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It is perceptions in the mind of the individual patient, not the market, that will define
the success of the future of laser vision correction.
BY RONALD R. KRUEGER, MD, MSE
The question addressed by Sheraz M. Daya,
MD, FACP, FACS, FRCS(Ed), FRCOphth, in
his article on page 37 is one on the minds
of all refractive surgeons, and Dr. Daya has
done a masterful job of outlining the issues
at hand. It is a curious question for several
reasons. First, LASIK is the most commonly
performed elective procedure in the world.
Second, it has produced excellent outcomes with rapid
recovery. Third, despite the success of the procedure, the
percentage of patients undergoing LASIK is only a small fraction of those who could benefit from the procedure.
Why has LASIK’s product lifecycle not seen the tipping point,
with the rapid S-shaped curve of growth described by Dr. Daya?
Why has its market penetration not gone beyond the 15%
to 16% of innovators and early adopters to that of the early
majority in the bell-shaped curve of product acceptance in the
market? Why, besides economic reasons, are we seeing a slight
downturn in LASIK volumes, rather than a continued rise?
HAS LASIK SEEN ITS PEAK?
The first logical conclusion and answer to these questions
is that LASIK has seen its peak and is now on the decline.
Market penetration has not exceeded the 15% to 16% needed
to move into the rapid growth of the majority, and the procedure is now declining to just an occasional procedure that
is not for everyone. None of us wants to believe that about
LASIK, and, in response, Dr. Daya has presented a great argument and reasons why this is not, and should not be, true.
Commoditization has affected laser vision correction and
LASIK in both good and bad ways. With LASIK presented as
a ubiquitous commodity rather than a risky procedure, many
early adopters have jumped in, helping to make LASIK the
most frequently performed elective procedure. This is good, as
it puts LASIK seemingly ahead of the curve. However, with the
huge market of patients eligible for LASIK, and with the procedure’s rapid and excellent functional recovery, LASIK has a
much greater potential than other elective procedures.
Perhaps a better question for us to ask is this: Why is
LASIK not as popular as contact lenses? According to the
COVER FOCUS
AN AMERICAN PERSPECTIVE
ON LASIK VOLUMES
Figure 1. Flap-related complications, including striae, epithelial
ingrowth, and trauma, are avoided with the SMILE procedure.
Vision of Council of America, contacts are used by nearly 20%
of American adults with some level of refractive error (75% of
the population), and this percentage rises much higher when
considering only myopes, who are the biggest users of contact
lenses and approximately 30% of the population. Perhaps this
discrepancy is because consumers perceive LASIK as different
AT A GLANCE
• The first logical reason for the slight downturn in LASIK
volumes is that LASIK has seen its peak and is now on
the decline.
• It may be that the unspoken psychological fear
associated with eye surgery limits the lifecycle of
consumer growth of LASIK.
• One strategy to increasing LASIK volumes once
again is educating patients that LASIK is not just a
consumer-marketed product, but rather a valuable
and professionally performed intervention in the hands
of respected surgeons who demonstrate excellence in
patient care above and beyond their desire for profit.
• SMILE has the potential to reach beyond the successes
and limitations of modern LASIK.
APRIL 2015 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 45
COVER FOCUS
“
from contact lenses, being a surgical procedure, even
though both have similar associated risks.
Despite the statistics showing that LASIK volume is
closely associated with economic consumer indexes,
and despite the excellent visual outcomes the procedure produces, it may be that the unspoken psychological fear associated with eye surgery limits the
lifecycle of consumer growth of LASIK. Some of this
fear has been alleviated over the years by modifications
that have made LASIK a better, safer procedure. These
include wavefront customization and optimization to
reduce the side effects of glare and halos and the use of
the femtosecond laser to create uniform, thin flaps in order to
further refine visual predictability and reduce the incidence of
dry eyes and flap-related complications with a blade. Despite
these improvements, LASIK may still have a guarded perspective for some who are slow to forget the past and who are
confused by the mixed messages of price and commoditization in the present.
PATIENT PERCEPTION
I believe that Dr. Daya is correct: The solution for declining
LASIK volumes seems to rest in the perception of perspective patients. We must educate patients that LASIK is not
just a consumer-marketed product, but rather a valuable
and professionally performed intervention in the hands of
respected surgeons who demonstrate excellence in patient
care above and beyond their desire for profit. Whether
the providers of LASIK will take this course, bringing an
increasing level of professionalism back to LASIK, has yet
to be determined. Even if the message surrounding LASIK
improves, will that change people’s perception and unspoken fear of LASIK from the past? Ultimately, LASIK may need
to evolve into a safer and less externally invasive procedure
that is untarnished by the past.
While PRK, LASEK, and epi-LASIK may be less invasive than
WATCH IT NOW
Dr. Krueger discusses if LASIK will still be king in 2025.
It is perceptions in the mind of the individual patient,
not the market, that will define the success of the future
of laser vision correction. Whether we see an upturn in
LASIK volumes with increasing professionalism among
our colleagues, or whether we see newer procedures
such as SMILE replace the damaged perspective of
LASIK, the secret lies in the psyche of the patient as a
consumer.
LASIK, the associated pain and delayed visual recovery of
these surface procedures will not allow widespread patient
acceptance. Small incision lenticular extraction (SMILE)
offers the hope of a less externally invasive procedure that
might replace negative perceptions of LASIK. Rather than a
circular incision of greater than 300º with a LASIK flap, the
external incision in SMILE, at less than 30° (2 mm), virtually
eliminates most of the risk of flap complications (Figure 1).
It also minimizes disruption of the anterior corneal fibers,
which provide the greatest tensile strength to the cornea
and house the anterior corneal nerves, therefore minimizing
the creation of neurotropic, laser-induced dry eyes.
Further benefits of SMILE include the creation of laser incisions and tissue excision in a closed system that is void of
environmental changes, such as temperature and humidity,
and the fresh perspective it brings as a minimally invasive
(and, therefore, safer) procedure.
The combination of all these positives has the potential
to take the market for SMILE beyond the successes and
limitations of modern LASIK. Of course, excellence and
professionalism among refractive surgery providers will be
required to develop the market for SMILE. Furthermore, just
as first-generation excimer lasers required modifications and
improvements to make the procedures of PRK and LASIK better, so will the femtosecond lasers we currently use for SMILE.
CONCLUSION
In the end, it is perceptions in the mind of the individual
patient, not the market, that will define the success of the
future of laser vision correction. Whether we see an upturn
in LASIK volumes with increasing professionalism among
our colleagues, or whether we see newer procedures such as
SMILE replace the damaged perspective of LASIK, the secret
lies in the psyche of the patient as a consumer. n
Ronald R. Krueger, MD, MSE
Medical Director, Department of Refractive Surgery,
Cole Eye Institute, Cleveland Clinic
n President, International Society of Refractive Surgery (ISRS)
n krueger@ccf.org
n Financial disclosure: Consultant (Alcon)
n
46 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | APRIL 2015