Cost-analysis of Surgical Intraocular Pressure Management in Glaucoma

The Finnish current care guideline for open-angle glaucoma

This article is an English translation of the 4th Finnish Current Care Guideline for diagnostics, treatment and follow-up of primary open-angle glaucoma, normal-tension glaucoma and pseudoexfoliative glaucoma. This guideline is based on systematic literature reviews and expert opinions with Finland's geographical and operational healthcare environment in mind.

Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

Cyclophotocoagulation as a Minimally Invasive Treatment Option for Glaucoma

Historically, the complications and inadequate efficacy of prior cyclodestructive procedures limited their role in glaucoma management. Recent advances in treatment techniques and parameters for laser cyclophotocoagulation has expanded its role in today's glaucoma practice. This review summarizes the role of different cyclophotocoagulation techniques, including continuous wave transscleral cyclophotocoagulation and micropulse transscleral cyclophotocoagulation, in the management of glaucomatous optic neuropathy.

A Review of Cost-Effectiveness Analyses for Open Angle Glaucoma Management

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.

One-year costs of incisional glaucoma surgery and laser therapy

BACKGROUND

This study aimed to calculate one-year total costs of incisional glaucoma surgery and laser therapy in a real-world clinical setting.

METHODS

We conducted a retrospective cohort study from July 2010 to March 2021 using the Diagnosis Procedure Combination database. We included patients hospitalized for incisional glaucoma surgery (trabeculectomy, trabeculotomy, tube shunt surgery, Ex-PRESS surgery, or iStent implantation) or laser therapy (laser peripheral iridotomy, surgical iridectomy, laser trabeculoplasty, cyclocryotherapy, or cyclophotocoagulation). The outcomes were total costs, including costs of hospitalization, re-admissions, antiglaucoma drugs, ophthalmic examinations, and outpatient visits for incisional glaucoma surgery and laser therapy within one year.

RESULTS

We identified 49,202 eligible hospitalizations. The one-year median total cost was 707,497 yen [interquartile range: 546,887-944,664 yen]. The median total cost was the highest in patients undergoing tube shunt surgery, followed by Ex-PRESS surgery, iStent implantation, and trabeculectomy. The number and cost of postoperative outpatient visits and length of hospital stay were higher in patients who underwent trabeculectomy and Ex-PRESS surgery than in those after tube shunt surgery. The total costs of laser therapies were lower than those of incisional glaucoma surgeries. The total cost was the highest in the 0-19 age group (856,398 [649,419-1,258,844] yen).

CONCLUSIONS

Tube shunt surgery was the costliest in terms of total one-year costs. Trabeculectomy and Ex-PRESS surgery were associated with long hospital stays and incurred high postoperative costs. The costs of laser therapies were relatively low. However, cost-effectiveness of laser therapies compared with incisional surgeries needs to be analyzed in future research.

Clinical outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation laser for treatment of glaucoma

PURPOSE OF REVIEW

The complications and inadequate efficacy of prior cyclodestructive procedures limited their role in glaucoma management. Recent advances in treatment techniques and parameters for laser cyclophotocoagulation has expanded its role in today's glaucoma practice. In this review, we discuss the treatment outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) as a glaucoma surgical procedure for multiple types of glaucoma in lowering intraocular pressure (IOP).

RECENT FINDINGS

Slow-coagulation TSCPC is a relatively new technique for CW-TSCPC that, unlike the 'pop' power titration technique of laser energy delivery, aims to avoid the production of the 'pop' sound that signals explosive inflammatory energy delivery to the ciliary body and nearby tissue. In slow-coagulation TSCPC, laser energy is applied in a fixed and lower amount over a longer duration, compared with the conventional pop technique. This laser energy approach leads to more stable, reliable, titratable, and selective ciliary body ablation for control of IOP, especially relative to the controversial current use of micropulse TSCPC.

SUMMARY

Slow-coagulation CW-TSCPC can be used safely, efficiently, reproducibly, and efficaciously in wide range of glaucoma types including those with no history of incisional surgeries, good visual acuity, and medically refractory glaucomas.

Comparison of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification in primary open-angle glaucoma: a retrospective in vivo confocal microscopy study

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.

Incremental Health Care Expenditures Associated With Glaucoma in the United States: A Propensity Score-matched Analysis

PRCIS

Adjusting for sociodemographics and comorbidities, patients with glaucoma incur an annual incremental economic burden of $1863.17, translating to $9.2 billion nationally. When analyzed by the health care service sector, prescription medication expenditures were higher for glaucoma patients.

PURPOSE

The purpose of this study was to estimate the incremental health care burden, defined as attributable costs solely due to a diagnosis, of patients with diagnosed glaucoma, controlling for comorbidities, and sociodemographics.

DESIGN

A retrospective cross-sectional analysis of Medical Expenditure Panel Survey (MEPS) participants (age above 18 y) between 2016 and 2018.

METHODS

A cross-validated 2-part generalized linear regression model estimated the incremental glaucoma expenditures in aggregate and by sociodemographic subgroups and health care service sector [inpatient, outpatient (including surgical procedures), emergency room, home health, and medications] after 1:3 propensity matching.

RESULTS

After 1:3 propensity matching for sociodemographics and the Charlson Comorbidity Index, this study analyzed 1521 glaucoma patients (mean expenditures: $13,585.68±1367.03) and 4563 patients without glaucoma (mean expenditures: $12,048.92±782.49). A higher proportion of glaucoma patients are female, elderly, publicly insured (Medicare/Medicaid), college educated, identify ethnically as non-Hispanic, reside in the Northeast, and have more comorbidities (P<0.001). There were no differences in health care burden based on sex, income, insurance status, education, and year of care received for patients with glaucoma. Controlling for comorbidities and socioeconomic factors, propensity-matched glaucoma patients incur an annual incremental health care burden of $1863.17 (95% confidence interval, 393.44-3117.23, P=0.013), translating into an additional $9.2 billion in population-level US health care expenditures. By health care service sector, the expenditure ratio for health care expenditures was higher for prescription medications (expenditure ratio=1.20, 95% confidence interval, 1.02-1.42, P=0.031).

CONCLUSIONS

Glaucoma patients have a substantial incremental economic health care burden after accounting for demographics and comorbidities, largely secondary to prescription medications. There is a need to continue identifying and studying treatment options for patients with glaucoma to maintain vision while minimizing health care expenditures.