Trends in laser refractive surgery in the UK 2003

The past 12 months cannot have been an easy time for the UK's laser refractive surgery clinics. With damning media reports, charges of serious professional misconduct and the spiralling cost of medical insurance, 2003 must surely have been the industry's annus horribilis.
The publication in February of the Health Which? report on the safety of laser eye surgery, and the subsequent BBC Watchdog investigation, sparked adverse publicity and saw the major groups defending their practices. The newly formed Eye Laser Association, representing six laser eye surgery providers, was forced to defend the industry against the charge of 'gambling with [patients'] eyesight'.
That same week a laser surgeon was cleared by the General Medical Council following an accusation that he had failed to follow appropriate procedures or to explain the associated risks. Meanwhile, the cost of professional indemnity insurance for surgeons undertaking laser eye surgery rose to as much as three times that of their colleagues.
May brought news that, following the acquisition of the Eye Clinic group in October 2002, Optical Express had purchased the ailing Maxivision business. Maxivision was reported to have nearly 500 optical practices referring patients on a fee basis and had planned to open four new laser centres this year.
Most recently, Harley Street clinic Advance Visioncare Ð launched in January this year Ð was acquired by its principal surgeon after 'a dramatic decline' in the market. 'Unfortunately we opened our doors at the beginning of the biggest decline in patient volumes in the industry's history,' said the clinic's medical director.
Against this background, laser refractive surgery is increasingly recognised as an alternative to spectacles and contact lenses, and new treatments receive regular media coverage. Optometrists continue to report interest among their patients and need accurate and up-to-date information to answer enquiries and make appropriate referrals. Many practitioners are also involved in the co-management of refractive surgery cases either as employees of clinics or within their practices.
The purpose of this year's optician survey of UK clinics was therefore to provide accurate information on the current state of the market, as well as monitoring trends over the past three years.
For the first time, the survey was conducted jointly with the British Society for Refractive Surgery (BSRS), the organisation that represents the interests of ophthalmologists, optometrists and others involved in refractive surgery. The survey was also extended to cover clinics in Eire, which are reported separately on page 15.
THE SURVEY
As in previous years,1,2 a database of clinics was compiled using various sources, including equipment suppliers, professional organisations and websites such as www.lasik-eyes.co.uk. Each clinic was contacted to check they were currently offering treatments. The survey was then sent out by post and email in September and was posted on the BSRS website.
Questions were added to this year's survey to reflect perceived changes in the market and to determine the most significant developments for the industry and for individual clinics and groups over the past year.

THE CLINICS
This year, 92 clinics were identified in the UK, compared with 80 in 2002 and 47 in 2001 (Figure 1). The number of clinics in the UK has therefore increased by an estimated 15 per cent in the 12 months to September 2003, compared with an increase of 70 per cent the previous year.
A total of 64 completed surveys were received by the cut-off date, representing a response rate of 70 per cent (2002: 78 per cent; 2001: 68 per cent). A number of clinics were again reluctant to respond due to commercial sensitivities and others omitted to answer some of the questions for the same reason.
In previous years, our survey respondents have been broadly representative of all clinics in the UK in terms of single clinics/groups and types of premises. This year, our sample tended to be biased towards private clinics and those that are part of a group. Response rates among single clinics and private hospitals were lower.
The geographical spread of clinics identified is similar to last year, with new sites opening in major centres such as London and Belfast, but also in towns such as Rotherham, Bolton and Hillsborough, Co Down.
Growth in the proportion of clinics that are part of a group has slowed down (Figure 2). We estimate that 63 per cent of all clinics are now part of a group rather than a single clinic compared with 67 per cent in 2002, although this was an increase of 18 per cent on the previous year. The largest group, Ultralase, opened eight clinics in the year to September 2002 to take its total from six to 14, but this year opened no new sites.
Optimax added two clinics, in Southampton and Ipswich, to bring its total to 11, and Optical Express, having acquired The Eye Clinic and Maxivision and opened an additional clinic in Bristol, had 10 clinics by September. Last year Boots doubled its number of clinics from four to eight, but this year opened only one new site, again in Bristol. Glasgow-based Advanced Laser Eye Clinics added a fourth outlet and its first outside Scotland, in Belfast.
There were more changes this year among the single clinics. Euromedicare in Newcastle-upon-Tyne is the most recently opened and carried out its first procedures in April. This clinic, previously located in the BUPA Hospital Washington, was one of several that either moved premises or changed names or ownership this year. The Eye Academy became Capio Eye London and Sunrise Laser Vision Correction is now the London Vision Centre.
The distribution of types of premises occupied is similar to last year (Figure 3). More than half of all centres (59 per cent) are private clinics, similar to the proportion in 2002 (56 per cent) and higher than the previous year (49 per cent). The proportions sited in private hospitals (16 per cent), optical practices (15 per cent) and NHS hospitals (10 per cent) remained stable.
Two interesting developments are the arrival of overseas-based companies and the emergence of groups of consultants serving more than one centre. Baviera Eye Clinic opened in January in Hammersmith west London and is one of 23 clinics across Europe Ð 21 in Spain and one in Italy. Grange Eye Consultants is a group of three surgeons operating at Nuffield Hospitals in Chandlers Ford and Taunton, with consulting rooms at BUPA Southampton.
A majority of clinics responding to the survey provide surgery only on a private basis although eight, mostly in NHS hospitals, also offer treatment on the NHS. All Clear Belfast and the Midland Eye Institute in Solihull are among the few private clinics carrying out both NHS and private procedures.

