The history of LASIK is fascinating from many perspectives. Today it stands as an amazing, truly 21st-century procedure that has revolutionized refractive surgery, reliably providing phenomenal outcomes to millions of patients. Initially high volumes provided many surgeons with cash flow such as they had never seen previously, enabling them to build organizations that have improved service and delivery of ophthalmic care to patients. However, the ease of performing the procedure has been a double-edged sword, as will be seen below.

I performed my first LASIK procedure just more than 20 years ago, and, in those days, using the Automatic Corneal Shaper (Steinway/Chiron) was an art form that required fairly expert hands. Despite some relatively major flap complications (remedial work for corneal surgeons), the procedure grew in popularity, and outcomes at that time were overall good. With iterative improvements in technology, outcomes improved further.

Consider the situation now: Flaps are created with femtosecond lasers, a technology that is much more accurate than mechanical microkeratomes and with minimal complication rates. Modern lasers can customize treatments, providing aspheric profiles and wavefront treatments that truly enhance vision. Outcomes are as predictable as they can be, with almost 100% of eyes achieving 20/20 visual acuity. Despite these advances, LASIK volume has tapered in almost every country, except those with huge populations such as China and India.

What happened?

There are a number of views to account for this decline. The majority view is that, “It’s the economy, stupid!” In the past, whenever there was a slight reduction in refractive surgery volume, ophthalmic leaders and gurus would put up graphs at major meetings to show a direct correlation of volume with the Dow Jones Industrial Average (DJIA).

But is it really the economy? The DJIA has come back and, as of early March as this is written, is hovering around 18,000—an all time high (Figure 1). We are informed that the recession has been over for some time now, but there is still no sign of a major bounce-back in LASIK volumes.

There are obviously other influences, and I shall endeavor to list some of these below, from my perspective.

TIPPING POINT

Every product has a lifecycle, and plotting revenue against time provides an S-shaped curve (Figure 2): a slow, gradual start, then an exponential rise, eventually reaching a plateau of maturity, and then perhaps a decline. This product lifecycle can also be considered from the point of view of customer attitude toward innovation, which takes the form of a bell curve (Figure 3). Products get a gradual start with adoption by the innovators, followed by increased growth due to early adopters. Then, by the time 15% to 16% of the potential population is reached, an exponential rise takes place, with the early majority followed by the late majority and, ultimately, the laggards. To go exponential, 15% to 16% of the eligible population must have had a procedure, and then the mass effect takes place.

If, very conservatively, 30% of the population is suitable for LASIK, then, in a country with a population of 60 million (like the United Kingdom), there would be 18 million eligible individuals. To achieve 15%, it would be necessary for 2.7 million people to undergo LASIK (5.4 million procedures). At its peak, there were an estimated 130,000 LASIK procedures performed per year in the United Kingdom, and this active phase was maximal for 10 years (an optimistic estimate). That translates to 1.3 million LASIK procedures for 650,000 patients, or 3.6% of the eligible population—far short of the 15% required to go exponential.

This means that only a fraction of early adopters have had the procedure. The innovators would have undergone LASIK with barely a thought, while early adopters might have waited a while but definitely had the frame of mind to be treated. This raises the question, then: Have all the people who would consider the procedure had it done already? If this is the case, it is all over for LASIK. As a product, the procedure has been unsuccessful and has behaved more like the Segway (Segway) than the iPhone (Apple).

Why, for such an amazing procedure, has the uptake been so low in the United Kingdom, probably lower than in many other countries such as Spain, the United States, and the nations of Latin America? Besides the relatively conservative nature of the UK population, I believe there have been other influences that have adversely affected LASIK volumes.

COMMODITIZATION AND ITS EFFECTS

Unlike in many other countries, in the United Kingdom, there has been a dearth of ophthalmic providers with the courage to establish refractive surgery centers. This has permitted the entry of corporate groups that have dominated the provision of laser refractive surgery. I suppose someone had to do it, but the emphasis of care has perhaps been different from how individual doctors or group practices might have approached the procedure. The corporate focus purely on volume, efficiency, and profitability has influenced the messaging to the public.

The enticements of low prices and marketing techniques such as bait-and-switch offers, competitions, and other inducements have provided the public with a distorted perception of laser eye surgery: LASIK is a procedure that is available everywhere at similar standards, and the key is to be smart and choose on price (or get the procedure at no cost by winning a competition!).

Rather than becoming educated about what is involved and about how to differentiate one procedure or practitioner from another, patients have concentrated on getting the best deal. As a result, competing groups with large cost bases and dependent on high volumes have engaged in price wars, further distorting perceptions. (Editor’s note: See Guidelines for Refractive Surgery for a related article.)

