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Cover Focus: Corneal Refractive Surgery | Jul 2015

The Emphasis Has Shifted

Why we are de-emphasizing LASIK in our practice.

When I was approached to share this point of view on LASIK for our practice, I had some difficulty starting. As part of a large, multispecialty eye care company, we never want to “de-emphasize” anything. In fact, one part of our practice’s mission statement is to offer “comprehensive eye services for all eye conditions.” As I thought about it, however, it was not a conscious effort on our part to de-emphasize LASIK; it was simply the reality of what was currently happening. As the economy struggled and younger people had trouble finding good-paying jobs, they had less disposable income for out-of-pocket treatments like LASIK.

Conversely, as the older generation started working longer, they had greater requirements for their vision and the disposable income to do something about it: mainly refractive cataract surgery. It was these economic and demographic conditions in our area that forced our practice’s shift in emphasis away from LASIK and toward refractive cataract surgery.

When deciding to switch your practice’s emphasis away from refractive surgery and toward refractive cataract surgery, you must ask yourself, can I make the switch? How do I make the switch? Is it financially feasible?


Although the economy may have driven our emphasis towards refractive cataract surgery, it was the recent advances in cataract surgical technology that allowed us to do it. The modern cataract surgeon has tools at his or her disposal like never before to meet the demands of refractive cataract patients. A wide array of lenses gives excellent options for meeting desired postoperative goals. Technology like femtosecond laser cataract surgery and intraoperative aberrometry allows us to hit our refractive targets a greater percentage of the time.

Prior to these advances, we were only hitting our refractive targets within 0.50 D 70% of the time.1 That meant, 30% of the time, we were not delivering the quality of vision that patients paying out of pocket demand. Now, with the proper technology to guide us, including ORA (Alcon WaveTec), we can hit those targets 90% of the time (data on file with Alcon), a number much closer to what we experienced with LASIK.

With these tools, refractive cataract surgery is being performed every day.


One thing to remember when shifting the emphasis from LASIK to refractive cataract surgery is that the patient’s demands are different. In cataract patients, we deal with a wider range of visual problems, including presbyopia. LASIK is performed on younger patients who all have the same goals. With refractive cataract surgery, goals are much more individual. It is imperative that we preoperatively determine a patient’s objectives before moving forward. We have a lot of options, but we have to use the right tool for the right job.


There are numerous new lens technologies at your disposal. Which lens is right for your patient? Talk to him or her. Find out what activities are important to the patient to be able to perform postoperatively uncorrected. What are their hobbies? Answers to these questions will guide your choices.

If the patient desires sharp distance vision only, then make sure you have accounted for astigmatism. That means taking proper measurements preoperatively such as with topography and new-generation optical biometry. Once you have accurately determined the amount of astigmatism, choose the proper tool to address it surgically. If you have a femtosecond laser, you may feel comfortable treating up to 1.50 D of astigmatism with a laser arcuate incision. For anything higher, use a toric IOL.

If cataract patients are interested in a full range of vision, preoperative optical coherence tomography can rule out subtle macular changes that would contraindicate a multifocal implant. When patients choose multifocal IOLs, remember the importance of the tear film for quality vision. If even mild dryness is present before surgery, treat it. Among multifocal lenses, there are options. A 2.50 D lens like the AcrySof IQ Restor +2.5 D (Alcon) works well for a heavy computer user, but someone who reads books may do better with a 3.00 D lens.

The key to delivering quality outcomes with refractive cataract surgery is understanding your patients’ visual goals before proceeding with surgery.

At a Glance


• The author’s practice did not consciously decide to de-emphasize LASIK. It was the reality of what was currently happening in the marketplace.
• Recent advances in cataract surgical technology allow practices to emphasize refractive cataract surgery.
• Cataract patients have a wider range of visual problems than LASIK patients, and the goals of refractive cataract surgery are much more individualized.
• The necessary switch of emphasizing refractive cataract surgery over LASIK has been financially rewarding.


As small business owners, you may worry that a shift away from cash-pay refractive surgery like LASIK will hurt your bottom line. Our experience has been the opposite. Most cataract patients are older but still have great demands on their vision. Most are using smartphones or tablets, and many are still working. Patients in this age group understand the value proposition regarding health care choices and are often willing to pay out of pocket to obtain their desired goal. With the explosion of baby boomers reaching cataract age, your practice will have many opportunities to offer elective services.

My practice has found the necessary switch in emphasis from LASIK to refractive cataract surgery a rewarding one for our patients and for us. We have noticed an improvement in our financial bottom line as well.

If you have found your LASIK volume decreasing due to changing economic and demographic factors, I strongly recommend you consider emphasizing refractive cataract surgery. n

1. Behndig A, Montan P, Stenevi U, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register Study. J Cataract Refract Surg. 2012;38(7):1181-1186.

Michael P. Jones, MD
• managing partner of Quantum Vision Centers in St. Louis, Missouri and Southern Illinois
• financial disclosure: consultant to and clinical researcher for Alcon

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