Glaucoma in the United States and europe: predicting costs and surgical rates based upon stage of disease

The Significance of Screening Family Members in Glaucoma: Opportunities and Challenges

PRECIS

This article delves into the imperative of screening family members of patients with glaucoma due to the disease's hereditary nature. It discusses the significant risks faced by first-degree relatives, approaches for identification, and challenges in implementing effective screening strategies. Emphasizing education, targeted campaigns, community involvement, and collaborative healthcare approaches, the article highlights the potential for mitigating undiagnosed glaucoma cases through strategic interventions targeting high-risk individuals.

PURPOSE

This article underscores the importance of screening family members of glaucoma patients, emphasizing the hereditary nature of the disease and the potential for screening to allow for early intervention to help prevent unnecessary vision loss.

METHODS/RESULTS

Glaucoma, affecting over 111.8 million by 2040, is relatively asymptomatic until late in the disease. Genetics predispose to glaucoma, with up to 70% heritability. High-risk individuals, particularly first-degree relatives, exhibit substantially elevated glaucoma risks-up to 22% compared with 2.3% in controls. Family history also correlates with greater disease severity. Identifying high-risk family members through cascade screenings for causative genes or direct examinations during proband visits emerges as efficient strategies. Challenges persist, including slow progression, healthcare accessibility, and ethical dilemmas in implementing family member screening. Challenges extend to the healthcare system, socioeconomic barriers, and familial communication issues. Efforts to educate probands and the public on the hereditary nature of glaucoma are pivotal. Tailored education campaigns, leveraging clinic visits, and community screenings, complemented by optometrist collaboration, form essential strategies.

CONCLUSIONS

Although challenges hinder family member screening, educating probands, targeted patient education, collaborative healthcare approaches, and community involvement offer promising avenues to combat undiagnosed glaucoma cases.

Knowledge, attitude, and practice (KAP) towards glaucoma among new glaucoma patients and their first-degree relatives: A cross-sectional study in a tertiary eye care centre in Riyadh, Saudi Arabia

PURPOSE

Glaucoma, a disease characterized by optic nerve damage and associated visual field defects, is the main cause of irreversible loss of vision, both globally and locally. Appropriate management of glaucoma involves early diagnosis in addition to early and continuous control of the disease to protect the optic nerve from further damage. This study aimed to assess the knowledge, attitude, and practice (KAP) towards glaucoma among patients making their first visit to the glaucoma clinics, at King Khaled Eye Specialist Hospital in Riyadh, and their first-degree relatives.

METHODS

This cross-sectional study used self-administered questionnaires. Informed consent was obtained prior to questionnaire distribution. The questionnaire included four sections on sociodemographic data, and awareness, and KAP towards glaucoma.

RESULTS

Overall, 120 participants were included in our study: 70 (58.3%) were glaucoma patients and 50 (41.7%) were first-degree relatives. Forty-four (62.9%) participants in the patient group and 39 (78%) in the relative group were men. Thirty-four (48.6%) patients were aged 41-65 years, whereas 41 (82%) relatives were aged 18-40 years. Thirty-six patients (52.2%) and 35 relatives (70%) had heard of the term 'glaucoma'. The correct definition of glaucoma was selected by only 12 participants (17.1%) in the patient group and 4 (8.2%) in the relative group. Living outside the central region of Saudi Arabia and having a negative systemic medical history were associated with poorer knowledge of glaucoma definition (p < 0.05). Although 84.8% of patients believed that compliance with anti-glaucoma medications helps in disease control, only 22.7% reported good compliance. The correct method of instilling eye drops was stated by 43.9% of the patients, and good hospital visit habits were reported by 53.03%. Eighty percent of glaucoma patients strongly recommended that their first-degree relatives be screened for glaucoma.

CONCLUSION

Knowledge about glaucoma is still limited, and awareness programs need to be further activated to spread correct knowledge about the nature of glaucoma, the importance of compliance with treatment, the correct method of instilling eye drops, and the significance of screening at-risk individuals. Patient families should also be involved in educational programs.

Cost-utility analysis of treating mild stage normal tension glaucoma by surgery in China: a decision-analytic Markov model

BACKGROUND

Many individuals suffer from normal tension glaucoma (NTG) in China. This study utilized Markov models to evaluate the cost-utility of applying many medications and surgery for mild-stage NTG when disease progression occurred at a mild stage.

METHODS

A 10-year decision-analytic Markov model was developed for the cost-utility analysis of treating mild-stage NTG with surgery and increased application of medication. We hypothesized that all 100,000 samples with a mean age of 64 were in mild stages of NTG. Transitional probabilities from the mild to moderate to severe stages and the basic parameters acquired from the CNTGS were calculated. Incremental cost-utility ratios (ICUR) were calculated for treating all patients with NTG by probabilistic sensitivity analysis (PSA) and Monte Carlo simulation. One-way sensitivity analysis were conducted by adjusting the progression rate, cost of medications or trabeculectomy, cost of follow-up, and surgical acceptance rate.

RESULTS

The ICUR of treating mild stage NTG with medication over 10 years was $12743.93 per quality-adjusted life years (QALYs). The ICUR for treating mild stage NTG patients with a 25% and 50% surgery rate with medication were $8798.93 and $4851.93 per QALYs, respectively. In this model, the cost-utility of treating NTG was sensitive to disease progression rate, surgical treatment rate, and medication costs.

CONCLUSIONS

According to the results of the cost-utility analysis, it was a reasonable and advantageous strategy to administer a lot of medication and surgery for NTG in the mild stages of the disease. In the model, the greater the probability of patients undergoing surgery, the strategy becomes more valuable.

Teleophthalmology and retina: a review of current tools, pathways and services

Telemedicine, the use of telecommunication and information technology to deliver healthcare remotely, has evolved beyond recognition since its inception in the 1970s. Advances in telecommunication infrastructure, the advent of the Internet, exponential growth in computing power and associated computer-aided diagnosis, and medical imaging developments have created an environment where telemedicine is more accessible and capable than ever before, particularly in the field of ophthalmology. Ever-increasing global demand for ophthalmic services due to population growth and ageing together with insufficient supply of ophthalmologists requires new models of healthcare provision integrating telemedicine to meet present day challenges, with the recent COVID-19 pandemic providing the catalyst for the widespread adoption and acceptance of teleophthalmology. In this review we discuss the history, present and future application of telemedicine within the field of ophthalmology, and specifically retinal disease. We consider the strengths and limitations of teleophthalmology, its role in screening, community and hospital management of retinal disease, patient and clinician attitudes, and barriers to its adoption.

