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This year has been a less controversial one for the laser refractive surgery market, with more emphasis on new treatments and improved technology. Alison Ewbank reports on the findings of Optician's sixth annual survey of clinics in the UK and Ireland

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The old adage 'No news is good news' could well be applied to the current state of the laser eye surgery market. After several years of bad press, the past 12 months have seen relatively little media coverage and less political scrutiny than recent times.

2003 was the industry's annus horribilis, when largely favourable press reports for refractive surgery turned more negative. Safety fears raised by consumer magazine Health Which? and BBC's Watchdog were followed by a downturn in patient throughput. The following year, Boots' decision to pull out of laser eye surgery attracted further adverse publicity and the debate about safety moved from the media to parliament.

December 2004 marked a low point for the sector, when the National Institute for Clinical Excellence (NICE) raised concerns about the long-term safety of Lasik. On the same day, the All Party Parliamentary Panel of Enquiry released its report, calling for a range of measures towards stricter regulation of the industry. Both developments were widely reported in the press.

2005 was another eventful year as Which? again turned its attention to laser eye surgery, with claims that clinics were not informing patients about the potential health risks involved and calls for government to enforce tougher standards.

In contrast, this year has been a less controversial one with a return to more positive news. In March, NICE updated its 2004 guidance and said current evidence suggested that laser refractive surgery was safe and efficacious for use in appropriately selected patients (News, March 23). The guidance stressed the need for clinicians to have adequate training before performing these procedures and acknowledged that patients found it difficult to identify properly trained practitioners.

Away from the media spotlight, the private members' Regulation of Laser Eye Surgery Bill that resulted from the parliamentary enquiry failed to get a second reading in May. Responsibility for the training and qualification of surgeons has been taken up by a working group of the Royal College of Ophthalmologists.

From the commercial standpoint, 2005 has also been a quiet year. There were no major changes in ownership among the major groups and no great change in business direction. Instead, clinics of all types have been expanding the range of treatments they offer and adopting new technologies to improve clinical outcomes for their patients.

THE SURVEY

Now in its sixth year, Optician's annual survey of laser eye clinics provides a snapshot of developments in the market. This year, the survey was again conducted jointly with the British Society for Refractive Surgery and was also supported by the Eye Laser Association.

As in previous years,1-5 a database of clinics was compiled using various sources including websites such as www.lasik-eyes.co.uk and www.healthcarecommission.org.uk. The survey was conducted in September and October 2006 by post and email and was also available on the BSRS website. Each clinic was asked to identify any new clinics opening in their town, city or surrounding area over the past year.

In order to encourage more clinics to respond, this year's survey was much simpler and easier to complete. We omitted questions that may be commercially sensitive, such as the number of treatments carried out, which some clinics had consistently been reluctant to divulge. Questions were included to investigate perceived changes in the market and determine the most significant developments for the industry and for individual clinics and groups over the past 12 months.

THE CLINICS

This year, 95 clinics were identified in the UK, the same number as in 2005 and similar to the 2004 and 2003 figures of 92 (Figure 1). In all, 80 completed surveys were received representing a response rate of 84 per cent, an increase on 2005 (64 per cent) and 2004 (73 per cent). However, there was again a low response rate from clinics in Ireland, with replies from just four of the 15 sites identified.

As in previous years, our sample is biased towards groups of clinics, although more single sites responded this year. Caution should therefore be exercised in extrapolating the results to the total market. In terms of type of premises, the largest proportion of our sample (59 per cent) are private clinics, followed by optical practices (24 per cent). Ten respondents described their locations as private hospitals and four as NHS hospitals.

The three major groups between them now operate in 50 locations, accounting for more than half of all clinics identified in the UK. Optical Express has joined Optimax as the two largest groups, each with 18 clinics. Glasgow-based Optical Express recently opened new clinics in Cheltenham and Uxbridge, Middlesex, continuing the trend in recent years for locations outside the major cities. The company also has three sites in Holland, in Amsterdam, The Hague and Eindhoven.

Optimax acquired the Advanced Laser Eye Clinics in Belfast and Aberdeen in November 2005. The Advanced clinic in Glasgow's Sauchiehall Street closed down and business was transferred to Optimax's Charing Cross Mansions premises.

