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Baby Boomers galore There are about 78 million Baby Boomers between the ages of 47 and 67—not many of whom want or adapt to monovision. These patients want the vision of their youth, and they've been lucky enough to main- tain good paying jobs and manage- able debt. Corneal inlays are working their way through the U.S. regulatory process, and we'll likely have our first inlay available on a commercial basis in 2015. That will enable us to remarket back to the Baby Boomers who previously underwent LASIK and to new Boomer patients with a means to correct their presbyopia and the remainder of their refractive errors as well with LASIK. How the market will recover Echo Boomers are about a decade away from wanting vision correction outside of contact lenses or specta- cles in high numbers. They're not yet presbyopic, but they are highly active and don't want the inconven- ience of contact lenses or spectacles. Unfortunately, unemployment in the Echo Boomer group is high and most have graduated college with a heavy debt load. They need to get established in their careers, pay off some debt and have some disposable income before they consider laser vision correction in high numbers. Right now, it's anybody's guess how long that may take. I think we'll start to see the Echo Boomers come into the market in their later 20s and early 30s instead of the late 30s we experienced with the Baby Boomers. Again, I think an uptick in Echo Boomer LASIK volume is prob- ably two to three years away, but I do think they'll start opting for LASIK in increasing numbers in the back half of this decade, 2015-2020. Collagen corneal crosslinking will be another advancement that is going to help the laser vision correc- tion market recover. Most of us turn away close to 15% of our potential LASIK patients because of abnormal- ities of the cornea, usually a thin pachymetry or an atypical topogra- phy. Patients with thin corneas or atypical topography will be able to be treated once crosslinking is avail- able in the U.S., and with several companies pursuing U.S. approval, I believe we'll have this in our arma- mentarium by 2015 as well. Refractive cataract surgeons are increasing their premium lens busi- ness, but it will continue to grow slowly. LASIK will continue to grow slowly in this market as well, as patients need enhancements. I don't expect this to become a large part of our revenue, but growth in the pre- mium IOL sector will grow corneal refractive surgery as well. My personal business plan I don't see a lot of short-term prom- ise in the LASIK market, but I do anticipate we'll start seeing more growth return around 2015. My belief is that growth will continue over a long period of time as more and more Baby Boomers take advan- tage of the presbyopic treatments we'll have available that are per- formed in conjunction with LASIK and the Echo Boomers' transition from contact lenses to LASIK. Surgeons who want to stay in this channel will have to expand their offerings. The economic down- turn discouraged new surgeons from entering this sector and may have pushed some others out. So even though there are fewer LASIK surger- ies, there are also fewer of us per- forming LASIK. I predict even more surgeons will drop out of LASIK in the next 18-24 months. For those of us who opt to remain, there will likely be fewer than 2,000 dedicated refractive specialists by 2020. It will be a rough ride for the next few years, but it will get better. In the interim, talented refractive surgeons should expand into other ophthalmic surgery—including cataract, aesthetic plastic surgery, or glaucoma. The good news is there is no shortage of patients for all of ophthalmology's offerings, and I have always believed fortune favors the prepared mind, so I hope these insights into the major trends affect- ing LASIK volume will be of use. Dr. Lindstrom is founder and attending surgeon, Minnesota Eye Consultants, Bloomington, and adjunct professor emeritus, Department of Ophthalmology, University of Minnesota. He holds more than 30 patents in ophthalmology and is a past president of the American Society of Cataract & Refractive Surgery and currently serves on its Executive Committee. He can be contacted at rllindstrom@mneye.com. Figure 3. As illustrated here, the correction ratio is closer to 1.0 (ideal), especially for higher levels of preop cylinder, when using the new wavefront- guided system compared to the current system. Source (all): Steve Schallhorn, MD correction; more of the astigmatism is corrected with the iDesign and with lower variance in results (tighter standard deviation). The outcomes show less axis deviation as well with 64% of eyes with less than 5 degrees of axis shift, compared with 55% in the current system. What the patients say Patient satisfaction with their out- comes is already high after a wave- front-guided procedure, but we're finding outcomes to be slightly more favorable after the iDesign. In conclusion, the new aber- rometer produces results at least as good as what we are currently using—and that system has under- gone years of analysis and refine- ment. There is similar refractive predictability, superior cylinder cor- rection, better uncorrected visual outcomes, and similar best corrected outcomes. Our technicians have noted they prefer the new aberrome- ter because the capture and interface issues are smoothed out. Chromatic aberrations have been addressed, resulting in less disparity between the manifest and wavefront sphere. In my opinion, if a center is al- ready using wavefront-guided tech- nology, it is an easy learning curve to adjust to this system. I believe the results available out of the box are excellent, but undoubtedly we will still be able to improve outcomes. Currently, we are evaluating the system in several thousand eyes to determine what we need to do to even further optimize the system. Dr. Schallhorn is global medical director, Optical Express; in private practice in San Diego; and clinical professor of ophthalmology, University of California, San Francisco. He can be contacted at scschallhorn@yahoo.com. continued from page 7 EW San Francisco Update on the latest in refractive cataract techniques and technologies 9 AMO Saturday supplement_SF2013-dl.qxp_Layout 1 4/19/13 11:27 PM Page 9

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