Recent Trends in Treatment and Associated Costs of Primary Angle-Closure Glaucoma: A Retrospective Cohort Study

PURPOSE

To describe recent trends in the treatment for primary angle-closure glaucoma (PACG) and its associated costs in a clinical setting.

DESIGN

A retrospective cohort study.

SUBJECTS

We included patients with PACG from 2011 to 2020 using a large-scale administrative claims database in Japan.

METHODS

We calculated the frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries, stratified by fiscal years and age groups.

MAIN OUTCOME MEASURES

Frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries.

RESULTS

We identified 5654 patients with PACG (15 338 patient-years). Prostanoid FP receptor agonist, nonselective β-blocker, and topical carbonic anhydrase inhibitor use decreased, whereas prostanoid EP2 receptor agonist, α-2 adrenergic agonist, Rho-associated protein kinase inhibitor, and fixed-combination eyedrops use increased. The total amount of drug per patient-year significantly decreased. In recent years, the frequency of cataract surgery increased, whereas that of laser peripheral iridotomy decreased. Visual field testing, slit-lamp examination, intraocular pressure measurement, and funduscopy were performed 0.83, 6.65, 5.15, and 4.61 times/patient-year, respectively. The total cost of drugs, examinations, and surgeries was 60 338 yen per patient-year. Patients with PACG spent more than twice the money on surgeries and examinations than they did on antiglaucoma drugs.

CONCLUSION

The amount of antiglaucoma drugs dispensed decreased, and the proportion of fixed-combination and newly introduced eyedrops increased. Frequency of cataract surgery increased whereas that of laser peripheral iridotomy decreased in recent years. Surgeries and examinations were the major cost drivers for PACG treatment. The current results would be valuable information for future economic analyses and policy making.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Glaucoma Suspects: The Impact of Risk Factor-Driven Review Periods on Clinical Load, Diagnoses, and Healthcare Costs

Purpose

To model the healthcare impact (clinical attendance time and financial cost) and clinical outcomes (glaucoma diagnoses) of different risk factor–driven review frequencies for glaucoma suspect patients up until the point of discharge or diagnosis.

Methods

Medical records of 494 glaucoma suspects were examined to extract the clinical diagnosis. Two criteria for review periods were defined, based on contrasting stringency from established clinical guidelines: American Academy of Ophthalmology (AAO), more stringent/less frequent; and the Australian National Health and Medical Research Council (NHMRC), less stringent/more frequent. We used these data to model patient outcomes and healthcare costs using a Markov model.

Results

The less stringent/more frequent criterion resulted in more high-risk glaucoma suspects requiring more frequent review compared with the more stringent/less frequent criterion. Across the 15 Markov cycles (7.5 years), the less stringent/more frequent review criterion resulted in 6.6% more diagnoses and fewer overall clinical visits (14.7%) and reduced cost per diagnosis by 12% to 32% (P < 0.0001). The number of glaucoma diagnoses made using each criterion converged at 2.5 to 3 years.

Conclusions

The stringency of risk assessments for glaucoma suspects impacts review periods and therefore clinical load, healthcare costs, and diagnosis rates. Using current testing methods, more frequent review periods appear advantageous for diagnostic efficiency, with both lower clinic load and lower cost up until the point of discharge or glaucoma diagnosis.

Translational Relevance

A less stringent criterion for assessing the risk of developing glaucoma potentially offers a more cost-effective method for reviewing glaucoma suspects, especially within the first 2.5 years.

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.

Association of systemic inflammation indices with visual field loss progression in patients with primary angle-closure glaucoma: potential biomarkers for 3P medical approaches

RELEVANCE

Accumulating evidence suggests a dysfunction of the para-inflammation in the retinal ganglion cell layer and the optic nerve head in patients with glaucoma. Currently, circulating blood platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and lymphocyte-to-monocyte ratio (LMR) are regarded as novel indicators of systemic inflammation. Biomarkers allow early identification of patients with visual field (VF) loss progression and timely implementation of replacement therapies.

OBJECTIVE

This study aimed to investigate whether higher inflammatory indices (PLR, NLR, and LMR) were associated with VF loss progression in patients with primary angle-closure glaucoma (PACG) for the predictive diagnostics, targeted prevention, and personalization of medical services.

METHODS

This prospective cohort study followed up 277 patients with PACG for at least 24 months, with clinical examination and VF testing every 6 months. Inflammatory cell quantification, including platelets, neutrophils, lymphocytes, and monocytes, was measured using the Sysmex XN-A1 automated inflammatory cells quantification system. Three systemic inflammatory indices, PLR, NLR, and LMR, were determined on the basis of baseline neutrophil, lymphocyte, monocyte, and platelet counts in patients with PACG. The risk factors for PACG were analyzed using logistic regression, Cox proportional hazards regression, and the Kaplan-Meier curve.

RESULTS

Our results revealed that 111 (40.07%) patients showed VF loss progression. The PLR was significantly higher (P = 0.046) in the progression group than in the non-progression group. A higher PLR (OR 1.05, 95% CI 1.01-1.08, P = 0.004) was a risk factor for PACG progression. In multivariate analyses, PLR independently predicted VF loss progression (HR 1.01, 95% CI 1.00-1.01, P = 0.04). Kaplan-Meier curve analysis showed that higher PLR indicated significantly higher rates of VF loss progression (66.91% vs. 52.90%, P = 0.03). Comparable results were observed in the male and female subgroups.

CONCLUSION

Our findings revealed the significant association between a high PLR and a greater risk of VF loss progression in patients with PACG. PLR may be highly recommended as a novel predictive/diagnostic tool for the assessment of VF loss progression from the perspectives of predictive, preventive, and personalized medicine in vulnerable populations and for individual screening.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13167-021-00260-3.