TREATMENTS
All but one of the clinics (St Thomas' Hospital, London) that responded to the survey carry out Lasik, which remains the treatment most commonly offered (Figure 4). The noticeable trend towards Lasek at the expense of PRK continues this year; 81 per cent now perform Lasek, compared with 69 per cent in 2002 and only 38 per cent the previous year.
Other surgical techniques are also becoming more widely available, particularly phakic IOLs and clear lens extraction. Some hospital-based clinics, such as Centre for Sight in East Grinstead, offer a wide range of treatments including accommodative IOLs and corneal inlays.
Among the larger groups, Lasik and Lasek are the most commonly available treatments (Table 1). None of these groups now offers PRK and Boots continues to offer only Lasik. Optimax has introduced phakic IOLs to its range of treatments and Ultralase offers conductive keratoplasty under its 'Ultra RF' brand.
The most common types of laser and microtome used by respondents were still Bausch & Lomb's Technolas 217 and Hansatome. The Technolas is more prevalent among the major groups, which often use more than one type of laser across their clinics, although Boots used only LadarVision models.
Last year's survey showed that the level of charges for treatments had remained fairly constant since 2001 but, this year, prices for the less common techniques have gone up. Average charges increased from £1,049 to £1,090 per eye for Lasik, from £859 to £947 for Lasek, and from £721 to £851 for PRK. Phakic IOLs and clear lens extraction (CLE) now cost, on average, £1,188 and £1,813 respectively.
There were again wide variations in charges between clinics (Figure 5). The lowest charge for Lasik was £650 per eye, at the Somerset and Wessex Nuffield Hospitals, and the highest was £1,600, at the BUPA clinic in Worcester, the London Vision Clinic and OptimEyes in Brentwood. Prices for Lasik at the high-street groups are the same as last year, ranging from £750 at the 11 Optimax clinics to £1,250 at Boots Opticians. One exception is Ultralase, where the cost of Lasik has increased from £999 to £1,250.
Almost all clinics now include aftercare in the cost of treatment but policies on charging for retreatment vary. About half of the clinics responding say they never charge for retreating their patients, and where charges are made these usually apply only after a given time limit, ranging from 1-2 years postoperatively. Other clinics always charge for retreatment and one (MDA Clinic, Cardiff) charges patients retreated whose vision is 6/12 or better after the initial treatment. Charges for retreatment range from £200 to £500 per eye.
A key finding of this year's study is that all of the major groups have run some form of special promotion or offer, ranging from two-years' interest-free credit, buy now pay later, two-for-one (bring a friend) and discounts of up to £400 on the cost of treatment. Only three of the single clinics responding had run promotional offers; two offered a reduced or refunded consultation fee and another offered discounts for doctors and nurses.

NUMBER OF TREATMENTS
Patient throughput remains one of the most sensitive areas investigated in the survey, perhaps understandably given reports of declining demand. Nevertheless, 46 of the 64 clinics responding replied to questions relating to the number of procedures they had carried out.
With the exception of Boots, the major groups provided figures for their total number of procedures to date. Optimax estimates it has performed 70,000 PRK, 40,000 Lasik and 32,000 Lasek procedures. Ultralase, the longest established group, has carried out more than 10,000 PRK, 62,000 Lasik and 650 Lasek treatments, while Optical Express reports 24,000 Lasik and 2,000 Lasek procedures. Among the single clinics and hospital-based centres, Centre for Sight in East Grinstead has carried out 5,000 Lasiks since it was established in 1996.
The number of procedures carried out per week is perhaps the most useful and accurate indicator of current throughput and this year confirms that the market is in decline. The average number of procedures (all treatments) currently carried out by the 49 clinics responding to this question was 23 compared with 37 in 2002.
Since the base for the two years is not the same, and the breakdown of the types of clinic responding this year was slightly different, this figure can only provide an indication of the state of the market. It also reflects the very small number of treatments carried out by some of the single clinics and others that have only recently opened. Nevertheless, the size of this difference is such that it is highly likely to indicate a significant downturn.
Similarly, the number of procedures clinics anticipate carrying out in 2004 compared with 2003 indicates more modest growth in capacity than in previous years. Last year some clinics predicted that in 2003 they would more than double the number of procedures carried out, but this year some are already anticipating no growth or a decline in throughput over the next 12 months. Most expect a further shift away from PRK towards Lasek although Lasik will continue to be the most commonly used technique.
The proportion of treatments that are repeat procedures again varies widely, from 0.1 per cent to 10 per cent, and has seen a further increase year on year. The average this year was 5 per cent, compared with 3.5 per cent in 2002 and 2.4 per cent in 2001.

WAVEFRONT TECHNOLOGY
The most significant development in treatments over the past year has been the wider uptake of wavefront technology (Figure 6). In 2002, fewer than half (44 per cent) of respondents had invested in this technology but almost all (92 per cent) now have it. The most widely used wavefront system is the Bausch & Lomb Zyoptix, followed by the VISX and Nidek systems.
Last year, opinions were divided on the future potential for wavefront technology and whether it should be used routinely. This year, for the first time, our survey asked clinics what proportion of their treatments were wavefront-guided and how these patients were selected. Responses to these questions were surprisingly varied; some clinics were only using wavefront on a trial basis and others in less than 1 per cent of treatments. Patients were either selected on the basis of prescription or if they requested the treatment.
Two clinics Ð London Vision Clinic and the Kirkwood Fyfe optical practice Ð reported that more than half of their treatments were wavefront-guided. Another single clinic declined to respond to the survey on the grounds that it was a specialist centre using customised procedures to treat compromised eyes (through previous surgery or injury) as well as virgin eyes, and that comparisons with other clinics might therefore be misleading.
The wider use of wavefront technology was cited more often than any other factor as the most significant development in laser refractive surgery over the past 12 months, both for the industry as a whole and for individual clinics. Adverse publicity arising from Health Which? and other reports was also seen as significant. New treatments, such as reading implants for presbyopia and accommodative IOLs, were important advances for some clinics, while for others business developments and the volume of patients were more significant.

PATIENTS
All but three of the clinics responding had advertised their services to consumers and just over a half (54 per cent) had also advertised to the optical profession. Personal recommendation remains the most common source of patients, although the proportion referred by this method fell slightly from 49 per cent in 2002 to 44 per cent this year (Figure 7). In contrast, referrals by optometrists and dispensing opticians rose from 8 per cent to 13 per cent in the year to September and the proportion referred via websites also increased slightly. Very few patients are referred by GPs or ophthalmologists.
The lower age limits set by clinics for PRK, Lasik and Lasek vary from 18 to 24 years. The most common minimum age for Lasik is still 21 years, but some of the major groups have changed their policy since last year. Boots has raised its lower age limit for Lasik from 18 to 21 and Ultralase now sets different limits for hyperopes (18 years) and myopes (21 years). Some clinics set an upper age limit of 55 years for Lasik but many have no maximum age for any of their treatments. Despite the wider use of techniques for correcting presbyopia, the average age of patients treated across all clinics and treatments remained the same as in previous years, at 37 years.
The range of refractive errors treated again varies widely between clinics but the maximum amounts of myopia, hyperopia and astigmatism remain the same as last year at -15.00D, +6.00D and 6.00DC respectively. However, there has been a marked change in previous mode of correction among patients presenting for treatment, with more contact lens wearers coming forward for surgery. Three out of four patients undergoing treatment have previously worn contact lenses and one in three were full-time wearers (Figure 8).
Only 81 per cent of clinics now offer bilateral Lasik on the same day compared with 97 per cent in 2002, although a change in policy by the Optimax group may account for this difference. Almost all clinics (97 per cent) offer monovision correction for presbyopes but they are now less likely to trial these patients with monovision contact lenses first (74 per cent; 2002: 89 per cent). All clinics require contact lens wearers to leave their lenses out for at least a week prior to surgery and some require RGP wearers to discontinue wear for six to seven weeks.

