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Eye Wars

Not too long ago the future was 20/20. Thanks to laser technology and a fiercely competitive marketplace, perfect vision at reasonable prices seemed within sight for almost everyone.

Eyeglasses and contact lens were history.

And ophthalmologists would prosper.

But in recent months the outlook has become blurred. Lawsuits, bankruptcies and skirmishes over pricing have shaken up the booming laser eye surgery market, a $2-billion-a-year industry in the U.S. that did not even exist a half-dozen years ago. The upheavals have been especially wrenching in Florida, a major battleground in the competition for patients willing and able to pay up to $2,500 an eye for a high-tech cosmetic procedure that most insurance companies don't cover.

"It's almost like the end of World War II, and we're in the reconstruction period," says Stephen Kilmer, a spokesman for TLC Laser Eye Centers Inc., a Canadian firm that offers outpatient laser eye surgery at 49 outlets in the U.S., including four in Florida. "We had been growing at the rate of 100% a year, and that just wasn't sustainable. So now the market is stabilizing."

This year the simple operation ophthalmologists call "flap and zap" will become the most widely performed surgical procedure in the nation, whether elective or medically necessary. The quest for near-perfect vision is now more popular even than breast enlargements or nose jobs. According to Market Scope, a St. Louis company that tracks refractive surgery, an estimated 1.1 million people will undergo laser eye surgery this year, up 25% from 2000.

"We project that next year the growth will slow even further, to about 20%, and hold," says Market Scope President Dave Harmon.

While physicians and insurers agree that choosing to improve one's vision is elective, the surgery is more a matter of lifestyle than cosmetics, especially in regions such as Florida, where outdoor activities beckon year-round. "No headaches, no eye irritation and now I can open my eyes under water,'' says Miami resident Nathalie Descalzo, 23, who since age 7 had been dependent on either glasses or contacts until she had the surgery last year. "And I can wake up in the morning and see the alarm clock. It's been great for me."

In the middle of the price war, Descalzo and her mother both had the surgery done at Mount Sinai Hospital for what then seemed like a top-shelf rate of $1,800 an eye. Although the Lake Worth-based Laser Vision Institute still advertises the procedure for as low as $499 an eye, the average price has leveled off at just under what the Descalzos paid, Harmon says.

For the billions of people worldwide who are nearsighted, farsighted or have astigmatism, the procedure called Lasik -- an acronym for laser in situ keratomileusis -- seems like a miracle. After a surgeon makes a small incision in the covering of the cornea, a small flap of the clear lens is lifted and a laser is used to reshape the cornea so that it focuses properly. The operation takes only minutes, is usually painless, and recovery is quick.

The Food and Drug Administration approval in 1995 of the excimer laser for use in eye surgery triggered a stampede to the marketplace. Eye surgeons who could afford the equipment -- $500,000 or more -- jumped on the procedure as a lucrative boost to practices reeling from sharp cuts in Medicare reimbursement for cataract surgery. Many ophthalmologists leased lasers or teamed up with fellow surgeons in joint ventures.

Corporate eyes also grew wide over the prospects for mass marketing the procedure. Risks were low, and with initial prices pegged at up to $4,500 an eye, profit margins were high.

Then, from 1997 until just recently, came years of marketing turmoil. "When the discounters came in, Lasik surgery moved from a medical procedure to a business commodity, and when that happens, you lose that doctor-patient rapport," says Eric J. Rothchild, a Delray Beach ophthalmologist who has performed more than 5,000 such surgeries in the last six years. "You can't run patients through like cattle."

As private practitioners like Rothchild fought for market share, corporate players such as the Laser Vision Institute and Icon Laser Eye Centers employed circuit-riding surgeons and mobile laser machines that were trucked between various outpatient centers to offer the procedure at rock-bottom prices. Millions were spent on advertising: Direct mail, internet, billboards and television infomercials. Celebrity patients such as golfer Tiger Woods and champion Olympic swimmer Amy Van Dyken weighed in with endorsements. The number of surgeries soared, and the prices tumbled. "No private practitioner can compete with $499," says Wayne Bizer, one of six surgeons associated with the Fort Lauderdale Eye Institute.

Last year, near the apex of the advertising frenzy, the FDA posted an online warning urging consumers to beware of "slick" advertising and deals that seemed too good to be true. The agency also listed the rare but possible complications of the surgery, including blurry vision, problems with night vision, dry-eye syndrome and "even irreversible blindness."