Medication adherence, self-efficacy and health literacy among patients with glaucoma: a mixed-methods study protocol

INTRODUCTION

As the world population ages, glaucoma is becoming an increasingly significant cause of blindness. A key component in the management of glaucoma is the use of prescribed medications and the adherence to treatment. However, there is evidence of low adherence to prescribed medication in chronic diseases, such as glaucoma. This study aims to explore the level of medication adherence, self-efficacy, social support and health literacy among the patients with glaucoma and to determine if there are any correlations between them. The ultimate aim is to use the information to develop an educational programme for patients with glaucoma at a later stage.

METHODS AND ANALYSIS

This is a mixed-methods study which includes two stages: a descriptive study (stage 1) and focus group discussions (stage 2).

SAMPLE

Patients with glaucoma or ocular hypertension, using at least one kind of drops, from two ophthalmology clinics. Selected measures include: The Glaucoma Treatment Compliance Assessment Tool, The European Health Literacy Survey Questionnaire, The Glaucoma Medication Self-Efficacy Questionnaire and The Multidimensional Scale of Perceived Social Support. Two focus groups will be used for the collection of qualitative data, aiming to enrich the study with the patients' experiences. The data will be analysed with SPSS, using descriptive and inferential statistics for stage 1 whereas content analysis will be used for the data from the focus group discussions (stage 2).

ETHICS AND DISSEMINATION

Permission to conduct the study was received from the National Bioethics Committee and the board of management of the two ophthalmology clinics. All participants will be informed fully on the purpose and methods of the study. Consent forms will be signed and at any time participants will have the right to withdraw. Confidentiality and the protection of data will be respected at all times.

Clinical and Economic Burden of Glaucoma by Disease Severity: A United States Claims-Based Analysis

PURPOSE

To provide updated estimates of the clinical and economic burden in patients with ocular hypertension (OHT) or open-angle glaucoma (OAG) by disease severity in the United States and to estimate incremental costs associated with disease progression.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with 1 or more International Classification of Diseases, 10th Revision, Clinical Modification, diagnoses for OAG or OHT who are 40 years of age or older.

METHODS

Patients were identified from IQVIA's PharMetrics Plus database during the index period (October 1, 2015, to August 31, 2017). Patients had continuous health plan enrollment for 12 months or more before and after the index date (first OAG or OHT diagnosis during index period) and were stratified by baseline disease severity based on diagnosis code. Annual eye-related outpatient healthcare use and costs were estimated on a per-user basis. A generalized linear model was used to estimate adjusted mean costs by severity and to evaluate the impact of observed disease worsening on costs. A multivariate logistic regression analysis evaluated the relationship between severity and odds of falls or fractures.

MAIN OUTCOME MEASURES

Total eye-related outpatient costs and odds of falls or fractures.

RESULTS

One hundred seventy-seven thousand three hundred fifty-two OHT and OAG patients were identified (67.8% with OAG). Open-angle glaucoma patients showed higher eye-related outpatient costs than OHT patients (median, $516 [interquartile range (IQR), $323-$898] vs. $344 [IQR, $197-$617], respectively). Patients with severe OAG showed higher eye-related outpatient costs than moderate and mild OAG patients (median, $639 [IQR, $381-$1264] vs. $546 [IQR, $345-$950] vs. $476 [IQR, $304-$765], respectively; P < 0.0001), as well as higher glaucoma-related pharmacy costs (median, $493 [IQR, $122-$1457] vs. $244 [IQR, $84-$1113] vs. $139 [IQR, $66-$818], respectively; P < 0.0001). In adjusted analyses, disease worsening was associated with at least 2-fold higher annual eye-related outpatient costs (P < 0.0001). Severe OAG patients had significantly higher odds of fall or fracture compared with OHT patients (odds ratio, 1.34; 95% confidence interval, 1.13-1.59).

CONCLUSIONS

Updated estimates showed highest eye-related costs for those with severe disease and disease progression among patients with OAG and OHT. Severe OAG was associated with increased risk of falls or fractures compared with patients with OHT. Therapies that delay disease progression may provide clinical and economic benefits.

Time trends and heterogeneity in the disease burden of glaucoma, 1990-2017: a global analysis

Background

To evaluate the disease burden of glaucoma in terms of disability-adjusted life years (DALY) and assess the contribution of risk factors to DALY due to glaucoma.

Methods

Global, regional, and country DALY number, rate, and age-standardized rates of glaucoma were obtained from the Global Burden of Disease Study 2017 database. The Human Development Index (HDI), Inequality-Adjusted HDI, Socio-Demographic Index (SDI), and other country-level data were derived from international open databases. Regression analysis was used to assess the correlations between the age-standardized DALY rate and the variables.

Results

The global DALY due to glaucoma increased by 81% from 1990 to 2017 and decreased by 10% over the last two decades after adjusting for age and population size. Males had higher age-standardized DALY rates (P < 0.001). The age-standardized DALY rate was higher in countries with lower income or lower SDI (P < 0.001). The country-level age-standardized DALY rates in 2017 were negatively associated with HDI, SDI, country-level age-standardized prevalence rates of cataracts, cataract surgery rates (CRS), physician rates, and Inequality-Adjusted HDI. Stepwise multiple regressions showed that HDI, CRS, and Inequality-Adjusted HDI were significantly negatively associated with the country-level age-standardized DALY rate in 2017 after adjusting for other confounding factors (P < 0.001).

Conclusions

Higher education, higher CRS, and diminishing the inequality in resource distribution may help reduce the disease burden of glaucoma. These findings can provide information for policymakers and could serve as an impetus for efforts toward alleviating the disease burden of glaucoma.

Measuring Disability in Glaucoma

BACKGROUND

Glaucomatous visual field loss can have far-reaching and debilitating consequences on an individual, affecting one's ability to perform many important tasks. Although assessment of glaucoma-related disability constitutes an important part of clinical care, there remains a lack of organized, detailed information on the most suitable methods to capture disability in glaucoma.

PURPOSE

This review details the available methods to measure glaucoma-related disability and highlights important findings from studies utilizing these various methods.

