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An exploration of what influenced declining volume and what can
be done to increase it again.
BY SHERAZ M. DAYA, MD, FACP, FACS, FRCS(Ed), FRCOphth
The history of LASIK is fascinating from many
perspectives. Today it stands as an amazing,
truly 21st-century procedure that has revolutionized refractive surgery, reliably providing
phenomenal outcomes to millions of patients.
Initially high volumes provided many surgeons
with cash flow such as they had never seen
previously, enabling them to build organizations that have improved service and delivery of ophthalmic
care to patients. However, the ease of performing the procedure has been a double-edged sword, as will be seen below.
I performed my first LASIK procedure just more than 20 years
ago, and, in those days, using the Automatic Corneal Shaper
(Steinway/Chiron) was an art form that required fairly expert
hands. Despite some relatively major flap complications (remedial work for corneal surgeons), the procedure grew in popularity, and outcomes at that time were overall good. With iterative
improvements in technology, outcomes improved further.
Consider the situation now: Flaps are created with femtosecond lasers, a technology that is much more accurate than
mechanical microkeratomes and with minimal complication
rates. Modern lasers can customize treatments, providing aspheric profiles and wavefront treatments that truly
enhance vision. Outcomes are as predictable as they can
be, with almost 100% of eyes achieving 20/20 visual acuity.
Despite these advances, LASIK volume has tapered in almost
every country, except those with huge populations such as
China and India.
What happened?
There are a number of views to account for this decline. The
majority view is that, “It’s the economy, stupid!” In the past,
whenever there was a slight reduction in refractive surgery
volume, ophthalmic leaders and gurus would put up graphs
at major meetings to show a direct correlation of volume with
the Dow Jones Industrial Average (DJIA).
But is it really the economy? The DJIA has come back
and, as of early March as this is written, is hovering around
18,000—an all time high (Figure 1). We are informed that the
recession has been over for some time now, but there is still
no sign of a major bounce-back in LASIK volumes.
COVER FOCUS
WHATEVER HAPPENED
TO LASIK (VOLUMES)?
There are obviously other influences, and I shall endeavor
to list some of these below, from my perspective.
TIPPING POINT
Every product has a lifecycle, and plotting revenue against
time provides an S-shaped curve (Figure 2): a slow, gradual
start, then an exponential rise, eventually reaching a plateau
of maturity, and then perhaps a decline. This product lifecycle
can also be considered from the point of view of customer
attitude toward innovation, which takes the form of a bell
curve (Figure 3). Products get a gradual start with adoption
by the innovators, followed by increased growth due to early
adopters. Then, by the time 15% to 16% of the potential
(Continued on page 39)
AT A GLANCE
• The recession has been over for some time now, but
there is still no sign of a major bounce-back in LASIK
volumes.
• Apart from leading to phenomenal risks for businesses,
price wars and discounts provide the public with a
confusing message: The procedure on offer is not
serious and is easily available at bargain-basement rates.
• The fallout of having a growing population of
dissatisfied patients includes the formation of patient
advocacy groups, postings on Internet forums, negative
articles in the sensationalist press, and a further change
in the public’s perception of the procedure. The
message becomes: Perhaps laser eye surgery is not that
safe after all, and let’s no longer consider it as an option.
• Outcomes are as predictable as they can be, with
almost 100% of eyes achieving 20/20 visual acuity.
Despite these advances, LASIK volume has tapered
in almost every country, except those with huge
populations such as China and India.
APRIL 2015 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 37
COVER FOCUS
CRST EUROPE READERS SOUND OFF:
How have you changed the way you present
LASIK to your patients—in other words,
what do you do now to present LASIK as an
attractive surgical option? John S.M. Chang, MD
Recently there has been bad press on LASIK in Asia from a doctor in Taiwan, from the consumer council in Japan, and from the
press in Korea. As a result, many refractive surgeons practicing in
Asia have switched to the ReLEx SMILE procedure and
claim it does not have the problems LASIK has.
However, I tell my patients the following:
1. Corneal refractive surgery has been
around for nearly 50 years. Because it
is not a new procedure, we know it
very well by now.
