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Lee TC, Fung SE, Hu JQ, Villatoro GA, Park KS, Fung BM, Groessl EJ, Korn BS, Kikkawa DO, Liu CY. Is Blepharoplasty Cost-effective? Utility Analysis of Dermatochalasis and Cost-effectiveness Analysis of Upper Eyelid Blepharoplasty. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00366. [PMID: 38534072 DOI: 10.1097/iop.0000000000002649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
PURPOSE This cross-sectional prospective study measured utility values of upper eyelid dermatochalasis to quantify its impact on quality of life and assess cost-effectiveness of upper blepharoplasty. METHODS Utility of dermatochalasis was assessed using the standard reference gamble and time trade-off methods, with dual anchor points of perfect eye function and perfect health. The utility value obtained was used to create a Markov model and run a cost-effectiveness analysis of blepharoplasty as a treatment for dermatochalasis while utilizing the societal perspective. RESULTS One hundred three patients with dermatochalasis recruited from an urban outpatient ophthalmology clinic completed the utility survey. The authors determined utility values for dermatochalasis ranging from 0.74 to 0.92 depending on the measurement method (standard reference gamble/time trade-off) and anchor points. The cost-effectiveness analysis yielded an incremental cost-effectiveness ratio of $3,146 per quality-adjusted life year, well under the conventional willingness-to-pay threshold of $50,000 per quality-adjusted life year. Probabilistic sensitivity analysis with Monte Carlo simulation demonstrated that blepharoplasty would be cost-effective in 88.1% of cases at this willingness-to-pay threshold. CONCLUSIONS Dermatochalasis has an impact on quality of life that is significantly associated with level of perceived functional impairment. Rising health care costs have underscored the importance of providing value-based treatment to patients, and the results of this study suggest that blepharoplasty is a cost-effective treatment option for symptomatic bilateral upper eyelid dermatochalasis.
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Affiliation(s)
- Tonya C Lee
- Department of Ophthalmology, University of California, San Diego School of Medicine, La Jolla, California, U.S.A
| | - Sammie E Fung
- Department of Ophthalmology, University of California, San Diego School of Medicine, La Jolla, California, U.S.A
| | - Jenny Q Hu
- Viterbi Family Department of Ophthalmology, UC San Diego, San Diego, California, U.S.A
| | - George A Villatoro
- Viterbi Family Department of Ophthalmology, UC San Diego, San Diego, California, U.S.A
| | - Kathryn S Park
- Department of Ophthalmology, University of California, San Diego School of Medicine, La Jolla, California, U.S.A
| | - Brian M Fung
- Department of Ophthalmology, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, U.S.A
| | - Erik J Groessl
- Department of Family Medicine and Public Health, University of California, San Diego Herbert Wertheim School of Public Health, La Jolla, California, U.S.A
- Department of Behavioral Science, UC San Diego Health Services Research Center, San Diego, California, U.S.A
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, UC San Diego
- Division of Plastic Surgery, Department of Surgery, UC San Diego, La Jolla, California, U.S.A
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, UC San Diego
- Division of Plastic Surgery, Department of Surgery, UC San Diego, La Jolla, California, U.S.A
| | - Catherine Y Liu
- Viterbi Family Department of Ophthalmology, UC San Diego, San Diego, California, U.S.A
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, UC San Diego
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Bedrood S, Berdahl J, Sheybani A, Singh IP. Alternatives to Topical Glaucoma Medication for Glaucoma Management. Clin Ophthalmol 2023; 17:3899-3913. [PMID: 38111854 PMCID: PMC10726774 DOI: 10.2147/opth.s439457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/22/2023] [Indexed: 12/20/2023] Open
Abstract
Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life.
