As Economy Slows, So Do Laser Eye Surgeries

April 23, 2008

By BARNABY J. FEDER
Call it the Lasik indicator. As the economic downturn forces consumers to cut back on discretionary spending, laser vision-correction surgeries have been falling — as they did during the last recession.
Although more than 800,000 Americans got Lasik surgery in 2007, a slight increase from 2006, the numbers started slumping along with the economy in the second half of last year. And industry analysts are now seeing a Lasik recession.
“We’re forecasting a 17 percent drop for 2008,” said David Harmon, president of Market Scope, an eye surgery market research house.
Mr. Harmon said that when first-quarter data become available next month, he expects it to show an even sharper decline in Lasik surgeries than in 2001, when the sour economy triggered a three-year slump in the laser procedures, which are typically not covered by insurance.
Lasik — for laser-assisted in situ keratomileusis — typically costs anywhere from $800 to $3,000 or more an eye.
Mr. Harmon’s forecast is based on the relatively strong correlation in recent years between Lasik procedures and the Conference Board’s index of consumer confidence in the economy.
Doctors and analysts said a wide range of elective medical procedures, including breast implants and skin treatments like Botox injections, are also being affected.
“People are just being a little more conservative about their finances,” said Dr. Robert Cykiert, a New York ophthalmologist who does both eye surgery and Botox injections.
In the case of Botox, for example, Dr. Cykiert’s existing patients are not spacing out their treatments but some who are interested have been hesitant to start, he said.
So far, though, Lasik procedures are the most evidently affected.
Still uncertain is the extent to which, beyond economic considerations, the Lasik downturn may also reflect the growing number of complaints about poor results from the procedures. Federal regulators have received reports about dry eyes, double vision and distorted night vision, among other things. And numerous blog sites carry sobering tales of more serious eye damage or cases where vision improvements seemed to disappear within a few years.
Those concerns will be reviewed Friday at a meeting of the Food and Drug Administration’s advisory board on ophthalmic devices. The panel is also expected to consider proposing a major new study on Lasik outcomes.
The F.D.A. is also asking the panel to suggest ways to get more doctors, patients and hospitals to report problems stemming from laser surgery or lens implants. One goal cited in documents the agency published Wednesday is to gather more Lasik data through SightNet, an online network of ophthalmologists who are voluntarily linked to the agency’s Medical Product Safety Network.
Lasik involves cutting a flap in the surface of the cornea to gain access to the central portion of that natural lens, which is then reshaped by the laser. Lasik can reduce or in many cases eliminate nearsightedness, far-sightedness and astigmatism.
Lasik practitioners say a recent analysis of past studies showed 95 percent satisfaction rates, regardless of whether the data is arranged to compare patients in the United States to overseas, procedures before and after 2000, short-term or long-term results or anonymous versus identified patients. But with 12 million patients having undergone the procedure in the United States since 1995 when it was first approved, the sheer number of individuals with unhappy outcomes is growing steadily, and more of their stories are gaining public attention.
“My eyes are damaged beyond repair,” Pamela C. Barncastle, 62, of Albuquerque, N.M., said in a phone interview. Mrs. Barncastle said she underwent the surgery in 2001 but now suffers double vision, as well as seeing halos and spikey bursts of blurred light at night that prevent her from driving then.
She said she needed to undergo a corneal transplant, which would be paid for by a settlement with her doctor. But she said that for now she is living with her vision problems because she is the sole caregiver for her father and her husband, an Alzheimer’s patient.
Mrs. Barncastle said she was also worried about the large number of Lasik patients she has talked to who seem to be developing cataracts. “There needs to be a lot more monitoring of the industry and studies of the long-term effects,” she said.
Publicity about the complaints being aired at the F.D.A. panel hearing Friday could hit the shares of Advanced Medical Optics, which gets just over a third of its revenue from the sale of lasers and related gear used in the surgery, said Lawrence Biegelsen, a medical device analyst for Wachovia Capital Markets.
The growing attention to unhappy Lasik outcomes is also bad news for companies that operate chains of laser surgery centers, like LCA-Vision and TLC Vision, which have already seen their stocks pummeled by declines in procedure at the end of last year that they attributed to the economy.
No immediate action is expected from the F.D.A. In the last year, the agency has been working with the National Eye Institute, American Society of Cataract & Refractive Surgeons, and American Academy of Ophthalmology to design a trial that will track patients who undergo Lasik or get implanted contact lenses. Most past studies have focused on the degree of vision correction attained and medical complications like infection rather than everyday vision issues like night vision and contrast that can affect quality of life.
Medical complications are now below 1 percent, an all-time low, according to Dr. Kerry Solomon, the co-chairman of the committee trying to develop the study design. “But there haven’t been a lot of good quality of life studies,” said Dr. Solomon, who is a professor of ophthalmology at the Medical University of South Carolina.
One result of the study might be to further clarify which patients are not good candidates for Lasik, he said.

brown patches

Melasma

http://www.aad.org/public/publications/pamphlets/common_melasma.html
Melasma is a skin condition presenting as brown patches on the face of adults. Both sides of the face are usually affected. The most common sites of involvement are the cheeks, bridge of nose, forehead, and upper lip.

