Laser surgery brings new wave in eye care

Cut-rate services are drawing business to Canada, Lower 48

Posted: Tuesday, October 03, 2000

How much are you willing to pay to have 20/20 vision? How much are you willing to risk?

The latter, in some doctors' opinions, is the more valid question.

Laser-assisted corrective eye surgery, particularly the LASIK procedure (for "laser in situ keratomileusis"), is making relics of clunky glasses and desert-dry contacts, and an ultra-competitive market is making prices more affordable. That's important, because most insurance plans won't cover corrective surgery on one's eyes, affixing the "cosmetic" label to the process.

"I don't wear glasses any more," said Juneau's Ted Lehrbach, 50, who after the surgery saw his 20/200 vision improve to 20/20 in his left eye and 20/15 in his right. "I'm really very happy with the results. It's one of the best things I've ever done as far as my health goes."

Lehrbach's response echoes most patients' sentiments. Not all have had perfect results, a few have had disastrous experiences, but most who've had the surgery speak highly of life after LASIK.

As more locals travel outside of Juneau to correct their vision, it affects the business of local optometrists though not necessarily in a negative fashion.

"Not a day goes by that someone doesn't ask, 'Am I a candidate for that?'" said Dr. Jill Geering, an optometrist at the Alaska Vision Center in Juneau.

"Obviously, people who have this (LASIK surgery) done won't have as much of a need," for corrective lenses, Geering said. "But we do pre- and post-op care for the surgery. And even with someone who doesn't wear glasses, I'd still like to see them on yearly basis to make sure they're healthy."

Still, while locals may assist in the procedure, the actual surgery is where the bulk of the money is being spent. The opportunity to live free of corrective lenses has sent many locals to Anchorage, Seattle and Vancouver, British Columbia a sort of Mecca for laser eye surgery to have LASIK surgery.

Vancouver is a particular hotbed for Juneau residents because it offers the surgery at the lowest prices in the Northwest. The Lexington Eye Institute in Surrey, B.C., is one of the lowest-priced clinics in the greater Vancouver area. It charges $1,175 (American dollars) for both eyes for what it calls the buddy price that's the price if you bring a friend who also will have the surgery done.

The technology

The LASIK process involves the excimer laser, a precise instrument using an ultraviolet laser that can remove 39 millionths of an inch of tissue from the eye in 12 billionths of a second, according to information on the Laser Eye Center Web site.

"These are profoundly expensive machines," said Dr. Gordon Preecs of Juneau's Tongass Eye Clinic. "They're so extraordinary. They hire computer experts to run these things. It's more technological sophistication than medical."

In the first step of the process, a computer creates a detailed map of the eyes' surface and a surgeon calibrates the excimer laser to the patient's prescription. Then, a microscopic circular flap on the outer layers of the cornea is cut and moved out of the way. A small uncut portion of the skin acts as a hinge, allowing the circular flap of tissue to drop out of the way while exposing the deeper layers of the cornea that need to be processed by the laser.

The laser then reshapes the cornea, fixing the farsightedness, nearsightedness or astigmatism according to the prescription, and the cornea's flap is put back in place.

"It's like an artist to a carving," said Nestor Ugali, marketing director for the Lexington Eye Institute. "Without the proper equipment, you can't do fine work."

The actual surgery takes only five to 10 minutes per eye and it's pain free, according to the industry.

Canada gets fast start

Preecs of the Tongass Eye Clinic used to perform the procedure with his partner, Dr. Robert Breffeilh, but they stopped because they couldn't compete with the plummeting prices offered elsewhere. No one else in Juneau offers it, either.

Part of the problem, Preecs said, is that the Canadians and other countries get a head start in such technology because they don't have to deal with a governing body like the Food and Drug Administration, as United States firms must. Canada began developing the LASIK process around 1992 while the U.S. began around 1996.

The lag put the U.S. behind in the race to build a customer base. As a result, Preecs had to charge about $5,000 per pair of eyes whereas the lowest Canadian clinic charge for one person was $1,275 in American dollars.

"While we were crossing our fingers, people in Canada were promoting it," Preecs said. "The FDA in its careful and cautious way has brought the American market along slowly."

James Watson, executive vice president of operations at LASIK Vision, one of North America's largest and fastest growing LASIK providers, agrees with that assessment.

"We had the benefit of doing the procedure four or five years before the U.S. so we had more experience," he said.

Still, many of the company's 15 American clinics charge only a small amount more than its 16 Canadian clinics. How?

"We discovered we could do it for less money without compromising our standard of medical care," Watson said. "We buy so many things in large quantities, we're such a large customer, we can buy in discount."