METHODS

The literature was reviewed to identify papers evaluating disability in glaucoma and findings were summarized by research methodology used and area of impairment.

RESULTS

Identified methods for capturing glaucoma-related disability included qualitative descriptions, glaucoma-specific quality of life questionnaires, vision-specific questionnaires, general health questionnaires, functional domain-specific questionnaires, evaluation of task performance, event assessment (ie, falls and motor vehicle accidents), and real-world behavior (ie, daily physical activity). Findings using these methods show a strong relationship between glaucoma and/or glaucoma severity and difficulties with reading, driving, mobility, and other tasks such as prehension and facial recognition. In addition, glaucoma has financial and psychological implications on the patient, and can affect caregivers in some cases as well.

CONCLUSIONS

A wide variety of research tools have been used to characterize the disability resulting from glaucoma. Together, these tools show that glaucoma affects many abilities which are important for independent living. Strengths and limitations of the various research techniques are discussed so that future studies may use the method(s) most suitable for answering the research question posed.

A Comparison of Resource Use and Costs of Caring for Patients With Exfoliation Syndrome Glaucoma Versus Primary Open-Angle Glaucoma

PURPOSE

To characterize differences in resource utilization and cost of managing enrollees with exfoliation glaucoma (XFG) compared to primary open-angle glaucoma (POAG).

DESIGN

Retrospective utilization and cost comparison using Medicare claims data.

METHODS

We identified Medicare beneficiaries with XFG or POAG and ≥5 years of continuous enrollment from January 2008 to December 2014. We distinguished newly diagnosed cases from those with preexisting disease. We compared ophthalmic resource utilization and costs over 2 years of follow-up for persons with newly diagnosed and preexisting XFG vs those with POAG. Main outcome measures were number of clinic visits, diagnostic procedures, medication fills, laser and incisional surgery, and mean eye care costs per beneficiary.

RESULTS

Among 192 eligible enrollees (median age 77.6 years) with newly diagnosed XFG and 7339 enrollees (median age 77.3 years) with newly diagnosed POAG, those with XFG had more office visits (mean, 9.1 vs 7.9; P = .001), cataract surgery (34.9% vs 19.0%; P < .0001), and glaucoma surgery (28.7% vs 19.7%, P = .002). They also experienced 27% higher mean total eye care costs ($3260 vs $2562, P = .0001) over 2 years of follow-up. Among 2745 enrollees (median age 80.5 years) with preexisting XFG and 89 036 persons (median age 79.5) with preexisting POAG, persons with XFG had more office visits (mean 9.3 vs 7.3; P < .0001), perimetry (85.3% vs 79.8%; P < .0001), cataract surgery (23.4% vs 12.3%; P < .0001), laser trabeculoplasty (18.6% vs 9.6%; P < .0001), and trabeculectomy (8.1 vs 1.8%; P < .0001) and experienced 37% higher total mean eye care costs ($3764 vs $2739; P < .0001).

CONCLUSIONS

Healthcare resource utilization and costs are substantially higher for managing patients with XFG compared to POAG.

Presence and Risk Factors for Glaucoma in Patients with Diabetes

Diabetes mellitus represents a growing international public health issue with a near quadrupling in its worldwide prevalence since 1980. Though it has many known microvascular complications, vision loss from diabetic retinopathy is one of the most devastating for affected individuals. In addition, there is increasing evidence to suggest that diabetic patients have a greater risk for glaucoma as well. Though the pathophysiology of glaucoma is not completely understood, both diabetes and glaucoma appear to share some common risk factors and pathophysiologic similarities with studies also reporting that the presence of diabetes and elevated fasting glucose levels are associated with elevated intraocular pressure-the primary risk factor for glaucomatous optic neuropathy. While no study has completely addressed the possibility of detection bias, most recent epidemiologic evidence suggests that diabetic populations are likely enriched with glaucoma patients. As the association between diabetes and glaucoma becomes better defined, routine evaluation for glaucoma in diabetic patients, particularly in the telemedicine setting, may become a reasonable consideration to reduce the risk of vision loss in these patients.

Cost of glaucoma treatment in a developing country over a 5-year period

The aim of the study was to disclose a realistic estimate of primary open-angle glaucoma treatment, follow-up costs, and patients' monthly glaucoma-economic burden in an ophthalmology hospital in Mexico City.Prospective survey of 462 primary open-angle glaucoma patients from 2007 to 2012 was carried out. Costs from visits, glaucoma follow-up studies, laser, and glaucoma surgical procedures were obtained from hospital pricings. Education, employment, and monthly income were interrogated. Total cost was divided into hypotensive treatment cost, nonpharmacologic treatment cost (laser and surgeries), and follow-up studies and consults. Average wholesale price for drugs analyzed was obtained from IMS Health data; monthly cost was calculated using: Monthly cost  = ([average wholesale price/number of drops per eye dropper] × number of daily applications) × 30 days.Patients were classified according to their glaucoma severity, and data were analyzed based on monthly income (average annual exchange rate: 12.85 Mexican pesos = 1 USD).The mean age was 70 ± 10 years, women = 81%, elementary school = 39%, and unemployed = 53%. Low-income group = 266 patients (57%), 146 with mild glaucoma; moderate-income group = 176 patients (38%), 81 with mild glaucoma; high-income group = 20 patients (4.3%), 10 with mild glaucoma. Patients' monthly average economic burden in glaucoma treatment: low-income patients = 61.5%, moderate-income patients = 19.5%, and high-income patients = 7.9%.Glaucoma-economic burden is substantial not only for health systems, but for the family and the patient. Therefore, screening plans for earlier diagnosis, and health policies that lessen the cost of disease management and increase adherence to treatment, and reduce the prevalence of blindness attributed to glaucoma are essential. These would improve quality of life, reduce personal and national expenditure, and help increase national economy.

More frequent, more costly? Health economic modelling aspects of monitoring glaucoma patients in England

BACKGROUND

Chronic open angle glaucoma (COAG) is an age-related eye disease causing irreversible loss of visual field (VF). Health service delivery for COAG is challenging given the large number of diagnosed patients requiring lifelong periodic monitoring by hospital eye services. Yet frequent examination better determines disease worsening and speed of VF loss under treatment. We examine the cost-effectiveness of increasing frequency of VF examinations during follow-up using a health economic model.

