More than 700,000 of your patients will opt for LASIK this year. And, in a category where projections are all over the proverbial map, that's considered a fairly conservative forecast. Whatever the final number, however, the critical question is: Does this herald the beginning of the end for eyeglasses? Or, like contact lenses before them, will refractive surgery procedures merely take a powerful place alongside eyeglasses as a viable option for vision correction?

Though the nation's 3,400 refractive surgeons express one fairly vocal opinion, no one knows the answer. Everyone, however, is asking the question. It was definitely a hot topic at the winter meeting of Vision Council of America (VCA). You could, in fact, have heard a pin drop when Louis Catania, O.D., of ClearVision Laser Centers, quoted UCLA's Robert Maloney, M.D., as saying, "Spectacles and contact lenses will not exist by the year 2020."

To see where most of your peers stand on this volatile subject, Eyecare Business has contacted a variety of leaders within the industry. Most certainly feel refractive surgery will impact incomes-especially O.D.s who have become accustomed to the referral and post-op care contributions to their bottom lines. Opticians see themselves being affected more in terms of product, and say they'll be filling fewer high prescriptions, but selling more AR and sunwear.

Regardless of their O, most also agree with Bill Thomas, VCA's CEO, who views laser surgery as, "another step in technology." And most agree that even with corrections for presbyopia, traditional solutions will survive.

The current reality is that though the number of procedures is nearly doubling every year, fewer than 900,000 Ameri-cans had opted for LASIK by the beginning of the year. That sounds like a lot, but it's less than 0.6 percent of the country's vision-corrected population, reports Spectrum Consulting.

And looking ahead, Irving Aarons, the group's managing director, told attendees at VCA's Winter meeting that even by the year 2002-when he foresees some five million people as having had refractive surgery-that will still only represent 2.87 percent of the country's vision care population.

PRICES AND PROCEDURES

The battle for eyeballs is, however, a hard-fought one. There are plenty of players in the flap-and-zap game, and competition is fierce among the 700-plus laser centers in the United States.

Though prices, and, in many cases, profits are falling, procedures are rising. Last month, for instance, Laser Vision U.S., with 87 lasers in the United States, reported year-to-year case volume for the first quarter increased 40 percent. And, according to Optistock News, ICON Laser Eye Centers' number of procedures in July '00 were up 361 percent from July '99.

The number of optical operations adding lasers is increasing, as well. More and more regional chains and practice groups are adding the surgery. It's a point of differentiation, and, they hope, of profits.

Price is, indeed, a drawing card to some of these operations. Just last month, LCA-Vision reported a drop in average price per procedure to $1,080 from $1,4352 in the first quarter. And, a recent ad in the Food Section of the Washington Post touted $950 per eye at University Vision Centers.

Go north, and you can reportedly get two for $999 in Vancouver. That's why researcher and corneal specialist Michael Lemp, M.D., with the George Washington University Medical Center, refers to refractive surgery as a procedure of "marketing, not just medicine."

Allen Leck, president of Primary Eyecare Network, a Calif.-based practice management company, agrees.

"We are seeing a change even over the last six months in the role of price competition and in (the pursuit of) ways for surgeons to save money on co-management fees," he says. As LASIK becomes more widely utilized, consumer marketing and public awareness will be big issues, he adds.

They already are. In fact, an ABC report recently showed refractive surgery being performed "through a window" at a mall in Virginia.

Some say this commercialization and price are natural steps in the evolutionary process. Others say it heralds bad news for consumers who opt for the lowest cost care (news, they add, that will translate into more business for optometrists and opticians whose jobs it will be to correct problems by using traditional lenses and lens treatments-the very devices the patient was trying to dump).

SAFETY STATS

For the vast majority of patients, however, the FDA reports that LASIK is both safe and successful. In fact, the American Society of Cataract and Refractive Surgery (ASCRS) reports that, according to an FDA panel presentation, LASIK was above the FDA's effectiveness guidelines "with 84-91 percent of the cases achieving within 1.0 D of the attempted manifest refraction spherical equivalent of within 1.0 D of attempted."

