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.
Figure 1. Flap-related complications, including striae, epithelial ingrowth, and trauma, are avoided with the SMILE procedure.
Perhaps a better question for us to ask is this: Why is LASIK not as popular as contact lenses? According to the 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 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.
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 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.
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
- President, International Society of Refractive Surgery (ISRS)
- Financial disclosure: Consultant (Alcon)