METHODS

Two different VF monitoring schemes defined as current practice (annual VF testing) and proposed practice (three VF tests per year in the first 2 years after diagnosis) were examined. A purpose written health economic Markov model is used to test the hypothesis that cost effectiveness improves by implementing proposed practice on groups of patients stratified by age and severity of COAG. Further, a new component of the model, estimating costs of visual impairment, was added. Results were derived from a simulated cohort of 10000 patients with quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) used as main outcome measures.

RESULTS

An ICER of £21,392 per QALY was derived for proposed practice improving to a value of £11,382 once savings for prevented visual impairment was added to the model. Proposed practice was more cost-effective in younger patients. Proposed practice for patients with advanced disease at diagnosis generated ICERs > £60,000 per QALY; these cases would likely be on the most intensive treatment pathway making clinical information on speed of VF loss redundant. Sensitivity analysis indicated results to be robust in relation to hypothetical willingness to pay threshold identified by national guidelines, although greatest uncertainty was allied to estimates of implementation and visual impairment costs.

CONCLUSION

Increasing VF monitoring at the earliest stages of follow-up for COAG appears to be cost-effective depending on reasonable assumptions about implementation costs. Our health economic model highlights benefits of stratifying patients to more or less monitoring based on age and stage of disease at diagnosis; a prospective study is needed to prove these findings. Further, this works highlights gaps in knowledge about long term costs of visual impairment.

Outcomes of combined trabecular micro-bypass and phacoemulsification in a predominantly Hispanic patient population

PURPOSE

The purpose of this study was to evaluate intraocular pressure (IOP) and topical ocular hypotensive medication burden at 12 months postoperatively in a predominantly Hispanic patient population with primary open-angle glaucoma each implanted with one trabecular micro-bypass stent during cataract surgery.

METHODS

This was a retrospective, consecutive case series. The main objective was to assess reduction of IOP and/or medication burden in all eyes at the 12-month postoperative exam. A secondary objective was to assess outcomes in 3 subgroups, distinguished preoperatively by IOP control and by medication burden (suboptimal or maximum therapy) and with different treatment goals. Group 1 had medication-controlled IOP and goal to reduce medications while maintaining IOP control (n=65); Group 2 had uncontrolled IOP on ≤2 medications and goal to reduce IOP and maintain/reduce medication burden (n=31); and Group 3 had uncontrolled IOP on ≥3 medications and goal to reduce IOP and avoid filtering surgery (n=38). Evaluations included IOP, medication use, cup-to-disc ratio, visual fields, complications, and interventions. One hundred subjects (134 eyes) have been followed for 12 months.

RESULTS

Most patients (80%) were Hispanic and had moderate or severe glaucoma (87%). At 12 months, mean IOP reduced to 12.9 mmHg vs 16.5 mmHg preoperatively; 92% had an IOP ≤15 mmHg at 12 months (99% had ≤18 mmHg). Mean medication burden had decreased to 0.9 vs 2.3 preoperatively. At the 12-month time point, 94% of all eyes achieved their predefined treatment goal of reduced IOP and/or medications. Reductions in medication burden for Group 1, and in IOP for Groups 2 and 3, were highly statistically significant (P<0.001). Two eyes in Group 3 had filtering surgery; the remaining 95% avoided such treatment. No other complications were reported.

CONCLUSION

This mainly Hispanic population with predominantly moderate or severe glaucoma had substantial reduction of IOP and medication and favorable safety for 12 months following stent implantation during cataract surgery, with treatment success achieved in all 3 subgroups. These data show this stent technology to be effective in Hispanic eyes with more advanced disease.

Incremental Healthcare Service Utilization for Open-angle Glaucoma: A Population-Based Study

PURPOSE

To investigate differences in the utilization of healthcare services between subjects with open-angle glaucoma (OAG) and comparison subjects without OAG using Taiwan's National Health Insurance population-based database.

PATIENTS AND METHODS

The study comprised 2204 subjects with OAG and 2204 sex-matched and age-matched subjects without OAG. We individually followed each subject for a 1-year period to evaluate their healthcare resource utilization. Outcome variables of the healthcare resource utilization were as follows: numbers of outpatient visits and inpatient days and the mean costs of outpatient and inpatient treatment. In addition, we divided healthcare resource utilization into ophthalmologic and nonophthalmologic services.

RESULTS

As for the utilization of ophthalmologic services, OAG subjects had significantly more outpatient visits (7.4 vs. 1.3, P<0.001) and significantly higher outpatient costs (US$272 vs. US$39, P<0.001) than comparison subjects. For nonophthalmologic services, OAG subjects also had significantly more outpatient visits (29.4 vs. 21.8, P<0.001) and significantly higher outpatient costs (US$1263 vs. US$847, P<0.001) than comparison subjects. Furthermore, OAG subjects incurred significantly higher inpatient costs compared with comparison subjects (US$434 vs. US$234, P<0.001). For all healthcare services, OAG subjects had significantly more outpatient visits (36.8 vs. 23.1, P<0.001) and significantly higher outpatient (US$1535 vs. US$887, P<0.001) and total (US$2245 vs. US$1122, P<0.001) costs than comparison subjects. In other words, the total cost was about 2-fold greater for OAG subjects than comparison subjects.

CONCLUSIONS

We concluded that subjects with OAG had significantly higher utilization of all healthcare services than comparison subjects.

An adherence based cost-consequence model comparing bimatoprost 0.01% to bimatoprost 0.03%

OBJECTIVES

Estimate the long-term direct medical costs and clinical consequences of improved adherence with bimatoprost 0.01% compared to bimatoprost 0.03% in the treatment of glaucoma.

