Refractive cataract surgery will continue to grow and benefit society – Tips & Results

December 20, 2021

3 min read


Disclosure: Lindstrom states that it has relevant financial information for AcuFocus, Alcon, Bausch + Lomb, ForSight Vision6, Gondola, Harrow Health/Imprimis, Johnson & Johnson Vision, Lensar, Minnesota Eye Consultants/Unifeye Vision Partners, Novartis, Ocular Therapeutix, RxSight and Zeiss .

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At this year’s American Academy of Ophthalmology convention, I was asked by the International Society of Refractive Surgery to present a keynote address on cataract refractive surgery.

I asked my friend and colleague David Harmon at Market Scope to help me with some recent data. In the following paragraphs I will share some highlights from this talk.

Richard L Lindstrom

Richard L Lindstrom

My personal definition of refractive cataract surgery (RCS) is an “improvement on standard cataract surgery aimed at better vision compared to standard cataract surgery”. In my opinion it does not imply a general focus on distance, intermediate or near vision, or monovision/blend vision using standard biometrics and a monofocal IOL. It includes correction of preoperative astigmatism, targeting the patient’s desired uncorrected vision at multiple distance ranges, and reduction of visually significant higher-order aberrations to treat corneal irregularities.

The products and services that support RCS increase the cost and time required to provide that service and warrant an additional fee billed directly to the patient. These additional products and services include but are not limited to toric IOLs, presbyopia correcting IOLs, adjustable IOLs, small bore diameter IOLs, limbal/corneal relaxation incisions, corneal topography/tomography, OCT, femtosecond laser when used to improve refractive outcomes be used, aberrometers, precision capsulotomy devices and procedures, and the use of refractive laser surgery or refractive incision surgery to adjust postoperative refractive outcomes. If it is refractive surgery, it is generally not part of the standard cataract surgery procedure and belongs to the RCS category.

Refractive cataract surgery is a win for patients and their families, society, surgeons, institutions and industry. Patients enjoy improved vision with an increased quality of life and may suffer fewer falls due to better vision, stereopsis, depth perception and reduced dependency on glasses, allowing them to remain independent and productive for longer. Society gains a better functioning, more independent older population. Surgeons are developing enhanced surgical skills that also benefit patients who choose standard cataract surgery, and ophthalmology practices benefit from another source of revenue in an increasingly difficult international environment. Industry benefits from product sales that support continued investment in incremental and disruptive innovation. This industry investment in human and financial capital has trickling benefits for surgeons, patients and society. RCS is a winner on every level.

According to Market Scope, the average incremental out-of-pocket expense for a patient for RCS is $2,444 per eye. A manual limbal or corneal relaxant incision costs an average of $700 (if performed with a femtosecond laser, the fee increases to $1,250); a post-operative LASIK, PRK or SMILE enhancement costs an average of $1,400; a toric IOL, $1,450; a presbyopia-correcting IOL, $2,400; a phakic IOL, $3,800; and an easily adjustable IOL or refractive lens replacement, about $4,600. The just over 5 million RCS procedures, which are expected to take place worldwide in 2021, will generate an estimated $2.2 billion in incremental revenue for the industry and a staggering $12.1 billion in additional fees for providers to generate. Cataract refractive surgery and corneal refractive surgery are important revenue streams for experienced anterior segment surgeons and care extenders in advanced countries.

Two concerns: Not all patients who might benefit can afford the additional cost of RCS, and not all surgeons have the full training, skills, and confidence to support a cash service. This limits RCS acceptance.

In 2010, approximately 10% of patients undergoing cataract surgery in the US received RCS, and in 2021, Market Scope projects RCS market share to be 16.2%. RCS market share is expected to continue growing at 0.5% to 1% per year as technology advances and more surgeons become involved. Several think tanks and key opinion leader summits I’ve attended in the US suggest that 33%, one-third of all cataract surgeries per year, is a reasonable target for top RCS market share in the US. At the current growth rate, we will reach that number by 2040.

The field of refractive cataract surgery is strong and growing. The revenue generated supports investments and innovations in diagnostics, devices and medicines as well as increasingly advanced and effective training of surgeons. This is positive for eye care and the industry that supports us, but the biggest beneficiaries are the patients and society.

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