Lindstrom's Perspective

Millennials will be the next target for laser vision correction

The American Refractive Surgery Council was founded more than 10 years ago by American Society of Cataract and Refractive Surgery leadership in collaboration with industry partners Alcon, Johnson & Johnson Vision and Bausch + Lomb. I was the founding ASCRS representative on ARSC and remain active today along with Eric Donnenfeld, MD, and Kerry Solomon, MD. Jim Wachtman, with 30 years’ experience in the refractive surgery field, is our executive director. Liana Miller of Engaged Communication is our director of communications. With the approval of SMILE, Zeiss joined the group as a core industry member, and several other refractive surgery companies with smaller footprints in the U.S., such as Ziemer, also participate.

Since the founding by ASCRS, leadership from the American-European Congress of Ophthalmic Surgeons (John Doane, MD, John Vukich, MD), the Refractive Surgery Alliance (Greg Parkhurst, MD, Lance Kugler, MD) and the International Society of Refractive Surgery of the American Academy of Ophthalmology (John Kanellopoulos, MD) have also joined the council. The council is now considering a renaming to Refractive Surgery Council (RSC) and reaching out to our international refractive surgeon colleagues worldwide, starting with the European Society of Cataract and Refractive Surgeons. According to the RSC website, the mission of RSC is “to provide education and information about safety, clinical value and lifestyle benefits of vision correction surgery, and support research into new refractive surgery technologies and techniques.” RSC has also served as a fact-based advocate for the potential benefits of refractive surgery to society, the military and individual patients — all laudable goals in my opinion. As you can see, the mission of RSC is currently expanding, and it is likely that its constructive contributions to the field of refractive surgery will become better known and more widely appreciated.

One positive outcome of this collaboration is that the major manufacturers in our field have agreed to share their U.S. sales numbers with an independent third party who then makes them available to all interested parties. This gives us accurate, reliable numbers of what is really happening nationwide in regard to laser corneal refractive surgery volume, including LASIK, PRK and SMILE. In the future, it is hoped that this collaboration will expand to include intraocular and intracorneal lens-based refractive surgery and eventually allow accurate numbers for outside the U.S. as well. This will be valuable to everyone engaged in refractive surgery.

The now accurate numbers from RSC confirm that laser corneal refractive surgery has kept growing in the U.S. for the past 3 years and in 2018 surpassed 800,000 eyes per year. LASIK dominates, followed by PRK and finally the more recently launched SMILE. The trends to me suggest that there is increasing interest and growth in alternatives to LASIK, such as PRK, transepithelial PRK and SMILE. I believe this is primarily driven by a desire to enhance the safety and perhaps the simplicity of laser corneal refractive surgery, as efficacy is quite excellent with all three procedures. I think this investment in enhancing the safety and simplicity of laser corneal refractive surgery is well worth supporting and to the benefit of our patients.

Laser corneal refractive surgery was initially driven by the so-called “baby boomer” patient. When the first excimer laser was approved in 1995, most baby boomers were in their 30s, in many ways the ideal age for laser corneal refractive surgery. Demand was strong, and in the first 5 years, the volume of procedures doubled every year. By 2000-2001, the U.S. volume of laser refractive surgery approached 1.4 million procedures a year. In our practice at Minnesota Eye Consultants, we did more than 7,000 laser corneal refractive surgeries in those years, twice as many as the number of cataract surgeries we performed. Most experts predicted that the volume would grow to nearly 3 million procedures a year and then flatten. Investment was robust, with many surgeons focusing their practices solely on refractive surgery, and several corporate laser refractive surgery center companies were founded (TLC Vision, LCA-Vision, LASIK Vision Institute, Joffe MediCenter). As we all know, the predicted growth to 3 million procedures did not happen. Exactly the opposite occurred, with the procedure volume declining to about 600,000 procedures a year over the next decade and then stabilizing at less than half the 1.4 million procedures of 2000-2001. So, what happened?

In my opinion, this unexpected decline in laser refractive corneal surgery volume as well as the current 3 years of growth can primarily be explained by two things: economic prosperity (or lack thereof) and demographics. On Sept. 11, 2001, tragedy struck the U.S. in the form of a severe and unexpected terrorist attack. The economy crashed, and people naturally hunkered down, unsure of the future. We suffered a meaningful recession and then a moderate recovery followed by the Great Recession of 2007-2009. For the past decade, we have experienced a strengthening of the U.S. economy as exemplified by our now 10-year-old bull market in stocks. Consumer confidence has strengthened, which usually results in increased consumer discretionary spending. Unfortunately, laser corneal refractive surgery volumes remained stagnant in the face of this growing prosperity until just 3 years ago, when growth in procedure numbers began again. So, it takes more than just a robust economy, increased consumer confidence and prosperity to catalyze laser refractive surgery volume growth.