2. The cornea gets tougher with age, so
degeneration is unlikely to show up
20 years later.
3. The US Army has performed more
than 0.5 million cases of LASIK since 1999,
and they have continually monitored these
soldiers. If LASIK was not safe, they would have
stopped offering the procedure by now. Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth),
FRCS(Edin)
I tell patients that more refractive surgeons have had LASIK than
any other profession pro rata. I tell them that the literature now
suggests that LASIK is safer than contact lens wear.1,2 I tell them
that, traditionally, the biggest fear has been post-LASIK ectasia, and,
because we can do CXL, post-LASIK ectasia is simply no longer
remotely the same concern as it was before. Concerns such as glare
can also be put to bed when we are able to offer wavefront- and
topography-guided procedures.
We have hung photographs in our clinic of staff members who
have had LASIK, and this also generates a feeling of comfort and
security for the prospective patient. Those who are interested
in LASIK are shown the refractive suite that we use for the procedure. It is a sleek laser setup and converts a lot more patients
than it scares off. We also have thick photo albums full of handwritten thank-you cards from patients lying around the clinic.
Reading these give patients a great sense that they are in the right
place and that LASIK is a great procedure.
1. Schein OD, Katz J. Comparing contact lens and refractive surgery risks. Arch Ophthalmol. 2007; 125(6):853-854; author reply,
854-855.
2. Mathers WD, Fraunfelder FW, Rich LF. Risk of lasik surgery vs contact lenses. Arch Ophthalmol. 2006;124(10):1510-1511.
38 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | APRIL 2015
Detlef Holland, MD
We perform femto-LASIK with the latest-generation excimer
laser in our clinic and introduce the procedure to patients as
a highly safe, predictable, and efficient surgery with more than
25 years of solid clinical evidence supporting it. We explain that,
because we treat our patients in the evidence-based range of
refractive error and exclude unsuitable eyes, the risks associated
with LASIK are absolutely minimized.
Aylin Kilic, MD
Many educational resources available on the Internet can be a
fantastic resource for our patients. However, these can sometimes
overwhelm patients or scare them away from having
the procedure. Just 20 years ago, there were only
130 websites total, and Google was not yet
in existence; 10 years ago, Skype, Facebook,
YouTube, Reddit, Twitter, Tumblr, Dropbox,
and Instagram did not exist. In 2003, fewer
than 1% of all telephones were considered
smartphones. Today, the Internet hosts
thousands of websites, but, unfortunately,
those dedicated to LASIK information
range from being incomplete and deficient,
to requiring a high reading level to understand,
to those that present the procedure in a positive
light. Patients relying on Internet content to make
LASIK decisions could be negatively influenced by deficiencies in the information provided, and we must always keep this in
mind when counseling patients.
Recently I have felt more pressure than ever before to give
patients detailed and scientific evidence on LASIK and LASIK
technology, as I believe it helps to make the procedure a more
attractive option. Vision quality is more important to patients than
spectacle independence, and talking to them about customizable
treatments, iris registration, precise astigmatism correction, and eyetracking systems can reduce patient anxiety and inform them that
LASIK can help them to achieve their visual goals. Because patients
can read about different kinds of refractive surgery methods online
and in company literature, I have many more patients coming in
for consultations with specific questions than I had in the past. I
believe that my new approach has helped to ease patient concerns
and to present LASIK positively. Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO,
FRCOphth, FEBO
I tell patients that LASIK can be used to correct presbyopia
(reading vision) as a 10-minute procedure that heals in a few
hours, without having to take the risk of going inside the eye and
replacing the natural lens with a lens that splits light to achieve
reading vision.
(Continued from page 37)
population is reached, an exponential rise takes place, with the
early majority followed by the late majority and, ultimately,
the laggards. To go exponential, 15% to 16% of the eligible
population must have had a procedure, and then the mass
effect takes place.