Ultralase, bought by Spanish-based cosmetic surgery provider Corporacion Dermoestetica in May 2005, opened last month in Glasgow, taking its total to 14. Last year, Ultralase said it intended to open six new clinics in the UK and Ireland by 2007. In April, Ultralase announced it had performed its 100,000th Lasik since it first offered the treatment in 1995 and its 25,000th wavefront treatment.

Of the smaller groups, Grange Eye Consultants now runs a third clinic, at the Radcliffe Infirmary in Oxford. The Capio private health care group, which has 21 hospitals in the UK, offers refractive surgery at three locations, in London's Harley Street, at the Capio Duchy Hospital in Truro and the Capio Winfield Hospital in Gloucester. The Allclear Eye Laser Clinics in Cambridge and Belfast are now independent and operate as single clinics.

There were few changes of ownership this year but several clinics changed their name. LaserVision in Harley Street is now ProVision. This company also has locations in Canada, New York and Brussels. Horizon Eye Centre, also in Harley Street, is now Focus Reading Vision Clinic.

Recent openings among single clinics included The Yorkshire Eye Clinic in Bradford and Viewpoint Vision Services in Old Trafford, Manchester. Two single clinics - Merseyside's Birkdale Clinic and Accuvision in west London - opened second treatment centres, in Rotherham and Solihull respectively.

A notable feature this year was the number of private hospitals no longer providing laser refractive surgery, among them the BUPA hospitals in Portsmouth, Bristol and Worcester, along with the Capio Springfield Hospital in Chelmsford, Essex. Another casualty was Euromedicare in Jesmond, Newcastle upon Tyne.

Several clinics identified last year were not contactable. In London, the Harley St Laser Eye Clinic and Holborn Laser Clinic were both number unobtainable and our mailing to Brentwood-based OptimEyes Laser Consultants was also returned.

Although Ireland was already particularly well served with clinics, a further four sites appear to have opened this year. Eye Laser Ireland now runs two sites, in Cork and Limerick.

TREATMENTS

As in 2005, almost all (97 per cent) of the clinics that responded to the survey carry out the most common treatment, Lasik, and a similar proportion (95 per cent) offer Lasek (Figure 2). Surprisingly, more clinics this year, although none of the major groups, said they carried out photorefractive keratectomy (PRK) 26 per cent of respondents compared with only 13 per cent in 2005.

Last year only four of our sample offered EpiLasik but this year 23 respondents (29 per cent) listed it among their treatments. However, this increase is mostly accounted for by Optimax which, alone among the major groups, now performs EpiLasik.

The trend towards clinics of all types offering a wider range of more invasive treatments continues. The proportion of respondents performing clear lens extraction (CLE) and phakic IOLs has increased markedly to 51 per cent and 70 per cent, from 23 per cent and 20 per cent respectively in 2005. However, in 2004 these figures were 40 per cent and 37 per cent, suggesting that differences in the sample may be, in part, responsible.

More than two out of three clinics (69 per cent) responding are now offering refractive procedures other than the six most common treatments, a similar proportion to last year. In 2002, only 2 per cent of clinics were offering any treatment other than PRK, Lasik or Lasek.

Among other treatments listed by our sample were conductive keratoplasty (CK), accommodating IOLs, astigmatic keratotomy (AK), phototherapeutic keratotomy (PRK), Intacs, refractive lens exchange (RLE), Prelex, corneal cross-linkage with Riboflavin and UVA (CR-3), and limbal relaxing incisions. Many clinics, again of all types, are now performing cataract surgery alongside treatments for refractive error.

One clinic, the London Centre for Refractive Surgery in Harley Street continues to offer radial keratotomy (RK) as well as other surgical (but no laser) procedures. One of the BUPA hospitals, the BUPA Wellesley in Southend-on-Sea, Essex no longer offers laser procedures but performs implantation procedures.

The major groups have expanded their services in the past year. Ultralase now performs CLE, CK and phakic IOLs, as well as Lasik and Lasek in its clinics, with IOL procedures and corneal relaxation treatment undertaken by Ultralase surgeons at partner eye hospitals. Optimax lists the widest range of treatments, including CLE, phakic IOLs and Intacs for keratoconus as well as cataract surgery. Optical Express offered only two treatments − Lasik and Lasek − at the time of the survey but this month introduced phakic IOLs.

