Acute primary angle closure-treatment strategies, evidences and economical considerations.

Acute primary angle closure requires emergency management that involves a rapid lowering of the intraocular pressure and resolution of relative pupil block - the most common mechanism of angle closure. Emergency strategies for lowering intraocular pressure include medical treatment and argon laser peripheral iridoplasty. Anterior chamber paracentesis and diode laser transcleral cyclophotocoagulation may be considered in special situations. Relative pupil block can be relieved by peripheral laser iridotomy and primary lens extraction; the latter is a more effective treatment according to the results of clinical trials. However, primary lens extraction can be technically demanding in the acute setting. Peripheral laser iridotomy has a role in relieving pupil block and should also be considered in most cases. Lens extraction may be combined with procedures such as goniosynechialysis, trabeculectomy or endoscopic cyclophotocoagulation. In this review, we aim to discuss the available evidence regarding the different treatment modalities. We also discuss the economic consideration, including cost-effectiveness and life expectancy, in the management of acute primary angle closure.

Shared Cared for Stable Glaucoma Patients: Economic Benefits and Patient-centered Outcomes of a Feasibility Trial.

PURPOSE: The purpose of this article is to assess the quality of care and economic benefits of a shared care model managing patients with stable glaucoma in a primary eye care (PEC) clinic compared with a tertiary specialist outpatient clinic (SOC) in Singapore. PATIENTS AND METHODS: A randomized equivalence feasibility trial was preformed comparing the PEC with SOC models. Participants recruited from the SOC had no visual field progression or change in management for at least 3 years, were on a maximum of a single glaucoma medication, had no previous tube-shunt implant and were at least 3-year posttrabeculectomy surgery.Primary outcomes were clinical assessment and management, economic benefits, and patient satisfaction. Differences were analyzed using equivalence testing and generalized odds ratios. RESULTS: The trial included 233 patients, consisting of 42.1% glaucoma disc suspects (PEC: 47.4%; SOC: 36.8%), 27.5% primary angle closure suspects (PEC: 25.0%; SOC: 29.9%), 13.7% with ocular hypertension (PEC: 13.8%; SOC: 13.7%), 3.9% with primary angle closure glaucoma (PEC: 4.3%; SOC: 3.4%), and 3.0% with primary open angle glaucoma (PEC: 1.7%; SOC: 4.3%). Glaucoma clinical care for patients at PEC was as good as SOC [rate difference, 6.83%; 95% confidence interval (CI), 2.84-11.12) and management (rate difference, 7.69%; 95% CI, 3.21-12.17). In 23 cases (9.9%), 5.2% at PEC and 14.5% at SOC, there was disconcordance with the gold standard of senior consultant. Patient satisfaction at the PEC was equally high when compared with SOC (generalized odds ratio, 1.43; CI, 0.50-2.00). Direct costs per patient visit were 43% lower at PEC compared with SOC. CONCLUSION: Managing stable glaucoma patients at a primary care setting is a cost saving, safe, and effective shared care while enhancing professional collaboration between hospital and community settings.

Cost-effectiveness of Phacoemulsification Versus Combined Phacotrabeculectomy for Treating Primary Angle Closure Glaucoma.

PURPOSE: The purpose of this study is to compare the cost effectiveness of phacoemulsification and combined phacotrabeculectomy for lowering intraocular pressure (IOP) in primary angle closure glaucoma (PACG) eyes with coexisting cataract. METHODS: Real-life data of 2 previous randomized control trials that involved 51 medically uncontrolled PACG eyes and 72 medically controlled PACG eyes were utilized to calculate the direct cost of treatment. They were followed-up for 2 years. Cost of preoperative assessments, surgical interventions, additional procedures for managing complications and maintenance of filtration, postoperative follow-up, and cost of medications were considered. Cost data of 3 different regions (The United States, People's Republic of China, and Hong Kong) were used for comparison. RESULTS: The corresponding average costs for treating 1 eye with newly diagnosed PACG by phacoemulsification alone and combined phacotrabeculectomy were US$3479 and US$2439 in the United States, US$1051 and US$861 in China, and US$6856 and US$12087 in Hong Kong. Surgical and medications costs were the 2 key contributors. Combined phacotrabeculectomy was more cost-effective for IOP reduction when calculating with the United States and China cost data, but was less cost-effective when calculating with the Hong Kong cost data. The cost-effectiveness was insensitive to the costs of follow-up visit and investigations, the cost of surgical operations, and the cost of postoperative procedures, but sensitive to the cost fluctuation of medications. Furthermore, for the medically uncontrolled PACG group, phacoemulsification alone became more cost-effective when the cost of medication was reduced by >75%. CONCLUSIONS: Combined phacotrabeculectomy is a more cost-effective option for lowering IOP in PACG eyes with coexisting cataract, over a 2-year follow-up period.