Support groups have popped up in Florida and around the country for the estimated 5% of patients who report complications from laser surgery. (Surgical Eyes, an internet-based patient advocacy group, can be found at www.surgicaleyes.org.)

There have been casualties on the business side, too. Icon, which had centers in Miami, Orlando and Tampa, and a sister company, Lasik Vision, went belly up this spring. TLC, which saw its expansion stall and its stock price plummet last year, has rebounded by opening more centers and strengthening its referral network of optometrists and touting its after-care. The price of a Lasik procedure at TLC also runs about 25% higher than the national average of $1,600 per eye.

Laser Vision Institute has survived on price. Offering some procedures for as low as $499, the family-owned firm is now one of the nation's leading discounters, operating 20 centers, including four in Florida.

"We've seen a little bit of a slowdown in the last year because of the economy," says Laser Vision Institute CEO Max Musa, who forecasts revenues of $120 million in the year ahead from both Lasik procedures and optical sales through its 50-plus Eye Glass World outlets. "We are optimistic that we can stay strong."

Eye surgeons Bizer and Rothchild have also survived the shakeout, although each has seen his Lasik surgery numbers dip. "We have stayed in the high end price-wise, but we don't run a factory," says Rothchild, a corneal specialist. "But there were a lot of doctors chasing that discounted price, and they have had to drop refractive surgery."

Bizer's solution was to rent time on equipment owned by others. For example, Bizer and more than 35 other doctors from Miami to Palm Beach Gardens use the state-of-the-art, 3,000-sq.-ft. Plantation facility run by laser developer SurgiLight, blocking time to operate on their patients at rates ranging from $999 to $1,800 an eye.

"We are unable to compete at the levels we used to," says Bizer, "and our volumes have dropped precipitously -- by 50% to 75%."

Still, Bizer and his associates continue to spend an average of $1,000 a month to advertise for Lasik patients -- via infomercials, direct mail and presentations to employee groups -- because the procedure is lucrative. "We are faced with tough marketing decisions now," says Bizer. "We try to keep our prices in the affordable range -- about $999 an eye -- while offering services that the discount houses can't touch."

SurgiLight Vice President Richard Reffner says that although finding a niche in the laser surgery marketplace is a challenge, "there is room for everybody. The economy is not doing well right now. The growth in Lasik surgery has slowed, but there is an unlimited market for this,'' he says. "This is a high-tech business, constantly changing with new bells and whistles, and manufacturers are offering great deals now to places such as ours in hopes patients and doctors will come."

Indeed, technology is driving what many see as the catalyst for the next economic boom in eye surgery: Presbyopia. Some 50 million Baby Boomers are now well past or approaching an age where reduced elasticity of the eye lens has made reading a restaurant menu or the fine print on a medicine bottle an exercise in frustration.

Several research firms, including Orlando-based SurgiLight, are at work on what Harmon of Market Scope calls "the gold ring."

"The potential market here is at least two times what it is for laser surgery now," says Harmon. "All you have to do is live to be 45 and you're presbyopic. The technology is probably three years away. But it'll be huge."


When Marco Musa graduated from college in 1984 and was searching for something to do, his girlfriend suggested looking into her family business: Eyeglasses. The couple moved from Indiana to Florida and bought an existing optical outlet in Deerfield Beach.

The business thrived, but the relationship did not. When Musa and his girlfriend split four years later, she took the store. Musa capitalized on the experience. He and his younger brother Max -- just finishing up at Indiana University himself -- bought a store called Eye Glass World in Lake Worth. That store did well, too.

Today, there are three Musa brothers in the optical business. Marco, 39, Max, 35, and Marc'andrea Musa, 32, run a chain of more than 50 Eye Glass World outlets in 29 states. Their 20 Laser Vision Institute surgery centers, including four in Florida, command 10% of the market, according to company CEO Max Musa.

The privately held Lake Worth firm employs about 1,300 and expects revenues of $120 million this year, says Max Musa. About half of the company's income flows from laser surgery performed at cut-rate prices.

Musa says the company is already planning to be a player in the next big thing in ophthalmology -- laser surgery to correct presbyopia. The procedure has not been approved by the Food and Drug Administration, but it is being performed outside the U.S.

"We just did our first procedure in the Bahamas," Musa says. "The potential U.S. market for presbyopia is said to be $150 billion. And we want to be the first in."