STAFF
This year's survey looked in more detail at the qualifications of those currently carrying out laser refractive surgery. The proportion of clinics that say their surgeons are all consultant ophthalmologists Ð who hold or have held a consultant post in the NHS Ð has again fallen, from 44 per cent in 2001 and 40 per cent in 2002 to 35 per cent this year.
Those clinics whose surgeons are not all consultant ophthalmologists are almost all part of a major group, where the proportion of surgeons who are consultants varies from 10 per cent at Optimax to 85 per cent at Ultralase. We also asked these clinics what proportion of their surgeons were listed on the specialist register. All Ultralase surgeons and 94 per cent of Boots surgeons who are not consultants are listed on the register.
As in previous years, a high proportion (87 per cent) of laser clinics responding to the survey, including all the major groups, employ optometrists on their premises. Postoperative follow-up is the most common procedure carried out by employed optometrists (Figure 9) and there is a trend towards more involvement in immediate postoperative care. One in five of these optometrists now carries out procedures on the day of surgery and more than half are able to prescribe tear supplements. Wavefront analysis and punctal plug insertion are other areas where optometrists are now involved.
Nearly one in three laser clinics (31 per cent) pay optometrists to carry out various procedures in their practices, mostly postoperative follow-up. Last year, prior to its acquisition by Optical Express in May, Maxivision listed 39 locations at which pre and postoperative procedures for patients were referred to its laser centres in Manchester and London. Ultralase and All Clear are among those currently operating co-management schemes, where optometrists are paid fees by the laser companies rather than directly by the patient.
Training for optometrists in these procedures is becoming more structured. Most optometrists either employed by clinics or involved in co-management now undertake a combination of lectures, theatre experience and supervised practice. Boots offers its own in-house programme of training and certification.

FUTURE PLANS
Despite predictions that the throughput of patients will remain relatively flat in the coming year, most of the clinics remain optimistic about the future direction of the industry. Optimax expects to open a further two clinics before the end of the year and five more in 2004. All Clear is considering opening its fourth clinic, in Chester.
Others will be expanding the range of treatments they offer to correct a wider range of refractive errors, investing further in wavefront technology or diversifying into new clinical areas. St Paul's Excimer Laser Centre in Liverpool has already developed a keratoconus detection system and Ultralase reports that it will be the first to introduce iris recognition as part of its diagnostic and treatment procedures.

CONCLUSIONS
2003 was a year of consolidation and controversy for the laser refractive surgery market rather than significant growth. The most notable finding from last year's survey was the rapid expansion in the number of clinics operating. This year, growth in the number of outlets has slowed considerably, especially among the major groups. Instead there have been further changes of ownership, the involvement of overseas interests and widespread discounts and promotions.
The average throughput of patients has decreased, although the reasons for this decline are unlikely to be straightforward. Adverse publicity may have contributed to a downturn in demand and the industry may be suffering from over-expansion in previous years. The type of procedures offered and the professional staff involved is also evolving. Whatever the causes of the decline in throughput, many clinics expect increases in capacity in the coming year, although on a more modest scale than in previous years.
From the clinical point of view, the industry has seen some significant developments in the past 12 months, in particular the wider uptake of wavefront technology and increased use of Lasek. A more diverse range of treatments is now available and new procedures continue to emerge.
Our findings suggest that, despite a difficult year, laser refractive surgery is still a developing market in the UK. We would encourage all clinics to participate in next year's survey in order to provide accurate information on the state of the market and monitor future trends.

Acknowledgements
Thanks to NSM Research and Reed Research for data input and analysis, and to Catharine Chisholm, Shehzad Naroo and Sunil Shah of the BSRS and optician clinical editor Bill Harvey for their input to the questionnaire. Thanks also to all the clinics that responded to this year's survey Ð contact details are listed in the directory on page 27.

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.The past 12 months cannot have been an easy time for the UK's laser refractive surgery clinics. With damning media reports, charges of serious professional misconduct and the spiralling cost of medical insurance, 2003 must surely have been the industry's annus horribilis.
The publication in February of the Health Which? report on the safety of laser eye surgery, and the subsequent BBC Watchdog investigation, sparked adverse publicity and saw the major groups defending their practices. The newly formed Eye Laser Association, representing six laser eye surgery providers, was forced to defend the industry against the charge of 'gambling with [patients'] eyesight'.
That same week a laser surgeon was cleared by the General Medical Council following an accusation that he had failed to follow appropriate procedures or to explain the associated risks. Meanwhile, the cost of professional indemnity insurance for surgeons undertaking laser eye surgery rose to as much as three times that of their colleagues.
May brought news that, following the acquisition of the Eye Clinic group in October 2002, Optical Express had purchased the ailing Maxivision business. Maxivision was reported to have nearly 500 optical practices referring patients on a fee basis and had planned to open four new laser centres this year.
Most recently, Harley Street clinic Advance Visioncare Ð launched in January this year Ð was acquired by its principal surgeon after 'a dramatic decline' in the market. 'Unfortunately we opened our doors at the beginning of the biggest decline in patient volumes in the industry's history,' said the clinic's medical director.
Against this background, laser refractive surgery is increasingly recognised as an alternative to spectacles and contact lenses, and new treatments receive regular media coverage. Optometrists continue to report interest among their patients and need accurate and up-to-date information to answer enquiries and make appropriate referrals. Many practitioners are also involved in the co-management of refractive surgery cases either as employees of clinics or within their practices.
The purpose of this year's optician survey of UK clinics was therefore to provide accurate information on the current state of the market, as well as monitoring trends over the past three years.
For the first time, the survey was conducted jointly with the British Society for Refractive Surgery (BSRS), the organisation that represents the interests of ophthalmologists, optometrists and others involved in refractive surgery. The survey was also extended to cover clinics in Eire, which are reported separately on page 15.
THE SURVEY
As in previous years,1,2 a database of clinics was compiled using various sources, including equipment suppliers, professional organisations and websites such as www.lasik-eyes.co.uk. Each clinic was contacted to check they were currently offering treatments. The survey was then sent out by post and email in September and was posted on the BSRS website.
Questions were added to this year's survey to reflect perceived changes in the market and to determine the most significant developments for the industry and for individual clinics and groups over the past year.

