Technology has long driven the laser eye refractive surgery market as innovation and computing power provide the data and precision tools needed to secure better and better outcomes.
In this year’s refractive surgery survey Optician asks the UK’s clinics about the cost and popularity of the various corneal laser procedures available and asks clinics the method by which patients for refractive surgery arrive at their door.
The survey also looks at the choices being made for the implantation of intraocular lenses and the continuing trend towards the use of clear lens extraction (CLE) as the choice for those seeking surgical intervention for the correction of vision.
The Royal College of Ophthalmologists (RCOphth) states that over 100,000 refractive surgery procedures are undertaken every year, but despite results being generally very good, some concerns regarding inconsistencies with patient information and quality of care were raised by patient and consumer groups. To combat this, RCOphth created the Refractive Surgery Standards Working Group in 2018, which is made up of experienced refractive surgeons and ophthalmologists to develop and produce the Professional Standards for Refractive Surgery. This was aimed at surgeons and other medical professionals and provided guidance on the level of experience and knowledge refractive surgeons should ideally have, the environment for performing surgery safely, good communication and teamwork, continuity of care and maintaining trust.
A spokesperson for RCOphth says the College wishes to strongly highlight patient safety and care, hence the development of standards and guidance for the industry and patients.
‘Some of our concerns are that because it is offered like a product, with some businesses offering surgery as buy one get one free and accessible on the high street, the general public can be swayed into thinking it is easy and do not give due attention to it. At the end of the day, it is surgery and all surgery carries some form of risk. Relatively it is low with refractive surgery, but patients should still be informed and understand the risks.’
Bruce Allan, chair of the Refractive Surgery Standards Working Group, explains that the figure of 100,000 refractive surgery procedures per year was derived from Oxford BioBank data. He says: ‘There was a significant dip earlier this decade but a recovery more recently with a shift in the demographic towards the presbyopic age group.’
Allan sees refractive surgery as being most popular with baby boomers and their children. ‘When the parents are suddenly out of glasses, it motivates the rest of the family to look at vision correction. We are still some way short of uptake levels internationally in the UK. So we are likely to see continued growth here, especially in older patients. We have done considerable work on professional standards in UK refractive surgery that should go a long way towards eliminating poor practice and building public confidence.’
Shafiq Rehman, an ophthalmic consultant surgeon at Optegra, finds that there are two major peaks in popularity for laser eye surgery. He says: ‘Firstly [there is] the mid-twenties age group who are most often suitable for Lasik or Smile (Small Incision Lenticule Extraction) and then another peak in the 50-60 age range – people who are becoming increasingly fed up of reading glasses or varifocal type glasses and just want something done which is going to last a lifetime. Good results means more people get to know how safe and effective refractive surgery is in 2019.’
What types of laser eye surgery do you offer?
When asked if anything had changed in the refractive surgery profession within the past year, Allan mentions quite a few updates.
‘Trifocal intraocular lenses now have a very strong grip on the presbyopic refractive lens exchange and refractive cataract surgery sector and have been building momentum steadily in the last four years. ICL implantation continues to grow rapidly, taking over almost completely from iris clip phakic IOLs,’ he says. ‘Laser vision correction in all forms still dominates in younger patients, with a shift away from refractive lens exchange to Femto Lasik for 50-something hyperopic patients based on good results, less regression in particular, from newer laser platforms with larger optical zones.’
Allan thinks that laser eye surgery procedures have improved vastly since they were introduced. He says: ‘Excimer lasers used in TransPRK and Lasik are pretty far along the curve now but newer generation femtolasers emerging in 2020, incorporating image registration for Smile techniques should improve results. Someone, someday, will crack the biology of accommodating IOLs, rendering multifocal optics redundant. But this could be several years off.’
Rehman adds that within the past year, a range of new multifocal lens implants have appeared, including some that can be used in patients who have already had cataract surgery with previous lens implants. ‘Smile laser vision correction has gained further ground in challenging the position of Lasik as the go-to type of laser corrective procedure,’ he says.
Jonathan Ross, a consultant ophthalmic surgeon at Laser
Vision Scotland, says that he has seen ‘renewed attention towards topographical guided laser rather than wavefront optimised. This change recognises that better results can be achieved by separating out the focusing correction of the laser treatment from the local contour irregularities of the cornea, and treating both.’ He has also seen trifocal lens implants growing fast in market share and are increasingly being used in place of laser eye surgery in younger adults as a more permanent solution.
