Organising for Success

For Başak Bostancı MD, the goal of ophthalmic practice was always clear.

“From the very beginning of my residency, I knew I wanted to focus on surgical fields that offered rapid, tangible outcomes and high patient satisfaction,” she said. “I became fascinated by the potential of refractive technologies—not only in corneal surgery but also through premium intraocular lenses (IOLs).”

This led Dr Bostancı to focus more and more on refractive and cataract refractive services. After residency, she worked in public care for 4 years before switching to private practice, then university. She implants premium IOLs in about 90% of her cataract cases.

“This role gives me both the clinical freedom and the strategic responsibility to implement state-of-the-art technologies and patient-centred approaches,” Dr Bostancı added. “I provide refractive services primarily in Istanbul, but I also consult internationally and participate in collaborative research and training projects across Europe.”

In addition, Dr Bostancı serves on the faculty of a university hospital. “Sharing innovative diagnostic and treatment algorithms with the next generation keeps me constantly engaged with the latest technologies and evidence. Teaching, for me, is a two-way street—it helps me stay up to date while contributing to the field.”

Emerging trends?

Dr Bostancı may not be alone. Annual clinical trends surveys from ESCRS and The Fundingsland Group show a recent decline in respondents practising primarily at public hospitals from 37% in 2021 to 32% in 2023. Over that same period, those reporting private hospitals as their primary practice site increased from 19% to 21% and those in surgeon-owned clinics from 14% to 16%. Those reporting academic medical centres remained steady at 10%, although pre-pandemic surveys show no trends in these categories.

Similarly, the proportion of eligible patients implanted with ‘premium’ IOLs rose slowly but steadily to 18% for toric and 13% for presbyopia-correcting lenses in 2023, up from 7% for both in 2016.

While not conclusive, these numbers may reflect greater confidence in and acceptance of the efficacy and benefits of refractive surgery—as well as increasing reliance on patient out-of-pocket income.

Indeed, growing worries about declining payment for standard cataract surgery may be another factor. Concerns about reimbursement came in second in a survey of doctors participating in ESCRS’s 2024 iNovation Day. Refractive IOLs were their top innovation investment interest.

“The climate for ophthalmology (particularly for refractive solutions) is dynamic and full of potential in Turkey and Europe,” Dr Bostancı said. “We are seeing a growing awareness of and demand for refractive procedures—not only from younger patients but also those seeking spectacle independence after the age of 40. The population is relatively young and well-informed, which contributes to a receptive and evolving market.”

However, economics, local regulations, and practice culture are big factors, said management consultant Kristine Morrill. “Many places in Europe still don’t allow partial payment for implanting premium lenses in cataract cases. It varies from country to country and within countries that have multiple insurance plans with different reimbursement rules,” including Germany and Italy.

Still, demand for ophthalmic services is growing as the number of ophthalmologists shrinks, Ms Morrill added. As pay for standard cataract surgery declines, some surgeons are turning to growth areas such as intravitreal injections and glaucoma procedures.

But revenue is only half the story, Ms Morrill emphasised. “Every ophthalmologist is going to do well because of the shortage, bringing in a lot of money. But are you charging enough to cover expenses? Are you paying staff enough for them to stick with you and help you grow? You can take home a lot of money, but after expenses, is there anything left? Learning financial management helps you figure it all out.”

Finding a balance between professional and personal goals is critical to overall practice success.

Patient and personal benefits

Reaching private practice professional and personal goals requires constant innovation in technology and workflows. Innovative practice structures can support that, according to Erik L Mertens MD. In 2009, he opened one of the first private ophthalmic clinics in Belgium—and the first private chain in 2018.

He now heads a network of 8 clinics employing more than 55 doctors across the country, with an equity stake in each. Most of the doctors also own shares. A few non-physician investors own a minority of shares and hold 3 of 12 board positions in the mother company, which employs a full-time CEO.

Though his early efforts faced pushback among conservative colleagues, his approach has gained acceptance. For example, the national medical council began allowing non- MD shareholders to invest in medical practices in 2018. “An evolution is underway in Europe that we have already seen in the [US],” Dr Mertens said.