THE CLINICS
This year, 92 clinics were identified in the UK, compared with 80 in 2002 and 47 in 2001 (Figure 1). The number of clinics in the UK has therefore increased by an estimated 15 per cent in the 12 months to September 2003, compared with an increase of 70 per cent the previous year.
A total of 64 completed surveys were received by the cut-off date, representing a response rate of 70 per cent (2002: 78 per cent; 2001: 68 per cent). A number of clinics were again reluctant to respond due to commercial sensitivities and others omitted to answer some of the questions for the same reason.
In previous years, our survey respondents have been broadly representative of all clinics in the UK in terms of single clinics/groups and types of premises. This year, our sample tended to be biased towards private clinics and those that are part of a group. Response rates among single clinics and private hospitals were lower.
The geographical spread of clinics identified is similar to last year, with new sites opening in major centres such as London and Belfast, but also in towns such as Rotherham, Bolton and Hillsborough, Co Down.
Growth in the proportion of clinics that are part of a group has slowed down (Figure 2). We estimate that 63 per cent of all clinics are now part of a group rather than a single clinic compared with 67 per cent in 2002, although this was an increase of 18 per cent on the previous year. The largest group, Ultralase, opened eight clinics in the year to September 2002 to take its total from six to 14, but this year opened no new sites.
Optimax added two clinics, in Southampton and Ipswich, to bring its total to 11, and Optical Express, having acquired The Eye Clinic and Maxivision and opened an additional clinic in Bristol, had 10 clinics by September. Last year Boots doubled its number of clinics from four to eight, but this year opened only one new site, again in Bristol. Glasgow-based Advanced Laser Eye Clinics added a fourth outlet and its first outside Scotland, in Belfast.
There were more changes this year among the single clinics. Euromedicare in Newcastle-upon-Tyne is the most recently opened and carried out its first procedures in April. This clinic, previously located in the BUPA Hospital Washington, was one of several that either moved premises or changed names or ownership this year. The Eye Academy became Capio Eye London and Sunrise Laser Vision Correction is now the London Vision Centre.
The distribution of types of premises occupied is similar to last year (Figure 3). More than half of all centres (59 per cent) are private clinics, similar to the proportion in 2002 (56 per cent) and higher than the previous year (49 per cent). The proportions sited in private hospitals (16 per cent), optical practices (15 per cent) and NHS hospitals (10 per cent) remained stable.
Two interesting developments are the arrival of overseas-based companies and the emergence of groups of consultants serving more than one centre. Baviera Eye Clinic opened in January in Hammersmith west London and is one of 23 clinics across Europe Ð 21 in Spain and one in Italy. Grange Eye Consultants is a group of three surgeons operating at Nuffield Hospitals in Chandlers Ford and Taunton, with consulting rooms at BUPA Southampton.
A majority of clinics responding to the survey provide surgery only on a private basis although eight, mostly in NHS hospitals, also offer treatment on the NHS. All Clear Belfast and the Midland Eye Institute in Solihull are among the few private clinics carrying out both NHS and private procedures.

TREATMENTS
All but one of the clinics (St Thomas' Hospital, London) that responded to the survey carry out Lasik, which remains the treatment most commonly offered (Figure 4). The noticeable trend towards Lasek at the expense of PRK continues this year; 81 per cent now perform Lasek, compared with 69 per cent in 2002 and only 38 per cent the previous year.
Other surgical techniques are also becoming more widely available, particularly phakic IOLs and clear lens extraction. Some hospital-based clinics, such as Centre for Sight in East Grinstead, offer a wide range of treatments including accommodative IOLs and corneal inlays.
Among the larger groups, Lasik and Lasek are the most commonly available treatments (Table 1). None of these groups now offers PRK and Boots continues to offer only Lasik. Optimax has introduced phakic IOLs to its range of treatments and Ultralase offers conductive keratoplasty under its 'Ultra RF' brand.
The most common types of laser and microtome used by respondents were still Bausch & Lomb's Technolas 217 and Hansatome. The Technolas is more prevalent among the major groups, which often use more than one type of laser across their clinics, although Boots used only LadarVision models.
Last year's survey showed that the level of charges for treatments had remained fairly constant since 2001 but, this year, prices for the less common techniques have gone up. Average charges increased from £1,049 to £1,090 per eye for Lasik, from £859 to £947 for Lasek, and from £721 to £851 for PRK. Phakic IOLs and clear lens extraction (CLE) now cost, on average, £1,188 and £1,813 respectively.
There were again wide variations in charges between clinics (Figure 5). The lowest charge for Lasik was £650 per eye, at the Somerset and Wessex Nuffield Hospitals, and the highest was £1,600, at the BUPA clinic in Worcester, the London Vision Clinic and OptimEyes in Brentwood. Prices for Lasik at the high-street groups are the same as last year, ranging from £750 at the 11 Optimax clinics to £1,250 at Boots Opticians. One exception is Ultralase, where the cost of Lasik has increased from £999 to £1,250.
Almost all clinics now include aftercare in the cost of treatment but policies on charging for retreatment vary. About half of the clinics responding say they never charge for retreating their patients, and where charges are made these usually apply only after a given time limit, ranging from 1-2 years postoperatively. Other clinics always charge for retreatment and one (MDA Clinic, Cardiff) charges patients retreated whose vision is 6/12 or better after the initial treatment. Charges for retreatment range from £200 to £500 per eye.
A key finding of this year's study is that all of the major groups have run some form of special promotion or offer, ranging from two-years' interest-free credit, buy now pay later, two-for-one (bring a friend) and discounts of up to £400 on the cost of treatment. Only three of the single clinics responding had run promotional offers; two offered a reduced or refunded consultation fee and another offered discounts for doctors and nurses.

