Refractive cataract surgery will continue to grow, benefiting society
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At this year’s American Academy of Ophthalmology meeting, I was asked by the International Society of Refractive Surgery to give a keynote lecture on refractive cataract surgery.
I asked my friend and colleague David Harmon of Market Scope to help me with some current data. In the following paragraphs, I will share some highlights from this lecture.
My personal definition of refractive cataract surgery (RCS) is an “enhancement to standard cataract surgery targeting superior vision when compared to standard cataract surgery.” To me, it does not include general targeting of distance, intermediate or near vision or monovision/blended vision using standard biometry and a monofocal IOL. It does include correction of preoperative astigmatism, targeting patient-requested uncorrected vision in multiple distance ranges and reduction of visually significant higher-order aberrations to treat corneal irregularity.
The products and services supporting RCS add cost and time to the provision of this service and justify an extra fee charged directly to the patient. These additional products and services include but are not limited to toric IOLs, presbyopia-correcting IOLs, adjustable IOLs, small-diameter aperture IOLs, limbal/corneal relaxing incisions, corneal topography/tomography, OCT, femtosecond lasers when used to enhance refractive outcomes, aberrometers, precision capsulotomy devices and procedures, and the use of laser refractive surgery or incisional refractive surgery to adjust postoperative refractive outcomes. In general, if it is refractive surgery, it is not part of the standard cataract surgery procedure and is in the category of RCS.
Refractive cataract surgery is a win for patients and their families, society, surgeons, facilities and industry. Patients enjoy enhanced visual performance with increased quality of life and may suffer fewer falls because of better vision, stereopsis, depth perception and reduced dependence on glasses, allowing them to stay independent and productive longer. Society gains a better functioning, more independent elderly population. Surgeons develop enhanced surgical skills that also benefit those patients who opt for standard cataract surgery, and ophthalmology practices benefit from another source of revenue in an ever more challenging external economic environment. Industry benefits from product sales revenue that supports continuous investment in incremental and disruptive innovation. This industry investment of human and financial capital has a trickle-down benefit to surgeons, patients and society. RCS is, at every level, a winner.
According to Market Scope, the average additional out-of-pocket cost to a patient for RCS is $2,444 per eye. A manual limbal or corneal relaxing incision supports on average a $700 fee (if made with a femtosecond laser, the fee increases to $1,250); a postoperative LASIK, PRK or SMILE enhancement averages $1,400; a toric IOL, $1,450; a presbyopia-correcting IOL, $2,400; a phakic IOL, $3,800; and a light adjustable IOL or refractive lens exchange, about $4,600. The just more than 5 million RCS procedures predicted to occur globally in 2021 will generate additional revenue estimated at $2.2 billion for industry and an amazing $12.1 billion in incremental fees for providers. Refractive cataract surgery and refractive corneal surgery are important sources of revenue for skilled anterior segment surgeons and care extenders in advanced countries.
Two concerns: Not all patients who might benefit can afford the additional out-of-pocket expenses of RCS, and not all surgeons are fully trained and possess the skills and associated confidence to support a cash-pay service. This limits RCS adoption.
In 2010 in the U.S., approximately 10% of patients undergoing cataract surgery received RCS, and in 2021, the RCS market share is projected by Market Scope at 16.2%. RCS market share is expected to continue to grow at 0.5% to 1% per year as technology advances and more surgeons engage. Several think tanks and key opinion leader summits I have attended in the U.S. suggest that 33%, one-third of all cataract procedures performed per year, is a reasonable target for the peak U.S. RCS market share. At the current growth rate, we will reach that number in or before 2040.
The field of refractive cataract surgery is strong and growing. The revenue generated is supporting investment and innovation in diagnostics, devices and drugs as well as ever more advanced and effective surgeon training. This is positive for ophthalmology and the industry that supports us, but the greatest beneficiaries are patients and society.
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