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Up Front | Apr 2008

Update Your Ophthalmic Business Model

One surgeon shares his path of practicing the many niches of ophthalmology and his reasons for ultimately specializing solely in laser vision correction.

If I try to justify my position for only performing refractive laser vision correction 100 of the time, many ophthalmologists and optometrists will think I am a little unusual. Many ophthalmology practices promote the concept of the "comprehensive ophthalmologist" or the "comprehensive refractive surgeon." I decided some time ago, however, to abandon what I consider the inferior ophthalmic surgeries and treatments and to only perform LASIK. The practice of ophthalmology and industry have experienced a 20% decline, but some refractive laser vision correction surgeons including myself have been insulated from this drop, which I consider a testament to our success.

This article presents the nuts and bolts of specializing in one area of ophthalmology and shares my advice on how you can make it work for you and your practice.

Corneal Surgery
I became an ophthalmologist in 1994, because I wanted to focus on the eye. I initially specialized in corneal surgery and did my fellowship with Edward Holland, MD, in Cincinnati, who specialized in high-risk corneal transplant surgery. I performed penetrating keratoplasties for the next 5 years within the Canadian medical system where surgeons had to beg for OR time due to the limited resources of the socialized healthcare system. Although I loved the procedure, my patients were less happy with their compromised uncorrected postoperative vision. These challenges led me to abandon the penetrating keratoplasties.

I then focused my attention on cataract surgery in 1998. I thought it was an interesting and successful procedure that took a lot of talent to do well. With time, I improved my technique and was removing cataracts in less than 8 minutes. I later discovered, however, that I was reaching the threshold of the subspecialty surgical levels in Canada so that I was limited in the number of cataract surgeries I could perform within the socialized medical system. I felt that my surgical volume and hence my business successes were restricted and that I would not be able to achieve the same level of success with cataract surgery as I would if I pursued laser vision correction alone. I therefore reluctantly gave up performing cataract surgery in 2000.

I implanted phakic IOLs and the Visian Implantable Collamer Lens (ICL; STAAR Surgical Company, Monrovia, CA) for approximately 5 years. This was a very effective procedure for the treatment of extreme myopia, and some of those patients remain my most dramatic refractive surgery success stories. Nevertheless, I found myself worried extensively about whether or not these patients would have angle closure or if the ICL were properly placed. Even though these patients had extreme refractive errors (I would only perform ICL surgery on non-LASIK candidates), they were still just as averse to complications as LASIK patients. ICL patients accounted for 90 of my stress and very little of my surgical volume or income. In 2003 therefore I decided that I would no longer perform this procedure.

Finally, I abandoned refractive lens exchange in 2003 due to my concerns over potential capsular rupture in myopes and crowded anterior segments in hyperopes. Although I was able to perform some dramatic corrections for extreme refractive errors using bioptics techniques, in the end, I could not justify the potential complications of an entirely elective procedure.

This year, I decided to stop performing conventional laser treatments. Unless I have to execute PRK, I exclusively perform iLASIK with the IntraLase FS laser and the Visx CustomVue S4 excimer laser (both from Advanced Medical Optics, Inc., Santa Ana, CA). I feel that I made the right decision, because my facility adopted a tiered pricing model whereby patients can request treatment with a conventional microkeratome for approximately $1,000 or less. When I focus on iLASIK, I maximize my success and enjoyment versus enduring the pressure and stress of performing 500 to 600 conventional procedures per month and waiting for my next buttonhole flap to occur. If a patient decides that he would prefer to have the less advanced and less expensive procedure, he is referred to another surgeon for surgery. My stress level is one tenth of what it was when I performed refractive surgery with a mechanical microkeratome. iLASIK is 100 times safer in my estimation, because the complication rate is approximately one tenth of that with a microkeratome and the severity of the complications are 10 less than those with a microkeratome as well. My staff and the atmosphere in the OR are relaxed. I find that iLASIK allows me to perform safe, quality surgery with a consistently successful outcome. Moreover, I can perform about eight iLASIK procedures per hour.

TLC The Laser Eye Centers' business model was originally and entirely based on the comanagement of patients with optometrists. There is a threshold to the number of patients that can be referred by optometrists however. As a result, TLC recently added a more direct consumer-marketing system to communicate to the public the unique qualities of our practice. this new approach increased the community's awareness of our centers and stimulated new referrals from optometrists. Successfully delivering our marketing message and reasonable pricing are what appeal to potential LASIK candidates.

An ophthalmology resident once asked if I felt guilty that I had restricted my practice to only refractive corneal surgery. Although I do particularly miss the older cataract patients and the surgery, I have never regretted my subspecialization. I derive pleasure performing perfect procedures and creating happy patients. I do not miss the stress of managing serious complications or unhappy patients. iLASIK has allowed me perform LASIK with outstanding results and safety so why do anything else?

Louis E. Probst, MD, is Medical Director of TLC The Laser Eye Centers. He is a consultant to Advanced Medical Optics, Inc., and TLCVision. Dr. Probst may be reached at (708) 562-2020.

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Apr 2008