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Editors Selection IGR 12-3

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Comment by Kuldev Singh 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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Stein and colleagues are to be congratulated on a novel approach for weighing the relative merits of medical versus laser therapy for newly diagnosed glaucoma using a Markov model. The debate regarding whether or not laser trabeculoplasty should be recommended for newly-diagnosed glaucoma patients has raged for decades and has been the focus of many studies, large and small. It is not surprising that this Markov model reveals greater value with initial prostaglandin analog therapy relative to laser trabeculoplasty when assuming perfect compliance and the opposite when poor adherence results in a 25% reduction in prostaglandin efficacy. In addition to the obvious difficulties in assessing compliance for individual patients, another unknown with regard to this debate is what impact lack of compliance has on IOP lowering with prostaglandin use. In the absence of continuous 24-hour IOP monitoring for most patients, and studies showing that prostaglandin analog use can be associated with substantial IOP lowering beyond 24 hours after discontinuation, it is difficult to assess the impact of missing medication several days a week on the cumulative IOP lowering effect in an individual patient. One can hypothesize, for example, that missing 25% of prostaglandin analog doses may not result in a 25% reduction in the IOP lowering effect of a medication in this class.

No model is perfect, but the rigor displayed by Stein and colleagues in creating this Markov model to discuss an important clinical issue is most exemplary. At the very least, the model makes a strong case for considering initial laser trabeculoplasty for newly-diagnosed glaucoma in patients known to be generally non-compliant with other medications, either by self-admission, or by objective parameters such as mean possession ratio.

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