Early lens extraction with intraocular lens implantation for the treatment of primary angle closure glaucoma: an economic evaluation based on data from the EAGLE trial.

OBJECTIVE: To investigate the cost-effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle closure glaucoma (PACG) compared to standard care. DESIGN: Cost-effectiveness analysis alongside a multicentre pragmatic two-arm randomised controlled trial. Patients were followed-up for 36 months, and data on health service usage and health state utility were collected and analysed within the trial time horizon. A Markov model was developed to extrapolate the results over a 5-year and 10-year time horizon. SETTING: 22 hospital eye services in the UK. POPULATION: Males and females aged 50 years or over with newly diagnosed PACG or primary angle closure (PAC). INTERVENTIONS: Lens extraction compared to standard care (ie, laser iridotomy followed by medical therapy and glaucoma surgery). OUTCOME MEASURES: Costs of primary and secondary healthcare usage (UK NHS perspective), quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) for lens extraction versus standard care. RESULTS: The mean age of participants was 67.5 (8.42), 57.5% were women, 44.6% had both eyes eligible, 1.4% were of Asian ethnicity and 35.4% had PAC. The mean health service costs were higher in patients randomised to lens extraction: £2467 vs £1486. The mean adjusted QALYs were also higher with early lens extraction: 2.602 vs 2.533. The ICER for lens extraction versus standard care was £14 284 per QALY gained at three years. Modelling suggests that the ICER may drop to £7090 per QALY gained by 5 years and that lens extraction may be cost saving by 10 years. Our results are generally robust to changes in the key input parameters and assumptions. CONCLUSIONS: We find that lens extraction has a 67-89% chance of being cost-effective at 3 years and that it may be cost saving by 10 years. TRIAL REGISTRATION NUMBER: ISRCTN44464607; Results.

Impact of Socioeconomic Status on the Diagnosis of Primary Open-Angle Glaucoma and Primary Angle Closure Glaucoma: A Nationwide Population-Based Study in Taiwan.

PURPOSE: To understand the impact of socioeconomic status (SES) on the diagnosis of primary open-angle glaucoma (POAG) and primary angle closure glaucoma (PACG) in Taiwan. METHODS: Subjects with glaucoma were identified from the National Health Insurance Research Database of year 2006, which included one million randomly selected insurants. Individuals who had ≥4 ambulatory visits within one year which had the diagnosis code of POAG (ICD-9-CM 365.11 or 365.12) or PACG (365.23) and concurrent prescription of anti-glaucoma medication or surgery were selected. Individual SES was represented by monthly income calculated from the insurance premium. Neighborhood SES was defined based on neighborhood household income averages. Urbanization level of habitation was categorized into 3 levels. The odds ratio of having POAG or PACG in subjects with different SES was evaluated by using multiple logistic regression analysis. RESULTS: In total, 752 and 561 subjects with POAG and PACG, respectively, who were treated on a regular basis, were identified. The diagnosis of glaucoma was affected by age, gender, frequency of healthcare utilization, individual SES, and urbanization level of habitation. With the adjustment of age, gender, healthcare utilization, neighborhood SES and level of urbanization, subjects with lower income were more likely to be diagnosed as PACG, but less likely as POAG. CONCLUSIONS: Subjects with more frequent healthcare utilization were more likely to be diagnosed with glaucoma. Subjects with low SES were more susceptible to PACG, but subjects with high SES were more likely to be diagnosed as POAG. This information is useful for the design and target participant setting in glaucoma education and screening campaign to maximize the efficacy of limited resources in preventing glaucoma blindness.

The cost of glaucoma care provided to Medicare beneficiaries from 2002 to 2009.