Even the lasers, which can cost upward of $500,000 each.

Some doctors worry price has become the sole focus of customers considering the surgery, when many other factors should be taken into account. That could land the customer in a tough position, they say.

For example, said Michael Melenchuk, an optometrist at TLC Laser Eye Center in Vancouver, many customers may not research enough to know that some clinics choose to perform the surgery under nonsterile conditions because it isn't required by law.

"You're talking about a surgical procedure on your eyes," said Don Galer, executive director of TLC Laser Eye Center in Lynnwood, Wash. "It's not like buying tennis shoes. If it doesn't work on this pair, it'll work on the next pair? You don't want to test surgeons on your eyes."

Galer said his clinic typically charges $1,200 to $1,500 per eye. It's important the client know what's included in that cost, he said. Check the financial stability of the organization, the experience of the surgeons, and how many complaints have been filed against the clinic, among other things, he said. Are corneal surgeons being used? Does the clinic's operating room employ nurses or just technicians?

Lehrback of Juneau paid $2,400 total for both eyes at PCLI in Bellevue, Wash.

"I didn't go to the cheap shop," he said. "The doctor who did my eyes had, like, 13,000 (LASIK) operations."

Looking past the price

Juneau's Tamara Rowcroft and her family did similar research before she, her husband, her mom and her three sisters went to Vancouver's LASIK of Canada clinic in January 1999 to take advantage of a special price on the surgery $1,000 for both eyes.

They were lured by the price, she said, but that didn't blind them to the other issues. She said her family checked on all of the licensed physicians at the clinic and what kind of experience they had, and they checked on any lawsuits and complaints that might have been filed against the clinic.

"Absolutely, I would do all of those things," said Rowcroft, who noted LASIK of Canada passed her family's test. "If we hadn't done this much (research) it would have been more unsettling for us."

"I think that people have a tendency to make a comparison based on the thing they understand, which is money," Galer said. "If they take the time and are diligent, they'll find there are some more important issues to be sensitive to. The idea that surgery is a commodity is not very supportable."

Some doctors squirm with the high-volume, low-price equation, wondering if, somewhere along the line, service is sacrificed.

"We're very self-conscious and uncomfortable with the way it's conducted where volume is so high," said Preecs, the opthamologist at the Tongass Eye Clinic. "You're on the factory floor and marching right through. You see the doctor for maybe 10 minutes, then you're being managed and rearranged and discussed and advised by nonprofessional staff."

Assembly-line care?

Melenchuk, the optometrist at TLC Laser Eye Centers in Vancouver, agreed in part.

"Ask any doctor how many patients do you do per hour? Two patients an hour is safe, three an hour is questionable and four, I wouldn't go in there," he said.

But he said Canada's ability to move people through quickly and at a low price doesn't mean the patients aren't getting quality care.

Canada is able to offer less expensive service because of technology advancements, he agreed. But it's also because Canada doesn't have the laser user fees that U.S. doctors must pay, because Canadian doctors make dramatically less than U.S. doctors, and because Canadian doctors tend to specialize in one discipline such as LASIK surgery.

That philosophy to specialize enables Canada to streamline its operations more than the U.S. is capable of doing, he said. It allows Canadian doctors to see more LASIK patients because their operations are set up for that process alone.

"With the old model of surgeries, a doctor would do LASIK, then a cataracts (surgery), then a corneal. The changeover between all those in the OR room is quite long, whereas with this (single-minded focus on LASIK) it's easy to commodicize," Melenchuk said. "I call this LASIK procedure a technology-driven medical commodity. The younger surgeons pick up on that quickly, the older surgeons can't grasp that idea.

"That's the way the economy works, that's the glaring truth of the LASIK procedure."

"Standardization," agreed Watson, the director at LASIK Vision, "All of our surgeons do it exactly the same, hundreds of thousands of procedures. We know what to do to get the best results."

Rowcroft, the Juneau woman who went to Vancouver with her family, said experiencing Canada's medical system was a bit odd.

"Different," she said. "Much more an assembly line style than anything I've ever experienced in the U.S., but that's not to say it's a bad thing. They put a lot of people through, but I don't feel like I didn't get good quality care."

Almost every doctor interviewed agreed there are some clinics that act irresponsibly in both Canada and the U.S. But by researching the technology and knowing what questions to ask before you commit to surgery, the less likely you are to have a bad experience.

"It's very impressive," Preecs said. "I've never seen a terrible result or a bad process, but many people have not had perfect results. It takes caution to know how to recommend this to people."

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