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Up Front | Oct 2008

Strategically Incorporating Phakic IOLs into Your Practice

Once you master the safety phase, these lenses allow you to differentiate your clinic.

In today's refractive market, surgeons experience a constant struggle between embracing new technologies and maintaining the use of their current technology. Essentially, we must learn to expand our foresight into tomorrow's market—concentrating on what direction the ophthalmic industry is headed and integrating new technologies to differentiate your clinic's portfolio from its competitors. One such avenue is phakic IOLs. Over the next several issues of CRST Europe, I will explore this topic, providing readers with a roadmap for successfully incorporating phakic IOLs into your refractive practice. This three-part series will outline the steps and strategies to grow a total refractive clinic out of a laser vision correction practice.

LASIK currently dominates the refractive market; however, refractive surgery will increasingly transition toward intraoperative approaches. Phakic IOLs are an attractive refractive option because they provide superior visual quality in a reversible procedure. Although the Visian ICL (STAAR Surgical, Monrovia, California) has been available for many years, this lens has not been widely adopted. Compared with LASIK, the global penetration rate of the Visian ICL is 1% to 2%. On the other hand, some individuals have successfully incorporated phakic IOLs into their practices, performing as many as 35% of their refractive procedures with the Visian ICL. To reach this level of penetration, the surgeon must be willing to reengineer his practice—to transform his strategy from laser vision correction to refractive vision correction.

Regardless of the facility, institution, or industry, all markets seem to follow the same general pattern of development, going through four distinct phases: introduction, growth, maturity, and decline (Figure 1). Every clinic and every country goes through these phases, but some take more time to go through the cycle than others.

The same life cycle is applicable for managing a LASIK business. On a broader scope, the LASIK market in each country progresses through the life cycle as well. The difference in life cycle phases becomes evident when various strategic refractive markets are analyzed. For example, Singapore, Japan, and Germany are currently in the growth phase, whereas Spain is in the mature phase, and the United States is in the decline stage. This is distinguished based on the number of clinic acquisitions and the declining price of LASIK, caused by an increased competitive environment. Refractive clinics based in growth markets are taken over by refractive clinics based in mature markets.

Each refractive clinic has to decide whether to apply a pricing strategy or a differentiation strategy; otherwise, the clinic will not survive. Larger clinics tend to adopt a pricing strategy whereas smaller or individual LASIK clinics tend to pursue a differentiation strategy. To support the pricing strategy, clinics must increase volume to benefit from economics of scale and still generate profits despite reduced prices to patients. The differentiation approach requires a LASIK clinic to widen product offerings and allow a more customized treatment approach to their patient promoting alternative refractive treatments. This is where phakic IOLs start to become an important weapon in the refractive armentarium and where the life cycle of phakic IOLs is born. The surgeon and the clinic management decide how quickly the new technology passes through the phases of the life cycle. There are a number of aspects of the practice that will change as you move from phase to phase, including economic implications, staff involvement, and the product application.

Introduction phase. Also called the safety phase, this is a problem-solving phase. The majority of surgeons who currently use phakic IOLs fit into this category. If this is you, you have already made the mental investment to offer phakic IOLs. In this phase, the surgeon still performs LASIK in 99% of his patients; however, phakic IOLs are offered to those who have what I refer to as a special need—high refractions, thin corneas, dry eye, any form of suspicious cornea, keratoconus, or any other patient who is not a good LASIK candidate.

The introduction phase comes with its own set of headaches. The surgeon must learn the treatment options, establish a new process, and possibly meet with industry representatives and order new products. The investment, in terms of time and training, is hefty. In this phase, the surgeon does all of his own legwork, and the staff is not yet trained or involved in his process.

The true focus of this phase, as the name implies, is safety. Performing a safe procedure entails proper patient selection and understanding the tricks to master the technology. If you go beyond the indications for a phakic IOL, you have higher risks. This does not necessarily mean more complications—just simply higher risk for complications. That is why I advise implanting phakic IOLs only in special needs patients during the introduction phase. Typically, you neglect the economic aspect in this phase. The return profit may be negative at this time, but as you move through the cycle, profitability will become evident.

Growth phase. You cannot skip the safety phase and go straight into growth. It is a medical business, and therefore your first and foremost goal is establishing safety. If you have not fully digested your questions during the safety phase, you will find yourself back at square one when a complication arises. You will end up asking yourself, "Should I implant this lens again, despite believing that it could provide the optimal patient outcome?" I cannot stress enough that a lack of education will hurt the business initially.

