1. How Conductive Keratoplasty is
Impacting the Presbyopic Practice
Shareef Mahdavi • SM2 Consulting • Pleasanton, CA
Abstract represent a wide distribution by geography and by practice type
CK has been commercially available in the United (see Table 1). Most of the surgeons interviewed have been using
States for a little over 3 years. Refractec engaged SM2 the CK device for several years (mean = 2.6 years), with a range
Consulting to field a research survey to assess how that included a relatively new user (3 months) and two of the
surgeons are integrating this technology into their treat- original clinical investigators (7 years experience each).
ment of presbyopia. Surgeons indicate that CK clinical Questions focused on their current clinical experience with CK,
outcomes have improved dramatically using the with the additional goal of understanding patient motivation
“LightTouch” technique, restoring their confidence and and management with this procedure. Data were also collected
usage of the procedure. Also, the CK patient population on recent practice refractive procedure volume and pricing to
is dramatically different from that in a typical refractive understand where CK fits economically within the practice.
or cataract practice, and successful physicians have
adjusted their protocols to better attract, counsel and
Table 1: Demographics of CK Practices
manage these patients, significantly increasing patient
in Survey (N = 20)
satisfaction with the CK procedure. Perhaps more
Refractive Cornea
Refractive
importantly, CK serves as the first entry point into med- and
Cataract
General Specialist
Type of Practice
ical eye care services for many of these patients. Some 6 6 3 5
surgeons are using the opportunity to build a relation-
North South
East West
ship with these patients now, as they will likely need Central Central
Location
more eye care services (IOL’s, Glaucoma treatment, etc.)
6 7 4 3
over the next 10-20 years.
0 to 150 151 to 300 301 to 450 >450
Introduction
Quarterly LASIK Volume
Refractec (Irvine, CA) manufactures and sells a refractive (# of eyes treated in Q1 2005)
treatment system that allows ophthalmologists to perform 7 7 2 4
Conductive Keratoplasty (CK), a procedure which utilizes radio SM2 Survey of CK Surgeons (N=20), June 2005
frequency waves applied via a hand-held probe to alter the
shape of the cornea. The original application of CK was for
hyperopia, with the goal of steepening the outer optical zone to Results
induce a refractive change. Consequently, the Company has CK Clinical Outcomes: Much Better with “LightTouch”
received additional FDA approvals to market the device for the 19 of 20 surgeons interviewed had experience with the new
improvement of near vision in emmetropic presbyopes and low “LightTouch” technique. Physicians who use this new approach
hyperopic presbyopes, using similar methods. feel they are achieving significantly improved results over the
SM2 Consulting (Pleasanton, CA) was retained by Refractec conventional pressure technique. 18 of 20 had experience with
to conduct independent research interviews with surgeon cus- both the new and original techniques and could draw direct
tomers to assess the impact the technology is having in the typi- comparisons between the treatment methods. LightTouch offers
cal customer practice and to help better understand the the surgeon the ability to treat with fewer spots in a single ring
motivation and concerns of the patients for the CK procedure. placed further outside the optical zone. More refractive effect is
achieved and there is a near elimination of the induced cylinder
Methods commonly observed post-operatively with the conventional
A set of research objectives, discussion guide and data collec- method.
tion processes were developed and research interviews were con- The LightTouch method has generated a high level of confi-
ducted from a sample of 20 practices. Enrolled practices dence in CK among the surgeons that were interviewed.
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2. (cataract and/or refractive implants). See Figure 2.
Figure 1: As a surgeon, how would you rate your
CK Candidates: A Different Audience
confidence in the CK procedure?
The patient wanting CK is not likely to be found in the
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SM2 Survey of CK Surgeons (N=20), June 2005
waiting room of a typical ophthalmic surgeon’s practice. They
6 fit somewhere between the typical LASIK patient (younger,
5 myopic, haven’t enjoyed unaided vision for years) and the typi-
# of Practices
Mean Rating = cal IOL patient (older, having other aging and health issues).
