Ireland has changed enormously in the past 10 years—in so many ways—and this is reflected in the area of refractive surgery just about as much as any other area I can think of.

MARKET GROWTH
As recently as 5 years ago, the refractive market in Dublin, Ireland, with a then-population of 1.2 million, was only serviced by four centers. Refractive surgery was performed by local consultant ophthalmic surgeons residing in the town or city where they practiced. This is not necessarily the case today. With a population nearer to 1.5 million, now there are more than 10 laser centers in Dublin. This same increase in laser numbers is reflected throughout the country.

PATIENT MANAGEMENT
The traditional refractive model, still in existence at in the original four Dublin centers, is for an ophthalmologist to perform the evaluation, the surgery, and the follow-up. Patients are typically generated by word-of-mouth referrals, as the centers have been around for many years, have large patient bases, and—by and large—have good reputations.

Differences in patient management within the various clinics now make up the Dublin scene. Some centers have optometrists (sometimes local, sometimes itinerant) who do the evaluation. The surgeon then meets the patient and performs the surgery on the same day. Examination and all other follow-ups are performed by an optometrist, but not necessarily the same optometrist who did the work-up.

ADVERTISING
Advertisements supporting medical procedures and doctors are a relatively new phenomenon in Ireland. There has been some significant negative commentary toward laser refractive surgery advertising.

The media, in all its forms, is now saturated with advertisements for laser eye surgery. Print media is popular with many of the newer clinics, which seem to advertise in the newspaper and local magazines as well as in-flight magazines. The radio is also a popular medium for refractive advertisements; some local radio stations may have as many as three different laser centers advertising within a given hour. One center in particular uses television advertising profusely.

Whatever the media, all clinics are keen to position themselves within the market with respect to their perceived unique selling points. Strategies include making claims that their surgeon is the most famous in all of Europe. Other centers claim that they have the only femtosecond laser in the country, and yet others claim that their laser is the most accurate. Many include low pricing as the initial attraction.

Some of these claims do not stand up to scrutiny, and perhaps have only served to cause confusion within the Irish market. As different claims abound, potential patients are bombarded, and they often complain of bewilderment. As a result, there has been a significant increase in the number of patients who seek second opinions. I believe that the increase in second opinion consultations is related more to mixed messages in the marketplace than patients simply shopping around.

Media commentary on the shortcomings of some refractive practices has led to calls for legislation in an area that is remarkably, in fact almost completely, unregulated. Causing particular controversy has been the practice known as bait and switch, which involves baiting potential patients with price (eg, LASIK advertised for half the typical cost). Once the patient has their (usually free) assessment by an optometrist, they are more than likely found to be a suitable candidate. But, they are told that they cannot receive the advertised price, for various reasons that include they (1) are more than -1.00 D sphere, (2) have astigmatism, or (3) need to be upgraded to wavefront treatments. The prices are then suddenly bumped up into the same range as at established clinics.

An interesting phenomenon exists in Ireland: Doctors are not permitted to advertise their services, yet clinics or laser centers are. Nevertheless, advertising and other promotions have increased the public's interest in refractive surgery. Thus, clinics are busier than ever before—thanks to the increased public awareness of LASIK. Despite the concerns, refractive surgery is healthy and alive in Ireland, and because of the groundwork established by the original clinics 10 years to 12 years ago, there is a good body of happy patients out there spreading the goodwill of laser vision correction.

Most clinics provide laser eye surgery, but they do not offer any other form of refractive treatment. Only two centers in Dublin offer the whole range of refractive services (ie, phakic lens implants, clear lens extraction, cataract extraction, conductive keratoplasty, laser vision correction).

ECONOMIC CLIMATE, FUTURE TRENDS
Interestingly, Ireland is experiencing a spending spree that will last for approximately 1 more year. It has resulted from a government initiative to encourage people to save money. Five years ago, the Irish government established a system whereby for every ?4 saved by a registered resident, the government would add ?1 over a 5-year period. This was called the Special Savings Incentive Account (SSIA). The monthly savings limit is ?250, and those who save the maximum amount are due to cash in now (5 years later). The value of these funds is approximately ?21,000 for each saver. In many families, both the husband and wife invested in an SSIA, so these households are now ?42,000 better off than they were 5 years ago. Many people are using their SSIAs for luxuries like plastic surgery, LASIK, holidays, and building extensions. This has led to a buoyant LASIK market, which in part explains why the number of clinics has mushroomed. The imponderable is: What happens when the SSIA spending spree stops?

If history repeats itself and trends in other parts of the world are reflected here, then suddenly a good number of these clinics are going to be finding market conditions less favorable. It is my contention that clinics where quality of service and good medical practice prevail will be best positioned to survive any change in the economic climate.

Arthur Cummings, MB ChB, MMed(Ophth), FCS(SA), FRCS(Ed), is Partner and Consultant Ophthalmologist at the Wellington Eye Clinic, in the Beacon Medical Campus, in Sandyford, Dublin. He states that he has no financial interest in any of the products or companies mentioned. Dr. Cummings is a member of the CRST Europe Editorial Board. He may be reached at +353 1 293 0470; abc@wellingtoneyeclinic.com.