NUMBER OF TREATMENTS
Patient throughput remains one of the most sensitive areas investigated in the survey, perhaps understandably given reports of declining demand. Nevertheless, 46 of the 64 clinics responding replied to questions relating to the number of procedures they had carried out.
With the exception of Boots, the major groups provided figures for their total number of procedures to date. Optimax estimates it has performed 70,000 PRK, 40,000 Lasik and 32,000 Lasek procedures. Ultralase, the longest established group, has carried out more than 10,000 PRK, 62,000 Lasik and 650 Lasek treatments, while Optical Express reports 24,000 Lasik and 2,000 Lasek procedures. Among the single clinics and hospital-based centres, Centre for Sight in East Grinstead has carried out 5,000 Lasiks since it was established in 1996.
The number of procedures carried out per week is perhaps the most useful and accurate indicator of current throughput and this year confirms that the market is in decline. The average number of procedures (all treatments) currently carried out by the 49 clinics responding to this question was 23 compared with 37 in 2002.
Since the base for the two years is not the same, and the breakdown of the types of clinic responding this year was slightly different, this figure can only provide an indication of the state of the market. It also reflects the very small number of treatments carried out by some of the single clinics and others that have only recently opened. Nevertheless, the size of this difference is such that it is highly likely to indicate a significant downturn.
Similarly, the number of procedures clinics anticipate carrying out in 2004 compared with 2003 indicates more modest growth in capacity than in previous years. Last year some clinics predicted that in 2003 they would more than double the number of procedures carried out, but this year some are already anticipating no growth or a decline in throughput over the next 12 months. Most expect a further shift away from PRK towards Lasek although Lasik will continue to be the most commonly used technique.
The proportion of treatments that are repeat procedures again varies widely, from 0.1 per cent to 10 per cent, and has seen a further increase year on year. The average this year was 5 per cent, compared with 3.5 per cent in 2002 and 2.4 per cent in 2001.

WAVEFRONT TECHNOLOGY
The most significant development in treatments over the past year has been the wider uptake of wavefront technology (Figure 6). In 2002, fewer than half (44 per cent) of respondents had invested in this technology but almost all (92 per cent) now have it. The most widely used wavefront system is the Bausch & Lomb Zyoptix, followed by the VISX and Nidek systems.
Last year, opinions were divided on the future potential for wavefront technology and whether it should be used routinely. This year, for the first time, our survey asked clinics what proportion of their treatments were wavefront-guided and how these patients were selected. Responses to these questions were surprisingly varied; some clinics were only using wavefront on a trial basis and others in less than 1 per cent of treatments. Patients were either selected on the basis of prescription or if they requested the treatment.
Two clinics Ð London Vision Clinic and the Kirkwood Fyfe optical practice Ð reported that more than half of their treatments were wavefront-guided. Another single clinic declined to respond to the survey on the grounds that it was a specialist centre using customised procedures to treat compromised eyes (through previous surgery or injury) as well as virgin eyes, and that comparisons with other clinics might therefore be misleading.
The wider use of wavefront technology was cited more often than any other factor as the most significant development in laser refractive surgery over the past 12 months, both for the industry as a whole and for individual clinics. Adverse publicity arising from Health Which? and other reports was also seen as significant. New treatments, such as reading implants for presbyopia and accommodative IOLs, were important advances for some clinics, while for others business developments and the volume of patients were more significant.

PATIENTS
All but three of the clinics responding had advertised their services to consumers and just over a half (54 per cent) had also advertised to the optical profession. Personal recommendation remains the most common source of patients, although the proportion referred by this method fell slightly from 49 per cent in 2002 to 44 per cent this year (Figure 7). In contrast, referrals by optometrists and dispensing opticians rose from 8 per cent to 13 per cent in the year to September and the proportion referred via websites also increased slightly. Very few patients are referred by GPs or ophthalmologists.
The lower age limits set by clinics for PRK, Lasik and Lasek vary from 18 to 24 years. The most common minimum age for Lasik is still 21 years, but some of the major groups have changed their policy since last year. Boots has raised its lower age limit for Lasik from 18 to 21 and Ultralase now sets different limits for hyperopes (18 years) and myopes (21 years). Some clinics set an upper age limit of 55 years for Lasik but many have no maximum age for any of their treatments. Despite the wider use of techniques for correcting presbyopia, the average age of patients treated across all clinics and treatments remained the same as in previous years, at 37 years.
The range of refractive errors treated again varies widely between clinics but the maximum amounts of myopia, hyperopia and astigmatism remain the same as last year at -15.00D, +6.00D and 6.00DC respectively. However, there has been a marked change in previous mode of correction among patients presenting for treatment, with more contact lens wearers coming forward for surgery. Three out of four patients undergoing treatment have previously worn contact lenses and one in three were full-time wearers (Figure 8).
Only 81 per cent of clinics now offer bilateral Lasik on the same day compared with 97 per cent in 2002, although a change in policy by the Optimax group may account for this difference. Almost all clinics (97 per cent) offer monovision correction for presbyopes but they are now less likely to trial these patients with monovision contact lenses first (74 per cent; 2002: 89 per cent). All clinics require contact lens wearers to leave their lenses out for at least a week prior to surgery and some require RGP wearers to discontinue wear for six to seven weeks.