4
8.6 Many patients that choose CK have never had a relationship
3
with an eye care professional and only now are in need of help
2 with their vision. Blessed with good distance vision all their
1 lives, they reach their late 40s and find themselves increasingly
0 frustrated and even angry at their inability to perform near and
1 2 3 4 5 6 7 8 9 10 intermediate visual tasks. The frustration can be classified in
Confidence Rating (1 = lowest, 10 = highest) terms of the physical and emotional context of getting older.
When paired with the view that there is nothing redeeming
As shown in Figure 1, the average confidence was 8.6 (on a 1 to about wearing reading glasses, the CK candidate comes in say-
10 scale, 10 being highest) and no surgeon rated their confi- ing, “I feel old and I look old.” All surgeons reported the aver-
dence below a 7. Although not directly asked, surgeons indi- age CK patient age is from 48 to 52 years of age, which can be
cated that the reason for their high confidence was directly among the most active and financially productive years of a
attributable to the LightTouch method. Had they been asked person’s life. The motivation for CK is simple: reduce depend-
this question a year ago, confidence levels would have been ency on reading glasses.
rated much lower. Similar to research conducted about motivation for LASIK,
Many surgeons have noticed a difference in the immediacy the CK patient also wants to improve performance. In the con-
of the effect of CK, with LightTouch providing a stronger text of presbyopia, performance means being able to read the
“WOW! Factor” based on the statements of patients who have cell phone, price tags, restaurant menu, and newspaper without
had the new procedure. Although LightTouch has been in use a the need for reading glasses.
little more than one year, surgeons indicate that the incidence of Surgeons also reported that many of their CK patients would
retreatment is already significantly less than what they experi- never have had LASIK, either because they didn’t need it for dis-
enced with the original technique. tance correction or due to perceived risk. In contrast to using
The leading indication for CK use is for primary treatment of lasers and keratomes, CK allows surgeons to offer a less invasive
plano presbyopes (100%), followed by 11 of 20 surgeons (55%) approach which serves as a “stepping stone” before more dra-
who use CK for post-LASIK refinement. Thirty percent of those matic procedures will be required (or desired) later on in life.
interviewed will also treat mild hyperopes bilaterally, and 25% CK can be compared to other less invasive self-improvement
indicate they are using it for refinement of IOL implant results options available at midlife: Botox before a facelift, teeth
whitening before veneers, and collagen injection before knee
replacement.
Figure 2: Percentage of Practices Using CK by
Indication (Multiple responses allowed) This low level of invasiveness resonates very deeply with
someone who has had “perfect eyes” for 50 years. The more
Post-IOL SM2 Survey of CK Surgeons (N=20), June 2005 conservative and mature profile of this age group is a good fit
25%
Refinement
with a procedure that gives back capability they previously
Mild Hyperopes
30% enjoyed.
(Bilateral CK)
Post-LASIK 55% CK Surgeons: Setting Expectations
Refinement
How the surgeon sets expectations with patients is perhaps
Plano
Presbyopes 100% the single most critical factor in achieving success with CK.
These patients have emotional needs that differ greatly from that
0% 20% 40 % 60% 80% 100 %
of the typical LASIK or cataract patient. Sometimes described as
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3. “high maintenance,” these patients are often dealing with vision CK Patients: How do you find them?
problems for the first time in their lives and are unaccustomed
to needing any help to function. Our interviews found that the The ideal CK candidate is one who says, “I’ve had great
process begins with the surgeon and how he views (and ulti- vision my whole life. I’m only 50 – I’m not old. I’m in the
mately presents) his expectations of the procedure. prime of my life and have the money to spend on things that
Surgeons who do best with this procedure are able to sepa- can help me. I want to feel better, look younger and perform
rate CK from LASIK in their minds. Objectively, they feel it is at the top of my game.”
