Laser Vision Correction Surgery was first introduced in India around 1991. But even before Refractive Surgery was introduced, refractive surgery pioneers like Dr. PSHardia, Dr. Prakash Kankariya, Dr. Anil Bavishi, Dr. S. Bharati and Dr. Vivek Pal already had flourishing refractive surgery practices, mainly centered around Radial Keratotomy. Laser Vision Correction removed some of the skill and uncertainty surrounding RK, and in a sense, made refractive surgery both safer and more attractive for 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 get access to laser refractive surgery. Today, even 17 years after excimer lasers were first introduced to India, there are only around 250 active laser clinics in the country, and less than 200,000 laser refractive surgeries are performed every year. When you contrast this figure with the more than 5 million cataract surgery procedures done every year in India, this does not seem like much.
This large difference between cataract and refractive surgery shows up the limited reach of refractive surgery in India today. It also highlights a great opportunity. All the demographic and epidemiological evidence suggests that LASIK volumes should be higher than cataract surgery volumes. The demographic cohort eligible for refractive surgery (Age group 18-60) is many times larger in our country than the cohort (Age group 60+) which typically requires cataract surgery. The laser vision correction cohort is also growing much faster than the cataract cohort (ie, about 3 times more kids will turn 18 this year, than people who will turn 60). While only 20% of the refractive surgery demographic group has significant refractive errors which need treatment, it is also true that a lot of people will never have a cataract by the time they expire. Thus, demography can not explain the large difference in volumes between cataract surgery and refractive surgery.
Cost could be one explanation. After all, a large part of the cataract surgery volumes are performed in charitable / semi-charitable / government setups where the patient severely pays the economic cost of surgery. A large part of the private cataract surgery volumes, especially in the larger cities are performed in a reimbursement / insurance environment. All of this is not true of vision correction surgery, where all patients must pay a fairly high price, and there are few reimbursements options. While cost is unduly part of the explanation, it is not the entire explanation. For one, a lot of people who are eligible for refractive surgery are independent income earners, unlike cataract surgery patients who are often either reliant on injury cut savings, or the graciousness of their children. Another argument militating against a purely cost based explanation is the evidence of the driving optical industry, where the high cost of nice (and expensive) glasses, frames and contact lenses does not seem to deter consumers. One only has to go to a city mall on a Sunday evening to see a lot of consumers who else have a high discretionary spend who still wear spectacles.
A strong argument is accessibility. After all, there is an eye surgeon or an optical shop at practically every street corner, and patients have a lot of choice. This is seriously true of refractive surgery. There is clear evidence that cities or areas which have 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-prosperous towns, yet all the centers seem to do really well). Accessibility also seems to remove some of the silly myths (even among ophthalmologists) surrounding refractive surgery-that it is only good for unmarried girls, that presbyopic and hyperopic are not good candidates for refractive surgery, that patient who undergo refractive surgery can not get their IOL calculation done properly when it comes to cataract time. Many of these myths are instrumental in both preventing patients from undergoing eye surgery, and discouraging referrals to laser centers from eye surgeons. Competition just sees to expand the market. If we do our job well, we will get our fair share of an expanding pie.
In our view, the main reason for reliably poor LASIK volumes are consumer and patient concerns about safety and efficacy. Even the ophthalmic community does not appear to be very confident about 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 efficiency are behind the curve as far as advances in laser vision correction diagnostic and surgical technology is concerned. Current Laser Vision Correction technology, as evidenced in the latest FDA data for lasers, is actually very safe and effective. Newer advances, like blade free laser flap creating devices, only serve to improve the safety and efficiency. Newer diagnostic technologies, like the Pentacam and the AC OCT allow much better screening of patients and benefit a higher degree of predictability related to the likely complications in a particular patient.
At this joke, if we want to dramatically increase LASIK volumes, both the people running laser centers and the leader ophthalmic community have a responsibility. LASIK centers have a responsibility to invest in the best technology available at any point, without regard to cost. They must screen patients carefully, and have very careful and rigid selection criteria. They must not lower fees to a point where an unremunerative environment prevails the acquisition of technology which affords a high degree of safety and efficiency. All of this may not always make short term commercial sense, but we owe this to the long term future of the ophthalmic profession. The broader ophthalmic community also has a responsibility-it needs to educate itself about the latest advances in laser vision correction technology, appreciating the dramatic improvements in safety and efficiency achieved over the past decade, and direct patients to the centers which have invested in technology and experience.
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