Refractive
Summer 2024
by Ellen Stodola
Editorial Co-Director
LASIK volumes in the U.S. have declined in the last year, but this isn’t necessarily a bad thing, according to several EyeWorld Editorial Board members who commented on their recent observations with LASIK volumes compared to refractive surgery volume as a whole.
Luke Rebenitsch, MD
According to Dr. Rebenitsch, data shows LASIK is down between 10–15%, but overall refractive surgery is not down as much as that. There is some increase in lens-based procedures. Dr. Rebenitsch is seeing similar trends in his clinic. His clinic has been consistent with the national trends in LASIK in 2023 compared to 2022.
In terms of marketing, Dr. Rebenitsch finds that LASIK is still the “catch-all” term for vision correction. The majority of the general public still sees LASIK as synonymous to vision correction. “But we have seen more and more people coming in asking for other options such as custom lens replacement and refractive lens exchange by name, knowing the options for presbyopia,” he said. “We have been educating our market for around 10 years on these additional refractive surgery options. As a result, we have seen a significant uptick in patients asking for procedures by name rather than just LASIK.”
In his clinic, the volume of ICLs has increased over time, too, he said. When presented the option of the EVO ICL (STAAR Surgical) vs. LASIK, they are seeing more opting for the ICL.
Dr. Rebenitsch thinks that LASIK is down because patients under the age of 40 are more affected by economic challenges than those over 40. Those under 40 don’t have as much money as they used to, but Dr. Rebenitsch thinks it will bounce back. “Our March numbers were much better than February. I think this is just a temporary drop in LASIK,” he said.
Refractive lens exchange is growing because it’s something “new” that is being promoted by more surgeons and practices, and many patients are just hearing about it now. The outcomes of advanced technology IOLs are also much better than they were 5–10 years ago, he said.
LASIK is here to stay for years, Dr. Rebenitsch said. “In years past, we only qualified 70–75% of people for LASIK; now, more than 90% of people who come to our clinic qualify for something, and that’s fun as a refractive surgeon to have all those tools. It’s good for patients, too, because they get better visual outcomes and a procedure more tailored to them.”
Vance Thompson, MD
Dr. Thompson agreed that LASIK volumes are down across the country, including in his practice. He does around 1,000 LASIK cases per year and in addition does a fair amount of refractive lens exchange and phakic IOLs.
“It amazes me how many people come in for refractive surgery consultation, especially in their 50s–60s, who are still correctable at 20/20, so that’s one criteria of LASIK, and they think that’s what they want,” he said. “But when you start talking with them about LASIK, one reason they’re interested is they think it’s going to help them with the reduction in low-light image quality that they’re experiencing and/or presbyopia.”
He continued that when you educate them, they shift from wanting LASIK to wanting a lens replacement procedure. When they talk about the changes they’re noticing in low-light image quality, you can do a brightness acuity test, and if they glare down to a visually significant number, they may actually qualify for cataract surgery. With surgeons being more aware of the visual issues with early cataracts, a lot of what you would think of as refractive lens exchange becomes early cataract surgery.
Dr. Thompson said the “sweet spot” of LASIK has come down over the years. Some people would say 7 or 8 D of myopia is the cutoff. “If I was a 30-year-old patient, and I was more than a 3 D myope, in addition to corneal refractive surgery, I’d be considering a phakic IOL,” he said, adding that he talks to patients about that.
If a patient is a good candidate for LASIK or a phakic IOL, many choose LASIK for cost and familiarity with the procedure, but more people are choosing phakic implants in the moderate range. Dr. Thompson said that he would consider a phakic implant if he was in that scenario because of his experience doing LASIK and phakic IOLs for 30 years. A lot of patients are coming in for cataract surgery that he did LASIK and phakic IOLs on a long time ago, and now that we can quantify HOAs and look at topography and epithelial thickness, some old LASIK cases can’t have all the implant options that modern day technology has brought us, he said. “With phakic IOL patients, as long as they took care of their eyes, didn’t rub their eyes, I monitored them over the years, their corneas are pristine, at the time of cataract surgery, I just take out the phakic IOL and put in whatever implant they want like they never had refractive surgery,” he said. “It’s a pretty powerful value proposition in the long run for an implant.”
