The New Normal

Refractive Surgery Returns After COVID-19 Lockdowns by Brooke Herron

Refractive procedures were among the first to go when the COVID-19 pandemic pushed the “pause button” on non-emergent surgeries. Now, as social distancing measures begin to relax around the world, clinics are reopening for elective procedures. But are patients returning?

To find out, we reached out to four refractive specialists from three different continents to gauge the new normal in patient volume and demographics in these areas.

India’s procedures resume at lower volume

In India, things are slowly getting back to normal. “Refractive surgery has resumed, but it’s at a lesser volume. However, for many patients that are coming now, it’s because they have time to recover from surgery. They are not working full-time or are working from home, and so they have more time and flexibility,” shared Dr. Soosan Jacob, director at Dr. Agarwal’s Refractive and Cornea Foundation and senior consultant of Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai.

“Plus, postoperative follow-up is not as intensive for refractive surgeries compared with some other procedures, which makes them easy to undergo at this time,” she added.

At her hospital, they offer all types of refractive procedures, but the majority of corrections are done with small incision lenticule extraction (SMILE). “SMILE has a lot of advantages. However, we do all the procedures, including laser-assisted in-situ keratomileusis (LASIK), femto-LASIK, photorefractive keratectomy (PRK), Contoura Vision, etc. We give them all the options — but many patients prefer SMILE if they can afford it,” continued Dr. Jacob.

For the most part, patient demographics have remained similar to pre-pandemic conditions. “It’s remained steady, there’s not much change. However, we have seen more students coming in lately, those doing their graduate or postgraduate studies. They have time now that colleges have closed down,” she said. “We are also seeing patients pre-marriage. They want to get rid of their glasses before marrying. All of these patients are still coming.”

Safety measures have also increased. Dr. Jacob says her hospital has implemented safety protocols from the government, as well as associations like All India Ophthalmological Society (AIOS), plus guidelines from her own hospital group, which has 90 locations.

“We were involved with AIOS in forming their COVID-19 safety guidelines — and we put safety guidelines into place at our locations before the first lockdown was ever announced in India,” she said. “When we first heard about Wuhan, we knew this would be an issue, so we immediately prepared and implemented safety measures at a very high level.”

This is not just for the safety of physicians and staff, but also for patients. “Each surgical patient gets personal protective equipment (PPE) and an N95 mask. This is important for

both patient trust and peace of mind.”

As noted by Dr. Jacob, patients now have time off to recover from refractive procedures. However, this “vacation” from work, could put some people in a precarious financial position. This has not gone unnoticed by her hospital.

“We understand that people may have some economic issues or problems with their work. We take that into consideration when we advise them, and we do have special offers for students and people with certain needs. We are trying to help them,” explained Dr. Jacob.

The US sees increased demand

“Year-to-date, we are up 50% — despite being off for six weeks. The demand is incredible,” shared Dr. John F. Doane, a refractive surgeon in Kansas City, Missouri, USA. His practice reopened on May 4.

He shared that patient demographics cover ages 17 to 80, with requested procedures like SMILE, LASIK, PRK, as well as premium intraocular lenses (IOLs), toric IOLS, and standard IOLs. In addition, Dr. Doane said that the demand for cataract surgery also appears to be inelastic.

“We are busier now than pre-COVID. It’s not at all explained by being off and playing catch up,” he continued.

At his clinic, Dr. Doane’s patients and staff wear masks at all times for increased safety. Prior to entering, patients must fill out a health questionnaire and have their temperature taken. Staff must also have their temperature taken twice daily.

“If their temperature is high, or if they have a positive response to the questionnaire, they are sent home and they must see a physician,” Dr. Doane said.

Refractive correction in Ireland skews younger

According to Dr. Arthur Cummings, consultant ophthalmologist and medical director at Wellington Eye Clinic in Dublin, Ireland resumed laser vision procedures in mid-May, and intraocular surgeries on July 1.

He shared that procedures like LASIK, PRK, implantable contact lens (ICL) and custom lens replacement or refractive lens exchange (CLR or RLE) are available. And interestingly, the patient demographics are now skewing younger.

“LASIK patients are younger than before the lockdown — the average age is below 30-years-old,” said Dr. Cummings. “Presbyopes are in their early 50s on average, which is, again, younger than before lockdown.”

According to Dr. Cummings, conversions are up significantly since the lockdown. “Patients are not shopping around. If they are suitable, they simply go ahead as soon as they can get an appointment for surgery,” he shared. “Uptake of presbyopia-correcting IOLs has gone up significantly in my practice, from around 10% to around 50%.”