If, very conservatively, 30% of the population is suitable
for LASIK, then, in a country with a population of 60 million
(like the United Kingdom), there would be 18 million eligible
COVER FOCUS
Figure 1. DJIA as of March 19, 2015.
individuals. To achieve
15%, it would be necessary
for 2.7 million people to
undergo LASIK (5.4 million
procedures). At its peak,
there were an estimated
130,000 LASIK procedures
performed per year in the
United Kingdom, and this
active phase was maximal
for 10 years (an optimistic
estimate). That translates
to 1.3 million LASIK procedures for 650,000 patients,
or 3.6% of the eligible
population—far short of
the 15% required to go
exponential.
This means that only a
fraction of early adopters
have had the procedure.
The innovators would have undergone LASIK with barely a
thought, while early adopters might have waited a while but
definitely had the frame of mind to be treated. This raises
the question, then: Have all the people who would consider
the procedure had it done already? If this is the case, it is all
over for LASIK. As a product, the procedure has been unsuccessful and has behaved more like the Segway (Segway) than
the iPhone (Apple).
SALES VOLUME
(DOLLAR INDEX)
20
15
10
5
STAGE #1
MARKET
DEVELOPMENT
STAGE #2
GROWTH
STAGE #3
MATURITY
STAGE #4
DECLINE
0
YEARS
1 23 45 6
Figure 2. Product life cycle.
APRIL 2015 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 39
COVER FOCUS
What it Takes for a Product
to Go Exponential
©istockphoto
Products get a gradual start with adoption by
the innovators, followed by increased growth
by early adopters. Then, by the time 15% to
16% of the potential population is reached,
an exponential rise takes place, with the
early majority followed by the late
majority and, ultimately, the laggards.
To go exponential, 15% to 16% of
the eligible population must
have had a procedure, and
then the mass effect
takes place.
Why, for such an amazing procedure, has the uptake been
so low in the United Kingdom, probably lower than in many
other countries such as Spain, the United States, and the
nations of Latin America? Besides the relatively conservative
nature of the UK population, I believe there have been other
influences that have adversely affected LASIK volumes.
COMMODITIZATION AND ITS EFFECTS
Unlike in many other countries, in the United Kingdom,
there has been a dearth of ophthalmic providers with the courage to establish refractive surgery centers. This has permitted
the entry of corporate groups that have dominated the provision of laser refractive surgery. I suppose someone had to do it,
but the emphasis of care has perhaps been different from how
individual doctors or group practices might have approached
the procedure. The corporate focus purely on volume, efficiency, and profitability has influenced the messaging to the public.
The enticements of low prices and marketing techniques such
as bait-and-switch offers, competitions, and other inducements
have provided the public with a distorted perception of laser
eye surgery: LASIK is a procedure that is available everywhere at
similar standards, and the key is to be smart and choose on price
(or get the procedure at no cost by winning a competition!).
Rather than becoming educated about what is involved
and about how to differentiate one procedure or practitioner from another, patients have concentrated on getting the
40 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | APRIL 2015
best deal. As a result, competing groups with large cost bases
and dependent on high volumes have engaged in price wars,
further distorting perceptions. (Editor’s note: See Guidelines
for Refractive Surgery on page 50 for a related article.)
Apart from leading to phenomenal risks for businesses,
price wars and discounts provide the public with a confusing message: The procedure on offer is not serious and is
easily available at bargain-basement rates. The desirability of
the procedure is in turn affected, as it is easily available. As
patients have said to me, “I always felt that when I needed
it I would have it done.” Rather than wanting the procedure
right away, they categorized it as something they would
have done if it ever became necessary—for example, if they
became intolerant to contact lenses.
An analogy might be made to a desire to have a particular
brand of expensive watch, one that is just a little expensive
and out of one’s price range, for which one might have
to save and buy at a date in the future. If the brand then
becomes easily available and advertised widely with a low
sticker price and the promise that it might get lower, the
watch goes from being a bit unaffordable and desirable to
being highly affordable and, in turn, not as desirable. I believe
this has happened with LASIK.
