Disclosures: Lindstrom reports he has relevant financial disclosures for Alcon, ASCRS, Bausch + Lomb, Glaukos/Avedro, ISRS of AAO, Johnson & Johnson Vision, Minnesota Eye Consultants/Unifeye Vision Partners, RSA, RSC and Zeiss.
September 02, 2021
3 min read

Refractive corneal surgery poised for strong comeback in 2021

Disclosures: Lindstrom reports he has relevant financial disclosures for Alcon, ASCRS, Bausch + Lomb, Glaukos/Avedro, ISRS of AAO, Johnson & Johnson Vision, Minnesota Eye Consultants/Unifeye Vision Partners, RSA, RSC and Zeiss.
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The top five procedures performed by United States ophthalmologists are:

  1. intravitreal injections: now more than 6 million per year in the United States;
  2. cataract surgery and IOL implantation/refractive cataract surgery: just more than 4 million procedures a year;
  3. YAG laser capsulotomy: just more than 1 million procedures a year;
  4. refractive corneal surgery including LASIK, PRK and SMILE: projected to hit 900,000 procedures in 2021; and
  5. glaucoma surgery including selective laser trabeculoplasty, peripheral iridotomy, MIGS, trabeculectomy and tube shunt: estimated at about 400,000 procedures per year.

Most of the intravitreal injections are performed by approximately 2,000 fellowship-trained retina/vitreous specialists. The growth in this office-based procedure has made retina the best compensated specialty in American ophthalmology.

Richard L. Lindstrom
Richard L. Lindstrom

Approximately 10,000 anterior segment surgeons, which include about 1,200 fellowship-trained corneal surgeons and a similar number of fellowship-trained glaucoma surgeons, perform cataract IOL/refractive cataract surgery, YAG laser, refractive corneal surgery and glaucoma surgery. We train our fellows at Minnesota Eye Consultants to participate in all four sectors of anterior segment surgery and to provide office-based therapies such as dry eye disease procedures and collagen cross-linking. The anterior segment ophthalmologist who offers cataract IOL/refractive cataract surgery, YAG laser capsulotomy, refractive corneal surgery, MIGS and laser glaucoma surgery, along with medical and surgical cornea treatment, can also do quite well financially, especially if they own equity in an ASC or office-based surgery center. There are a lot of surgical suite and office-based surgeries for the anterior segment and posterior segment surgeon to perform today, and the number is increasing every year.

The accompanying cover story is focused on refractive corneal surgery, an area of special interest. I will disclose that I consult widely in this field and have since first participating as a surgeon in the PERK study in 1980.

The first two excimer lasers (Summit and Visx) were approved in the United States in 1995 and 1996. By 2001, U.S. case volumes of PRK and LASIK had grown from near zero to approximately 1.4 million procedures per year, and most projected continuing growth. Then the Sept. 11 attacks occurred, followed by a mild economic contraction and then the Great Recession of 2008. Refractive corneal surgery declined to just more than 500,000 cases a year in 2010, a 65% reduction from 10 years earlier. Most practices, including ours, shifted their emphasis from refractive corneal surgery to cataract IOL/refractive cataract surgery, glaucoma and corneal procedures.

In 2008, in response to the severe slump in refractive corneal surgery and increasingly negative publicity, the American Society of Cataract and Refractive Surgery catalyzed the creation of the Refractive Surgery Council (RSC). The mission of the RSC is to support the health and growth of the refractive surgery category by presenting consumers, industry and surgeons with an unbranded, unified base of authority in vision correction surgery. The current members of RSC today include the ASCRS, Alcon, Johnson & Johnson Vision, Zeiss, Ziemer, American-European Congress of Ophthalmic Surgery, the International Society of Refractive Surgery of the American Academy of Ophthalmology, and the Refractive Surgery Alliance.

The RSC keeps accurate count of the laser refractive corneal surgeries performed each year. By 2015, annual refractive corneal surgery case volumes rebounded to 600,000 procedures per year and by 2019 to 800,000 procedures per year. Then the COVID-19 pandemic hit, and in 2020, only 500,000 laser refractive corneal procedures were performed. We are now seeing a post-pandemic surge in refractive corneal surgery case volumes that, if it persists, will take us to just more than 900,000 procedures in 2021.

The reason for this surge in refractive corneal surgery is likely multifactorial. The millennial generation is aging toward the sweet spot for refractive corneal surgery, patients find spectacle and contact lens wear more challenging while wearing a mask, savings and consumer discretionary spending are up, consumer confidence is high, and many practices have resumed internal and external marketing in the refractive surgery category. This is good news for the anterior segment surgeon who performs LASIK, PRK or SMILE and for the industry and societies that support this category.

I encourage interested surgeons to peruse the RSA website and look again at the opportunity refractive corneal surgery offers their practice, their surgeons and their patients.