As I watched the Discovery Channel's “Shark Week,” I could not help but think that the great white shark and glaucoma have something in common. Both are feared by those who are familiar with them. For the most part, their presence is unknown as they lurk silently below the water or behind the lens, until the shark attacks without warning or the disease is diagnosed suddenly, leaving the patient afraid of going blind.

RED- AND BLUE-OCEAN MARKETING STRATEGIES

Shark-infested waters can become what is termed a red ocean, when a pod of sharks harm each other as they aggressively converge on a limited supply of food. In medical marketing, a red ocean arises from all of the current technologies, treatments, and markets (eg, laser cataract surgery, cataract surgery with or without premium IOLs, and cosmetic surgery). So many doctors compete in these limited spaces that the cutthroat competition bloodies the waters. A blue ocean, as described by Kim and Mauborgne,1 contains technology, treatments, and markets that have yet to be saturated and that offer an opportunity for rapid, profitable growth in an environment that is low on or free of competition. Glaucoma treatment, I have discovered, represents a blue ocean.

As recently as 2010, I disliked this subspecialty and feared performing trabeculectomies. Essentially, I felt the same way about the disease as my patients do. When my patients needed trabeculectomies or tube shunts, I referred them to the local academic glaucoma service. My lack of enthusiasm for surgical glaucoma treatments was not unusual. Many other general ophthalmologists (and even a few fellowship-trained glaucoma specialists I know) do not look forward to glaucoma surgery in the same way they do cataract surgery.

To be profitable, a blue-ocean strategy requires something that will appeal to the target market that did not previously exist. Although trabeculectomies and tube shunts get patients' IOPs into a desired range, bleb- or tube-dependent surgery does not appeal to most glaucoma patients. (Facebook's glaucoma user groups can be eye opening [pun intended] for those who feel that patients do not mind a bleb.)

IDENTIFYING UNMET NEEDS

At one time, refractive surgery represented a blueocean strategy. It took vision for doctors to perceive that patients would want to surgically address refractive errors. It also took a relatively safe procedure that patients would choose over the inconvenience and cost of wearing spectacles or contact lenses. Today's red ocean of refractive surgery often requires expensive advertisements to draw patients in from outside the practice. What if, instead, we ophthalmologists were able to focus on the unmet needs of patients already in our practices? There would be almost no marketing costs other than those required for educating our existing patients and staff. Glaucoma represents this type of opportunity.

Traditional glaucoma treatment has much in common with the use of spectacles and contact lenses in that it is both inconvenient and expensive. The use of eye drops can produce symptoms ranging in severity from irritating to life threatening. Studies have reported how patients' compliance plummets when they are required to use more than one eye drop.2,3 Selective laser trabeculoplasty is unlikely to get patients off of multiple drops,4 and most glaucoma specialists are not going to offer a trabeculectomy or tube shunt to a patient with otherwise stable glaucoma just because he or she is experiencing side effects or cannot afford eye drops. Microinvasive glaucoma surgeries hold promise for the future, but all of the currently FDA-approved devices require a pseudophakic ocular state or use in combination with cataract surgery, limiting the benefit to many glaucoma patients.

THE SUPPLY-DEMAND SWEET SPOT

Kim and Mauborgne claim that businesses need to shift their focus from supply (traditional glaucoma treatments) to demand (what patients want). It may be easier to identify what glaucoma patients do not want. Generally speaking, they do not want to use eye drops. In a survey of over 200 patients, three-quarters of those using two or more eye drops per day said they were interested in a surgical alternative to topical glaucoma therapy (Figure; data on file with iScience Interventional). How do we ophthalmologists meet this demand?

Canaloplasty has the potential to satisfy these patients. Three-year results on the safety and efficacy of canaloplasty indicated that half of patients who had undergone the procedure no longer required eye drops. When combined with phacoemulsification, the number increased to 78% of patients. Additionally, no eyes lost vision secondary to complications from canaloplasty.5

Within the first year of offering canaloplasty to my patients, my experience with glaucoma surgery changed from referring out a half-dozen patients per year who had to have traditional glaucoma surgery to personally performing canaloplasty on 60 patients who chose to have surgery.

We all have patients in our practices who are essentially “on hold,” because their glaucoma is not clearly progressing while they are on topical therapy but they are having difficulty with cost, compliance, or side effects. In the past, the only available option was to expose these patients to the risks of bleb-dependent surgery (something neither we nor the patient desired). For that reason, most practices already have existing patients who desire a treatment other than maximumtolerated medical therapy that is safer than trabeculectomy or the implantation of a tube shunt. When I made canaloplasty available to this group of patients, their demand drove their acceptance of the newly supplied procedure.

A VALUE INNOVATION

Blue-ocean strategies are built on what are called value innovations. Canaloplasty offers patients something they value, and the iTrack microcatheter (iScience Interventional) is the innovation. Unlike in refractive and cataract surgery, innovative, blebless glaucoma surgeries create a growing and largely untapped market.

Value innovations are rare in most industries. Those of us who discover these blue oceans have a unique opportunity to leapfrog our competition. Given the pent-up demand of patients unhappy with their current glaucoma treatments and the limited number of surgeons currently performing alternatives such as canaloplasty, the blue ocean promises to be a refreshing alternative for both patients and surgeons.

David D. Richardson, MD, is in private practice in Pasadena and San Gabriel, California. He is a consultant to and investor in iScience Interventional. Dr. Richardson may be reached at (626) 289-7856; david.richardson@pasadena-eye.com.

  1. Kim WC, Mauborgne R. Blue Ocean Strategy. Boston:Harvard Business School Press. 2005.
  2. Gurwitz JH, Glynn RJ, Monane M, et al. Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993;83(5):711-716.
  3. Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606.
  4. Allingham R, Damji K, Freedman S, et al, eds. Shields' Textbook of Glaucoma. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2011:457.
  5. Lewis RA, von Wolff K, Tetz M, et al. Canaloplasty: three-year results of circumferential viscodilation and tensioning of Schlemm canal using a microcatheter to treat open-angle glaucoma. J Cataract Refract Surg. 2011;37(4):682-690.