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Affiliation(s)
| | | | - Arsham Sheybani
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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3
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Radcliffe NM, Shah M, Samuelson TW. Challenging the "Topical Medications-First" Approach to Glaucoma: A Treatment Paradigm in Evolution. Ophthalmol Ther 2023; 12:2823-2839. [PMID: 37855977 PMCID: PMC10640619 DOI: 10.1007/s40123-023-00831-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/29/2023] [Indexed: 10/20/2023] Open
Abstract
Topical glaucoma medications are effective and safe, but they have numerous well-documented limitations that diminish their long-term utility and sustainability. These limitations can include high rates of nonadherence (with associated glaucoma progression), concerning side effects, inconsistent circadian intraocular pressure (IOP) control, complex dosing regimens, difficulty with self-administration, costs, and decreased quality of life. Despite these limitations, topical medications traditionally have been first-line in the glaucoma treatment algorithm, as no other minimally invasive treatment alternatives existed. In recent years, however, novel interventional therapies-including sustained-release drug-delivery platforms, selective laser trabeculoplasty, and micro-invasive glaucoma surgery procedures-have made it possible to intervene earlier without relying on topical medications. As a result, the topical medication-first treatment approach is being reevaluated in an overall shift toward earlier more proactive interventions.
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Affiliation(s)
- Nathan M Radcliffe
- New York Eye Surgery Center, 1101 Pelham Parkway North, Bronx, NY, 10469, USA.
| | - Manjool Shah
- New York University (NYU) Langone Health, New York, NY, USA
| | - Thomas W Samuelson
- Minnesota Eye Consultants, University of Minnesota, Minneapolis, MN, USA
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Sood S, Iskander M, Heilenbach N, Chen D, Al-Aswad LA. A Review of Cost-Effectiveness Analyses for Open Angle Glaucoma Management. J Glaucoma 2023; 32:619-630. [PMID: 37311022 DOI: 10.1097/ijg.0000000000002249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/13/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Cost-effectiveness analyses (CEAs) quantify and compare both costs and measures of efficacy for different interventions. As the costs of glaucoma management to patients, payers, and physicians are increasing, we seek to investigate the role of CEAs in the field of glaucoma and how such studies impact clinical management. METHODS We adhered to the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines for our systematic review structure. Eligible studies included any full-text articles that investigated cost-effectiveness or cost-utility as it relates to the field of open angle glaucoma management in the United States. Risk of bias assessment was conducted using the validated Joanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations. RESULTS Eighteen studies were included in the review. Dates of publication ranged from 1983 to 2021. Most of the studies were published in the 2000s and performed CEAs in the domains of treatment/therapy, screening, and adherence for patients with primary angle open glaucoma. Of the 18 articles included, 14 focused on treatment, 2 on screening, and 2 on adherence. Most of these studies focused on the cost-effectiveness of different topical medical therapies, whereas only a few studies explored laser procedures, surgical interventions, or minimally invasive procedures. Economic models using decision analysis incorporating state-transition Markov cycles or Montecarlo simulations were widely used, however, the methodology among studies was variable, with a wide spectrum of inputs, measures of outcomes, and time horizons used. CONCLUSION Overall, we found that cost-effectiveness research in glaucoma in the United States remains relatively unstructured, resulting in unclear and conflicting implications for clinical management.