Who gets melasma?
Melasma mostly occurs in women. Only 10% of those affected are men. Dark-skinned races, particularly Hispanics, Asians, Indians, people from the Middle East, and Northern Africa, tend to have melasma more than others.

What causes melasma?
The precise cause of melasma is unknown. People with a family history of melasma are more likely to develop melasma themselves. A change in hormonal status may trigger melasma. It is commonly associated with pregnancy and called chloasma, or the "mask of pregnancy." Birth control pills may also cause melasma, however, hormone replacement therapy used after menopause has not been shown to cause the condition.



Melasma of forehead, cheeks, nose, upper lip and chin

Sun exposure contributes to melasma. Ultraviolet light from the sun, and even very strong light from light bulbs, can stimulate pigment-producing cells, or melanocytes in the skin. People with skin of color have more active melanocytes than those with light skin. These melanocytes produce a large amount of pigment under normal conditions, but this production increases even further when stimulated by light exposure or an increase in hormone levels. Incidental exposure to the sun is mainly the reason for recurrences of melasma.



UV photograph, which enhances pigmentation,
showing melasma of cheeks and forehead

Any irritation of the skin may cause an increase in pigmentation in dark-skinned individuals, which may also worsen melasma. Melasma is not associated with any internal diseases or organ malfunction.

How is melasma diagnosed?
Because melasma is common, and has a characteristic appearance on the face, most patients can be diagnosed simply by a skin examination. Occasionally a skin biopsy is necessary to differentiate melasma from other conditions.



Melasma of forehead

How is it treated?
While there is no cure for melasma, many treatments have been developed. Melasma may disappear after pregnancy, it may remain for many years, or a lifetime.

Sunscreens are essential in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. A SPF 30 or higher should be selected. In addition, physical sunblock lotions and creams such as zinc oxide and titanium oxide, may be used to block ultraviolet radiation and visible light. Sunscreens should be worn daily, whether or not it is sunny outside, or if you are outdoors or indoors. A significant amount of ultraviolet rays is received while walking down the street, driving in cars, and sitting next to windows.

Any facial cleansers, creams, or make-up which irritates the skin should be stopped, as this may worsen the melasma. If melasma develops after starting birth control pills, it may improve after discontinuing them. Melasma can be treatedwith bleaching creams while continuing the birth control pills.

A variety of bleaching creams are available for the treatment of melasma. These creams do not "bleach" the skin by destroying the melanocytes, but rather, decrease the activity of these pigment-producing cells. Over-the-counter creams contain low concentrations of hydroquinone, the most commonly-used depigmenting agent. This is often effective for mild forms of melasma when used twice daily. A dermatologist may prescribe creams with higher concentrations of hydroquinone. Normally, it takes about three months to substantially improve melasma. Creams containing tretinoin, steroids, and glycolic acid are available in combination with hydroquinone to enhance the depigmenting effect. Other medications which have been found to help melasma are azelaic acid and kojic acid. It is important to follow the directions of your dermatologist carefully in order to get the maximum benefit from your treatment regimen and to avoid irritation and other side effects. Remember, a sunscreen should be applied daily in addition to the bleaching cream. Some bleaching creams are combined with a sunscreen.



Melasma on bridge of nose

Chemical peels, microdermabrasion, and laser surgery may help melasma, but results have not been consistent. These procedures have the potential of causing irritation, which can sometimes worsen melasma. Generally, they should only be used by a dermatologist in conjunction with a proper regimen of bleaching creams and prescription creams tailored to your skin type. People should be cautioned against non-physicians claiming to treat melasma without supervision because complications can occur.

Management of melasma requires a comprehensive and professional approach by your dermatologist. Avoidance of sun and irritants, use of sunscreens, application of depigmenting agents, and close supervision by your dermatologist can lead to a successful outcome.

To learn more about mature skin, call toll free (888) 462-DERM (3376) to find a dermatologist in your area.

AAD Web site: www.aad.org
1-888-462-DERM