In the news
Earlier this year, Healthcare Improvement Scotland rated all Optical Express’s Scottish surgery clinics as Exceptional following inspections (Optician, 24.05.19). Optical Express has clinics in Glasgow, Aberdeen, Inverness and Dundee that offer a range of services to patients such as laser eye surgery, cataract surgery and lens replacement.
Optical Express’ clinical services director Stephen Hannan says: ‘These Exceptional ratings are a testament to the hard work and dedication shown by our clinical teams. I’m really pleased that colleagues are being recognised in this way by the regulator.’
As part of the inspections, Healthcare Improvement Scotland spoke to staff, managers and patients and observed the clinics in practice. Each clinic was rated for three different criteria and they all received two Exceptional grades and one Good. Inspectors were impressed with the clinics’ excellent service, leadership and by the way the teams involve carers and families in patients’ care.
Healthcare Improvement Scotland also praised the leadership of the clinics, with the inspectors finding that ‘a clearly defined leadership structure and a robust governance framework helped deliver safe, evidenced-based and patient-centred care.’
David Teenan, Optical Express surgeon and UK medical director, says: ‘It’s a pleasure to work alongside the exceptional Optical Express teams in Glasgow, Aberdeen, Inverness and Dundee, and this inspection rating spells out just how high quality the service is.’
Optical Express has also hit the headlines this year with its Thanks a Million campaign, which rewards members of the NHS and emergency service workers with free laser eye surgery as a result of a survey, which found that these groups are the people the British public want to thank the most (Optician, 05.07.19).
One person who has received free Lasik surgery in both eyes as a result of the campaign is David Salmon, a London Metropolitan Police officer. Salmon had started to lose confidence during gym workouts, saying: ‘I began to feel deflated after my workouts as I felt my eyesight was holding me back.’ He had also started to struggle making out vehicle number plates late at night.
Salmon says: ‘I can now see everything in HD. Day to day, my job has become much easier as I can now nap between shifts without having to continually remove and put my contact lenses back in. I’ve really enjoyed getting back into my fitness regime and pushing myself further than before now I don’t have the barrier of poor eyesight to worry about.’
Dawn Kondol, head of people at Optical Express, adds: ‘We wanted to reward [emergency service workers] in our own special way by providing free treatment, to help improve the lives of these everyday heroes. We’re delighted to have given so many deserving people free laser eye surgery through the Thanks a Million campaign, and we are looking forward to continuing to improve lives.’
The survey
In 2018, 79.4% of respondents offered Lasik treatment and 62% provided Lasek. This year, results from the survey show that 85.7% of respondents offer both Lasik and Lasek treatment. Interestingly, 85.7% also offer cataract surgery, highlighting that more people are in need of the surgery. Indeed, 100% of respondents say that cataract surgery is one of their top five most popular refractive surgery treatments.
Eva Liste, business operational manager at Advanced Vision Care, believes that refractive surgery will always be popular given that vision is something that changes throughout people’s lives. She says: ‘With time it will degrade and even those with 20/20 vision in their youth will eventually need some sort of visual aid when they are older. The longer we live, the longer we will need to depend on our eyesight. With the number of cataracts rising every year, cataracts surgery will become even more prevalent, especially if left untreated as it can eventually lead to blindness.’
Referrals for laser eye surgery
Last year’s survey revealed referrals by an optometrist were most common at 83%. A total of 75% said they received enquiries directly from patients and 41.7% got referrals from a GP or hospital. This year however, 100% of survey responses receive referrals directly from patients, which is a sharp increase, 84.6% of referrals came from an optometrist and 53.8% came from a GP or hospital.
When asked what they think is the most important factor when choosing a procedure during the survey, answers varied. Responses given suggested factors such as ‘choice of surgeon and accepting their recommendation on best procedure’, ‘speed of recovery and cost’ and ‘to be fully informed of the clinician carrying out the procedure, exactly what the process involves, and that patients understand they need to commit the time.’
Anthony Quinn, consultant ophthalmologist at Exeter Laser Eye Surgeons in Devon, agrees that patients need clear information about the pros and cons of laser and refractive lens surgery. He says: ‘If their Pentacam scan shows the cornea to be < 500µm, or they have a thin cornea and a highly myopic refractive error, they may be better to have Lasek ± MMC. All refractive procedures have their limitations and patients need a considerable amount of information to make the best choice, including no treatment if their expectations can’t reliably be met. This all takes time with experts and I think patients should have this long before their procedure.’