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Affiliation(s)
- Shefali Sood
- Department of Ophthalmology, Georgetown University School of Medicine, Washington, DC
| | - Mina Iskander
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Noah Heilenbach
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY
| | - Dinah Chen
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY
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Chang AC, Zebardast N. Is Prophylactic Laser Peripheral Iridotomy Cost Effective? Maybe Not. Ophthalmol Glaucoma 2023; 6:323-324. [PMID: 37061913 DOI: 10.1016/j.ogla.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023]
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Sood S, Sanchez V, Heilenbach N, Al-Aswad LA. Cost-effectiveness of Prophylactic Laser Peripheral Iridotomy in Primary Angle-Closure Suspects. Ophthalmol Glaucoma 2023; 6:332-341. [PMID: 37212626 DOI: 10.1016/j.ogla.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 05/23/2023]
Abstract
PURPOSE To investigate the cost-effectiveness (CE) of prophylactic laser peripheral iridotomy (LPI) in primary angle-closure (PAC) suspects (PACSs). DESIGN Cost-effectiveness analysis utilizing Markov models. SUBJECTS Patients with narrow angles (PACSs). METHODS Progression from PACSs through 4 states (PAC, PAC glaucoma, blindness, and death) was simulated using Markov cycles. The cohort entered at 50 years and received either LPI or no treatment. Transition probabilities were calculated from published models, and risk reduction of LPI was calculated from the Zhongshan Angle Closure Prevention trial. We estimated costs of Medicare rates, and previously published utility values were used to calculate quality-adjusted life year (QALY). Incremental CE ratios (ICER) were evaluated at $50 000. Probabilistic sensitivity analyses (PSAs) addressed uncertainty. MAIN OUTCOME MEASURES Total cost, QALY, and ICER. RESULTS Over 2 years, the ICER for the LPI cohort was > $50 000. At 6 years, the LPI cohort was less expensive with more accrued QALY. In PSA, the LPI arm was cost-effective in 24.65% of iterations over 2 years and 92.69% over 6 years. The most sensitive parameters were probability of progressing to PAC and cost and number of annual office visits. CONCLUSIONS By 6 years, prophylactic LPI was cost-effective. The rate of progressing to PAC and differing practice patterns most impacted CE. With uncertainty of management of narrow angles, cost may be a decision management tool for providers. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Shefali Sood
- Department of Ophthalmology, Georgetown University School of Medicine, Washington, District of Columbia
| | - Victor Sanchez
- Department of Ophthalmology, Grossman School of Medicine, New York University, New York, New York
| | - Noah Heilenbach
- Department of Ophthalmology, Grossman School of Medicine, New York University, New York, New York
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Longo R, Ghinelli F, Torelli F, Mader G, Masseria C, Patel C, Franic DM, Dickerson J, Nguyen D, Cantor L. OMNI® surgical system versus iStent inject® with concomitant cataract surgery for the treatment of mild-to-moderate primary open-angle glaucoma in the United States: a cost utility analysis. EXPERT REVIEW OF OPHTHALMOLOGY 2023. [DOI: 10.1080/17469899.2023.2193685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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8
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Cantor L, Lindfield D, Ghinelli F, Świder AW, Torelli F, Steeds C, Dickerson Jr JE, Nguyen DQ. Systematic Literature Review of Clinical, Economic, and Humanistic Outcomes Following Minimally Invasive Glaucoma Surgery or Selective Laser Trabeculoplasty for the Treatment of Open-Angle Glaucoma with or Without Cataract Extraction. Clin Ophthalmol 2023; 17:85-101. [PMID: 36636619 PMCID: PMC9831079 DOI: 10.2147/opth.s389406] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery. Methods This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated. Results A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from -31% to -13.7% at month 6 and from -39% to -11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified. Conclusion Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness.