In part, building the network was a risk diversification strategy to fund his eventual retirement—an important personal financial goal given the difficulty in transferring a solo or small group practice to younger partners, Dr Mertens said. “I’d rather have 9% of 8 clinics than 50% of 1 clinic. The financial risk we are carrying is much lower, and it is easier to attract young doctors. They can buy in 1–2% easily and create some value.” Lowering the buy-in cost also makes it possible for younger doctors to work 3–4 days a week, maintaining work-life balance, he added.

But patient service, not financial security, has always been Dr Mertens’ primary goal. He and a partner went out on their own in large part because the public hospital clinic he worked in was inefficient and impersonal. There were plenty of meetings and struggles with the board for control, but they handled only about 2 cataract cases per hour.

“We wanted to deliver a high-quality service—where patients see the same team. My team knows your name; you are not a number like in the hospital,” Dr Mertens said. This reduces patient stress, creating a welcoming, personalised experience that helps improve outcomes while building the practice’s reputation—and economic success.

Focusing on improving patients’ quality of life, Dr Mertens’ Antwerp clinic offers refractive and cataract refractive services in addition to general ophthalmology and glaucoma and retinal treatments. He does a lot of research in IOLs, working closely with industry. The clinic also offers dental and aesthetic care.

Facing rising tech costs

Though the explosion of new ophthalmic technologies enables ever-better refractive outcomes, the cost can be prohibitive. Rather than considering only theoretical financial return, how a new technology improves patient care should guide investment decisions, said Arthur B Cummings.

With new diagnostics, for example, “a more-informed decision gives you confidence. If you provide better results based on better data, ensure a great patient experience, the money will follow,” Dr Cummings said. Essentially, ophthalmologists don’t have to chase it.

Other technology, such as AI-powered records, can dramatically improve practice efficiency, Dr Cummings added. Pulling together all the diagnostic data needed to plan a case now takes seconds rather than minutes or hours, thanks to the implementation of systems that create efficiencies.

Technology is only one part of improving practice efficiency, Dr Cummings said. Staffing and training are also critical. He makes extensive use of optometrists in working up patients. That leaves him more time for surgery. All staff meet regularly to review and improve practice procedures. And once that trained, efficient staff is in place, it makes sense to pay them enough to stick around.

Dr Cummings performs privately paid surgery in his clinic and publicly insured standard cataract procedures in an adjacent hospital. His son Brendan, who shares his goals, has joined the practice.

In marketing his practice, Dr Cummings emphasises selling the result, which is better vision and the subsequent life benefits, rather than the technology. “Sell the destination, not how you will get there.”

Patients may not be eligible for a specific solution, so Dr Cummings markets his assessment services as a ‘lifestyle vision design’ consultation. Factors including age, lifestyle, eye health, anatomy, and physiology are considered before recommending a specific procedure. His entire practice, including training staff, is organised around this approach.

Still, Dr Cummings advised understanding the market before making major investments in new technology. For example, laser vision correction has generally been slow since the pandemic. “You are making a big investment in a flat market.” He noted implantable collamer lenses as a growth area, as are glaucoma and myopia prevention.

Due diligence

Indeed, in these days of stricter underwriting, banks will also look at the market and the practice’s structure and track record before lending, Ms Morrill noted. This makes it difficult for young surgeons to go out on their own. For equipment, leasing can be an attractive option. But she advised to read and run the numbers on any contract, particularly if it is a package deal—including using other products, such as the manufacturer’s IOLs. “You don’t want to end up paying twice as much for your laser.”

Similarly, Ms Morrill recommended caution when dealing with private equity investors. She’s seen several surgeons who sold their practices leave before their service agreements expired. Loss of control to the new owner was usually the cause. “Be sure you know what you are getting into before you sign.”

Başak Bostancı MD, FEBO is an assistant professor of ophthalmology in Bahçeşehir University School of Medicine and cataract and refractive surgeon in Dünyagöz Hospital, Istanbul, Turkey. drbbostanci@gmail.com

Erik L Mertens MD, FEBO, PCEO, FWCRS is founder of, and medical director and ophthalmic surgeon at Medipolis, Antwerp, Belgium. e.mertens@medipolis.be

Arthur B Cummings MMed (Ophth), FCS(SA), FRCS(Edin), FWCRS is an ophthalmologist at the Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland, and Associate Clinical Professor at UCD, Dublin. abc@wellingtoneyeclinic.com