The World College of Refractive Surgery recognizes eight types of refractive procedures: LASIK, PRK, laser-assisted lenticule extraction, phakic IOLs, lens replacement, refractive cataract surgery, allogenic corneal inlays, and CXL. Lens-based refractive correction in particular is becoming a significant driver of market growth. Last year, Market Scope projected modest growth in refractive surgery overall but more aggressive growth in lens-based procedures, including phakic IOLs.1 Future Market Insights, moreover, has reported that the phakic IOL market is expected to grow at a compound annual rate of 8.1%, reaching $897.4 million by the year 2033 (Table).2
I have long supported lens-based refractive procedures and was an early adopter of Implantable Collamer Lens (ICL; STAAR Surgical) technology. The implantation of earlier ICL models was a two-step process, including a preoperative laser peripheral iridotomy. The introduction of the EVO ICL (STAAR Surgical) has streamlined the procedure by eliminating the need for an iridotomy and reducing the incidence of pupillary block and anterior subcapsular cataract formation, among other risks.3-5 The EVO has expanded patient eligibility and increased my confidence in offering the procedure to individuals with -3.00 to -6.00 D of myopia.
I have also found that performing EVO ICL implantation in an office-based surgery (OBS) setting has maximized my return on investment (ROI). Highlighting the advantages of OBS during patient consultations has proven beneficial. Patients appreciate the increased comfort, relaxed atmosphere, and greater surgical efficiency.
INCREASED ADOPTION
Offering the ICL at ambulatory surgery centers (ASC) and our in-office surgical suite has increased our use of the lens from approximately 5% to 20% of our refractive volume. This growth can be attributed to the benefits of the EVO model and its integration into an OBS setting. OBS has made the ICL experience akin to LASIK by enhancing our control over the surgical process and patient care and improving patient comfort and acceptance.
Specifically, we control every aspect of the process—from surgical scheduling to intra- and postoperative care. This has reduced patient apprehension, fostered an environment conducive to patient comfort, and improved the patient experience (see The Poster Child). Surgery is quicker, and patients like being in the familiar environment of our office instead of an ASC. It helps them feel more relaxed. We have found that patients are more likely to embrace the ICL as an alternative to LASIK when the former procedure is performed in an OBS setting. This has been true irrespective of the price differential between the procedures.
THE POSTER CHILD
In a traditional ambulatory surgery center (ASC), patients undergo the implantation of an ICL (STAAR Surgical) in one eye at a time. In our office-based surgery (OBS) suite, we can perform immediately sequential bilateral surgery. One notable case involved a patient who received an ICL in one eye in an ASC and in the second eye in our OBS suite. He has become our poster child for OBS because his experience highlights how much easier surgery can be in an OBS setting compared to an ASC.
During surgery on the first eye in an ASC, the patient was very nervous despite receiving intravenous sedation. He moved a lot, which made surgery more challenging. Fortunately, his results were excellent. Given his previous state of mind, I was unsure how the patient would fare in our OBS suite. To my surprise, even with only oral sedation, he was much calmer and more relaxed. The surgical experience—for both of us—was significantly better
When addressing patients’ concerns about the cost of ICL surgery, we emphasize the ease of ICL removal and the familiar setting of an in-office procedure. Using oral sedation instead of intravenous sedation offers a comfortable experience. If patients are particularly nervous, we can give them a little more oral sedation with MKO Melt (ImprimisRx/Harrow Health). Additionally, intra- and postoperative monitoring requirements are reduced with oral sedation strategies, facilitating a faster recovery time and expediting their postoperative discharge time. Patients’ blood pressure is checked before they are released, but we have found that high blood pressure is less of a concern with oral versus intravenous sedation.
We leverage word-of-mouth referrals through platforms such as Vision Like Me (www.visionlikeme.com), which connects potential patients with individuals who have undergone procedures in our practice. The exchange of information enhances confidence and increases conversion rates.
FINANCIAL INCENTIVES
Operations
From an operational perspective, performing ICL surgery in an OBS suite has resulted in significant cost savings. It has eliminated the need for anesthesiologists, reduced personnel costs, and circumvented complex ASC regulations and facility fees, which can range from $1,500 to $2,000 per eye. In our OBS, the cost per eye is less than $500.
Pricing
Our transparent pricing model for EVO ICL procedures in the OBS suite helps maximize our ROI. Offering the surgery at a reduced price compared to ASC fees makes it more attractive to patients.
EXPANDING THE ROLE OF OBS IN REFRACTIVE SURGERY
Some refractive surgery candidates are hesitant to undergo ICL surgery because they are less familiar with it than LASIK. Training and certifying ophthalmologists in refractive surgery at our center has demonstrated to us the ease of mastering ICL procedures and the swift recovery process for patients. Rarely do patients receiving the ICL require an enhancement, making it a reliable option.
Integrating the EVO ICL into our OBS model has maximized our ROI. The implant’s expanded indications to include low myopia has opened new revenue streams. An OBS approach has streamlined our efficiency, reduced our operational costs, improved patient comfort, and ultimately increased procedural volume.
1. Market Scope: Lens-based procedures will push retail refractive surgery market to $12 billion. Eyewire. January 10, 2023. Accessed April 8, 2024. https://eyewire.news/news/market-scope-lens-based-procedures-will-push-retail-refractive-surgery-market-to-12-billion?c4src=article:infinite-scroll
2. Phakic intraocular lenses (IOL) market snapshot (2023 to 2033). Future Market Insights, Inc. July 2023. Accessed April 8, 2024. https://www.futuremarketinsights.com/reports/phakic-intraocular-lenses-iol-market#:~:text=According%20to%20Future%20Market%20Insights,US%24%20344.4%20million%20in%202021
3. Packer M. The Implantable Collamer Lens with a central port: review of the literature. Clin Ophthalmol. 2018;12:2427-2438.
4. Gimbel HV, LeClair BM, Jabo B, Marzouk H. Incidence of implantable Collamer lens-induced cataract. Can J Ophthalmol. 2018;53(5):518-522.
5. Albo C, Nasser T, Szynkarski DT, et al. A comprehensive retrospective analysis of EVO/EVO+ Implantable Collamer Lens: evaluating refractive outcomes in the largest single center study of ICL patients in the United States. Clin Ophthalmol. 2024;18:69-78.
