Global Courant
Laser Vision Correction Surgery was first introduced in India around 1991. But even before Laser Refractive Surgery was introduced, there were already pioneers in the field of refractive surgery like Dr. PSHardia, Dr. Prakash Kankariya, dr. Anil Bavishi, Dr. S. Bharati and Dr. had thriving refractive surgery practices primarily centered around radial keratotomy. Laser vision correction took away some of the skill and uncertainty surrounding RK and, in a sense, made refractive surgery both safer and more appealing to the average ophthalmologist. The introduction of LASIK in 1995 by Dr. Burjor Banaji accelerated this trend. Unfortunately, the initial cost of LASIK equipment forced a situation where only a select group of eye surgeons could access laser refraction surgery. Today, even 17 years after excimer lasers were first introduced in India, there are only about 250 active laser clinics in the country and fewer than 200,000 laser refraction surgeries are performed each year. When you compare this figure to the more than 5 million cataract surgeries performed in India every year, it doesn’t seem like much.
This major difference between cataract and refractive surgery shows the limited scope of refractive surgery in India today. It also points to a great opportunity. All demographic and epidemiological evidence suggests that LASIK volumes should exceed cataract surgery volumes. The demographic cohort eligible for refractive surgery (Age group 18-60) in our country is many times larger than the cohort (Age group 60+) that usually requires cataract surgery. The laser vision correction cohort is also growing much faster than the cataract cohort (that is, about 3 times more children will turn 18 this year than people who will turn 60). While only 20% of the refractive surgery demographic has significant refractive errors that require treatment, it is also true that many people will never have cataracts by the time they expire. So demographics cannot explain the large difference in volumes between cataract surgery and refractive surgery.
The cost may be an explanation. After all, a large proportion of cataract operations are performed in charitable/semi-charitable/government institutions where the patient hardly pays the economic costs of the operation. A large proportion of private cataract surgeries, especially in the larger cities, are performed in a reimbursement/insurance environment. None of this applies to vision correction surgery, where all patients have to pay a rather high price and there are few options for reimbursement. While cost is undoubtedly part of the explanation, it is not the full explanation. First, many people who qualify for refractive surgery are independent income earners, unlike cataract surgery patients who often rely on inflation-reduced savings or the kindness of their children. Another argument against a purely cost-based explanation is the evidence of the booming optical industry, where the high cost of fancy (and expensive) eyeglasses, frames, and contact lenses doesn’t seem to deter consumers. You only have to go to a shopping center in the city on a Sunday evening to see many consumers who otherwise have high discretionary spending and still wear glasses.
A strong argument is accessibility. After all, there is an eye surgeon or optician on almost every street corner and the patient has plenty of choice. This is hardly the case with refractive surgery. There is clear evidence that cities or areas with a high density of LASIK centers have a high rate of refractive surgery (Ambala has 3 laser centers, Rajkot has 5, and while both are relatively small and not so affluent cities, they are all the centers seem to be doing very well). Accessibility also seems to remove some of the silly myths (even among ophthalmologists) surrounding refractive surgery – that it’s only good for unmarried girls, that presbyopia and hyperopia aren’t good candidates for refractive surgery, that patients undergoing refractive surgery can’t get their IOL calculation performed correctly when it comes to tail time. Many of these myths play an important role in preventing patients from undergoing eye surgery, and discouraging referrals to laser centers by eye surgeons. Competition only seems to expand the market. If we do our job well, we get our share of a growing pie.
In our view, the main reason for the relatively poor LASIK volumes is consumer and patient concerns about safety and efficacy. Even the ophthalmic community seems to have little confidence in the safety and efficacy of laser vision correction, if the number of eye surgeons who continue to suffer from refractive errors is any indication. It is equally true that consumer concerns about safety and efficacy lag behind advances in diagnostic and surgical technology for laser vision correction. Current Laser Vision Correction technology, as evidenced by the latest FDA data for lasers, is actually very safe and effective. Newer developments, such as devices for creating knifeless laser flaps, only serve to improve safety and efficacy. Newer diagnostic technologies, such as the Pentacam and the AC OCT, allow much better screening of patients and offer a higher degree of predictability as to the likely complications in any given patient.
At this point, if we want to dramatically increase LASIK volumes, both the people who run laser centers and the wider ophthalmology community have a responsibility. LASIK centers have a responsibility to invest in the best technology available at any time, regardless of cost. They must carefully screen patients and apply very careful and strict selection criteria. They should not reduce fees to such an extent that an unprofitable environment prevents the acquisition of technology that offers high levels of safety and effectiveness. All of this may not always make commercial sense in the short term, but we owe it to the long-term future of the ophthalmology profession. The wider ophthalmology community also has a responsibility: to educate themselves on the latest advances in laser vision correction technology, to appreciate the dramatic improvements in safety and efficacy achieved over the past decade, and to refer patients to the centers that have invested in technology and experience.
Driving LASIK volumes in India
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