The percentage of clinics that have invested in wavefront technology remains similar to the past three years, at 90 per cent (2005: 93 per cent 2004 and 2003: 92 per cent) (Figure 3). Only eight of our sample do not have this technology and two of these say they will be using it in future. In 2002, fewer than half of all clinics (44 per cent) had wavefront technology.

A major finding this year has been the rapid uptake of the femtosecond laser (Intralase or similar). The Centre for Sight in East Grinstead was the first clinic to adopt this technology in August 2004. Two out of three clinics in our sample, including all three major groups, now use femotosecond lasers and six of the clinics who have not yet invested plan to do so in future.

CHARGES

Last year's survey showed that the level of charges for treatments had fallen again, continuing a downward trend since 2003. This year the average charge for Lasik was higher at £925 per eye compared with £860 last year but still less than the pre-2005 levels (Figure 4).

However, the average price again masks wide variation in charges between clinics. Optical Express quotes 'from £395' for Lasik, the same as last year and lowest of our sample. The two other major groups charge more than twice as much for this treatment: £850 at Optimax and £995 at Ultralase. Charges levied by other types of clinic tend to be higher still, mostly between £995 and £1,500, although one private clinic in central London charges £2,100 per eye for Lasik.

The average price of Lasek has also risen from £744 per eye in 2005 to £813 this year, although this figure is well below the average values the three previous years. Most clinics, including Optical Express and Ultralase, quote the same price for Lasek as Lasik, but Optimax charges only £595, the same as last year.

Other exceptions are St Paul's Excimer Laser Service in Liverpool and Kirkwood Fyfe in Aberdeen, whose charges for Lasek are half that for Lasik, although the latter charges £500 extra for wavefront Lasek. The maximum charge for Lasek was again £2,100 at the same London clinic.

Many clinics now charge more for wavefront-guided Lasik and Lasek, generally adding around £200-250 per eye but up to as much as £700 extra at one private clinic in Manchester. Among these is Optical Express which quotes prices from £795 for its CustomVue wavefront treatments.

Charges for PRK range from £495 to £1,500, with an average of £1,082 per eye.

CLE and phakic IOLs generally cost from £1,900 to £2,500 per eye. Exceptions outside this range are Optimax, which charges £1,295 for IOLs, and Ultralase, the highest priced, starting at £2,650.

SIGNIFICANT DEVELOPMENTS

For most clinics responding to our survey, the adoption of improved technology and new treatments was generally considered the most significant development for the industry as a whole (Table 1). Femotosecond lasers were most frequently mentioned, followed by improved wavefront techniques. Among the emerging procedures, CR-3 cross-linkage for keratoconus was seen as a significant advance.

The most important developments for individual clinics and groups over the past year were again almost exclusively technical rather than commercial. Of the major groups, Optical Express pointed to iris registration, wavefront and femotosecond as being most significant for its business. For Optimax, it was the introduction of new techniques and the ability to treat almost all prescriptions, and Ultralase singled out the introduction of femtosecond laser technology.

Several of our sample anticipate expanding their services, either by introducing new procedures, moving to larger premises or adding new clinics. Optimax plans to open two new sites over the next 12 months and Optical Express says it also expects to open more clinics. Ultralase says it has ongoing expansion plans, both geographically and in terms of additional products and services. Kirkwood Fyfe, which, like Ultralase, already offers facial cosmetic surgery such as blepharoplasty and Botox, plans continued expansion in this area.

LOOKING AT IRELAND

This was the fourth year that the Optician survey has been sent to laser refractive surgery clinics in Ireland. Fifteen clinics were identified: five in Dublin, five in Cork, three in Limerick and one each in Waterford and Galway. Four new clinics have opened including Eye Laser Ireland, the country's first group, with two clinics in Cork and Limerick.

Ireland's longest established laser business, the Wellington Laser Clinic, relocated to a new medical campus in the Sandyford area of Dublin with greater access to fully equipped ophthalmic operating theatres. The clinic says this will allow greater scope for intraocular refractive procedures.