STAFF
This year's survey looked in more detail at the qualifications of those currently carrying out laser refractive surgery. The proportion of clinics that say their surgeons are all consultant ophthalmologists Ð who hold or have held a consultant post in the NHS Ð has again fallen, from 44 per cent in 2001 and 40 per cent in 2002 to 35 per cent this year.
Those clinics whose surgeons are not all consultant ophthalmologists are almost all part of a major group, where the proportion of surgeons who are consultants varies from 10 per cent at Optimax to 85 per cent at Ultralase. We also asked these clinics what proportion of their surgeons were listed on the specialist register. All Ultralase surgeons and 94 per cent of Boots surgeons who are not consultants are listed on the register.
As in previous years, a high proportion (87 per cent) of laser clinics responding to the survey, including all the major groups, employ optometrists on their premises. Postoperative follow-up is the most common procedure carried out by employed optometrists (Figure 9) and there is a trend towards more involvement in immediate postoperative care. One in five of these optometrists now carries out procedures on the day of surgery and more than half are able to prescribe tear supplements. Wavefront analysis and punctal plug insertion are other areas where optometrists are now involved.
Nearly one in three laser clinics (31 per cent) pay optometrists to carry out various procedures in their practices, mostly postoperative follow-up. Last year, prior to its acquisition by Optical Express in May, Maxivision listed 39 locations at which pre and postoperative procedures for patients were referred to its laser centres in Manchester and London. Ultralase and All Clear are among those currently operating co-management schemes, where optometrists are paid fees by the laser companies rather than directly by the patient.
Training for optometrists in these procedures is becoming more structured. Most optometrists either employed by clinics or involved in co-management now undertake a combination of lectures, theatre experience and supervised practice. Boots offers its own in-house programme of training and certification.

FUTURE PLANS
Despite predictions that the throughput of patients will remain relatively flat in the coming year, most of the clinics remain optimistic about the future direction of the industry. Optimax expects to open a further two clinics before the end of the year and five more in 2004. All Clear is considering opening its fourth clinic, in Chester.
Others will be expanding the range of treatments they offer to correct a wider range of refractive errors, investing further in wavefront technology or diversifying into new clinical areas. St Paul's Excimer Laser Centre in Liverpool has already developed a keratoconus detection system and Ultralase reports that it will be the first to introduce iris recognition as part of its diagnostic and treatment procedures.

CONCLUSIONS
2003 was a year of consolidation and controversy for the laser refractive surgery market rather than significant growth. The most notable finding from last year's survey was the rapid expansion in the number of clinics operating. This year, growth in the number of outlets has slowed considerably, especially among the major groups. Instead there have been further changes of ownership, the involvement of overseas interests and widespread discounts and promotions.
The average throughput of patients has decreased, although the reasons for this decline are unlikely to be straightforward. Adverse publicity may have contributed to a downturn in demand and the industry may be suffering from over-expansion in previous years. The type of procedures offered and the professional staff involved is also evolving. Whatever the causes of the decline in throughput, many clinics expect increases in capacity in the coming year, although on a more modest scale than in previous years.
From the clinical point of view, the industry has seen some significant developments in the past 12 months, in particular the wider uptake of wavefront technology and increased use of Lasek. A more diverse range of treatments is now available and new procedures continue to emerge.
Our findings suggest that, despite a difficult year, laser refractive surgery is still a developing market in the UK. We would encourage all clinics to participate in next year's survey in order to provide accurate information on the state of the market and monitor future trends.

Acknowledgements
Thanks to NSM Research and Reed Research for data input and analysis, and to Catharine Chisholm, Shehzad Naroo and Sunil Shah of the BSRS and optician clinical editor Bill Harvey for their input to the questionnaire. Thanks also to all the clinics that responded to this year's survey Ð contact details are listed in the directory on page 27.

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.The past 12 months cannot have been an easy time for the UK's laser refractive surgery clinics. With damning media reports, charges of serious professional misconduct and the spiralling cost of medical insurance, 2003 must surely have been the industry's annus horribilis.
The publication in February of the Health Which? report on the safety of laser eye surgery, and the subsequent BBC Watchdog investigation, sparked adverse publicity and saw the major groups defending their practices. The newly formed Eye Laser Association, representing six laser eye surgery providers, was forced to defend the industry against the charge of 'gambling with [patients'] eyesight'.
That same week a laser surgeon was cleared by the General Medical Council following an accusation that he had failed to follow appropriate procedures or to explain the associated risks. Meanwhile, the cost of professional indemnity insurance for surgeons undertaking laser eye surgery rose to as much as three times that of their colleagues.
May brought news that, following the acquisition of the Eye Clinic group in October 2002, Optical Express had purchased the ailing Maxivision business. Maxivision was reported to have nearly 500 optical practices referring patients on a fee basis and had planned to open four new laser centres this year.
Most recently, Harley Street clinic Advance Visioncare Ð launched in January this year Ð was acquired by its principal surgeon after 'a dramatic decline' in the market. 'Unfortunately we opened our doors at the beginning of the biggest decline in patient volumes in the industry's history,' said the clinic's medical director.
Against this background, laser refractive surgery is increasingly recognised as an alternative to spectacles and contact lenses, and new treatments receive regular media coverage. Optometrists continue to report interest among their patients and need accurate and up-to-date information to answer enquiries and make appropriate referrals. Many practitioners are also involved in the co-management of refractive surgery cases either as employees of clinics or within their practices.
The purpose of this year's optician survey of UK clinics was therefore to provide accurate information on the current state of the market, as well as monitoring trends over the past three years.
For the first time, the survey was conducted jointly with the British Society for Refractive Surgery (BSRS), the organisation that represents the interests of ophthalmologists, optometrists and others involved in refractive surgery. The survey was also extended to cover clinics in Eire, which are reported separately on page 15.
THE SURVEY
As in previous years,1,2 a database of clinics was compiled using various sources, including equipment suppliers, professional organisations and websites such as www.lasik-eyes.co.uk. Each clinic was contacted to check they were currently offering treatments. The survey was then sent out by post and email in September and was posted on the BSRS website.
Questions were added to this year's survey to reflect perceived changes in the market and to determine the most significant developments for the industry and for individual clinics and groups over the past year.