I believe the other primary factor is demographics. By the time we were recovering from the Great Recession, our baby boomer patients were now in their mid to late 40s and dealing with a new problem, presbyopia. Laser corneal refractive surgery continues to be challenged in the treatment of presbyopia. The new potential patient was the child of a baby boomer, the so-called millennial, born between 1981 and 1996. On the positive side, there are a large number of millennials, at least 83 million, slightly more than the 78 million baby boomers who sired them. On a negative note, more than half of them are still in their 20s and wearing contact lenses successfully (which continue to improve and get less expensive) when they want an alternative to glasses. As a group, they are all also somewhat economically challenged as they are often saddled with college debt, and many are struggling to establish themselves in a competitive marketplace.

In my opinion, once the millennials reach their mid 30s, they will start to experience contact lens intolerance after 10 to 20 years of wear, just like their baby boomer parents. In addition, over time they will pay down debt and get more financially established as they displace us baby boomers from high-quality good-paying jobs. As this occurs, the millennial will seek laser refractive corneal surgery in the same or perhaps even a higher proportion than the baby boomer did when laser corneal refractive surgery prospered between 1995 to 2000-2001. One caveat: We may experience another meaningful recession in the next couple of years, which will likely temporarily short circuit refractive surgery growth, but the next economic revival from, say, 2021-22 until at least 2030 and perhaps 2040 is likely to be strong.

So, how do we keep this momentum going? One important consideration is ensuring a strong, consistent patient education message supporting the laser vision correction decision process for prospects. RSC’s programming supports a positive perception of the laser vision correction category. This means avoiding competitive, comparative analogies between procedures because to marginalize one negatively affects all. To help, RSC offers essential resources, including patient education content free of charge through the council’s RSC Verified program. In addition, RSC staff is available to provide guidance on responding to press inquiries. Therefore, I see nothing but growth ahead for laser corneal refractive surgery except during our to be expected short periods of economic recession. This will be good news for us laser refractive corneal surgeons and the industry that supports us. Surgeon and industry interest and investment will grow, and as a result, the efficacy and safety of the procedures we can offer our patients will improve. In addition, refractive surgery, whether cornea or lens based, will remain a cash-pay procedure, which will be ever more critical to economic stability of ophthalmology in the two decades ahead.

Disclosure: Lindstrom reports he consults widely in the field of refractive surgery, including for Alcon, Bausch + Lomb, Johnson & Johnson Vision, Zeiss, CorneaGen, Refractec, AcuFocus and Lensar.

The American Refractive Surgery Council was founded more than 10 years ago by American Society of Cataract and Refractive Surgery leadership in collaboration with industry partners Alcon, Johnson & Johnson Vision and Bausch + Lomb. I was the founding ASCRS representative on ARSC and remain active today along with Eric Donnenfeld, MD, and Kerry Solomon, MD. Jim Wachtman, with 30 years’ experience in the refractive surgery field, is our executive director. Liana Miller of Engaged Communication is our director of communications. With the approval of SMILE, Zeiss joined the group as a core industry member, and several other refractive surgery companies with smaller footprints in the U.S., such as Ziemer, also participate.

Since the founding by ASCRS, leadership from the American-European Congress of Ophthalmic Surgeons (John Doane, MD, John Vukich, MD), the Refractive Surgery Alliance (Greg Parkhurst, MD, Lance Kugler, MD) and the International Society of Refractive Surgery of the American Academy of Ophthalmology (John Kanellopoulos, MD) have also joined the council. The council is now considering a renaming to Refractive Surgery Council (RSC) and reaching out to our international refractive surgeon colleagues worldwide, starting with the European Society of Cataract and Refractive Surgeons. According to the RSC website, the mission of RSC is “to provide education and information about safety, clinical value and lifestyle benefits of vision correction surgery, and support research into new refractive surgery technologies and techniques.” RSC has also served as a fact-based advocate for the potential benefits of refractive surgery to society, the military and individual patients — all laudable goals in my opinion. As you can see, the mission of RSC is currently expanding, and it is likely that its constructive contributions to the field of refractive surgery will become better known and more widely appreciated.

One positive outcome of this collaboration is that the major manufacturers in our field have agreed to share their U.S. sales numbers with an independent third party who then makes them available to all interested parties. This gives us accurate, reliable numbers of what is really happening nationwide in regard to laser corneal refractive surgery volume, including LASIK, PRK and SMILE. In the future, it is hoped that this collaboration will expand to include intraocular and intracorneal lens-based refractive surgery and eventually allow accurate numbers for outside the U.S. as well. This will be valuable to everyone engaged in refractive surgery.

