The golden age of refractive surgery

Refractive surgeons have effective options for all types of patients at their disposal.

Refractive surgery has come a long way since the early days of radial keratotomy in the 1990s. This procedure helped spark the movement toward patients wanting an improved lifestyle through spectacle independence, which we could deliver across a demanding market. In the early days of refractive surgery, the financial barrier to entry was relatively modest. The radial keratotomy set cost around $50,000 and required no major practice buildout to accommodate. We could literally carry the tools in a briefcase from office to office.

Since those times, the refractive surgery market has transformed. The comprehensive refractive surgeon can now offer a variety of refractive procedures, including LASIK, PRK, ReLEx SMILE (Zeiss), refractive lens exchange (RLE), implantable contact lens (ICL), corneal inlays, corneal crosslinking and accommodating/multifocal or astigmatism-correcting IOLs. While these innovations have allowed for strides forward in patient safety and efficacy, they have also resulted in significantly increased demands and complexity for the provider in regard to financial commitment, staff and surgical training.

Here are the reasons that I believe we are in the golden age of refractive surgery.


Despite the increased complexity, more patients now benefit from the available refractive surgery options, as we can offer a refractive surgical procedure to fit nearly anyone’s needs. When LASIK/PRK were the main options, many patients were not candidates. This resulted in the occasional letdown and a stagnating force on the market.

It is important clinically to offer the correct procedure for the correct presentation. Patient expectations have risen dramatically, and it is important to meet or exceed their expectations — especially in the age of social media and online reviews — and provide a solution within its capabilities. For example, a patient with a high refractive error may have been a borderline candidate for corneal refractive surgery resulting in mediocre patient satisfaction in the past. Now, a lens-based procedure like ICL or RLE has the ability to hit a home run with regard to outcomes and meeting or exceeding expectations in even the extreme refractive errors.


Investments in diagnostic tools and therapeutic devices have converged, allowing for multipurpose tools useful in both lens-based and corneal refractive-based surgical approaches. For example, the Oculus Pentacam tomographer recently received an upgrade allowing it to perform biometry for IOL calculations. Also, newer OCT machines from Optovue and Zeiss have the ability to image the cornea as well as the retina, allowing us to utilize a comprehensive diagnostic tool in multiple arms of a practice.

Tools that are useful in both lens- and cornea-based surgery allow surgeons to simplify clinical flow, floor space requirements and financial investments. This is also playing out with therapeutic devices, such as the femtosecond lasers that provide both lens-based treatments and flap creation for LASIK. Multipurpose therapeutics decrease a practice’s capital commitments and recurring service fees.


Many patients are waiting on the sidelines for reasons that may include fear based on early results of early LASIK technology. New cornea-based treatments may help spark the market, as was seen in Europe and Asia. For example, Zeiss data showed that ReLEx SMILE grew refractive procedures in China by more than 200% on average per Zeiss VisuMax femtosecond laser from 2011 to 2015. This rising tide helped increase both new patient surgery but also helped raise the volume of traditional refractive surgery.

Take care when rolling out new technology marketing programs. If not done properly, confusion may occur, which can stifle growth. In general, external marketing should focus on the benefits of refractive surgery as opposed to the technology. Technology is constantly changing, and using it as the lead selling point can diminish the importance of skill and experience. Also, technology-only discussions can perpetuate the myth that any surgeon with the same technology may have the ability to provide the same outcomes. Instead, marketing efforts should focus on providing a better surgery experience and the advantages of lifestyle and spectacle independence. Then, the technology decision for a particular patient is left up to the provider, who is best suited to choose what is appropriate for that patient.


We have had success with internal marketing for corneal inlays for presbyopia correction. We learned early that it can be expensive to educate a market on these options through traditional marketing techniques. Also, these strategies sometimes had the counter effect of confusing the market and causing potential patients to hold off from any evaluation/surgery.

Ophthalmologists became familiar with discussing refractive upgrades on top of traditional cataract surgery. Patients routinely search out eye care to treat cataracts, which is the perfect opportunity to discuss the refractive surgery options that may be coupled with traditional cataract surgery. This allows us to target our already captive audience. This same strategy is successful with marketing corneal inlays to presbyopic patients as an “upgrade” to traditional LASIK. Patients already inquire about LASIK in our office, which is the perfect opportunity to discuss corneal inlays as an option to help eliminate the need for both distance and reading glasses. Furthermore, these discussions can help legitimize the investment younger patients make when choosing LASIK. You can discuss that LASIK will be sufficient to eliminate the need for glasses in their 30s; then they can reinvest and enhance your refractive surgery investment to eliminate the need for readers in their 40s.

Through internal marketing concepts, you can increase the incremental revenue for your current patient base and set your practice apart from other less comprehensive refractive practices while also helping patients learn about how they can benefit from these offerings.

The number of available refractive surgery options increases word-of-mouth marketing potential. The multigenerational aspect of refractive surgery allows young adults, their parents and their grandparents opportunities for refractive surgical correction. We have seen multiple situations in which we have offered a middle-aged parent LASIK with corneal inlay for distance and near vision correction. Then, after successful surgery, the patient may refer a child for traditional LASIK and/or a parent for refractive cataract surgery. Having the ability to offer multiple styles of refractive surgery based on age and lifestyle allows a practice to capitalize on its position in the market.

Furthermore, each patient can be a patient for life. Patients have a continuum of refractive needs throughout their lifetime. With modern-day refractive surgery offerings, we can provide spectacle independence for patients in their early 20s with simple refractive errors, through presbyopia development in midlife as well as lens-based solutions later in life.


With a wide array of offerings to help almost all patients decrease their dependence on glasses, we are reaching a golden age of refractive surgery. These solutions are often synergistic with each other and can be additive throughout a patient’s lifetime and/or be offered to multiple generations within a patient’s family. All of this helps further support and enhance the notion of a lifestyle better lived when being less dependent on glasses. Also, the financial incentives are favorable when particularly looking at internal marketing opportunities and the potential for current and future dual-purpose devices to help decrease the investment.

It may no longer be possible for refractive surgeons to offer only cornea-based refractive surgery, but there are plenty of opportunities and incentives to broaden one’s horizons. OM

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