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It is not a surprise to anyone in the refractive surgery field that surgical volumes are down compared with historical precedents. What is unknown is what exactly precipitated this decline, and, if the cause or causes can be identified, whether it is possible to fix the problem and trigger a resurgence.
One theory is that eroded consumer confidence based on erroneous safety concerns may be a significant factor. Two recent publications, one reporting data from the PROWL-1 and PROWL-2 studies and another reviewing the results of recent studies,1,2 attempt to answer those concerns. Ostensibly, PROWL-1 and PROWL-2, part of the LASIK Quality of Life Collaboration Project, were designed by the FDA to test the ability of a questionnaire to capture patients’ perceptions of LASIK and the percentage of patients having difficulty after surgery. They were largely a response to an infamous 2008 FDA panel meeting at which dissatisfied patients expressed concerns about the safety of LASIK.
The data collected in the PROWL studies confirmed many things already known about LASIK. Among participants in the studies, LASIK was safe and effective, leaving patients happy with their outcomes despite a high prevalence of visual symptoms and dissatisfaction with their vision preoperatively. The studies also highlighted the need for adequate patient counseling and demonstrated the gains our field has made in patient selection criteria.
It is admirable that the efforts represented in these studies were aimed at reassuring the public about LASIK. I am not convinced, however, that doing so was truly necessary. In some regards, these studies take as a starting point the false assumption that there was something wrong with LASIK to begin with, or that we had to do a better job of publicizing its positive aspects. Yet, in a survey of patients conducted in 2009, 95% of patients were satisfied with their visual outcomes after myopic or hyperopic LASIK.3
Note the timing of this survey, and the perspective it provides on the PROWL studies. The survey was performed just 1 year after the supposed furor over LASIK safety expressed at the FDA panel mentioned above. But the survey found that the overwhelming majority of patients are happy with their LASIK outcomes. Could it be that the public outcry over LASIK safety came from only a vocal minority? And, if that is the case, are efforts to reassure the public about the safety of LASIK a classic example of the tail wagging the dog?
OTHER CAUSES OF LASIK DECLINE
In my view, a key reason why refractive surgery volume is down is that many young people in the millennial generation do not have enough disposable income to invest in elective surgery. We may simply be witnessing a natural pendulum swing in the opposite direction after the explosion of LASIK in the 1990s and early 2000s.
From a historical perspective, LASIK came of age just as baby boomers started to express desire in surgical options to improve their quality of life. The massive surge in a generation of the population with disposable income coincided with the growth and improvement of LASIK technologies and techniques. It was the perfect combination to allow the industry and the profession to develop.
However, discretionary spending tends to be cyclical in nature, so a bursting of the LASIK bubble was inevitable. Coincidentally, the economic downturn in 2007 also helped to hasten the decline in LASIK volume. In addition, growth of lens-based refractive surgery gave patients additional options. As more patients opted for lens-based corrections, LASIK and other surgeries aimed at reshaping the cornea suffered as a consequence.
Now, as lens-based options for correcting presbyopia continue to emerge, patients are afforded even more choices for their discretionary income. The potential for ditching one’s reading glasses with a multifocal IOL refractive lens exchange may be more attractive for baby boomers than a corneal procedure that would leave them with distance correction only.
In short, LASIK has not gone and will not go away; instead, it has become one of many tools at our disposal to help patients obtain the vision they want. Modern LASIK adds to our ability to customize surgical vision correction for virtually any situation.
WHERE DO WE GO FROM HERE?
I remain optimistic about the future of LASIK because the surgery itself has only gotten better over time. Improved surgical technology allows us to reduce the rates of enhancements and complications. Diagnostic technologies have also gotten better, so surgeons can do a better job of ruling out inappropriate patients. The surge of knowledge about and greater emphasis on treating preoperative dry eye disease has also dramatically reduced the potential for refractive surprises and poor outcomes.
Yet all of these things represent incremental improvements on what has always been a very good and safe procedure. I have many patients who I performed LASIK on in the late 1990s who still have very good vision today.
To me, the power of technology to attract patients to a practice can go only so far. One can certainly purchase the latest laser that is faster than the last one, but one can never buy experience. Technologies may come and go, but expertise never goes out of fashion. Performing excellent refractive surgery and getting the outcomes that patients want is very much a human enterprise.
Because of this, I think trying to distinguish one’s practice as the one with the latest technology is often a losing proposition. Rather than emphasizing technology, when I discuss surgical options with patients, I emphasize my own experience. There is no one-size-fits-all procedure to fix patients’ visual symptoms, and, therefore, there cannot be a one-size-fits-all approach to patient education. Sorting through the various options still requires a thorough evaluation and a frank discussion between the doctor and the patient.
A regrowth of refractive surgery volume in the coming years will likely hinge on figuring out what makes millenials tick, so that we can effectively market products and services, including refractive surgery, to them. This is something our entire economy is trying to figure out at the moment. Assuming we can solve that puzzle, there is every reason to be hopeful for a return in refractive surgery volume—that is, refractive surgery as a category, rather than one particular procedure.
We have always known that LASIK is an excellent option for correcting vision, and it has only improved with time. Now it has been joined by other procedures, including small-incision lenticule extraction, or SMILE; presbyopia correction options, both lens based and corneal inlays; and truly refractive cataract surgery, offering patients more options than ever before. In the future, we will likely be combining these various procedures to offer patients the ability to reshape the optical system from front to back. We are primed for another growth period in refractive surgery because, just as at the dawning of the LASIK era, a population surge is occurring (this time among millennials) just as excellent surgical options are coming of age.
1. Eydelman M, Hilmantel G, Tarver ME, et al. Symptoms and satisfaction of patients in the patient-reported outcomes with laser in situ keratomileusis (PROWL) studies. JAMA Ophthalmol. 2017;135(1):13-22
2. Sandoval HP, Donnenfeld ED, Kohnen T, et al. Modern laser in situ keratomileusis outcomes. J Cataract Refract Surg. 2016;42(8):1224-1234.
3. Solomon KD, Fernández de Castro LE, Sandoval HP, et al; Joint LASIK Study Task Force. LASIK world literature review; quality of life and patient satisfaction. Ophthalmology. 2009;116(4):691-701.