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Editors Selection IGR 22-4

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Comment by Rupert Bourne on:

49037 Cost-effectiveness of Medications Compared With Laser Trabeculoplasty in Patients With Newly Diagnosed Open-Angle Glaucoma, Stein JD; Kim DD; Peck WW et al., Archives of Ophthalmology, 2012; 130: 497-505

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Attempts to determine cost-effectiveness of treatment options in glaucoma are to be welcomed. Using the results of the Glaucoma Laser Trial (GLT, Stein et al. compare 25-year cost-effectiveness of laser trabeculoplasty (LTP) versus topical medication versus observation in a hypothetical cohort of patients aged 60 years with mild (mean deviation of ‐6 dB or less of visual field) open-angle glaucoma (OAG). Despite the GLT study being 23 years old and the eye drop comparator being a beta blocker, the authors have estimated the effectiveness that might be expected had prostaglandin analogues (PGA) been used. The difficulties associated with using such an old study that involves adjunctive medications which are largely obsolete, meant that the authors made many assumptions. For example, they inferred a 30% reduced rate of progression with a PGA than a beta blocker, on account of 30% more efficacy in IOP lowering with PGAs. Another assumption is that of a 10% rate of progression from moderate OAG to more severe disease states per year for each of the three groups. One questions whether this is too simplistic a model to adequately characterize the 25-year behavior of OAG in these three groups. Certainly, reports like these would benefit from additional online material which explains the systematic reviews undertaken to build the evidence for the sensitivity analysis, and a more explicit description of how the survival rates were used to estimate the transition probabilities between the health states of the Markov model. It would be interesting to consider these treatment options in the contemporary routine clinical setting which is quite different to the GLT's study design, where LTP treatment may not be the primary therapy but may be instituted later, and may involve retreatments. However, this is an interesting paper, and more contemporary studies of cost-effectiveness such as that involving selective laser trabeculoplasty are eagerly awaited.

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