Apart from leading to phenomenal risks for businesses, price wars and discounts provide the public with a confusing message: The procedure on offer is not serious and is easily available at bargain-basement rates. The desirability of the procedure is in turn affected, as it is easily available. As patients have said to me, “I always felt that when I needed it I would have it done.” Rather than wanting the procedure right away, they categorized it as something they would have done if it ever became necessary—for example, if they became intolerant to contact lenses.

An analogy might be made to a desire to have a particular brand of expensive watch, one that is just a little expensive and out of one’s price range, for which one might have to save and buy at a date in the future. If the brand then becomes easily available and advertised widely with a low sticker price and the promise that it might get lower, the watch goes from being a bit unaffordable and desirable to being highly affordable and, in turn, not as desirable. I believe this has happened with LASIK.

Commoditization has had another negative impact, and this is the increased prevalence of unhappy individuals who have had laser eye surgery that has not gone as well as expected. To maximize profits and contain costs, riskier inexpensive models of care provision have been employed in some centers; for example, the use of optometrists to perform preoperative evaluations, with surgeons basically acting as technicians who perform the procedure with only a brief consultation with the patient immediately beforehand.

Additionally, the practice of upselling to wavefront and femtosecond laser options has been big business. Rather than concentrating on what is best for patients, the ophthalmic industry has educated providers to use the option of selling better technology as an added value or premium from which the practice can derive greater revenue. If all patients were evaluated thoroughly to eliminate contraindications such as abnormally shaped corneas and dry eye, and then underwent the best possible care available and customized to suit them, with femtosecond lasers and accurate treatments, and then received excellent postoperative care, the number of patients with problems would be small. Yes, perhaps it would be more expensive to provide this type of care without the premium icing on the cake, but it would mean a lot less trouble for patients and practitioners. In this context, cheap is expensive in the long term.

Further, the fallout of having a growing population of dissatisfied patients includes the formation of patient advocacy groups, negative postings on Internet forums, negative articles in the sensationalist press, and a further change in the public’s perception of the procedure. The message becomes: Perhaps laser eye surgery is not that safe after all, and let’s no longer consider it as an option.

The natural product lifecycle of LASIK has, at least in the United Kingdom, been arrested by commoditization, the consequence of which has been a change in public perception along with concerns about the safety of the procedure.

RESCUE TREATMENTS

At the American-European Congress of Ophthalmic Surgery (AECOS) in Barcelona last year, Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO, proposed an interesting perspective on how to limit damage like that discussed above and improve the perception of LASIK. He suggested that the ophthalmic industry make an effort to develop and provide remedial surgery for those who have had less-than-ideal refractive surgery outcomes.

He has a good point. If technology were easily available to correct problem cases (eg, topography-guided treatments), then those with undesirable outcomes could have their problems resolved promptly. A remedial procedure would be a bit like an enhancement, with rapid resolution, and would help to prevent patients from joining the ranks of online LASIK-haters.

Perhaps the ophthalmic industry has concentrated too much on providing great technology without enough attention on remedial surgery. It may not be too late to address this imbalance, and perhaps appropriate technology can be developed to treat those who have had unfortunate outcomes. This might help to provide an additional level of assurance to the public regarding safety of laser eye surgery.

I cannot help but think, however, that avoidance of problems in the first place is better. We all know what it takes to achieve good outcomes, including good patient evaluation and selection, phenomenal attention to detail, and exceptional follow-up care, in which we rapidly identify and address potential problems. If all patients were treated at a phenomenally high standard, minimal numbers would require remedial help. While this would be the ideal, unfortunately, the reality is otherwise.

THE SOLUTION?

Above I have identified some of the issues leading to what may be a sustained reduction in LASIK volumes for the foreseeable future. This does not mean I have a solution for a quick, easy fix. Rather, the fixes will be long and difficult. They might include the following:

• Going back to basics;
• Treating LASIK with a phenomenal level of respect;
• Taking care of every patient individually;
• Providing each patient with the best available care;
• Stepping out of the ring when it comes to price wars and discounts;
• Avoiding commoditization on all fronts;
• Engaging in responsible marketing that concentrates on educating the public rather than hyping price; and
• Providing a first class act in all respects.

Such actions, and many others that you and other practitioners can fill in to fit your own situations, will go a long way toward improving the perception of LASIK and restoring public confidence in a procedure that remains amazing. n

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth
– Director and Consultant Surgeon, Centre for Sight, East Grinstead, United Kingdom
– Chief Medical Editor, CRST Europe
– sdaya@centreforsight.com
– Consultant (Bausch + Lomb)