The now accurate numbers from RSC confirm that laser corneal refractive surgery has kept growing in the U.S. for the past 3 years and in 2018 surpassed 800,000 eyes per year. LASIK dominates, followed by PRK and finally the more recently launched SMILE. The trends to me suggest that there is increasing interest and growth in alternatives to LASIK, such as PRK, transepithelial PRK and SMILE. I believe this is primarily driven by a desire to enhance the safety and perhaps the simplicity of laser corneal refractive surgery, as efficacy is quite excellent with all three procedures. I think this investment in enhancing the safety and simplicity of laser corneal refractive surgery is well worth supporting and to the benefit of our patients.

PAGE BREAK

Laser corneal refractive surgery was initially driven by the so-called “baby boomer” patient. When the first excimer laser was approved in 1995, most baby boomers were in their 30s, in many ways the ideal age for laser corneal refractive surgery. Demand was strong, and in the first 5 years, the volume of procedures doubled every year. By 2000-2001, the U.S. volume of laser refractive surgery approached 1.4 million procedures a year. In our practice at Minnesota Eye Consultants, we did more than 7,000 laser corneal refractive surgeries in those years, twice as many as the number of cataract surgeries we performed. Most experts predicted that the volume would grow to nearly 3 million procedures a year and then flatten. Investment was robust, with many surgeons focusing their practices solely on refractive surgery, and several corporate laser refractive surgery center companies were founded (TLC Vision, LCA-Vision, LASIK Vision Institute, Joffe MediCenter). As we all know, the predicted growth to 3 million procedures did not happen. Exactly the opposite occurred, with the procedure volume declining to about 600,000 procedures a year over the next decade and then stabilizing at less than half the 1.4 million procedures of 2000-2001. So, what happened?

In my opinion, this unexpected decline in laser refractive corneal surgery volume as well as the current 3 years of growth can primarily be explained by two things: economic prosperity (or lack thereof) and demographics. On Sept. 11, 2001, tragedy struck the U.S. in the form of a severe and unexpected terrorist attack. The economy crashed, and people naturally hunkered down, unsure of the future. We suffered a meaningful recession and then a moderate recovery followed by the Great Recession of 2007-2009. For the past decade, we have experienced a strengthening of the U.S. economy as exemplified by our now 10-year-old bull market in stocks. Consumer confidence has strengthened, which usually results in increased consumer discretionary spending. Unfortunately, laser corneal refractive surgery volumes remained stagnant in the face of this growing prosperity until just 3 years ago, when growth in procedure numbers began again. So, it takes more than just a robust economy, increased consumer confidence and prosperity to catalyze laser refractive surgery volume growth.

I believe the other primary factor is demographics. By the time we were recovering from the Great Recession, our baby boomer patients were now in their mid to late 40s and dealing with a new problem, presbyopia. Laser corneal refractive surgery continues to be challenged in the treatment of presbyopia. The new potential patient was the child of a baby boomer, the so-called millennial, born between 1981 and 1996. On the positive side, there are a large number of millennials, at least 83 million, slightly more than the 78 million baby boomers who sired them. On a negative note, more than half of them are still in their 20s and wearing contact lenses successfully (which continue to improve and get less expensive) when they want an alternative to glasses. As a group, they are all also somewhat economically challenged as they are often saddled with college debt, and many are struggling to establish themselves in a competitive marketplace.

PAGE BREAK

In my opinion, once the millennials reach their mid 30s, they will start to experience contact lens intolerance after 10 to 20 years of wear, just like their baby boomer parents. In addition, over time they will pay down debt and get more financially established as they displace us baby boomers from high-quality good-paying jobs. As this occurs, the millennial will seek laser refractive corneal surgery in the same or perhaps even a higher proportion than the baby boomer did when laser corneal refractive surgery prospered between 1995 to 2000-2001. One caveat: We may experience another meaningful recession in the next couple of years, which will likely temporarily short circuit refractive surgery growth, but the next economic revival from, say, 2021-22 until at least 2030 and perhaps 2040 is likely to be strong.

So, how do we keep this momentum going? One important consideration is ensuring a strong, consistent patient education message supporting the laser vision correction decision process for prospects. RSC’s programming supports a positive perception of the laser vision correction category. This means avoiding competitive, comparative analogies between procedures because to marginalize one negatively affects all. To help, RSC offers essential resources, including patient education content free of charge through the council’s RSC Verified program. In addition, RSC staff is available to provide guidance on responding to press inquiries. Therefore, I see nothing but growth ahead for laser corneal refractive surgery except during our to be expected short periods of economic recession. This will be good news for us laser refractive corneal surgeons and the industry that supports us. Surgeon and industry interest and investment will grow, and as a result, the efficacy and safety of the procedures we can offer our patients will improve. In addition, refractive surgery, whether cornea or lens based, will remain a cash-pay procedure, which will be ever more critical to economic stability of ophthalmology in the two decades ahead.

Disclosure: Lindstrom reports he consults widely in the field of refractive surgery, including for Alcon, Bausch + Lomb, Johnson & Johnson Vision, Zeiss, CorneaGen, Refractec, AcuFocus and Lensar.