Biography: Hovanesian is a faculty member at the UCLA Jules Stein Eye Institute and in private practice at Harvard Eye Associates in Laguna Hills, California.
October 09, 2019
3 min read

BLOG: What makes a new procedure successful?

Biography: Hovanesian is a faculty member at the UCLA Jules Stein Eye Institute and in private practice at Harvard Eye Associates in Laguna Hills, California.
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In this issue of Ocular Surgery News, our cover story explores two new procedures that promise to restore natural accommodation among presbyopes: VisAbility from Refocus Group and LaserACE from Ace Vision Group. Each procedure works by a different mechanism, and each purports to significantly, permanently and safely restore natural accommodation.

How do we know these new procedures will be successful and become popular? Haven’t corneal inlays more or less failed, with three different technologies that came to market (or almost did so) and the remaining one having lackluster sales? I would suggest there are five broad criteria that would signal a procedure’s future success. Note that this list of criteria does not include safety, efficacy and stability. Those three are sine qua nons of any successful procedure. The following are softer rules but time tested:

1. A cool name. How does LASIK compare with PRK? RK? LASIK is catchy, memorable and — other than its similarity to a common diuretic — reminiscent of a high-tech laser solution. SMILE is similarly promising but is so far limited by Rule No. 4 below.

2. Easy for the patient to understand. Patients don’t even need to understand already popular procedures like LASIK. They just need to know that 12 of their friends are happy with it. At the opposite end of the understandability spectrum are monocular procedures or those requiring some form of monovision, which generally provoke a negative emotional response that limits candidates to risk-takers.

3. Easy for the patient to undergo. Its perception as less invasive and quick in-and-out boosted the success of conductive keratoplasty and laser thermokeratoplasty a decade ago, despite their lack of long-term stability. Procedures perceived as being more invasive, requiring more than 1 day off of work, or causing significant eye redness and prolonged need for mediation are perceived as less appealing in our world where there’s an app for everything. Affordability also fits into this criterion. Some companies price their offerings so highly that even if patients are willing to pay, surgeons may not be willing to ask for a price close to a typical patient’s monthly salary per eye. Naturally, pain too is a deal breaker, as you will recall if you practiced in the early days of PRK.

4. Easy for the surgeon. Surgeons busy in their existing practices will steadfastly defend the status quo of procedures they perform. Successful new procedures will have a low equipment cost with a payoff in 3 to 6 months, even for a lower-volume refractive practice. Surgeons should be completely comfortable performing procedures without guidance after the first three patients. If surgeons have to travel to an unfamiliar location to perform procedures because only a few local colleagues can afford the equipment, they will simply hesitate to recommend the new procedure.

5. Adequate margins for the practice. Too many recent offerings (cross-linking, Botox, ICLs) have such high material or equipment costs that there is little financial incentive for physicians to begin offering them. In business — and we are all for now still in business — high margins cure all ills. The drug and device industry must understand that physicians are struggling already with rising costs of doing business and significantly declining reimbursement. Shifting our focus to a new procedure cannot be met with a lackluster financial reward. Both the amortized cost of equipment and the per-procedure margin must be reasonable, despite upward pricing pressure from investors.

To date, we have seen no procedure that squarely satisfies all these rules, and of course we have to be somewhat forgiving of every new offering. In fact, the new presbyopia offerings, including drops and procedures, will serve an enormous market of highly motivated folks (like me) who are ready to explore our options and spend our precious resources to live a better life. I wish these new procedures much success and long life.

Disclosure: Hovanesian reports he is a consultant and investor to a number of new technology companies, but he has no relevant financial disclosures for Ace Vision Group or Refocus Group.