That's not to say it's not without poor outcomes, however. In fact, critics recently appeared at an FDA Ophthalmic Devices Panel about problems. One of those who testified, Mitch Farrell, also appeared on the TV show 20/20 in January, saying, "You can have 20/20 vision and see double or triple...but your doctor will label you a success because you could see the 20/20 line."

There's even a Website, called surgicaleyes.org, launched by Ron Link, who also appeared on 20/20, that is an "informational site" about problems associated with refractive surgery. It's also reported that a class action suit is being prepared on behalf of some individuals whose outcomes have not been satisfactory.

According to an ASCRS report, "Three to four percent of patients reported mild complications, while more serious complications occurred in fewer than one percent of cases."

An FDA Talk Paper, released when LASIK was approved, listed the side effects that patients had reported experiencing six months after treatment as: under-correction (11.9 percent), over-correction (4.2 percent), severe halo (3.5 percent), loss of best corrected vision with eyeglasses (3.0 percent), several visual fluctuations (2.6 percent), and severe glare (1.7 percent).

PATIENT PROFILE

Despite some concerns, most patients are very satisfied with their outcomes. And, just who are those patients? According to VISX, seven out of 10 are between the ages of 30 and 50.

More than 60 percent are contact lens wearers or dropouts, and 55 percent are women. Most are myopes; only 10 percent are hyperopes. And at this juncture, the patient profile does not include most presbyopes.

The age range is broadening, however, and so is the downward range of corrections. "Initially patients were skewed in the 5, 6, 7, and 8 diopter range," recalls Lemp. Now, however, he says that there is an increasing number of patients in the 1-2 D range.

Several doctors report a rise in the number of men opting for LASIK. "What drives a lot of them is a desire to improve distance vision for outdoor activities," says Lemp. And in no sport has the procedure been more popular than among golfers.

Since Tiger Woods came out of the LASIK closet, becoming a TLC spokes-man in the process, more than 80 other pro golfers, reports USA Today, have disclosed they, too, have had the procedure. 

One oft forgotten fact is that many patients still need vision correction, at least part-time, after surgery. "It isn't an either/or proposition," stresses Russ Tolar, president of the Opticians Assoc-iation of America (OAA).

"Rather, you can use optical appliances as a complement product. Anti-reflective coatings are essential, just as sunglasses are. And, beyond that, there's the needs of patients who have a residual prescription," he adds.

What are those needs and the options you should be offering to meet them?

Monovision. Lemp sees many post-refractive surgery patients as having an "option for monovision."

Night Vision. According to Howard Braverman, O.D., president of the American Optometric Association (AOA), "Numerous surgeons leave patients with approximately 0.50 D of nearsightedness so that when the patient reaches presbyopia, he can still read a menu."

However, adds Braverman, this low residual myopia "means the patient still needs a night driving correction."

And, according to a Canadian study at the University of Ottowa, night vision difficulties are creating problems for many patients. The recommendation? Anti-reflective coatings can help.

Early Presbyopes. Tolar adds, "We are seeing the pre-presbyopic patient need reading glasses a little earlier following LASIK."

Aphakes. "Just like presbyopes," says Art De Gennaro, a practice management consultant and optician from Lexington, S.C., "aphakes will still need reading prescriptions."

IMPACT ON PRODUCT

This is not to say product is not being impacted, however. The OAA's Tolar finds laser surgery is "having some impact on sales, especially on the upper end or luxury frames," while the AOA's Braverman sees "a reduction in the number of contact lens wearers-but they still need eyeglasses and also sunglasses."

As for the impact on disposables, Phil Keefer, Vistakon's President of the Americas, says, "When patients go into a doctor's office and learn about the price of LASIK as well as what happens during the procedure, the vast majority choose not to have it done. However, many still want a way to see better [without eyeglasses] and opt for disposables."