THE CLINICS
This year, 92 clinics were identified in the UK, compared with 80 in 2002 and 47 in 2001 (Figure 1). The number of clinics in the UK has therefore increased by an estimated 15 per cent in the 12 months to September 2003, compared with an increase of 70 per cent the previous year.
A total of 64 completed surveys were received by the cut-off date, representing a response rate of 70 per cent (2002: 78 per cent; 2001: 68 per cent). A number of clinics were again reluctant to respond due to commercial sensitivities and others omitted to answer some of the questions for the same reason.
In previous years, our survey respondents have been broadly representative of all clinics in the UK in terms of single clinics/groups and types of premises. This year, our sample tended to be biased towards private clinics and those that are part of a group. Response rates among single clinics and private hospitals were lower.
The geographical spread of clinics identified is similar to last year, with new sites opening in major centres such as London and Belfast, but also in towns such as Rotherham, Bolton and Hillsborough, Co Down.
Growth in the proportion of clinics that are part of a group has slowed down (Figure 2). We estimate that 63 per cent of all clinics are now part of a group rather than a single clinic compared with 67 per cent in 2002, although this was an increase of 18 per cent on the previous year. The largest group, Ultralase, opened eight clinics in the year to September 2002 to take its total from six to 14, but this year opened no new sites.
Optimax added two clinics, in Southampton and Ipswich, to bring its total to 11, and Optical Express, having acquired The Eye Clinic and Maxivision and opened an additional clinic in Bristol, had 10 clinics by September. Last year Boots doubled its number of clinics from four to eight, but this year opened only one new site, again in Bristol. Glasgow-based Advanced Laser Eye Clinics added a fourth outlet and its first outside Scotland, in Belfast.
There were more changes this year among the single clinics. Euromedicare in Newcastle-upon-Tyne is the most recently opened and carried out its first procedures in April. This clinic, previously located in the BUPA Hospital Washington, was one of several that either moved premises or changed names or ownership this year. The Eye Academy became Capio Eye London and Sunrise Laser Vision Correction is now the London Vision Centre.
The distribution of types of premises occupied is similar to last year (Figure 3). More than half of all centres (59 per cent) are private clinics, similar to the proportion in 2002 (56 per cent) and higher than the previous year (49 per cent). The proportions sited in private hospitals (16 per cent), optical practices (15 per cent) and NHS hospitals (10 per cent) remained stable.
Two interesting developments are the arrival of overseas-based companies and the emergence of groups of consultants serving more than one centre. Baviera Eye Clinic opened in January in Hammersmith west London and is one of 23 clinics across Europe Ð 21 in Spain and one in Italy. Grange Eye Consultants is a group of three surgeons operating at Nuffield Hospitals in Chandlers Ford and Taunton, with consulting rooms at BUPA Southampton.
A majority of clinics responding to the survey provide surgery only on a private basis although eight, mostly in NHS hospitals, also offer treatment on the NHS. All Clear Belfast and the Midland Eye Institute in Solihull are among the few private clinics carrying out both NHS and private procedures.

TREATMENTS
All but one of the clinics (St Thomas' Hospital, London) that responded to the survey carry out Lasik, which remains the treatment most commonly offered (Figure 4). The noticeable trend towards Lasek at the expense of PRK continues this year; 81 per cent now perform Lasek, compared with 69 per cent in 2002 and only 38 per cent the previous year.
Other surgical techniques are also becoming more widely available, particularly phakic IOLs and clear lens extraction. Some hospital-based clinics, such as Centre for Sight in East Grinstead, offer a wide range of treatments including accommodative IOLs and corneal inlays.
Among the larger groups, Lasik and Lasek are the most commonly available treatments (Table 1). None of these groups now offers PRK and Boots continues to offer only Lasik. Optimax has introduced phakic IOLs to its range of treatments and Ultralase offers conductive keratoplasty under its 'Ultra RF' brand.
The most common types of laser and microtome used by respondents were still Bausch & Lomb's Technolas 217 and Hansatome. The Technolas is more prevalent among the major groups, which often use more than one type of laser across their clinics, although Boots used only LadarVision models.
Last year's survey showed that the level of charges for treatments had remained fairly constant since 2001 but, this year, prices for the less common techniques have gone up. Average charges increased from £1,049 to £1,090 per eye for Lasik, from £859 to £947 for Lasek, and from £721 to £851 for PRK. Phakic IOLs and clear lens extraction (CLE) now cost, on average, £1,188 and £1,813 respectively.
There were again wide variations in charges between clinics (Figure 5). The lowest charge for Lasik was £650 per eye, at the Somerset and Wessex Nuffield Hospitals, and the highest was £1,600, at the BUPA clinic in Worcester, the London Vision Clinic and OptimEyes in Brentwood. Prices for Lasik at the high-street groups are the same as last year, ranging from £750 at the 11 Optimax clinics to £1,250 at Boots Opticians. One exception is Ultralase, where the cost of Lasik has increased from £999 to £1,250.
Almost all clinics now include aftercare in the cost of treatment but policies on charging for retreatment vary. About half of the clinics responding say they never charge for retreating their patients, and where charges are made these usually apply only after a given time limit, ranging from 1-2 years postoperatively. Other clinics always charge for retreatment and one (MDA Clinic, Cardiff) charges patients retreated whose vision is 6/12 or better after the initial treatment. Charges for retreatment range from £200 to £500 per eye.
A key finding of this year's study is that all of the major groups have run some form of special promotion or offer, ranging from two-years' interest-free credit, buy now pay later, two-for-one (bring a friend) and discounts of up to £400 on the cost of treatment. Only three of the single clinics responding had run promotional offers; two offered a reduced or refunded consultation fee and another offered discounts for doctors and nurses.

NUMBER OF TREATMENTS
Patient throughput remains one of the most sensitive areas investigated in the survey, perhaps understandably given reports of declining demand. Nevertheless, 46 of the 64 clinics responding replied to questions relating to the number of procedures they had carried out.
With the exception of Boots, the major groups provided figures for their total number of procedures to date. Optimax estimates it has performed 70,000 PRK, 40,000 Lasik and 32,000 Lasek procedures. Ultralase, the longest established group, has carried out more than 10,000 PRK, 62,000 Lasik and 650 Lasek treatments, while Optical Express reports 24,000 Lasik and 2,000 Lasek procedures. Among the single clinics and hospital-based centres, Centre for Sight in East Grinstead has carried out 5,000 Lasiks since it was established in 1996.
The number of procedures carried out per week is perhaps the most useful and accurate indicator of current throughput and this year confirms that the market is in decline. The average number of procedures (all treatments) currently carried out by the 49 clinics responding to this question was 23 compared with 37 in 2002.
Since the base for the two years is not the same, and the breakdown of the types of clinic responding this year was slightly different, this figure can only provide an indication of the state of the market. It also reflects the very small number of treatments carried out by some of the single clinics and others that have only recently opened. Nevertheless, the size of this difference is such that it is highly likely to indicate a significant downturn.
Similarly, the number of procedures clinics anticipate carrying out in 2004 compared with 2003 indicates more modest growth in capacity than in previous years. Last year some clinics predicted that in 2003 they would more than double the number of procedures carried out, but this year some are already anticipating no growth or a decline in throughput over the next 12 months. Most expect a further shift away from PRK towards Lasek although Lasik will continue to be the most commonly used technique.
The proportion of treatments that are repeat procedures again varies widely, from 0.1 per cent to 10 per cent, and has seen a further increase year on year. The average this year was 5 per cent, compared with 3.5 per cent in 2002 and 2.4 per cent in 2001.