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Affiliation(s)
- Louis Cantor
- Eugene and Marilyn Glick Eye Institute, Indiana School of Medicine, Indianapolis, IN, USA
| | - Dan Lindfield
- Royal Surrey County Hospital, Guildford, England, UK
| | | | | | - Francesca Torelli
- Valid Insight, Macclesfield, England, UK,Correspondence: Francesca Torelli, Valid Insight, Ropewalks, Newton St, Macclesfield, SK11 6QJ, UK, Tel +44 203 750 9833 Ext 703, Email
| | | | - Jaime E Dickerson Jr
- Sight Sciences, Menlo Park, CA, USA,North Texas Eye Research Institute, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Dan Q Nguyen
- Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UK
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Comparative Cost-effectiveness of Trabeculectomy versus MicroShunt in the US Medicare System. Ophthalmology 2022; 129:1142-1151. [PMID: 35636620 DOI: 10.1016/j.ophtha.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To assess the societal cost-utility of the MicroShunt compared with trabeculectomy for the surgical management of glaucoma in the US Medicare system. DESIGN Cost-utility analysis using efficacy and safety results of a randomized controlled trial and other pivotal clinical trials. PARTICIPANTS Markov model cohort of patients with open-angle glaucoma. METHODS Open-angle glaucoma treatment costs and effects were analyzed with a deterministic model over a 1-year horizon using TreeAge software. Health states included the Hodapp-Parrish-Anderson glaucoma stages (mild, moderate, advanced, blind) and death. Both treatment arms received additional ocular hypotensive agents to control intraocular pressure (IOP). Treatment effect was measured as mean number of ocular hypotensive medications and reduction in IOP, which had a direct impact on transition probabilities between health states. Analyses of scenarios were performed with longer time horizons. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the impact of alternative model inputs. Both treatment arms were subject to reported complication rates, which were factored in the model. MAIN OUTCOME MEASURES Incremental cost per quality-adjusted life-year (QALY) gained. RESULTS At 1 year, the MicroShunt had an expected cost of US dollars (USD) 6318 compared with USD 4260 for trabeculectomy. MicroShunt patients gained 0.85 QALYs compared with 0.86 QALYs for trabeculectomy, resulting in a dominated incremental cost-utility ratio of USD 187 680. Dominance is a health economic term used to describe a treatment option that is both more costly and less effective than the alternative. The MicroShunt remained dominant in 1-way sensitivity analyses using best-case input parameters (including a device fee of USD 0). At a willingness-to-pay threshold of USD 50 000, the likelihood of the MicroShunt being cost-effective was 6.4%. Dominance continued in longer time horizons, up to 20 years. CONCLUSIONS Trabeculectomy appears to be a dominant treatment strategy over the MicroShunt in the surgical management of glaucoma. More independent, long-term studies are required for the MicroShunt and other subconjunctival microstent devices to evaluate their use in clinical practice.
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Hu R, Guo D, Hong N, Xuan X, Wang X. Comparison of Hydrus and iStent microinvasive glaucoma surgery implants in combination with phacoemulsification for treatment of open-angle glaucoma: systematic review and network meta-analysis. BMJ Open 2022; 12:e051496. [PMID: 35705355 PMCID: PMC9204447 DOI: 10.1136/bmjopen-2021-051496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To compare the efficacy and safety of two Schlemm's canal-based microinvasive glaucoma surgery (MIGS) devices, the Hydrus Microstent and the iStent Trabecular Bypass combined with phacoemulsification for treatment of open-angle glaucoma. DESIGN Systematic review and network meta-analysis. METHODS Literature searches were conducted on PubMed, Web of Science, Cochrane Library and ClinicalTrials.gov to identify randomised controlled trials (RCTs) assessing the Hydrus or the iStent implantation combined with phacoemulsification for treatment of open-angle glaucoma until September 2020. Risk of bias was assessed using a six-item modified Jadad scale. Effects were estimated using the intraocular pressure (IOP) reduction (IOPR), the percentage of IOPR and the proportion of medication-free patients at follow-up end. Safety was estimated using the proportions of adverse events. The network meta-analysis was conducted within a Bayesian framework using the Markov Chain Monte Carlo method in ADDIS software. RESULTS Six prospective RCTs comprising 1397 patients were identified. Regarding the absolute value and the percentage of IOPR, the Hydrus and 2-iStent implantation combined with phacoemulsification were significantly more effective than phacoemulsification alone. Rank probability analysis revealed the Hydrus might be the best choice to lower IOP. There was no significant difference in the proportion of medication-free patients among groups. The Hydrus and 2-iStent implantation had a higher probability to achieve the medication-free status versus the 1-iStent implantation and phacoemulsification alone. Overall safety profiles were good for each device with the focal peripheral anterior synechiae more frequently reported in Hydrus eyes. CONCLUSIONS The Hydrus implantation may have a slight advantage over the 1-iStent or 2-iStent implantation in combination with phacoemulsification to treat open-angle glaucoma. Our findings might be of some uncertainty due to the limited included data. Further studies are needed to investigate whether our findings are robust, including high-quality RCTs to directly compare these MIGS devices.