METHODS

A cost-consequence model was constructed from the perspective of a US healthcare payer. The model structure included three adherence levels (high, moderate, low) and four mean deviation (MD) defined health states (mild, moderate, severe glaucoma, blindness) for each adherence level. Clinical efficacy in terms of IOP reduction was obtained from the randomized controlled trial comparing bimatoprost 0.01% with bimatoprost 0.03%. Medication adherence was based on observed 12 month rates from an analysis of a nationally representative pharmacy claims database. Patients with high, moderate and low adherence were assumed to receive 100%, 50% and 0% of the IOP reduction observed in the clinical trial, respectively. Each 1 mmHg reduction in IOP was assumed to result in a 10% reduction in the risk of glaucoma progression. Worse glaucoma severity health states were associated with higher medical resource costs. Outcome measures were total costs, proportion of patients who progress and who become blind, and years of blindness. Deterministic sensitivity analyses were performed on uncertain model parameters.

RESULTS

The percentage of patients progressing, becoming blind, and the time spent blind slightly favored bimatoprost 0.01%. Improved adherence with bimatoprost 0.01% led to higher costs in the first 2 years; however, starting in year 3 bimatoprost 0.01% became less costly compared to bimatoprost 0.03% with a total reduction in costs reaching US$3433 over a lifetime time horizon. Deterministic sensitivity analyses demonstrated that results were robust, with the majority of analyses favoring bimatoprost 0.01%. Application of 1 year adherence and efficacy over the long term are limitations.

CONCLUSIONS

Modeling the effect of greater medication adherence with bimatoprost 0.01% compared with bimatoprost 0.03% suggests that differences may result in improved economic and patient outcomes.

Comparison of resource utilization in the treatment of open-angle glaucoma between two cities in Finland: is more better?

INTRODUCTION

Glaucoma is a progressive optic neuropathy associated with neural rim loss of the optic disc and the retinal nerve fibre layer typically causing visual field (VF) deterioration. Generally, glaucomatous lesions in the eye and in the visual field progress slowly over the years. In population-based cross-sectional studies, the percentage of unilateral or bilateral visual impairment varied between 3-12%. In screening studies, 0.03-2.4% of patients have been found to suffer visual impairment. Glaucoma has previously been associated with substantial healthcare costs and resource consumption attributable to the treatment of the disease. The disease also causes reduction in health-related quality of life (HRQoL) in patients with glaucoma.

OBJECTIVE AND METHODS

This study compares patients with diagnosed open-angle glaucoma from two geographically different regions in Finland. A total of 168 patients were examined, 85 subjects from an area with higher per patient treatment costs (Oulu) and 83 patients from a region with lower per patient treatment costs (Turku). All patients had a history of continuous glaucoma medication use for a period of 11 years. For each patient, the total direct costs from glaucoma treatment were calculated and the total amount of resource consumption was determined from registries and patient records. Each patient underwent a clinical examination with visual field assessment and fundus photography. These data were used to determine the current stage of disease for each patient. Health-related quality of life questionnaire (15D) was used in determining each patient's subjective HRQoL score.

RESULTS

When applying the current diagnostic criteria for open-angle glaucoma, a total of 40% of patients did not to display any structural or functional damage suggesting glaucoma after 11 years of continuous medical treatment and follow-up. Patients with higher glaucoma stage (worse disease) were found to have statistically higher treatment costs compared with those at lower disease stages. Resource consumption was also greater in the patients in higher glaucoma stage. Patients in the Oulu district consumed more resources, and glaucoma treatment was more expensive than in the Turku area. The total treatment cost in Oulu and Turku was 6010 € and 4452 €, respectively, for the whole 11-year period. There was no statistically significant difference in quality-of-life scores between the two areas. No difference was noted between the higher-spending and lower-spending areas in this respect. However, when the population was analysed as a whole, patients with higher glaucoma stage were found to have lower vision-based 15D scores compared with those at lower disease stages. This observation was made also at both districts independently.

CONCLUSIONS

Major cost source in open-angle glaucoma treatment is medication, up to 74% of annual costs. In addition, it seems that higher resource consumption and higher treatment costs do not increase the patients' HRQoL as assessed by the 15D instrument.

Direct cost and predictive factors for treatment in patients with ocular hypertension or early, moderate and advanced primary open-angle glaucoma: the CoGIS study in Germany

BACKGROUND

The main objectives of this analysis were to assess the treatment costs and to identify major cost drivers and factors predicting direct costs in German patients with ocular hypertension (OHT) or primary open-angle glaucoma (POAG).

METHODS

This non-interventional cross-sectional study was conducted in two university hospitals and 13 ophthalmology practices in Germany regions (Bavaria, Rhineland-Palatinate, North Rhine-Westphalia, Hamburg and Mecklenburg-Western Pomerania) between May 2009 and January 2010 to assess resource utilisation in patients with OHT (ICD-10: 40.0) or POAG (ICD-10: 40.1) at early, moderate or advanced stages, according to the European Glaucoma Society classification Guidelines. Treatment patterns and direct costs were evaluated retrospectively for 5 years. Resource utilisation data (medication, hospitalisation, outpatient surgery, visits to ophthalmologists) were abstracted from the charts, and unit costs were applied to estimate direct costs per year (in Euros, 2009), calculated from the perspective of the statutory health insurance in Germany (Gesetzliche Krankenversicherung). Factors predicting costs were assessed in multivariate regression analysis.

RESULTS

One hundred and fifty-four patients (17.5% OHT, 27.9% early, 22.7% moderate, and 31.8% advanced POAG), on average 67 years old (SD 11) were included in the study. Average total annual direct costs per patient for OHT were <euro>226 (SD 117), for early POAG <euro>423 (SD 647), moderate <euro>493 (SD 385) and advanced POAG <euro>809 (SD 877). Glaucoma-related medications and hospitalisation represented the two major components of direct costs, increasing with the progression of glaucoma. In addition to treatment switches (p = 0.0001), factors predictive of an increase in total direct costs included the number of hospital interventions (p < 0.0001), disease-state changes since the start of treatment (p = 0.05), and current disease state (p = 0.05).

CONCLUSIONS

Direct costs of treatment are higher in glaucoma compared to OHT and further increase in more severe glaucoma states. Additional treatment changes are major contributing factors to the increased treatment costs of glaucoma. If intraocular pressure can be controlled over the long term, progression to moderate and advanced states avoided, and patients remain on initial treatments, treatment costs could decline due to reduced and less expensive healthcare resource utilisation.