not as “good” a procedure as LASIK; with a deficiency similar Because they’ve had good vision, many ideal CK patients
to how hyperopic LASIK is viewed when compared to myopic are not native to the practice. Nor are they being referred in
LASIK. That is, CK does not enjoy the same level of predictabil- great numbers by optometrists who co-manage, presumably
ity or stability. However, they recognize this procedure serves a because they have not had a strong need for primary eye
different purpose for a different audience. These surgeons are care services in their youth and younger adulthood. As with
able to view CK in its own right as a solution that fills the gap LASIK referrals patterns, word-of-mouth seems to be the
between LASIK and IOLs. While imperfect, it is a solution that dominant means of acquiring patients. This is especially true
is much better than what all of eye care has been doing for years now with the LightTouch method, with a greater initial
to this audience, namely turning them away and sending them “WOW! Factor” that is helping spur increased referrals.
to drug stores for reading glasses. “You need to make me and my friends aware of what you
can do to help me get rid of these reading glasses, which I
CK and the Patient Evaluation find truly annoying.”
There are 3 critical steps in evaluating a patient for CK, and Advertising and news stories are essential sources of CK
surgeons were adamant that they cannot be skipped in the patients, and 16 of the 20 surgeons interviewed conduct
process. external marketing; they spend an average of $12,650 per
First, surgeons employ a wide variety of analogies to help month total on their advertising (range $2,000 to $45,000).
educate the CK patient, generally focusing around giving back This equates to anywhere from 5% – 12% of their monthly
capability that has been lost. With experience, these surgeons refractive revenue (one exception is a surgeon who markets
have determined what words and phrases best describe the pro- and performs CK as his only refractive procedure; marketing
cedure and set proper expectations. “The procedure works well expenditures are at 30% of revenue).
but you will continue to age,” is a statement that captures this Most surgeons believe that “cross promotion” of proce-
sentiment. Surgeons believe it is essential that patients under- dures in their marketing has been effective. In other words,
stand that they will be given a “reprieve” until their accom- advertising for CK generates more LASIK business and
modative needs increase beyond what can be successfully vice-versa. Further analysis was done by looking at the
managed via CK. reported percentage of the marketing and advertising
Second, surgeons ask detailed and probing questions about message devoted to CK (as opposed to LASIK, IOLs, or
profession and hobbies. They describe this process as a form of a refractive surgery in general). All but one of the surgeons
psychological profile or personality test, looking for indicators who advertise had some portion of their advertising dedi-
that a patient might not be happy with anything less than 100% cated to CK, with a mean of 22% (range 5% to 100%).
crisp vision for the distance. Pilots, engineers, attorneys, and those Comparing advertising dollars invested towards CK to the
who are fanatical golf or tennis players probably won’t tolerate amount of revenue generated by CK yielded a mean ratio of
what they may have to give up at distance to achieve better 5.7 to 1. Because the spread of this ratio in this interview
unaided vision for near and intermediate. These simply are not sample is so large (from 1.2 to 13.3), we believe it is more
good candidates. However, patients with less demanding visual meaningful to express the average by using the median
needs who express high frustration with reading glasses (example: (3.8) rather than the mean (5.7) value. Using the median,
“these just aren’t for me”) are ideal candidates for CK. for every dollar spent on CK messaging, an average of
Third, surgeons perform one or more tests to determine $3.80 was generated in CK revenue.
compatibility with a mono- or blended- vision procedure. All “Reach out and find me today and help me improve my
surgeons employed a loose lens test followed by a contact lens vision. I will stay with you for the rest of my life.”
trial (if doubt persists) for one to two days. The critical decision
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4. point here is whether or not the patient can “psycho adapt” to doing between 20 and 49 eyes. The mean among all surgeons
the reduction in binocularity, the key factor in predicting the was 32.1 eyes for the quarter and the median (half of surgeons
patient’s likelihood for success with this change in their vision. above, half below) was 18.6 eyes for the quarter. The range
Following the CK procedure, successful surgeons employ a includes one surgeon who did not perform CK in Q1 2005 and
different protocol for post-op management than is required for another who did 120 CK procedures during the same time
LASIK. The initial “WOW! Factor” experienced on the first day period. There was no correlation between high-volume LASIK
for near tasks is often followed by a temporary worsening of and high volume CK; both the highest and lowest volume CK
distance vision that lasts from 1 to 2 weeks and gradually surgeons interviewed were the highest-volume LASIK surgeons
improves. Thus, the postoperative Day 1 visit is often viewed as in this sample. Importantly, surgeons also indicated that their
a wasted effort as long as the patient is not experiencing some volumes are increasing at a rapid rate due to the improved
atypical symptom. CK’s safety profile affords this luxury, in con- results from the LightTouch technique.