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Affiliation(s)
- Rongrong Hu
- Department of Ophthalmology, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Dongyu Guo
- Department of Ophthalmology, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Nan Hong
- Department of Ophthalmology, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Xiuyuan Xuan
- Department of Ophthalmology, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Xiaoyu Wang
- Department of Ophthalmology, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
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Elhusseiny AM, Yannuzzi NA, Khodeiry MM, Lee RK, Smiddy WE. Response to Letter to the Editor: Cost-analysis of Surgical Intraocular Pressure Management in Glaucoma. J Glaucoma 2022; 31:e12-e13. [PMID: 34954749 DOI: 10.1097/ijg.0000000000001974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Sood S, Chen D, Al-Aswad LA. Letter to the Editor: Cost-analysis of Surgical Intraocular Pressure Management in Glaucoma. J Glaucoma 2022; 31:e11-e12. [PMID: 34954750 DOI: 10.1097/ijg.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shefali Sood
- Departments of Ophthalmology
- Wagner School of Public Policy New York University
| | - Dinah Chen
- Department of Ophthalmology, NYU Langone Health, New York, NY
| | - Lama A Al-Aswad
- Departments of Ophthalmology
- Population Health, Grossman School of Medicine
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13
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Ahmed IIK, De Francesco T, Rhee D, McCabe C, Flowers B, Gazzard G, Samuelson TW, Singh K. Long term outcomes from the HORIZON randomized trial for a Schlemm's canal microstent in combination cataract and glaucoma surgery. Ophthalmology 2022; 129:742-751. [PMID: 35218867 DOI: 10.1016/j.ophtha.2022.02.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE 5-year results of the HORIZON trial comparing cataract surgery combined with an intracanalicular microstent to cataract surgery alone. DESIGN Prospective, multicenter, controlled randomized clinical trial. PARTICIPANTS Patients with cataract and POAG treated with ≥ 1 glaucoma medication, washed out diurnal intraocular pressure (DIOP) 22-34 mmHg and no prior incisional glaucoma surgery. METHODS Eyes were randomized 2:1 to receive a Hydrus® Microstent (Ivantis, Inc.) or no stent after successful cataract surgery. Follow-up was conducted through 5 years postoperatively. MAIN OUTCOME MEASURES IOP, glaucoma medication usage, repeat glaucoma surgery, visual acuity, visual field, procedure related adverse events, and corneal endothelial cell counts. RESULTS 369 eyes were randomized to microstent treatment (HMS) and 187 to cataract surgery only (CS). Study groups were well matched for preoperative IOP, medication usage, washed out DIOP, and glaucoma severity. Five year follow up was completed in 80% of patients. At 5 years, the HMS group had a higher proportion of eyes with IOP ≤18 mmHg without medications compared to CS (49.5% vs. 34.8%, p=0.003) as well as a greater likelihood of IOP reduction of ≥ 20% without medications compared to CS alone (54.2% vs. 32.8%, p<0.001). The number of glaucoma medications was 0.5 ± 0.9 in the HMS group and 0.9 ± 0.9 in the CS group (p<0.001), and 66% of eyes in the HMS group were medication free compared to 46% in the CS group (p<0.001). The cumulative risk of incisional glaucoma surgery was lower in the HMS group (2.4% vs. 6.2%, log-rank p=0.027). There was no clinical or statistically significant difference in the rate of endothelial cell loss from 3 months to 60 months between the HMS and CS groups (p=0.261). Visual acuity did not differ between groups, and there was no difference in long term postoperative adverse events. CONCLUSIONS The addition of a Schlemm's canal microstent in conjunction with cataract surgery was safe, resulted in lowered IOP and medication use, and reduced the need for postoperative incisional glaucoma filtration surgery compared to cataract surgery alone after 5 years. Long term presence of the implant did not adversely affect the corneal endothelium.