Direct healthcare costs of glaucoma treatment

AIMS

To report the complete lifetime direct healthcare costs of glaucoma treatment in a database of 1136 patients attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK.

METHOD

The database was interrogated to identify all patients who had initiated treatment at the Glaucoma Clinic at Glasgow Royal Infirmary, and who had subsequently died of natural causes. The healthcare resource use based cost assessment was based on two aspects of the direct National Health Service cost: drug costs (prescribed medications) and non-drug costs (inpatient or outpatient/and surgical or procedure costs).

RESULTS

106 patients (53 men, 53 women) were identified for whom there were lifetime treatment data. The mean lifespan of the patients was 80.5 years, and the mean number of years attending the glaucoma clinic was 7.05 years (range 1-22 years). The mean cost of glaucoma treatment over the lifetime of the patients was £3001, with an annual mean cost per patient of £475. Non-drug and drug costs made up 66% and 34% respectively, of the lifetime costs.

CONCLUSIONS

This is the only study to directly assess the lifetime treatment costs of glaucoma. Awareness of the costs of glaucoma treatment may be of increased importance in these financially challenging times.

Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: two-year follow-up

PURPOSE

To assess the long-term safety and efficacy of a single trabecular micro-bypass stent with concomitant cataract surgery versus cataract surgery alone for mild to moderate open-angle glaucoma.

SETTING

Twenty-nine investigational sites, United States.

DESIGN

Prospective randomized controlled multicenter clinical trial.

METHODS

Eyes with mild to moderate glaucoma with an unmedicated intraocular pressure (IOP) of 22 mm Hg or higher and 36 mm Hg or lower were randomly assigned to have cataract surgery with iStent trabecular micro-bypass stent implantation (stent group) or cataract surgery alone (control group). Patients were followed for 24 months postoperatively.

RESULTS

The incidence of adverse events was low in both groups through 24 months of follow-up. At 24 months, the proportion of patients with an IOP of 21 mm Hg or lower without ocular hypotensive medications was significantly higher in the stent group than in the control group (P=.036). Overall, the mean IOP was stable between 12 months and 24 months (17.0 mm Hg ± 2.8 [SD] and 17.1 ± 2.9 mm Hg, respectively) in the stent group but increased (17.0 ± 3.1 mm Hg to 17.8 ± 3.3 mm Hg, respectively) in the control group. Ocular hypotensive medication was statistically significantly lower in the stent group at 12 months; it was also lower at 24 months, although the difference was no longer statistically significant.

CONCLUSIONS

Patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better IOP control on no medication through 24 months than patients having cataract surgery alone. Both groups had a similar favorable long-term safety profile.

FINANCIAL DISCLOSURE

Dr. Craven was an investigator in the clinical trial of the iStent. Dr. Katz is a consultant to Glaukos and was the medical monitor for the clinical trial of the iStent. Dr. Katz is a stockholder in Glaukos. Mr. Wells and Ms. Giamporcaro are employees of Glaukos.

Longitudinal trends in resource use in an incident cohort of open-angle glaucoma patients: resource use in open-angle glaucoma

PURPOSE

To characterize the costs of caring for patients with open-angle glaucoma (OAG) in the United States over time and to identify factors that influence these costs.

DESIGN

Longitudinal cohort study.

METHODS

Claims data from 19 927 newly diagnosed OAG patients enrolled in a large United States managed care network were reviewed to identify glaucoma-related charges for all incident OAG patients from 2001 through 2009. Average glaucoma-related charges for enrollees with OAG were characterized in 6-month blocks from the date of initial OAG diagnosis through the ensuing 5 years. Factors associated with being an enrollee in the costliest 5% for glaucoma-related charges (accruing $5810 or more in charges in the first 2 years) were identified using logistic regression.

RESULTS

The costliest 5% of enrollees were responsible for $10 202 871 (24%) of all glaucoma-related charges. By comparison, those whose costs fell within the lower 50% of the cost distribution collectively amassed only $7 986 582 (19%) of all glaucoma-related charges. A spike in glaucoma-related charges occurred in the 6-month period around the time of OAG diagnosis, stabilized by 1 year after diagnosis, and remained relatively constant over time. Risk factors associated with being in the costliest 5% for glaucoma-related care included younger age, Northeastern United States state residence, undergoing cataract surgery, and possessing ocular comorbidities (P < .006 for all comparisons).

CONCLUSIONS

A small subset of enrollees account for a large proportion of all glaucoma-related charges. Understanding the characteristics of these individuals and finding ways to reduce disease burden and costs associated with their care can result in substantial cost savings.

Determinants of medication adherence to topical glaucoma therapy

INTRODUCTION/PURPOSE

To determine the associations between medical, demographic, socioeconomic, and ocular factors and adherence to topical glaucoma ocular hypotensive therapy.

METHODS

One hundred sixteen patients with ocular hypertension or open-angle glaucoma from 2 tertiary glaucoma services participated in this prospective study. Adherence to ocular hypotensive therapy was measured using an electronic dose monitor (Travatan Dosing Aid, Alcon Laboratories Inc., Fort Worth, TX) and collected data at 3 months after enrollment. We used 3 different definitions of adherence: 1) Definition 1: the proportion of days taking the prescribed number of drops within 3 hours of the prescribed dosing time; 2) Definition 2: the proportion of days taking any drops within 3 hours of the prescribed dosing time; and 3) Definition 3: the proportion of days taking any drops within 6 hours of the prescribed dosing time. Univariate and multivariate models were used to determine the association between the 3 adherence definitions, medical, demographic, socioeconomic, and ocular factors at 3-month follow-up. The main outcome measures for this study were risk factors for poor objective medication adherence.

RESULTS

Adherence, using Definition 1, Definition 2, and Definition 3, was 64%, 75%, and 80%, respectively. Age, total number of other eye diseases, and race were significantly associated with full treatment adherence (Definition 1), with race alone significantly predicting 11% of full treatment adherence. For Definition 2, age, income, level of education, and total number of eye diseases were significantly associated with partial adherence (3 h), again race alone significantly predicted 15% of partial adherence (any drops within 3 h). For Definition 3, race, income, level of education, and total number of other eye diseases significantly predicted partial adherence (any drops within 6 h), both race and income predicted 19% of partial treatment adherence. Significant differences for adherence rates between patients of European descent and those of African descent were found for all 3 definitions with those who were less adherent more likely to be of African descent.