trast to the post-op requirement for LASIK. However, what CK Using these figures, doing just several eyes per month cost
post-op management does require is a form of “psychological justifies the CK device and all but one of the surgeons inter-
hand holding” that is not generally present with the typically viewed met this criteria.
younger LASIK patient. Fortunately, the lack of instant gratifica-
tion is well-matched to the more tolerant, more mature patient Figure 3: # of CK Eyes Treated Per Quarter (Q1 2005)
that needs CK.
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CK As An Investment SM2 Survey of CK Surgeons (N=20), June 2005
As with all technology, CK also needs to be measured on its 6 Mean = 32.1 eyes
Median = 18.6 eyes
ability to provide a return on investment for the surgeon. What
# of Practices
5
is unique about CK is that there is a three-tier rationale that
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needs to be considered; we will describe these one at a time as
3
follows and how they support investment into this technology.
1) Positive ROI - Ability to do enough procedure volume to 2
pay for the device 1
At approximately $60,000, the up-front investment for a CK
0
device is nominal when compared with a laser (either excimer or 0 <10 10 to 19 20 to 49 50 to 75 120
femtosecond), yet has a disposable component of $175 or more # of CK Eyes
per eye that is roughly equivalent to that charged for use of a
laser. Additionally, the time required to perform the procedure is
minimal and does not require a special room or dedicated tech- 2) Part of the refractive toolkit - Surgeons indicated that CK
nicians. Some surgeons find it quick enough that they can add it was also effective at building other sources of revenue; LASIK
to an existing appointment or squeeze it in, eliminating the need procedure volume benefits from offering CK. This makes sense
to burden the schedule with CK-specific appointments. A con- intuitively when viewed from the perspective of the eye care
servative approach would factor in one-half of a full time equiv- consumer. The consumer knows he is bothered by having to
alent employee to assist with the additional hand holding wear glasses and wants to get rid of them, yet has no clue as to
required with CK patients. which vision solution will best meet his needs. News stories or
The average collected fee per CK treatment among these sur- advertising about any form of visual performance benefit is
geons was $1,637 (range: $1,250 to $2,000) and it is typically likely to generate interest from these consumers. Inquiries about
performed in only one eye. Surgeons who perform a bilateral CK can often lead to a LASIK procedure and vice-versa. it is the
treatment (for low hyperopes) tend to charge a discounted fee surgeon’s job to properly educate and steer patients to the right
for the second eye resulting in $2,500 collected OU. solution. As a result, all twenty surgeons interviewed believe
An analysis of the distribution of the number of CK eyes that CK is an essential tool and would purchase the system
treated during Q1 2005 in this sample follows a normal distri- again if given the choice today.
bution (see Figure 3), with the largest group of surgeons (35%)
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5. 3) Building the patient base - Strategic significance for both surgeons and their patients. The other half (8) see CK
future eye care services remaining an important “niche player” much as it is today, with
The third rationale, described by several surgeons as key to its role limited to a step between the full refractive correction
their long-term strategy, was the use of CK as a way to begin a offered by LASIK for pre-presbyopes and by an IOL for presby-
relationship with patients that they would not otherwise see for opes both with and without a cataractous lens.
another 10 to 15 years. Leveraging the less invasive and less The remaining 20% of surgeons interviewed (4 of 20) feel
expensive aspects of the procedure (relative to an IOL), CK that CK will become obsolete once presbyopic LASIK or a
allows the surgeon to form a bond with a patient and begin a corneal inlay becomes available. They are hopeful that a differ-
dialog that will continue for many years down the road when ent solution will provide better predictability with less risk than
more invasive and expensive eye care services are needed or an intraocular implant. Admittedly, however, they do not have
required. As one physician noted, the reasoning is simple: enough data to evaluate whether or not a multifocal approach
“If I don’t begin this relationship now, that patient will never via ablation or inlay will be good enough in real world clinical
know I exist and will just as likely choose another surgeon when practice. Only time will tell. While these surgeons are expecting
it comes time for a cataract or refractive IOL.” advancements beyond CK, this is still an important tool in their
Thus, CK serves as an entry point for the patient into med- refractive practice today.