Once safety is fully established, you are ready to graduate to the business aspect. Now you can start to look at optimizing the efficiency of the procedure. In this phase, the surgeon works to widen the application of the phakic IOL. Set a standard (eg, anything above -8.00 D or -6.00 D), and implant an ICL in any patient who fits that criterion. In this phase you start to benefit from the differentiation against your competitors and experience key benefits such as superior visual quality on a larger scale. The latter is particularly the case with the Toric ICL (STAAR Surgical, Monrovia, California), currently available outside the United States.

As we have found with increasing use, the surgical process also changes. The staff becomes involved, and a clear process is established, including counselors advising patients on LASIK and phakic IOLs. The staff typically is involved in the pre- and postoperative care of patients and gets used to guiding patients based on initial results of their investigations before seeing the surgeon. This makes your processes simpler and counseling time shorter.

Penetration will rise, capping at approximately 15%; we are still in our growth phase. When looking at the financial aspects, the surgeon should analyze the procedure according to the cost of the lens and how much time goes into the procedure. At this phase, you are focused on the profitability of the individual procedure; however you are not yet ready to look at the profitability of the whole clinic.

Maturity phase. After peaking the growth phase, the surgeon entering the maturity phase will work to maximize the efficiency of his clinic and increase profitability. In this phase, some surgeons may wish to establish a more aggressive standard, influenced principally by the concept of differentiation. For instance, 3.00 D may be the new cutoff for the use of phakic IOLs. The penetration should reach between 15% and 30%; however, some clinic managers, such as Mark Rosenberg, of the Barnet Dulaney Perkins Eye Center in Phoenix, Arizona, suggest that the penetration may rise as high as 70%.1

At this point, the facility should be transformed into a total refractive center with 100% staff involvement in all aspects of the business. Financially, the surgeon is now concerned with profitability on the total refractive center.

From the patient's point of view, they feel like they have options. Phakic IOLs are presented as a primary treatment, not an afterthought of LASIK. There is no doubt that the patient's decision to undergo the procedure is greatly influenced by the level of confidence the refractive practice presents. Patients are quick to pick up on and be put off by even the slightest level of hesitation by members of the practice.

Decline phase. Like all products and services, reaching a point of decline is inevitable. In this stage, phakic IOLs are still offered, but quite likely there will be something new (ie, line extensions, lens modifications, widening the patient indication, or a completely new technology). The surgeon will try to keep phakic IOLs in his process as long as possible until eventually another technology introduced.

In offering a differentiation strategy, refractive surgery practices should incorporate a wide range of technologies. Surgeons who wish to be high-solution providers may consider adding phakic IOLs into their refractive practices. The general rule of thumb is to first focus on safety, then growth and maturity (ie, profitability).

Make sure your staff learns to offer phakic IOLs as a solution to patients with special needs in the introduction stage, building to all patients as you enter the growth and maturity stages and become fully comfortable with the procedure. Eventually, give patients the option at the outset of the counseling process; it will make them feel like they are more involved in the process and avoid disappointment at the end of the counseling process. Offering the phakic IOL as a premium procedure is a strategy that positions LASIK versus the phakic IOL. Reversibility and keeping the eye preserved for future treatments can be strong postive points in the patients' mind.

Always remember that refractive surgery is multifaceted. The medical side is only one aspect—and it is important—but properly managing the business side is vital to surviving as a refractive clinic. The market is changing, and as surgeons we need to roll with the punches. Currently, the mainstream refractive procedure is LASIK, but offering the option of phakic IOLs is becoming more prominent.

Change your clinic from the inside out: Make the staff believe in phakic IOLs, and then learn to make the patient experience equal to the LASIK experience. The market is changing so rapidly that nobody can afford not to take a position. We will see the changes in the future.

Use this four-step process as a blueprint to analyze your clinic's position and make decisions about incorporating phakic IOLs into your practice.

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), is Director and Consultant, Corneoplastic Unit and Eyebank, Centre for Sight, Queen Victoria Hospital, East Grinstead, UK. Dr. Daya is the Co-Chief Medical Editor of CRST Europe. He may be reached at e-mail: sdaya@centreforsight.com.