Laser Vision Correction Recovers

Masks, extra disposable income drive volumes higher. By Howard Larkin

After coming to a standstill during COVID-19 lockdowns in early 2020, laser vision correction (LVC) rebounded smartly in 2021. In many markets around the world, 2021 volume of LASIK, PRK, SMILE, and other laser and lenticular refractive procedures well exceeded 2019 and may be on track to continue this year, according to observers across Europe and the USA.

“Everyone I have spoken to, all of my peers in the refractive space, have seen two things happen: there’s been growth in laser vision correction and there has also been growth in premium IOLs,” said Arthur B Cummings MMed(Ophth), FCS(SA), FRCS(Edin), who runs the private Wellington Eye Clinic in Dublin, Ireland. “Looking at the Market Scope numbers and the Refractive Surgery Alliance forum, everyone has seen the growth.”

Dr Cummings attributed growth to two factors. First, with fogging and eye dryness, spectacles and contacts don’t work well with masks. “That really brought people in. We always ask, and in the last 18 months, at least half have mentioned spectacle problems,” he said.

Second, “the whole pandemic has made people think about life differently. People are a lot more interested now in looking after themselves and are more likely to spend money on self-care than [material] things,” Dr Cummings said.

EXTRA CASH Economics also played a role, said Boris Malyugin MD, PhD, of the S Fyodorov Eye Microsurgery State Institution, Moscow, Russia. “With the financial stimulus in many countries, people had a little extra money.” After a down year in 2020, he saw an increase in refractive surgery of about 25% to 30% in 2021 over 2019. The increase was mostly driven by younger people, who tended not to be as afraid of COVID-19, he said. Cataract surgeries were also down during the same period, possibly due to greater COVID-19 concern in the older population.

Marguerite McDonald MD, clinical professor of ophthalmology at New York University’s (NYU) medical school in New York City, USA, added another economic factor, the availability of more funds for stay-at-home workers due to reduced commuting, clothing, lunch, and other costs of going to an office every day.

Dan Z Reinstein MD, MA(Cantab), FRCSC, DABO, FRCOphth agreed. Positive LVC factors included “more disposable income given lack of spending opportunities—holidays, restaurants, cinema, bars, etc.—and more flexible working hours making it easier to attend appointments. This does seem to be a global phenomenon with an increase in refractive surgery in virtually all countries.”

In the USA, many patients also have tax-free medical spending accounts they can use for refractive surgery, noted Dr McDonald, who also saw volume increase in 2021. She believes the upward trend may continue through 2022 as many people are only returning to in-person work on a limited schedule.

Overall, USA LVC volume hit 833,000 procedures in 2021, including a 32% increase in the fourth quarter, according to the Refractive Surgery Council. This marked the highest volume since the council began tracking LASIK, SMILE, and PRK procedures in 2015 and may be the first time LVC volume topped 800,000 in the USA since 2008 after hovering around 1.4 million annually in the early 2000s, according to estimates by Stephen N Joffe MD.i

Not every area saw the same level of increase. “In Europe and Greece in particular, we did see a boost in cases in late 2020 and early 2021, although we did not quite reach the levels of market

recap that the USA experienced,” said A John Kanellopoulos MD, who directs LaserVision.GR Institute in Athens, Greece, and is clinical professor of ophthalmology at NYU.

In Greece, intermittent lockdowns in 2021 slowed the market, Dr Kanellopoulos said. But he expects COVID-19 restrictions to ease in the second quarter of 2022. “We feel there will be a new surge of mainly younger people who will seek spectacle independence.”

NEW TECHNOLOGIES, NEW OPTIONS Germany also saw a rise in refractive procedures of all kinds in 2021, said Michael C Knorz MD, professor of the Medical Faculty Mannheim at the University of Heidelberg and head of FreeVis LASIK Zentrum—both based in Mannheim, Germany. He is currently seeing about a 10% annual increase in LVC with most of the growth in SMILE myopic procedures. “LASIK alone is declining, as it is replaced by SMILE and even PRK. We have transepithelial PRK available for some years now, which led to an increase in PRK surgeries.” However, LASIK remains the procedure of choice for high astigmatism and hyperopia.

By contrast, Dr Knorz reports a 20% annual growth rate in lens implants. These include both the Visian Implantable Contact Lens (ICL), which he recommends for most myopes needing more than -5.0 D correction, and trifocal IOLs for refractive patients over age 50. “So even a -2.0 D myope at age 55 is today a potential candidate for refractive lens exchange with a trifocal IOL.”

Recent developments in IOL technology such as the ZEISS AT LISA® trifocal, the Alcon PanOptix®, and the Johnson & Johnson Vision Tecnis Synergy™ show excellent results in these patients, he said.

Dr Reinstein says he has used Presbyond LASIK for the last 15 years instead of refractive lens exchange for the vast majority of his presbyopic patients, adding his practice has remained very busy and stable both before and after the pandemic lockdowns and restrictions. The growth in his practice since the pandemic has been mostly in younger patients, and he believes SMILE has played a role in it. Patients like the idea of a flapless procedure that heals in a few hours. SMILE has replaced LASIK in 80% of his cases where both procedures would be indicated because of the rapid recovery, next-day return to all activities with no restrictions, less dry eye, and “extremely good spherical aberration control.” LASIK is still used for patients requiring customised ablations or Presbyond presbyopia corrections, while ICLs are used for about 2% of patients who have corneas not suitable for corneal surgery. In his practice, refractive lens exchange is reserved for those not suitable for ICL monovision due to a shallow anterior chamber or other reasons.

However, Dr Reinstein stressed his clinic prefers to be able to offer all refractive procedures. “We prefer to be in the position to offer the patient the best possible option for their eyes—rather than perceiving one procedure as competing against another.”

Dr Cummings amplified this sentiment. Surgeons should stress the safety and efficacy of the entire range of refractive technologies—and their own skill in helping patients choose the best option.

“When you board an airplane, you don’t ask if it’s made by Boeing or Airbus, you assume it is safe because it meets the general standards, and the pilot has the skill to get you there safely. It should be the same for refractive surgery,” Dr Cummings said.

Dr McDonald agreed. She noted LASIK is still unmatched in precision and quite safe—and has a large installed base that won’t go away soon. Indeed, the current comeback in LASIK “underlines the safety and efficacy of this brilliant procedure,” Dr Kanellopoulos said. Still, patients today are better informed than ever about technology, so ophthalmologists need to be ready to have the discussion, Dr McDonald said.

BLESSING IN DISGUISE While COVID-19 forced practices worldwide to adopt stringent infection control and social distancing measures that tend to slow patient flow, for some, it sparked changes that actually improved efficiency. For example, Dr Knorz has gone to a paperless office, collecting most patient information electronically before the appointment. Dr Cummings has completely reworked his patient pathway around online surveys and virtual consultations that greatly improved office efficiency and increased patient flow. “These improvements were always on the wish-list, but the pandemic forced the issue.”

However, virtual visits are not for everyone, Dr McDonald said. While colleagues in California tell her they have successfully incorporated virtual pre-op visits, she believes local culture may limit it. “Our patients value face-to-face time,” she said.

i Clinical Ophthalmology. 2021; 15: 1163–1172.

Michael Knorz knorz@eyes.de Arthur Cummings abc@wellingtoneyeclinic.com A John Kanellopoulos ajk@laservision.gr Marguerite McDonald margueritemcdmd@aol.com Boris Malyugin boris.malyugin@gmail.com Dan Z Reinstein dzr@londonvisionclinic.com Stephen Joffe stephen@sjoffe.com

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