From Lenses to Lasers
Converting contact-lens patients to refractive patients takes some careful strategizing during an economic downturn.
BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR
As refractive surgeons are painfully aware, the current economic downturn has procedure rates down across the country, with no end yet in sight. According to Market Scope, procedures in the fourth quarter of 2008 fell to their lowest levels since 1998 and were 39.9% lower than the year-ago quarter.1 Thus, it is essential that surgeons need to know which contact lens wearers can be "turned" to refractive surgery patients, but wasted time and marketing dollars can cost a practice dearly. Here, top surgeons around the country talk about how they identify and cultivate the patients most likely to ditch their contact lenses for permanent spectacle-free vision.
Identify Your Candidates
A decline in refractive surgery rates does not mean a decline in interest in the procedure, according to expert surgeons. The interest is there, and likely right under your nose.
"What we find is that the vast majority of patients who are very interested in refractive surgery are either contact lens wearers or have tried contact lenses in the past," says Daniel S. Durrie, M.D., of Overland Park, Kan. He estimates that 50% of those wearing glasses are comfortable with them and are not considering contact lenses or surgery. Of the remaining 50%, "you have about 20% who tried wearing contact lenses and failed," he says, and the remaining 30% are wearing contact lenses either successfully or "quasi-successfully."
The reason for the failures and the qualified successes is most frequently discomfort. To identify these patients, says Michael Caplan, M.D., of the Woodlands, Texas, one need only pay attention.
"One of the biggest ways that we convert people from contact lens use to LASIK is by listening to the patient and looking for signs that he is a poor contact lens candidate," he explains. "Some patients have a hard time inserting their contacts, or may be symptomatic from lens wear; they may have dry eyes or red eyes, or they may be inconsistent in their contact lens wear."
David R. Shapiro, M.D., of Ventura, Calif., adds another category. "Patients who have had a scare by experiencing an infection due to contact lens wear are often eager to find a surgical alternative," he says. An audience of patients with any of these problems is usually receptive to refractive surgery.
Women in their 40s and older are another group that tend to drop out of contact lenses due to discomfort from hormonally related ocular surface changes. Albuquerque's Stephen Coleman, M.D., points out that the perimenopausal years are linked to dryness issues, which translates to discomfort with contact lenses. "That demographic is a big part of my practice," he says.
Yet another group of patients receptive to refractive surgery's advantages are those who tend to abuse their contact lenses, according to Dr. Caplan. "Patients are usually pretty honest with you about how they wear their contacts. If they're not adhering to the normal contact lens wearing time schedule, we will often explain to them that it's in their best interest for the health of their eyes to consider LASIK."
Dr. Coleman has a profile of the ideal contacts-to-refractive-surgery-patient. "The contact lens person who is ultimately happiest following a laser procedure is someone who, roughly, is between 0 and 6 diopters and wears a soft contact lens that only corrects nearsightedness." Following a laser procedure, they typically see better than they did with their lenses because the laser profile is "way more complex" than what can be achieved with lenses, he says. "So let's say someone has 4 D of myopia. The laser profile with a custom treatment will treat not only the myopia, it will also treat the very small amount of astigmatism that occurs in everybody, as well as higher-order optical aberrations."
Lenses and Lifestyles
Toric lens wearers were cited as generally being "the least happy of the contact lens patients and therefore the most likely to become frustrated with their contacts," as Dr. Shapiro put it, due to the lens's rotation with each blink. And toric lens wearers who are involved in sports are even more eager to convert to refractive surgery patients, says Jay S. Pepose, M.D., Ph.D., professor of clinical ophthalmology at Washington University in St. Louis.
"Some people wearing toric lenses notice that the clarity of their vision sort of goes in and out with blinking, particularly if they are into sports where their reaction time is critical," he explains. "Years ago I did LASIK on one of our St. Louis Blues goalies, and I was kind of amazed that he was even able to function before, because he was wearing a toric lens. Every time he blinked it would rotate slightly, and if you've got a puck coming at you at 100 miles an hour, that microsecond could mean a big difference! His performance improved dramatically with LASIK."
Be on the lookout for other patients whose active lifestyles may make them interested in parting ways with their contact lenses. "The more athletic and outgoing a person is, the greater the odds that they will be more motivated to get out of their contact lenses," Dr. Pepose says.
Dr. Durrie adds military personnel, police and firefighters to those whose lifestyle predisposes them to an interest in refractive surgery. For them, he says, it is something that could help them perform better in their jobs.
The Environmental Issue
A region's climate conditions can also help surgeons identify likely candidates. With the rates of seasonal allergy rising across much of the country, refractive surgery may make life much more tolerable for allergy sufferers.
"Here in St. Louis, we are probably one of the allergy capitals of the United States," says Dr. Pepose. "Contact lenses, particularly soft contact lenses, will almost act as a sponge for allergens. They absorb pollen. So if a patient has hay fever and wears contacts, that person might really benefit from getting out of contact lenses."
Out in Albuquerque, by contrast, hay fever may not be as great a problem for contact lens wearers, but a very dry climate is. "I moved here from New York City in 1995," explains Dr. Coleman, "and one of the reasons I did was to do PRK/LASIK." He explains that Albuquerque is at 5,000 feet above sea level, and his clinic is actually a little bit above that — the elevation is nearly a mile. "At high altitudes there's less oxygen to go across the contact lens," he says, and because of the relative hypoxia, his patients "are very, very motivated from a comfort perspective. It's completely different from people at sea level." That environment helped get his refractive practice off the ground quickly, and he says that it keeps patient interest high, even when the economy is not conducive to out-of-pocket procedures.
