Since 2009, the time of Optician’s last refractive surgery survey, the market has undergone some fundamental changes. The number of clinics providing refractive surgery has increased, new types of treatment are available and public attitudes towards the procedure have changed.
Optician’s survey received dozens of responses from clinics across the country. Conversations with some of the main players as well as independent practices about their experiences over the past decade have helped create a picture of an innovative and changing marketplace, albeit one somewhat marred by disputes around patient information.
‘Surgery to correct refractive errors, using lasers or implants, to provide freedom from glasses or contact lenses is increasingly popular,’ state the Royal College of Ophthalmologists’ (RCO) refractive surgery standards. ‘Over 100,000 refractive surgery procedures (laser vision correction surgery) are undertaken every year in the UK and implant based alternatives are now widely available.’
Chair of the Refractive Surgery Standards Working Group (RSSWG), Bruce Allan, says this figure may actually be an underestimate. ‘This [100,000] is actually a very rough estimate based on UK biobank data suggesting that 4% of the adult population has had laser vision correction (LVC). This equates to around two million people,’ says Allan.
‘LVC took off in the late 1990s. So, most of these procedures have been performed over the last 20 years. One hundred thousand LVC procedures a year is therefore likely to be a significant underestimate of the annual rate, whatever the fluctuations over time,’ he added.
According to the RCO, 95% of patients who proceed with refractive surgery are ‘satisfied’ with the outcome. This has not changed since 2009 when a global study of 13 countries by the American Society of Cataract and Refractive Surgeons found the same level of satisfaction, 95%, for Lasik procedures performed between 1988 and 2008.
This year’s survey, however, did reveal a number of changes to the refractive surgery market over the past decade.
The survey
Based on respondents to Optician’s survey, it was revealed that the number of clinics offering a ‘form of refractive surgery’ have increased from 138 in 2009 to 208 this year.
Meanwhile, the prevalence of different surgery types have changed noticeably. In 2009, 99% of respondents provided Lasik treatment and 97% Lasek. This has shrunk to 79.4% and 62% in 2018, respectively.
In addition, clinics offering cataracts and clear lens extraction have increased to more than half of all respondents, compared with 33% and 32% in the 2009 survey. Interestingly, the provision of EpiLasik and Intacs – the reshaping of the cornea – have basically swapped places in their prevalence. In 2009, 23% of clinics offered EpiLasek and 15% offered Intacts. Now, 23.5% of clinics who responded offer Intacts and only 14.7% offer EpiLasek.
What types of surgery do you offer?
In terms of the cost of undergoing laser eye surgery, prices vary considerably. Optician’s ninth annual survey ending in 2009 showed a general trend towards lower prices for Lasik eye surgery, although the financial crash of 2008/9 did skew the data considerably. It revealed that the average charge for the procedure was £951 in 2009 – down from a high of £1,090 in 2003. This year’s survey has revealed a broad price range, with reported costs ranging from £400 to £3,290.
Commenting on the changes in price for laser vision correction, Allan says: ‘I do not have access to any research on this [as a whole] but in the centres of excellence, laser vision correction is around 20% more expensive than 10 years ago.’
To put this in perspective, prices today are around 27% higher than in 2009 when inflation is taken into account, according to the Office for National Statistics (ONS). This suggests a falling cost for those obtaining laser vision correction in a ‘centre of excellence’, let alone the ‘average’ clinic.
Where do your referrals come from?
When it comes to the geographical distribution of clinics, most can be found in and around London. However, as London contains approximately 15% of the UK’s population, there was nothing in the survey to suggest that there is a geographical inequality when it comes to accessing refractive surgery.
Allan says so long as patients are in good health there are ‘very few limitations’ due to location. But he added: ‘Many patients travel long distances to have their surgery performed in a centre of excellence.’The survey also revealed that referrals to a clinic by an optometrist were most common – 83% of clinics said their referrals came from an optometrist. Exactly 75% said they also received enquiries directly from patients. And less than half, 41.7%, said they get referrals from a GP or hospital.