And, of course, this is all done under enhanced safety measures. In his clinic, social distancing is in place, with both parties wearing masks. In addition, they are using telemedicine for part of the consultation process, which cuts down in-person meeting time.

Hong Kong avoids lockdown and stays steady

In Hong Kong, they fortunately never had to lock down. “This is because of our painful experience with SARS in 2013, everyone immediately practiced mask-wearing and social distancing. So everything is quite under control,” shared Dr. John Chang, director of GHC Refractive Surgery Center at Hong Kong Sanatorium & Hospital and clinical associate professor in the Department of Ophthalmology at the University of Hong Kong.

“Although we are presently having a third wave of a community outbreak, the death toll is still relatively low, so elective surgeries were never stopped,” he continued. consults, 70% of patients request SMILE, and the remaining 30% don’t have a preference. In the end, 50% of his patients undergo SMILE and the other half have LASIK.

According to Dr. Chang, patient demographics have changed a bit, although demand has remained steady. “In our cataract center, the number of older patients has dropped by 70%. Most of the patients now are around 60 years old or younger,” he explained, adding that the older patients have stayed away because their mortality rate for COVID-19 is quite high.

“Surprisingly, our refractive volume never went down — we are as busy as ever,” shared Dr. Chang. He shared that during the worst period of the outbreak, the patient volume dropped by about 90% at the cataract center, but only by 40% at the refractive surgery center. “However, patient volume returned rapidly after the second outbreak, and our volume did not drop at all during the present third outbreak.”

Dr. Chang noted that in Korea, some refractive centers have reported a 120% increase in surgical volume. This can be attributed to several reasons: First, younger patients are not as concerned about the virus as their mortality rates are very low. Another reason, also mentioned by Dr. Jacob, is that most people are working from home right now, so they can have surgery without needing to take time off work. “Younger patients also have more time at home now to communicate with their friends, thus sharing refractive surgery experiences,” continued Dr. Chang.

And the final reason: “Because of the mask-wearing, spectacles fog up, and also there is a higher possibility of contact lens-related eye infection,” he explained.

At his hospital, there are also some new safety regulations at the hospital. This includes providing and wearing surgical masks, and safe disposal of all masks and post-op surgical coverings. “They are folded patient-side-in and discarded in closed bins,” concluded Dr. Chang. He said a COVID-19 test is not required for refractive patients (as the center is not within the hospital), but other safety regulations still apply.

Contributing Doctors

Dr. Soosan Jacob, MS, FRCS,

DNB, MNAMS, is the director and chief at Dr. Agarwal’s Refractive and Cornea Foundation (DARCF) and senior consultant of Cataract and Glaucoma Services at Dr.

Agarwal’s Group of Eye Hospitals in Chennai, India. She has been the recipient of the following prestigious International awards: JRS (Journal of Refractive Surgery) Waring medal for editorial excellence; ISRS Kritzinger Memorial award (the first Indian and the first woman internationally to receive this award); Innovator’s award (Connecticut Society of Eye Physicians); ESCRS John Henahan award for Young Ophthalmologist; AAO International Ophthalmologist Education Award; AAO International Scholar award; AAO Achievement award; ASCRS Top-Gun Instructor Award; Bruce Jackson oration (Canadian Ophthalmological Society); Harold Stein Innovator lecture (Canadian Ophthalmological Society); and is also a two time recipient of ASCRS Golden Apple award and also the prestigious Indian awards: IIRSI (Intraocular Implant and Refractive Society of India) Special Gold medal; UKSOS Gold medal (Uttarakhand); AM Gokhale award and oration (Pune Ophthalmic Society); Dr. TN Gopinathan Menon Memorial Oration award & gold medal and the Dr. P R Mondal Memorial Oration Award. In addition, she has won more than 50 prestigious international awards for her surgical videos as well as Best Paper of Session awards on her innovations and challenging cases at prestigious international conferences in the USA and Europe.

dr_soosanj@hotmail.com Dr. John F. Doane, MD, FACS, has practiced as a corneal and refractive surgeon with Discover Vision Centers in Kansas City for the past 23 years. He is a clinical associate professor at Kansas University Medical Center Department of Ophthalmology in Kansas City, Kansas. Dr. Doane has written over 80 peer-reviewed articles and book chapters and has edited textbooks on refractive surgery. He has been an investigator with numerous FDA clinical trials for corneal refractive surgery, intraocular lens implants, and laser surgical techniques, as well as international studies of LASIK outcomes, prototype laser systems, and software applications. He is the founding editor of Cataract and Refractive Surgery Today which is a collaborative effort of ophthalmic surgeons, ophthalmic industry leaders, and ophthalmic research groups to address better treatment options for patients worldwide. He is the current Board Chairman of the American European Congress of Ophthalmic Surgery. He is an active speaker to audiences in the U.S. and internationally.

