,000 U.S. cataract surgeons, but here too procedure volumes have underperformed expectations. About 7% of patients undergoing cataract surgery have their astigmatism treated when as many as 50% might benefit. Only about 5% receive a presbyopia-correcting IOL although a larger number, as many as 20%, have some form of blended vision or monovision in which mild to moderate myopia is targeted in one eye. Still, 100% of patients undergoing cataract surgery might benefit from having their presbyopia treated.
Challenges here include the quality of vision and unwanted night vision symptoms associated with some presbyopia-correcting IOLs. In addition, many surgeons have difficulty hitting the ideal refractive target in a significant number of their patients, requiring a laser refractive corneal surgery enhancement for best outcomes. Unfortunately, only two of nine cataract surgeons are trained in laser refractive corneal surgery. In my opinion, PRK is an easy procedure to learn and is effective in treating residual refractive error after refractive cataract surgery. There are several mobile laser companies, including the market leader Sightpath, for whom I have consulted, that will bring a laser to any surgeon’s office or hospital, allowing access and training.
Likely the biggest barrier to refractive cataract surgery growth is lack of surgeon confidence in generating high patient satisfaction because it requires a refractive outcome near plano. Technology advances, surgeon training and improved technology access should allow steady growth in refractive cataract surgery, as most studies and focus groups suggest at least one-third of our senior patients seeking cataract surgery value reduced spectacle dependence and are willing to pay extra for this benefit.
Refractive corneal and cataract surgeries present an extraordinary opportunity for enhancing our patients’ quality of life. These procedures also represent a significant potential cash pay revenue stream for the ophthalmologist as pressure continues to mount in the third-party payment sector.