CONCLUSIONS

Electronic dose monitors provide important information regarding adherence to topical ocular hypotensive medications in glaucoma patients. Electronic dose monitors show low adherence in a significant number of participants. Future studies are needed to determine the reasons for these differences in health behaviors related to glaucoma treatment, which should guide treatment of poor adherence with glaucoma therapy.

An assessment of the health and economic burdens of glaucoma

PURPOSE

To bring together information concerning the epidemiology and the economic and individual burdens of glaucoma.

DESIGN

Interpretive essay.

METHODS

Review and synthesis of selected literature published from 1991 through December 2010.

RESULTS

An estimated 3% of the global population over 40 years of age currently has glaucoma, the majority of whom are undiagnosed. Vision loss from glaucoma has a significant impact on health-related quality of life even in the early stages of disease. The overall burden increases as glaucomatous damage and vision loss progress. The economic burden of glaucoma is significant and increases as the disease worsens.

CONCLUSIONS

Early identification and treatment of patients with glaucoma and those with ocular hypertension at high risk of developing vision loss are likely to reduce an individual's loss of health-related quality of life as well as the personal and societal economic burdens.

Treatment of glaucoma in clinical practice: four-year results from a patient registry in France

PURPOSE

To investigate long-term resource consumption and clinical outcome of patients with early primary open-angle glaucoma or ocular hypertension treated with prostaglandins in clinical practice in France.

METHODS

Thirty-four geographically spread specialized hospitals and private practices enrolled consecutive patients receiving, for the first time, a prostaglandin, alone or in combination. The study was based on routine practice and no consultations, examinations, or treatments were mandated by the protocol. Treating physicians recorded each consultation, including all examinations performed, referrals, admissions, and prescriptions. Descriptive analysis of resource consumption and development of intraocular pressure (IOP) and visual fields was performed, for all patients who completed the 4-year follow-up.

RESULTS

The study enrolled 602 patients and 78% completed 4-year follow-up. Mean age was 65 years and mean time since diagnosis was 4 years. Mean IOP was reduced from a baseline of 21.2 mm Hg to 16.5 mm Hg during the first year and remained stable throughout the study. Mean visual fields at baseline were -4.2 mean deviation and stable during the follow-up. Total mean health care costs per patient were €1947, of which medication represented 50%. Over half of the patients (52%) remained on their initial medication during the 4 years. Drug changes were mostly because of inadequate IOP control and the number of treatment switches was significantly related to costs.

CONCLUSIONS

This is the first prospective study of treatment with prostaglandins in clinical practice. The results indicate that many patients with early glaucoma managed primarily with prostaglandins will show very little progression over 4 years. Compared with the mid-90s, costs have not increased despite the higher acquisition cost of prostaglandins, as surgical interventions and medical consultations have decreased.

Cost of illness of glaucoma: a critical and systematic review

Cost-of-illness studies determine the total financial burden of a disease by considering direct and indirect costs, including medication, diagnostics and surgery. Studies of resource use and costs associated with primary open-angle glaucoma have used varying methodologies. Most have focused on consumption of healthcare resources at various stages of disease to anticipate costs. The direct costs associated with the disease often continue to increase as glaucoma progresses from the earliest to most advanced stages. Determinations of the costs associated with glaucoma progression and prevention should also incorporate the chance of patient non-compliance with treatment. Since glaucoma severity most often correlates with increased costs, minimizing or halting visual field loss and increasing patient treatment compliance may all contribute to a reduction in the overall economic burden of glaucoma.

Economic evaluation of medication, laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US

OBJECTIVE

Despite the significant clinical and economic burden associated with glaucoma, studies evaluating the long-term costs of existing treatments are limited. This study compared the 5-year costs of three treatment strategies: medication, laser trabeculoplasty, and filtering surgeries in managing patients with primary open-angle glaucoma whose intra-ocular pressures were not adequately controlled by two medications.

RESEARCH DESIGN AND METHODS

A Markov model was developed to simulate the transition of treatment progression over a 5-year period to evaluate the total treatment costs associated with each strategy. In the medication arm, medications were the only available treatment, whereas in the laser trabeculoplasty and surgery arms, patients would receive concomitant medications both at the time of the procedure and in subsequent years. Treatment states were determined by the rate of success in controlling patients' intra-ocular pressure in each year. The distribution of treatment states and the transition probabilities between these states were derived from published literature, adjusted or supplemented by the authors' own treatment experiences. Costs assessed in the model included treatment, complications associated with each treatment, and physician office visits obtained from published literature and standardized fees and schedules.

RESULTS

The 5-year cumulative costs were approximately $6571, $4838 and $6363 for patients in the medication, laser trabeculoplasty, and filtering surgery arms, respectively. Costs of third-line medication, first-line medication following laser trabeculoplasty, and post-surgery complications had the greatest impact on the model results in the medication, laser trabeculoplasty, and filtering surgery arms, respectively. Probabilistic sensitivity suggested the results were statistically significant (p < 0.001), favoring the use of laser trabeculoplasty.

CONCLUSIONS

Over 5 years laser trabeculoplasty was associated with the lowest total costs compared to treatment by medication alone or by filtering surgery for patients who were not adequately controlled by two medications. Future development of glaucoma treatment should focus on reducing the need for post-procedure medical therapy as well as lowering the rate of post-procedure complications. Limited by the availability of the transition probabilities in published literature, the model results need to be validated by prospective or retrospective observational studies.

Glaucoma: an area of darkness

This review of Primary Open Angle Glaucoma looks at the management of the condition today. It does this by looking at the following areas: (a) the size of the problem; (b) the position of IOP, with respect to its elevation and fluctuation; (c) optic nerve head changes; and (d) visual function changes. In doing so, it contrasts what is known now with ideas and concepts that were prevalent at the time of the two previous Bowman lecturers, Duke Elder and Drance, as well as noting concepts about the disease that were current at the time of William Bowman. The review concludes by suggesting challenges in this area that lie ahead.