Commoditization has had another negative impact, and
this is the increased prevalence of unhappy individuals
who have had laser eye surgery that has not gone as well
as expected. To maximize profits and contain costs, riskier
inexpensive models of care provision have been employed
in some centers; for example, the use of optometrists to perform preoperative evaluations, with surgeons basically acting
as technicians who perform the procedure with only a brief
consultation with the patient immediately beforehand.
Additionally, the practice of upselling to wavefront and
femtosecond laser options has been big business. Rather
than concentrating on what is best for patients, the ophthalmic industry has educated providers to use the option
of selling better technology as an added value or premium
from which the practice can derive greater revenue. If all
patients were evaluated thoroughly to eliminate contraindications such as abnormally shaped corneas and dry eye, and
then underwent the best possible care available and customized to suit them, with femtosecond lasers and accurate
treatments, and then received excellent postoperative care,
the number of patients with problems would be small. Yes,
perhaps it would be more expensive to provide this type of
care without the premium icing on the cake, but it would
mean a lot less trouble for patients and practitioners. In this
context, cheap is expensive in the long term.
Further, the fallout of having a growing population of dissatisfied patients includes the formation of patient advocacy
groups, negative postings on Internet forums, negative articles in the sensationalist press, and a further change in the
public’s perception of the procedure. The message becomes:
COVER FOCUS
Early
Adopters
13.5%
Early
Majority
34%
Late
Majority
34%
Laggards
16%
Innovators
2.5%
Figure 3. Adoption of new technologies. To go exponential, 15% to 16% of the eligible population must have adopted a product.
Perhaps laser eye surgery is not that safe after all, and let’s no
longer consider it as an option.
The natural product lifecycle of LASIK has, at least in the
United Kingdom, been arrested by commoditization, the
consequence of which has been a change in public perception along with concerns about the safety of the procedure.
RESCUE TREATMENTS
At the American-European Congress of Ophthalmic
Surgery (AECOS) in Barcelona last year, Dan Z. Reinstein,
MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO, proposed an interesting perspective on how to limit damage like
that discussed above and improve the perception of LASIK.
He suggested that the ophthalmic industry make an effort
to develop and provide remedial surgery for those who have
had less-than-ideal refractive surgery outcomes.
He has a good point. If technology were easily available to
correct problem cases (eg, topography-guided treatments),
then those with undesirable outcomes could have their problems resolved promptly. A remedial procedure would be a bit
like an enhancement, with rapid resolution, and would help to
prevent patients from joining the ranks of online LASIK-haters.
Perhaps the ophthalmic industry has concentrated too
much on providing great technology without enough attention on remedial surgery. It may not be too late to address
this imbalance, and perhaps appropriate technology can
be developed to treat those who have had unfortunate
outcomes. This might help to provide an additional level of
assurance to the public regarding safety of laser eye surgery.
I cannot help but think, however, that avoidance of problems
in the first place is better. We all know what it takes to achieve
good outcomes, including good patient evaluation and selection, phenomenal attention to detail, and exceptional follow-up
42 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | APRIL 2015
care, in which we rapidly identify and address potential problems. If all patients were treated at a phenomenally high standard, minimal numbers would require remedial help. While this
would be the ideal, unfortunately, the reality is otherwise.
THE SOLUTION?
Above I have identified some of the issues leading to what
may be a sustained reduction in LASIK volumes for the
foreseeable future. This does not mean I have a solution for
a quick, easy fix. Rather, the fixes will be long and difficult.
They might include the following:
• Going back to basics;
• Treating LASIK with a phenomenal level of respect;
• Taking care of every patient individually;
• Providing each patient with the best available care;
• Stepping out of the ring when it comes to price wars
and discounts;
• Avoiding commoditization on all fronts;
• Engaging in responsible marketing that concentrates on
educating the public rather than hyping price; and
• Providing a first class act in all respects.
Such actions, and many others that you and other practitioners can fill in to fit your own situations, will go a long way
toward improving the perception of LASIK and restoring public confidence in a procedure that remains amazing. n
Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth
Director and Consultant Surgeon, Centre for Sight, East
Grinstead, United Kingdom
n Chief Medical Editor, CRST Europe
n [email protected]
n Consultant (Bausch + Lomb)
n