National providers
While the survey sought to understand the experiences of all companies working in the refractive surgery industry, comments from large, national providers give a different type of market insight.
Rory Passmore, general manager of Optegra – one of the largest providers of refractive surgery – says patient numbers are ‘on the up’ and the company is seeing ‘double digit growth’ across ‘laser, refractive lens exchange, IOL and cataract surgery’.
Table 1: Additions and improvements to refractive surgery since Optician’s last survey*
Passmore says a variety of demographics are now seeking refractive surgery, and not just the young as was typically the case. ‘Older patients are becoming more aware of their options for eye health and hence there is a growth in the older generations proactively seeking spectacle independence but essentially we are seeing positive volume growth across all age groups and demographics,’ he says.
‘Cataract surgery remains very strong and is the most performed procedure,’ says Passmore. ‘From a vision correction perspective, we are seeing more patients interested in the third generation of laser surgery, “Relex Smile” and patients opting for blended laser vision correction.’
When asked about his thoughts on where the market was heading, Passmore says: ‘It’s going to continue to grow strongly.’ He says eye health and vision correction is not a ‘one size fits all’ solution and providers who can tailor their services to the needs of their patients will succeed in the coming years.
He believes ‘prices are relatively stable, and we expect this to continue’, but adds ‘to deliver great outcomes we need to continue to invest in facilities and technology so that we can always offer a solution to the vast majority of patients’.
In contrast, medical director of Advanced Vision Care, Dr CT Pillai, says patient numbers have ‘gone down compared to five years ago’. He also notes a change in the patient demographics, saying ‘laser patient age has increased slightly from 20-45 to 20-50 years old, while lens exchange patients stay between 50-75 years old’.
He attributes this change – the increase in the upper age of patients receiving laser eye surgery from 45 to 50 – to ‘the increasing success of laser monovision and blended vision’.
Pillai identifies a changing popularity in regard to refractive lens extraction and laser eye surgery, saying ‘lens extraction is more popular as these patients are above 50 years of age and are more financially established’. Demand for implantable contact lenses has also grown due to word of mouth at the same time as the laser market has contracted, he says.
‘More people are going for lens exchange than laser,’ says Pillai. ‘Lens exchange treatment is described by the World Health Organisation as one of the safest procedures carried out worldwide.
‘The future market remains tough due to Brexit, economic instability and other uncertainties. In addition, there is no unity among clinics, competition between high street and individual clinics intensify and negative reviews being blown out of proportion are also the contributing factors.’
While the price for lens exchange has stayed the same, ‘laser prices are down due to competition and the contraction of the laser market,’ says Pillai. ‘What we do not want to see is the industry turning into a price war just like we are experiencing with the supermarkets.’
Although Optical Express declined to comment on this year’s survey – it did take part, however – a consultation response in 2016 to the refractive surgery standards set out by the RSSWG states: ‘Optical Express undertakes over six in every 10 refractive surgery procedures performed in the UK.’
Currently, its website says ‘more than 99% of patients achieve 20/20 vision or better following treatment’, which was based on a study of almost 200,000 people with the most common prescriptions the company treats. It also states its surgeons have ‘performed over one million procedures worldwide’.
Practices’ experiences
In contrast to the market overview provided by the national chains, experiences of practices, and the types of conversations they have with patients about refractive surgery, can help us to understand the situation ‘from below’.
Jonathan Foreman, director of Observatory Wardale Williams, says: ‘We have two very distinct demographics. Affluent north London and traditional country. In the former we are asked a lot about laser surgery and have been since it started. In the country practices we have a much older patient and quite honestly they don’t ask us much.
‘We refer to a London clinic in some cases and they seem to have looked after those that have gone there very well,’ says Foreman. ‘We are very confident that an open and non-defensive approach is best. We are confident that this is respected and reciprocated in their opinion of us and that we will benefit from their recommendations or purchase of ancillary products.
‘While the technology is really amazing there does seem to be a sort of person who goes for it; life time high myopes who never got into contact lenses, and lifetime contact lens wearers who would never want to wear glasses.’