Art De Gennaro agrees lasers don't "have any chance of evaporating the marketplace. If, for example, 20 out of 100 people who attend a seminar opt for the procedure, that still leaves 80 people needing contact lenses and/or glasses and eye exams. The number of people having laser surgery after having met all of the parameters is minuscule."

According to VCA's Thomas, there are, in fact, entire segments that won't be affected. Says Thomas, "We are and will continue to see the pediatric population increase in myopia. In addition, most older patients still need some type of glasses."

IMPACT ON THE Os

There's no question, however, that practices are being affected. Darren Douglas, O.D., from Dallas says he expects to lose 15 percent of his high-end Rx sales to laser surgery by 2002. But he plans to make some of it up in sunwear sales and more than the rest up by helping post-LASIK patients solve problems like difficulties they will have with night driving.

And Dale Coe, an optician from Ur Eyes in suburban Chicago, adds that, "It's a question of positioning, and we plan to advertise 'Had LASIK? Have problems? See us.'"

The rise of refractive surgery is also impacting the internal structure of operations. De Gennaro says both doctors and opticians will need to "schedule time for training, and most of this will have to be done by the doctor or optician himself. It will also require staffers to be 'fully scripted' about all aspects of the procedure."

PEN's Leck agrees practices need to change. "You can no longer have the philosophy, 'if the patient doesn't ask, don't tell.'"

What you should have, he adds, is the philosophy that "if the patient falls into the criteria for LASIK, you or your staff are obligated to offer them that mode of vision correction"-and to educate them about it.

Education is one thing, but will optometrists continue to profit from co-management arrangements? Most say those golden days are on the wane.

According to Arthur D. Little, 20 percent of patients who've had refractive surgery have been co-managed by optometry. The fact that last year's ASCRS conference held courses for M.D.s on how to get referrals without optometrists certainly doesn't bode well for that number going anywhere but down. Neither does an article appearing last month in The New York Times, in which some ophthalmologists said that centers using co-management may be endangering the public.

WHAT TO TELL PATIENTS

The AOA's Braverman firmly believes, "All optometrists need to consider refractive surgery as another modality and avenue for those patients who are candidates. If, as an opto-metrist, you take the position of not referring anyone, you are not being fair to yourself or to the patient."

The OAA's Tolar agrees. "It's your job to give patients every option they need. Just like with any other product you sell, you need to present all the pros and cons."

Most people we interviewed agree that it's important to present refractive surgery to patients, but they add it's also important to give a balanced picture and-in the face of ads that boast consumers' ability to throw their glasses away-discuss the downside as well.

Candidates. VCA's Thomas says, "Caution patients that laser surgery is not for everyone and urge them to make sure they are good candidates. It is absolutely essential to know what the outcomes might be."

Lawsuits. He points to a class action medical malpractice lawsuit in California, which suggests that it is "buyers beware" market.

Internet. If consumers want to learn about problem cases, refer them to Surgicaleyes.org. That group has also raised the issue of whether, without warnings about potential complications, LASIK ads are in violation of federal laws.

So, what can you do? Run your own ads. Place signage in your window. Put yourself into the referral loop with a message like, "Ask us about LASIK." Or, conversely, become a post-LASIK problem solver and advertise "Post-LASIK problems? We can help!"

Sure, more technology is on the horizon. Just last month, SurgiLight showed attendees at the World Refractive Surgery Symposium its infrared laser system for treating presbyopia. Add to that efforts to enhance vision beyond 20/20 with custom ablations, and it's clear the fast pace of advances will continue.

Despite all this, everyone we interviewed agrees that LASIK and its offspring will co-exist with, rather than replace, eyeglasses and contacts. And with each technological breakthrough come new opportunities as well.

So, don't dump those frameboards. But do stay flexible and make sure your mix covers categories you know are going to stay strong. EB