The four clinics that responded this year tend to offer a more limited range of treatments than their UK counterparts. Of the laser procedures, all four perform only Lasik and Lasek. Cork's Ardfallen and Shanakiel clinics offer the widest range of treatments of those responding, with implantation techniques and conductive keratoplasty. The Wellington also offers CK. Three of our sample use wavefront technology and one, the Shandon Street Hospital in Cork, has femtosecond laser.

Charges for treatments tend to be similar to those in private hospitals and single clinics in the UK. The average charge per eye for Lasik among our respondents is just over €1,900 (about £1,250). At all but one of our sample, the charge for Lasek is the same as for Lasik. CK is priced from €1,500-€1,900 (about £1,000-£1,270).

As in the UK, the most significant market development mentioned by clinics in Ireland is technological: improvements in customised treatments through topography-guided ablation and asphericity-controlled ablation.

But with growing competition and a large number of clinics per head of population, the Irish market may find commercial developments become increasingly significant in the coming year.

CONCLUSIONS

2006 was a quiet year for the laser refractive surgery market. Media coverage of the industry was more favourable than in recent years and developments aimed at stricter regulation and maintaining standards have moved from the political to the professional arena. The emphasis this year has been on improved technology and new treatments.

Although some new clinics opened and others closed down over the past 12 months, the total number identified remained static. Average charges for the most common treatments rose, although these mask some surprisingly wide price differences.

Lasik and Lasek continue to be the most commonly offered treatments but the trend towards providing other eye surgery, particularly intraocular procedures, continues. Two out of three clinics in our sample are now offering refractive surgery other than Lasik, Lasek, PRK, EpiLasik, CLE and phakic IOLs.

It will be interesting to see whether these developments, coupled with more positive media coverage, will increase demand in the year to come.

Acknowledgements

Thanks to the BSRS for their input to the questionnaire and distributing it to members, the Eye Laser Association for supporting the survey and to all the clinics that responded this year - contact details are listed in the directory on page 28.

References

1 Ewbank A. The current status of laser refractive surgery in the UK. Optician, 2001 222:5824: 24-7.

2 Ewbank A. Trends in laser refractive surgery in the UK. Optician, 2002 224:5877 20-4.

3 Ewbank A. Trends in laser refractive surgery in the UK. Optician, 2003 226:5928 12-16.

4 Ewbank A. Trends in laser refractive surgery in the UK 2004. Optician, 2004 228:5979 16-21.

5 Ewbank A. Trends in laser refractive surgery in the UK 2005. Optician, 2005 230:6029 14-18.

Table 1

Comments on most significant industry developments in past year:

◆ Femtosecond technology

◆ Acceptance of the clinical superiority of femtosecond Lasik

◆ Maybe the introduction of femtosecond laser but too early to make any comment within the UK market as to its success

◆ Intralase

◆ Wavefront for hyperopes and aspherics

◆ Realisation that wavefront is not all that it might be - cutting flaps causes aberrations and pre-treatment/pre-flap wavefront is not the wavefront to treat. To do it properly, pre-treatment/post-flap cut wavefront is needed ( = commercial suicide)

◆ The emergence of CustomVis Pulzar solid-state refractive laser with Tracey aberrometry

◆ Tissue-saving technology

◆ Riboflavin/UVA cross linkage (CR-3) to stabilise ectasia after Lasik

◆ Intacs and CR-3 for keratoconus

◆ Iris registration

◆ Development of online pachymetry, adding real-time safety for monitoring flap thickness and ablation depth during laser treatment

◆ Having the all laser techniques and being able to be all disposable

◆ Shift towards skilled surgeons rather than technicians

◆ Discussion on forthcoming regulation of the industry

 

KEY FINDING 2006

◆ The number of clinics identified in the UK remains similar to the past three years, at 95

◆ The major groups expanded, while other new clinics opened and some closed down

◆ The three major groups between them now have 50 clinics, more than half of all those identified

◆ Four news clinics opened in Ireland, taking the total to 15

◆ Lasik and Lasek are the most common treatments offered but other procedures, particularly CLE and phakic IOLs, are becoming more widely available

◆ Charges for the most common treatments increased this year and still vary widely

◆ New techniques and improved technology are seen as the most significant developments this year, both for the industry and for individual clinics and groups

◆ A major finding this year has been the rapid uptake of the femtosecond laser

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