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Affiliation(s)
- Iqbal Ike K Ahmed
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Ticiana De Francesco
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Clinica de Olhos De Francesco, Fortaleza, Brazil & Hospital de Olhos Leiria de Andrade (HOLA), Fortaleza, Brazil.
| | - Douglas Rhee
- Case Western Reserve University Hospitals, Cleveland, Ohio
| | | | | | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, and Institute of Ophthalmology, University College London, London, United Kingdom
| | - Thomas W Samuelson
- Minnesota Eye Consultants, University of Minnesota, Minneapolis, Minnesota
| | - Kuldev Singh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
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Zhang Y, He B, Zhang Y, Zeng J, Chen Y, Niu Y, Yu H, Qin Y, Zhang H. Comparison of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification in primary open-angle glaucoma: a retrospective in vivo confocal microscopy study. EYE AND VISION (LONDON, ENGLAND) 2022; 9:7. [PMID: 35151343 PMCID: PMC8841063 DOI: 10.1186/s40662-022-00278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 01/12/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND To compare the efficacy of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification. METHODS A retrospective 12-month study on patients with coincident primary open-angle glaucoma (POAG) and cataract. The patients underwent combined phacoemulsification and Ex-PRESS implant (Phaco-ExPRESS, n = 35) or phacotrabeculectomy (Phaco-Trab, n = 35). The morphological structures of the filtering bleb were examined by slit-lamp, anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM). Complete success was defined as postoperative intraocular pressure (IOP) < 18 mmHg without the use of anti-glaucoma medication. Qualified success was defined as postoperative IOP < 18 mmHg with or without anti-glaucoma medications. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, and 12 months. RESULTS No significant difference in the variables such as age, IOP and perimetry was found between the groups of Phaco-ExPRESS and Phaco-Trab. At the one-year postoperative visit for filtering blebs, Phaco-ExPRESS increased the mean area of epithelial microcysts significantly from 0.10 ± 0.05 to 0.20 ± 0.09 μm2 per μm2, while Phaco-Trab decreased the mean area significantly from 0.08 ± 0.04 to 0.04 ± 0.06 μm2 per μm2. Notably, the hyperreflective dots detected by IVCM decreased by 84.9% in Phaco-ExPRESS but increased by 36.3% in Phaco-Trab. The hyperreflective dots were further identified as neutrophil- and monocyte-like cells. The number of these cells were negatively correlated with the microcysts area (r = - 0.7, P < 0.01) but positively associated with the grade of connective tissue (r = 0.5, P < 0.01). By creating different microstructural changes in the filtering blebs, Phaco-ExPRESS produced a higher complete success rate (84.9% vs. 41.2%, P < 0.01) and significant decrease in the number of anti-glaucoma medications (P < 0.01) when compared with those in Phaco-Trab. However, the qualified success showed no significant difference between the two groups (100.0% vs. 91.2%, P = 0.24). CONCLUSIONS At the one-year follow-up, Phaco-ExPRESS generated better filtering bleb with larger area of microcysts, looser connective tissues, and less inflammation than that of Phaco-Trab, providing adequate IOP control and less IOP-lowering medications. These findings indicate that Phaco-ExPRESS could be more preferred than Phaco-Trab for the treatment of patients with coincident POAG and cataract.
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Affiliation(s)
- Yuqiao Zhang
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, China
| | - Beiting He
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
- Department of Ophthalmology, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yulin Zhang
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, China
| | - Jin Zeng
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yanlei Chen
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Yongyi Niu
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Honghua Yu
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Yongjie Qin
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China.
| | - Hongyang Zhang
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, No. 106 Zhongshan Er Road, Guangzhou, 510080, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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