In the aftermath of this year's meeting of the American Academy of Ophthalmology (AAO; San Francisco), held last week in Atlanta, one thing is certain, according to Stephen McLeod, MD, professor and chairman of the department of ophthalmology at the University of California, San Francisco: "No one has been untouched by the decreased activity of laser-based refractive surgery."

That dreary observation was one of several McLeod shared with the investment community and members of the media Friday during a post-AAO ophthalmology webcast hosted by Joanne Wuensch, a med-tech analyst for BMO Capital Markets' Equity Research Group.

McLeod serves as a consultant to the Ophthalmic Devices Panel of the FDA, is on the editorial board of the American Medical Association's (Chicago) journal for ophthalmology research, Archives of Ophthalmology, and is chair of the Preferred Practice Pattern panel on refractive surgery for the AAO.

McLeod said a not-so-light moment for him during the meeting was when Robert Maloney, who is the exclusive LASIK surgeon for ABC's Extreme Makeover and one of the most well-known refractive surgeons in Los Angeles, introduced himself as 'Robert Maloney, former refractive surgeon.'

"Everybody's taking a hit on the laser refractive side," McLeod said.

His expertise is in the area of refractive surgery and corneal disease. In the field of refractive surgery, his expertise includes the diagnosis and surgical management of refractive error through laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK), while in the field of cornea and external disease his expertise includes conjunctival and anterior segment disorders, corneal infection, inflammation and opacification, ocular surface tumors, trauma, adult cataract and intraocular lens complications as well as infantile developmental corneal anomalies and pediatric cataract.

While elective refractive surgery is clearly taking a hit, McLeod told webcast listeners that the premium intraocular lens (IOL) market has actually seen quite a bit of resilience. He believes the reason for that is the difference between someone who wants to have refractive surgery as an alternative to wearing glasses or contacts but can easily hold off on getting LASIK until the market recovers and somebody who has to have cataract surgery because they have a compromise in visual function "and they're essentially making a decision about the [quality of vision] that they assume they're going to have for the rest of their life."

"So it's one thing to scrimp or to hold off on the purchase for elective refractive surgery, it's quite a different thing to say you're going to save a few hundred or a few thousand dollars at this point in time but forever forgo the ability to do a wide array of functions without glasses," he said. "So I think that there is a very good reason for the lack of sensitivity or the lesser sensitivity of the premium IOL market to the pressures of the day."

When asked to compare the current downturn in refractive surgery to the downturn McLeod experienced in his practice in 2001, McLeod said that the biggest difference is that in 2001 there were still a lot of people across all age ranges who had thought about refractive surgery and decided that was the right time. "Even though there was a slowdown, I think to some extent it was buffered a bit. I'm not seeing the same kind of buffer now," he replied.

Looking ahead, the 2009 refractive surgery market looks "dreadful," McLeod noted, but quickly added, "I'm a pessimist." He said he believes that whatever is happening in the market place will be reflected in the laser-based refractive surgery sector because it is discretionary spending.

Digging deeper into trends of the refractive surgery sector, McLeod said that looking at the distribution of device popularity over the last couple of years what seems to be happening is that while the total market is holding steady, the proportion of the market held by multifocal devices, sold currently by Alcon (Fort Worth, Texas) and Advanced Medical Optics (Santa Ana, California), seems to be slipping a bit and is being picked up by single accommodative devices (Medical Device Daily, Nov. 11, 2008).

He said it is probably because multi-focal lenses do come with some degree of downsides such as glare or halo whereas the main downside of single accommodative devices is that if it doesn't work the patient simply doesn't get to see as well up close as they had hoped.

When asked if there was any new technology presented at the AAO meeting that McLeod thought was particularly neat or that he thinks the ophthalmology community as a whole found particularly interesting, his answer was, essentially, no.

"At present there's more commitment to pulling the devices that seem to have some promise through the pipeline, but no, I actually didn't see anything that's about to break into the market that really represents a paradigm shift."

One area McLeod said would be interesting to watch, however, is the relationship between cornea crosslinking and corneal stability and the risk for keratoconus. He said there is a fairly large group of patients who don't qualify for LASIK surgery because of a thin or elastic cornea. In his own practice, McLeod says he ends up disappointing as many as one in five patients who come in wanting LASIK surgery by telling them it's not safe for them to have the surgery.

It turns out, he said, that there are new techniques being developed which have to do with making the cornea stiffer, which could open up the market of refractive surgery to those patients.