Allan also concurs about the importance of thoroughly informing patients about laser eye surgery procedures. He says: ‘The more good quality information, the better informed the choices are. The work we did on the Royal College of Ophthalmologists Refractive Surgery Working Group should help to ensure that patients get more time with their surgeon to discuss procedure choices, more time to reflect and access to good quality standard patient information.’
Optegra states that its staff endeavours to provide refractive patients with information through in-depth personal consultation followed up with written communication. Rehman says: ‘For patients who want to understand the nuances of refractive surgery, we make every effort to make sure no one is left in the dark about the pros and cons of refractive surgery with an individualised appraisal of the expected results.’
Liste mentions that there are now many clinics offering refractive surgery who all claim to use the ‘most advanced technology’ and the ‘most skilled surgeons’.
‘This combined with the fact that the majority of people do not do enough research, flashy advertising and cheap prices, makes it very difficult to tell which clinic they should choose, especially when considering their visual and lifestyle needs,’ she says. ‘It is up to all professionals in the refractive and the ophthalmic fields to make sure that not only are patients fully informed but to make sure that they do their own research when selecting a clinic.’
Kantilal Jain, consultant ophthalmologist and director of Lumivision Eye Clinic in Leicester, explains that within the past year, he has seen more patients over the age of 40 take an interest in refractive surgery and that it seems to be popular with young adults, as they have usually done plenty of online research before booking a consultation.
He says: ‘Patients are more aware of who their surgeon will be and want to have direct interaction with them before the procedure. In general, the quality of information about Lasik and Lasek is good as they are well established procedures. We find not all of the large providers give enough information to patients, especially when it comes to the difference between lens extraction and corneal procedures such as Lasik. Patients are often surprised to find out from us that a clear lens extraction is essentially like a cataract operation. They can be confused as while Femtolasers are used in clear lens extractions, Eximer lasers are used in Lasik, so from a patient’s point of view both are laser eye surgery procedures, but the risk profile between the two are very different.’
According to lasik-eyes.co.uk, the average price of Lasek surgery in the UK per eye is around £1,665 and £1,765 is the average cost per eye for UK Lasik surgery. Optician’s survey results showed that per eye, 83.8% of the respondents offer Lasek surgery that costs between £1,500 and £2,500, and 84.6% offer Lasik surgery that costs between £1,500 and £2,500, putting these figures in line with the national average. This is a big increase from 2009, where the average charge for Lasik treatment per eye was £951.
Five laser eye surgery procedures that are the most popular
Further survey results revealed that 58.3% of respondents charge between £2,500 and £3,500 for cataract surgery, similar figures to prices reported by lasik-eyes.com of between £1,995 and £4,155.
On the subject of rising prices, Jain says: ‘Quality has always been high, but running costs are definitely increasing for laser procedures especially related to function of laser machines.’ Liste agrees, commenting that prices will naturally rise as the cost of technology, maintenance and consumables increases with inflation.
Allan adds: ‘Patients are looking for time with their surgeon and good continuity of care, and rightly so. This adds cost but helps to ensure good communication, realistic expectations and timely interception of any problems. There has also been an increase in staff and infrastructure costs. Patients are looking for quality and safety.’
Ross, however, says that LaserVision Scotland’s prices have not increased over the past few years. ‘Laser prices have gone down in recent years due to aggressive price competition on the high street, however laser services are expensive to run so by necessity prices are now increasing again. The increased costs of more and more regulations is also placing upward pressure on prices.’
The future
As for the future of refractive surgery? Rehman says that in the next five to 10 years, he ‘can foresee a rapid increase in the proportion of patients opting for Smile over other forms of laser vision correction. I also think that refractive lens exchange has now entered an era of wider applicability and outcomes which compete with laser vision correction in terms of accuracy. In short, there has never been a better time to aim for better sight than now.’
• Optician would like to thank everyone for their participation in the survey and to LaserVision Scotland, Advanced Eye Clinic, Optegra, The Royal College of Ophthalmologists, Exeter Laser Eye Surgeons and Lumivision Eye Clinic for their comments.