ical eye care, and for the surgeon to develop a long-term rela-
tionship with that patient. Summary
This survey yielded several key findings that should prove
CK’s Role In The Future helpful to surgeons who are considering adopting the technology
Refractive surgery is a rapidly advancing field, and the future as well as current CK users who are looking to expand their use
is filled with other developments, many of which are geared and success with this device:
towards alleviating presbyopia. These include accommodating,
multifocal and phakic IOLs, corneal inlays and onlays, and pres- Not unlike other eye care technologies such as phacoemulsi-
byopic LASIK. Even with these potentially more advanced devel- fication or excimer laser ablation, Conductive Keratoplasty has
opments on the horizon, 80% of surgeons interviewed (16 of undergone an evolution in its approach that has refined the
20) believe that CK will still be important over the next 3-5 technique and improved outcomes.
years (see Figure 4). This majority is impressed with CK’s safety
profile and what it offers to patients who are risk averse. Half The patient that is ideal for CK is different than other
of this group (8) believe CK will grow into a “big player” in the patients currently seen by the ophthalmologist; it will take time
refractive field. They view market adoption as only a matter of to make them aware of, interested in and educated about CK.
time, allowing for growing awareness and acceptance of CK by This was also true of laser vision correction in its early days.
Surgeons need to approach CK differently than LASIK.
Figure 4: Where do you believe CK will From their own mindset through counseling patients pre- and
be in 3 to 5 years? post-operatively, the expectations for CK and the management
of those expectations are indeed different.
Niche Player The low acquisition cost of the CK device makes it easy to
40%
cost justify, with breakeven procedure volumes that are a frac-
tion of what is required to breakeven with LASIK. CK has an
additive effect to existing LASIK procedure volume and can be
Obsolete
Big Player 20% used as a tool to build the future growth of the practice from
40% advanced IOLs.
Even with more advanced technology on the horizon, CK is
destined to have a role within the ophthalmic practice. This is
SM2 Survey of CK Surgeons (N=20), June 2005
5

6. largely attributable to its strong safety profile relative to exist-
ing and emerging technologies designed for the presbyopic
population.
Discussion
To date, CK has struggled to find where it best fits in the
ophthalmic practice. LightTouch has helped solve some of this
equation, as the improved results from this technique are having
a definite and positive impact on the surgeons’ confidence in the
procedure and willingness to recommend it to patients.
Although many surgeons and industry participants naturally
compare CK to LASIK, that comparison is not truly appropri-
ate. While LASIK is a more refined procedure than CK, CK’s
value is in its ability to offer a solution not previously available
and to appeal to those who would never have even considered a
laser procedure. LASIK has been so dominant in part because it
has and likely will continue to be the best solution for myopia.
CK addresses a different problem – presbyopia - one that is
much more difficult to solve.
LightTouch has changed the dynamic of this process and cre-
ated a positive cycle that was previously broken by the wide-
ranging results of the original technique. Better outcomes lead to
fewer post-op issues (under response, induced cylinder, need to
enhance), which leads to a happier patient and a more confident
surgeon. Patient and surgeon are then working in tandem to
positively promote the procedure and attract future patients.
The intent of this research was to understand the benefits
and barriers to adoption of CK within the practice. The clinical
results from CK are sufficient to justify the investment, one that
pays off both today and in the future. Surgeons who have suc-
cessfully integrated CK in their practice believe that creating a
relationship with this new group of patients now solidifies their
position to provide more services for them in the future. CK
offers a means to building a high trust level with patients.
Given future trends in ophthalmology, we view this to be a most
compelling reason to get involved with the technology.
In short, CK should be viewed as an essential tool in the
refractive armamentarium if the practice is willing to reach a
currently under-served patient base.
© Copyright 2005, SM2 Consulting. All rights reserved.
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