Ian White, optometrist and council member for the College of Optometrists, tells Optician: ‘I am open-minded to all methods of correcting visual defects, but in the ideal candidates I am very pro-laser surgery.’
He only discusses surgery when it is raised by the patient, saying: ‘I believe the best candidates are those that are interested already, any notion of encouragement by the optometrist is wrong in my opinion.
‘Many patients have unrealistic expectations and see laser as a panacea. I am very happy to pass on my knowledge to aid their research, but I inform them that the surgeon will give them any definitive answers at their consultation.’
When asked about whether the demand for refractive surgery is increasing, White says he is not ‘privy to the raw data’, but that ‘the number of my patients interested in laser is increasing’.
Kathryn Anthony, owner of Kathryn Anthony Opticians in Bath, has a ‘very open attitude to laser eye surgery’. She says it is now ‘relatively safe’ and an option for those who do not like wearing glasses.
She discusses it infrequently, however, as the demographic of her customer base ‘means that we don’t have a large number of spectacle wearers in their twenties and thirties, which is probably the main market for this’.
‘I probably get about 20 customers a year asking about [refractive surgery] but on discussing things further only about half are suitable,’ says Anthony. ‘We probably get about a dozen though who are suitable or fit the profile for lens replacement surgery, half of whom may proceed to surgery.
‘I explain to them that it is an option, give them some information, pros and cons, suitable prescriptions, expectations but then suggest that they need to contact one of the suppliers for more information on how to proceed.’
When patients ask Karl Spinks, managing director of Batty and Dexter Opticians in the North West, about refractive surgery he explains ‘the pros and cons of surgery and manage their expectations. Patients with very high expectations of their level of visual acuity tend not to be suitable for refractive surgery’.
Spinks says surgery is discussed ‘very infrequently’ and that the number of people enquiring about the process has fallen over the years.
‘I do not directly refer any clients for refractive surgery. I give honest advice and I advise the patients that as it is an elective surgery that has the potential to harm patients eyesight,’ says Spinks. ‘I tell the patients to do as much research as they can about the provider of the surgery before they make a decision to go ahead or not. I don’t personally think that the changes in technology have made the procedures any safer. There are now just more options to consider.’
Regulatory issues
According to the RCO, results for refractive surgery are ‘generally very good’. It does, however, say that ‘concerns have been raised by patient and consumer groups regarding inconsistent patient information and quality of care.’ Similar concerns were raised in the 2009 survey, when the consumer magazine Which? claimed high-street clinics were giving unsatisfactory advice to customers.
Given the persistent concerns, the RCO has enlisted the help of experienced surgeons and ophthalmologists from across both the public and private sector to form the RSSWG. It has produced guidelines for surgeons who conduct refractive surgery to ‘improve patient safety and quality of care’. Although, Allan says the standards need ‘legislation to back them up’.
‘At the moment it is up to providers to ensure that they are in step with the Standards and, where this fails, it is up to the regulators (the GMC, the CQC, and the ASA) to act,’ says Allan.
The RSSWG has also put together information leaflets on common procedures that ‘offer patients balanced and independent advice, based on the results of clinical trials, on the risks and benefits of refractive surgery to help patients make the right choices,’ says the RCO.
Allan says: ‘We had three aims derived from the 2013 Keogh report addressing the elective, self-pay lifestyle surgery sector: to set standards for good quality clinical practice, to provide high quality patient information, and a better mechanism of redress where things go wrong.’
The group has already delivered on the first two aims, but Allan says ‘redress is more complex’. While he argues most complications in refractive surgery can be fixed, he says NHS treatment of complications is ‘patchy’ and patients who have lost faith in private providers can face ‘open ended financial commitments’ in seeking redress. ‘Locating refractive surgery provision within large teaching hospitals – as at Moorfields Eye Hospital, London – is part of the answer,’ he says.
‘But problems with patient satisfaction in refractive surgery most often relate to poor communication,’ adds Allan. ‘Good continuity of care and adherence to the Refractive Surgery Standards will help to avoid these kind of issues.’