jdoane@discovervision.com

Dr. Arthur Cummings, MD, is a cataract and refractive surgeon in Dublin, Ireland. He works closely with industry and colleagues in an attempt to grow refractive surgery and bring the benefits of refractive surgery to more people.

abc@wellingtoneyeclinic.com Dr. John Chang, MD, is presently the director of the Guy Hugh Chan Refractive Surgery Centre of Hong Kong Sanatorium & Hospital. Dr. Chang was trained in ophthalmology at Jules Stein Eye Institute, UCLA. He then went to UCSF and did a fellowship there. He is presently the president of International Society of Refractive Surgery. Dr. Chang is a past president of the Hong Kong Association of Private Eye Surgeons. He is an honorary associate professor of the University of Hong Kong and the Chinese University of Hong Kong. He is on the executive committee of the APACRS. He is on the editorial board of CRST, APJO, EyeWorld (Asia Edition), Ocular Surgery News (APAO Edition), the Open Ophthalmology Journal, Chinese Journal of Ophthalmology (CJO), and EyeNet (AAO), and is the chief editor of EuroTimes (China Edition). He has also been awarded the “Certified Educator Award” by the APACRS, “Gold Medal” by IIRSI- India, “Distinguished Service Award” and “Achievement Award” by APAO, “Casebeer Award” and “Founders’ Award” by the International Society of Refractive Society (ISRS), the American Academy of Ophthalmology’s “Secretariat Award” and “Senior Achievement Award” by the AAO. Dr. Chang is also active in research, publishing and traveling abroad to give lectures as an invited speaker.

John.SM.Chang@hksh.com

INDUSTRY UPDATE

DE-128 (MicroShunt) from Santen Continues on Path to FDA Approval

In early July 2020, Santen Pharmaceutical Co. Ltd. announced that the United States Food and Drug

Administration (FDA) has accepted the

Premarket Approval (PMA) application for review for the DE-128 (MicroShunt).

Now, DE-128 will undergo an in-depth review, following which the FDA will make a decision as to whether the PMA is approved. This process usually takes 180 days from receipt of application. Designed to reduce intraocular pressure (IOP) in patients with primary open angle glaucoma (POAG), DE-128 is an investigational, ab-externo, minimally invasive, surgical implant. The implant helps drain eye fluid and reduce IOP in patients with POAG whose IOP is not controlled when using maximum tolerated glaucoma medications.

DE-128 is made with a proprietary, biocompatible material called “SIBS” [poly(styrene-block-isobutylene-blockstyrene)], the implant is a flexible, 8.5mm-long tube with planar fins to help fixate the device in the tissue and prevent leakage and migration.

If approved, this could expand treatment options for the estimated 3.7 million Americans living with POAG, a leading cause of blindness.

For more information, visit www.santen. com.

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INDUSTRY UPDATE

Schwind ATOS and SmartSight Receive CE Approval

The latest CE approval for Schwind’s ATOS femtosecond laser and SmartSight broadens options for lenticule extraction as a treatment option for refractive correction.

Developed by Schwind, SmartSight is the latest generation of lenticule extraction, performed entirely with the ATOS. The system features eye tracking with pupil recognition and cyclotorsion compensation to provide precise centering of the patient’s eye along the visual access, and to ensure maximum safety and predictable treatment outcomes.

SmartSight is suitable for the treatment of myopia and astigmatism up to 5D. In addition, ATOS offers high-precision flaps for femto-LASIK.

Managing Director Rolf Schwind said: “Schwind is continuously working on the goal of providing the eye surgeons and their patients with state-of-the-art, particularly safe and high-precision treatment options based on our latest technologies. With the CE approval for our femtosecond laser, we have reached another milestone.”

According to the company, the ATOS expands Schwind’s comprehensive range of applications — and with the combination of SmartSquare (with ATOS and the AMARIS excimer laser), it covers the most up-to-date all-laser procedures in refractive surgery. In addition to the ATOS SmartSight lenticule extraction, and flap cutting for femtoLASIK, the AMARIS can be used for intrastromal LASIK treatment and touchfree TransPRK/SmartSurfACE surface treatment.