As a result of the sweet spot of LASIK coming down and the comfort of phakic IOLs and refractive lens exchange going up, refractive surgery is alive and well, Dr. Thompson said. Sometimes, refractive surgery volumes get equated with the name LASIK, but refractive surgery is a lot more than that and is a lot healthier because it’s PRK, LASIK, SMILE, phakic IOLs, refractive lens exchange, AK, allogenic corneal inlays, etc., he said.
Dr. Thompson thinks all of the options in refractive surgery now fit together well because you have the safest and most efficacious approach to doing the best procedure that fits the patient’s situation. He also said that modern-day diagnostics are teaching us a lot. Patient outcomes and satisfaction are showing us which groups of patients are best for corneal refractive, etc., but diagnostics are telling us why, he said, and oftentimes it has to do with measuring optical scatter in the cornea with too high of a corneal refractive procedure. We’ve also learned the image quality enhancing power of the tear film, Dr. Thompson added. We’re more aggressive with tear film management and tear film health for therapeutic and optical reasons than we were 20 years ago.
Blake Williamson, MD
“We were down with LASIK 4%, but when we looked at our other procedures like custom lens replacement and ICLs, we were way up. We made massive gains on those two segments,” Dr. Williamson said. He thinks this is partly because his practice has been aggressively marketing custom lens exchange and ICL. “That 45-year-old patient who’s a little myopic, who may have gotten LASIK before, is coming in and saying, ‘I like the idea of seeing without reading glasses as well,’” he said, adding that these patients tend to lean to custom lens replacement. Similarly, that patient who’s always come in for LASIK, they come in because they heard an ad about EVO ICL, he said, adding that many people haven’t heard of the ICL before, even though it’s been an option for many years.
Dr. Williamson said his previous marketing centered on LASIK, and now he’s trying to market EVO ICL and custom lens replacement. “This is not because we’re down on LASIK,” he said. “We love LASIK. It’s more about offering these people something else. They’ve heard about what we do over and over for 20 years. You don’t have to advertise LASIK anymore. What’s better is to advertise other things you’re doing. Give them something else, something new, something they’ve never heard of, something they can Google that peaks their interest.” As a result of marketing other technologies, Dr. Williamson also thinks this will increase LASIK volumes as well. “I think because we marketed these other procedures and some people were a –1 or –2 and they could only have LASIK,” he said. “But at least I had the opportunity to have them in the chair and explain the benefits of modern LASIK, and if they had any hesitancy, I could try to understand that and advise them so they could make the right decision.”
For patients who are around –1 up to –3, they can only have LASIK, Dr. Williamson said, adding that the ICL starts around –3.
For a younger patient, someone in their 20s, Dr. Williamson said he might recommend an ICL because chances are they’re going to have some refractive drift as they age. You can then do primary LASIK later, he said, instead of trying to lift an old flap or do PRK. In an older patient who is myopic, Dr. Williamson said he might lean toward doing LASIK if he’s anticipating doing a lens replacement for presbyopia in the near future. For someone with dry eye or a thinner cornea, Dr. Williamson is looking for any reason why LASIK might not be the perfect solution and the ICL would be the perfect solution. If they’re perfect for both an ICL and LASIK, we’ll offer both, and I’ll give pluses and minuses, Dr. Williamson said, adding that some patients like the removability of the ICL. Other times they like that their parents had LASIK, and it worked great, and that’s the procedure they know and that’s what they want.
“We’re doing more ICLs and lens replacement than we’ve ever done, and I think that’s catching on in our community and our state,” Dr. Williamson said, adding that he sees many out-of-town patients coming to him for these procedures. “They’re seeing ads on social media and hearing us talk about EVO ICL, and a lot of time, they don’t have any doctors in their town doing it.”
Lance Kugler, MD
Dr. Kugler has also seen a shift in his practice regarding LASIK volumes. “I think the data from the Refractive Surgery Council is the most accurate data available on LASIK volumes in the U.S. because it is anonymously audited data from the manufacturers, and it reflects the actual number of procedures that are being done,” he said.