WAVEFRONT TECHNOLOGY
The most significant development in treatments over the past year has been the wider uptake of wavefront technology (Figure 6). In 2002, fewer than half (44 per cent) of respondents had invested in this technology but almost all (92 per cent) now have it. The most widely used wavefront system is the Bausch & Lomb Zyoptix, followed by the VISX and Nidek systems.
Last year, opinions were divided on the future potential for wavefront technology and whether it should be used routinely. This year, for the first time, our survey asked clinics what proportion of their treatments were wavefront-guided and how these patients were selected. Responses to these questions were surprisingly varied; some clinics were only using wavefront on a trial basis and others in less than 1 per cent of treatments. Patients were either selected on the basis of prescription or if they requested the treatment.
Two clinics Ð London Vision Clinic and the Kirkwood Fyfe optical practice Ð reported that more than half of their treatments were wavefront-guided. Another single clinic declined to respond to the survey on the grounds that it was a specialist centre using customised procedures to treat compromised eyes (through previous surgery or injury) as well as virgin eyes, and that comparisons with other clinics might therefore be misleading.
The wider use of wavefront technology was cited more often than any other factor as the most significant development in laser refractive surgery over the past 12 months, both for the industry as a whole and for individual clinics. Adverse publicity arising from Health Which? and other reports was also seen as significant. New treatments, such as reading implants for presbyopia and accommodative IOLs, were important advances for some clinics, while for others business developments and the volume of patients were more significant.

PATIENTS
All but three of the clinics responding had advertised their services to consumers and just over a half (54 per cent) had also advertised to the optical profession. Personal recommendation remains the most common source of patients, although the proportion referred by this method fell slightly from 49 per cent in 2002 to 44 per cent this year (Figure 7). In contrast, referrals by optometrists and dispensing opticians rose from 8 per cent to 13 per cent in the year to September and the proportion referred via websites also increased slightly. Very few patients are referred by GPs or ophthalmologists.
The lower age limits set by clinics for PRK, Lasik and Lasek vary from 18 to 24 years. The most common minimum age for Lasik is still 21 years, but some of the major groups have changed their policy since last year. Boots has raised its lower age limit for Lasik from 18 to 21 and Ultralase now sets different limits for hyperopes (18 years) and myopes (21 years). Some clinics set an upper age limit of 55 years for Lasik but many have no maximum age for any of their treatments. Despite the wider use of techniques for correcting presbyopia, the average age of patients treated across all clinics and treatments remained the same as in previous years, at 37 years.
The range of refractive errors treated again varies widely between clinics but the maximum amounts of myopia, hyperopia and astigmatism remain the same as last year at -15.00D, +6.00D and 6.00DC respectively. However, there has been a marked change in previous mode of correction among patients presenting for treatment, with more contact lens wearers coming forward for surgery. Three out of four patients undergoing treatment have previously worn contact lenses and one in three were full-time wearers (Figure 8).
Only 81 per cent of clinics now offer bilateral Lasik on the same day compared with 97 per cent in 2002, although a change in policy by the Optimax group may account for this difference. Almost all clinics (97 per cent) offer monovision correction for presbyopes but they are now less likely to trial these patients with monovision contact lenses first (74 per cent; 2002: 89 per cent). All clinics require contact lens wearers to leave their lenses out for at least a week prior to surgery and some require RGP wearers to discontinue wear for six to seven weeks.

STAFF
This year's survey looked in more detail at the qualifications of those currently carrying out laser refractive surgery. The proportion of clinics that say their surgeons are all consultant ophthalmologists Ð who hold or have held a consultant post in the NHS Ð has again fallen, from 44 per cent in 2001 and 40 per cent in 2002 to 35 per cent this year.
Those clinics whose surgeons are not all consultant ophthalmologists are almost all part of a major group, where the proportion of surgeons who are consultants varies from 10 per cent at Optimax to 85 per cent at Ultralase. We also asked these clinics what proportion of their surgeons were listed on the specialist register. All Ultralase surgeons and 94 per cent of Boots surgeons who are not consultants are listed on the register.
As in previous years, a high proportion (87 per cent) of laser clinics responding to the survey, including all the major groups, employ optometrists on their premises. Postoperative follow-up is the most common procedure carried out by employed optometrists (Figure 9) and there is a trend towards more involvement in immediate postoperative care. One in five of these optometrists now carries out procedures on the day of surgery and more than half are able to prescribe tear supplements. Wavefront analysis and punctal plug insertion are other areas where optometrists are now involved.
Nearly one in three laser clinics (31 per cent) pay optometrists to carry out various procedures in their practices, mostly postoperative follow-up. Last year, prior to its acquisition by Optical Express in May, Maxivision listed 39 locations at which pre and postoperative procedures for patients were referred to its laser centres in Manchester and London. Ultralase and All Clear are among those currently operating co-management schemes, where optometrists are paid fees by the laser companies rather than directly by the patient.
Training for optometrists in these procedures is becoming more structured. Most optometrists either employed by clinics or involved in co-management now undertake a combination of lectures, theatre experience and supervised practice. Boots offers its own in-house programme of training and certification.

FUTURE PLANS
Despite predictions that the throughput of patients will remain relatively flat in the coming year, most of the clinics remain optimistic about the future direction of the industry. Optimax expects to open a further two clinics before the end of the year and five more in 2004. All Clear is considering opening its fourth clinic, in Chester.
Others will be expanding the range of treatments they offer to correct a wider range of refractive errors, investing further in wavefront technology or diversifying into new clinical areas. St Paul's Excimer Laser Centre in Liverpool has already developed a keratoconus detection system and Ultralase reports that it will be the first to introduce iris recognition as part of its diagnostic and treatment procedures.

CONCLUSIONS
2003 was a year of consolidation and controversy for the laser refractive surgery market rather than significant growth. The most notable finding from last year's survey was the rapid expansion in the number of clinics operating. This year, growth in the number of outlets has slowed considerably, especiall