PURPOSE: To estimate payments for glaucoma care among Medicare beneficiaries from 2002 to 2009. DESIGN: Database study. PARTICIPANTS: Data from a 5% random sample of Medicare billing information from 2002 to 2009. METHODS: Medicare beneficiaries, aged 65 years or older, with both Parts A and B fee-for-service (FFS) enrollment comprised the annual denominator. For each year, we included those with a defined glaucoma diagnostic code linked to a glaucoma visit, diagnostic test, or laser/surgical procedure. Open-angle, angle-closure, and other glaucoma were categorized separately. Claims were classified into glaucoma care, other eye care, and other medical care. MAIN OUTCOME MEASURES: Cost of glaucoma care in the Medicare Fee-for-Service Population. RESULTS: In 2009, total glaucoma payments by Medicare were $37.4 million for this subset, for an overall estimated cost of $748 million, or 0.4% of an estimated cost of $192 billion for all Medicare FFS payments. Office visits comprised approximately one half, diagnostic testing was approximately one-third, and surgical and laser procedures were approximately 10% of glaucoma-related costs. Coded open-angle glaucoma (OAG) and OAG suspects accounted for 87.5% of glaucoma costs, whereas cost per person was highest in "other glaucoma." In 2009, <3% of patients with OAG underwent incisional surgery and approximately 5% had laser trabeculoplasty. Laser iridotomy was the highest cost category among patients with angle-closure glaucoma, whereas office visits was the highest cost category among the "other glaucoma" group. The total cost of nonglaucoma eye care for patients with glaucoma was 67% higher than their glaucoma care costs; these were chiefly costs for cataract surgery and treatment of retinal diseases. From 2002 to 2009, FFS glaucoma care costs calculated in 2009 dollars were stable and cost per person per year in 2009 dollars decreased from $242 to $228 (P = 0.01 by test for linear trend). CONCLUSIONS: Annual glaucoma care costs per person decreased in constant dollars from 2002 to 2009. Cataract and retinal eye care for patients with glaucoma substantially exceeded the cost of their glaucoma care each year. Visit payments represented the largest category of costs.

The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): study protocol for a randomized controlled trial.

BACKGROUND: Glaucoma is the leading cause of irreversible blindness. Although primary open-angle glaucoma is more common, primary angle-closure glaucoma (PACG) is more likely to result in irreversible blindness. By 2020, 5·3 million people worldwide will be blind because of PACG. The current standard care for PACG is a stepped approach of a combination of laser iridotomy surgery (to open the drainage angle) and medical treatment (to reduce intraocular pressure). If these treatments fail, glaucoma surgery (eg, trabeculectomy) is indicated. It has been proposed that, because the lens of the eye plays a major role in the mechanisms leading to PACG, early clear lens extraction will improve glaucoma control by opening the drainage angle. This procedure might reduce the need for drugs and glaucoma surgery, maintain good visual acuity, and improve quality of life compared with standard care.EAGLE aims to evaluate whether early lens extraction improves patient-reported, clinical outcomes, and cost-effectiveness, compared with standard care. METHODS/DESIGN: EAGLE is a multicentre pragmatic randomized trial. All people presenting to the recruitment centres in the UK and east Asia with newly diagnosed PACG and who are at least 50 years old are eligible.The primary outcomes are EQ-5D, intraocular pressure, and incremental cost per quality adjusted life year (QALY) gained. Other outcomes are: vision and glaucoma-specific patient-reported outcomes, visual acuity, visual field, angle closure, number of medications, additional surgery (e.g., trabeculectomy), costs to the health services and patients, and adverse events.A single main analysis will be done at the end of the trial, after three years of follow-up. The analysis will be based on all participants as randomized (intention to treat). 400 participants (200 in each group) will be recruited, to have 90% power at 5% significance level to detect a difference in EQ-5D score between the two groups of 0·05, and a mean difference in intraocular pressure of 1·75 mm Hg. The study will have 80% power to detect a difference of 15% in the glaucoma surgery rate. TRIAL REGISTRATION: ISRCTN44464607.

What is the direct cost of treatment of acute primary angle closure glaucoma? The Singapore model.

AIM: To estimate the cost of management of acute primary angle closure glaucoma in Singapore. METHODS: In this cost analysis using retrospective data, the authors performed a MEDLINE search of published papers on acute primary angle closure glaucoma (APACG) in Singapore. Using information from published data, clinical management pathways were constructed and clinical outcomes identified. For each management path, costs of medical treatment, hospitalization, clinic charges, investigations, laser treatment and surgery were identified and accounted over a 5-year treatment period, using year 2002 rates. RESULTS: Given that, in Singapore, APACG affects 12.2 per 100,000 per year (95% confidence interval [CI], 10.5-13.9) in those aged 30 and older, each annual cohort would need to pay 261,741.78 US dollars (95%CI: US$225 310.90-298 265.10) or 287,560.26 US dollars (95%CI: 247,274.04-330,624.84 US dollars), if inclusive of cataract surgery, over 5 years after the episode of APACG. In this period, individuals would have to commit between 879.45 US dollars and 2576.39 US dollars, depending on the complexity of disease and accompanying cataract surgery. CONCLUSION: Acute primary angle closure glaucoma produces a substantial financial burden on society as well as on the individuals.