While the numbers are down from a year ago, he said there’s more to it. If we look at our own data, we’re seeing a pretty substantial shift from LASIK to IOL-based procedures, such as ICLs, and refractive lens exchange, Dr. Kugler said. “I think that what you’re seeing is that a lot of patients who would have had LASIK a few years ago are now being recommended to have either an ICL or RLE, so that’s a big reason for the apparent decrease in LASIK volumes that we’re seeing.”
Dr. Kugler said that patients will come in asking about certain procedures, but he finds that there is low public awareness of RLE. When they hear about it, it’s usually that they had no idea that it was a solution for them, he said, adding that some patients hear about it as an option because family or friends have had the procedure.
He has seen similar experience with ICLs, where patients might know about this from family or friends. STAAR Surgical is doing some successful direct-to-consumer marketing around the ICL, he said. A lot of times they might not be a candidate for it, even though they come in asking about it, but there’s public interest around RLE and ICLs.
“I do think that the EVO ICL is appealing to people, particularly younger people who don’t like the idea of something that’s not reversible or upgradable,” Dr. Kugler said. “This group likes the idea of something they can do now to fix their vision and adjust later should they need to.”
Rather than pitching every single option to patients, Dr. Kugler said he has a discussion with the patient, and this determines what he will recommend. Patients will never be able to understand the nuances of all these procedures, he said, and as the experts on these procedures, the onus is on us to recommend what is best for them. “Once we’re clear on what the recommendation is, then we can talk about the risks, benefits, and costs. Patients appreciate a clear plan. They come to us for a recommendation and guidance, and I think they are more comfortable when we confidently know what’s going to meet their needs.”
Dr. Kugler said there’s still a place for LASIK. “LASIK is still the clear leader in precision in terms of low power treatments. It’s very precise. It’s probably the most precise we have for astigmatism as well,” he said. “If you have someone who needs that treatment, LASIK is very hard to beat.”
I think it’s difficult, if not impossible, to have a refractive surgery practice without access to LASIK, Dr. Kugler said. To not have LASIK means that you cannot address those situations, he said, adding that you also cannot enhance SMILE without LASIK, and the same is true with IOLs. There are 10–15% of multifocal IOL procedures that require low diopter enhancements, and that is best done with LASIK, he said. “LASIK will continue to be important for the foreseeable future.”
Dr. Kugler said that he is seeing more consistency among doctors. “Ultimately, as a community of refractive surgeons, we continue to strive for a standard approach. Until that is achieved, it’s important for each surgeon to be consistent with how they’re using technology to help their nomograms be better and help staff better discuss expectations with patients,” he said. “The biggest challenge we have in refractive surgery is we don’t have agreed upon standards on how to apply the technologies consistently, and that’s causing confusion among the public and holding us back as an industry. We all want patients to see as well as they can. I think in order to achieve the growth of refractive surgery that we all would like to see, it’s incumbent to have agreed upon standards that we can use together.”
About the physicians
Lance Kugler, MD
Kugler Vision
Omaha, Nebraska
Luke Rebenitsch, MD
Medical Director
ClearSight
Oklahoma City, Oklahoma
Vance Thompson, MD
Vance Thompson Vision
Sioux Falls, South Dakota
Blake Williamson, MD
Williamson Eye Center
Baton Rouge, Louisiana
Relevant disclosures
Kugler: None
Rebenitsch: Carl Zeiss Meditec, Johnson & Johnson Vision, OSRX Pharmaceuticals, RxSight, STAAR Surgical
Thompson: Alcon, Bausch + Lomb, BVI, Carl Zeiss Meditec, Johnson & Johnson Vision, Lenstec, Rayner, RxSight, STAAR Surgical
Williamson: Bausch + Lomb, Johnson & Johnson Vision, STAAR Surgical
Contact
Kugler: lkugler@kuglervision.com
Rebenitsch: Dr.Luke@ClearSight.com
Thompson: vance.thompson@vancethompsonvision.com
Williamson: blakewilliamson@weceye.com