Today's 18-year-olds are nearly as old as LASIK itself. The generation of people who have grown up in the refractive surgery era has come of age, Dr. Durrie points out, and these patients require no convincing to sign up for the procedure. Patients aged 18 to 24 already perceive LASIK as a viable alternative to wearing glasses or contact lenses.
"Refractive surgery has been around since they got their first pair of glasses or contact lenses," Dr. Durrie explains. "They've been thinking about it almost from day 1." Their attitude, he says, is that they may have to wear glasses or contacts for the time being, but signing up for refractive surgery is only a matter of time.
"In our practice, this group of patients choosing elective laser surgery in the 18-24 age group has gone from being almost non-existent 4 years ago to 4% 2 years ago to 15% of the patients we're doing surgery on now," Dr. Durrie says. "And it's quite an interesting group, because contact lenses are not meeting their needs for a different reason — they don't want to wear glasses or contact lenses when there is another alternative." These are patients who could be defined from a physician's standpoint as successful contact lens patients, he says. "But they don't want to put things in their eyes, they don't want to take the risk of contact lenses, and they don't want to pay for lenses and solutions over a lifetime." They look at refractive surgery as a way to save money over a lifetime, "which is something we never really thought of as we developed these procedures years ago."
Dealing With Resistance
Even contact lens wearers who are good candidates for refractive surgery, though, may still feel some trepidation, sometimes over visual problems that are no longer nearly as likely as they once were, such as halos around lights. Surgeons stress the need for honest, evenhanded education.
"Patients need to be told of both the benefits and the downsides of refractive surgery in the most honest way possible," says Dr. Shapiro. "They appreciate honesty and will be more comfortable with their decision when they don't feel they are being ‘sold’ or mislead."
Dr. Caplan agrees. "If somebody is a good contact lens patient and they are happy with their contact lens, just keep up a good rapport with that patient." They may ultimately decide to have LASIK and you'll want to maintain them in your practice when the time comes. "They have to know that their best interest is what's motivating you. If they are happy with their contact lenses, I certainly wouldn't try to convince them that that's not the right thing to do."
That said, however, sometimes patients merely need to be informed as to what the latest technology can do, which several surgeons report is often underestimated. The aforementioned halos are a case in point. Dr. Pepose says questions about them pop up regularly. "You have to explain that it's possible to get a halo, but the odds are significantly reduced now that we have wave-front-guided surgery and larger optical zone treatments than we had years go. Some people may not be aware of that."
Dr. Durrie says that astigmatism is another issue patients tend to be behind the times on. "I'll be out socially just having a casual conversation with people. Someone will ask me what I do and I tell them, and nine times out of 10, someone says to me, ‘I'd like to have that kind of surgery, but I have astigmatism.’ And it just amazes me, because one of the best things laser surgery does is correct astigmatism. It's almost the more astigmatism the better, because while it makes glasses and contact lenses harder to wear, modern surgery can correct astigmatism extremely well."
The public is also often underinformed about presbyopia solutions such as monovision and presby-LASIK. Dr. Durrie points out that while some presbyopic patients may need an enhancement to remain free of reading glasses, others, including himself, do not.
Dr. Coleman believes patient education is very important when addressing this concern. "People will say to me, ‘Well, I had a friend who had LASIK and they needed reading glasses.’ To me, this sounds like it's typically more of a communication breakdown with a 43-year-old," he says. "You need to let them know that this is what's going to happen — not might happen, will happen. Tell them, ‘You're going to need reading glasses as you go forward, in the absence of monovision.’ I try to say that three or four times to really embed it in that person's thought process."
According to Dr. Pepose, there are patients out there who still simply have a general fear of refractive surgery. In fact, he finds it to be the most significant barrier he encounters. "Price is always a concern, especially in these bad economic times," he says, "but fear I would put as reasons 1, 2 and 3 that patients resist refractive surgery."
He says that he responds to this by pointing out that the contact lenses the patient has embraced pose risks too, including a much higher risk of infection that they assume every time they insert the lens. "And if patients wear the lens overnight or if they smoke, there are other risk factors that increase the chance of getting an ulcer," he says. "Contact lenses are not risk-free, and neither is refractive surgery. I think that when people hear that for the first time, it helps them put it in a different perspective."
Weathering the Recession
The good news is that while the economic crisis may keep casting its pall over refractive surgery rates in the near term, interest in refractive surgery is still strong. Dr. Durrie reports that patients are still coming in for consultations, but they tend to want to put off the surgery until they feel their financial situation is more secure. "I think we are due for an upswing eventually," he says.
Dr. Shapiro agrees. "Continued contact lens use is not cheap and patients still face the same set of options — glasses, contact lenses, surgery — regardless of the economy."
In the meantime, many surgeons focus on making the consultation process as patient-friendly as possible. Dr. Coleman offers free consultations. "It's mostly an educational process," he explains. "We describe some of our approaches. I don't promote technology and never have stratified pricing based on what technology I was using at the time. My goal is always to use the best technology available. I have staff show patients around the office and talk to them. We try to do something different with each person, to change the process to make it a little bit more appealing. This helps to determine the true reason they are there."
And while his marketing budget may not be as large in the current circumstances, he doesn't feel that has hurt his practice. Word of mouth, say he and other surgeons, is what brings in many patients.
"The biggest change for me [due to the economy] is that there are more people who are overtly shopping around for a surgeon," says Dr. Coleman. Though he says he didn't take offense, he admits that it was irksome. "Now I look at it as an opportunity to really make the practice shine, to work a little bit harder for them. And I think it's a win-win. It's good for us and for patients to look around and try to find a good fit for them." OM
1. Harman D. Demand for Refractive Surgery Fades as Economic Crisis Accelerates. Market Scope. Feb. 2009;14:1-3.