Commentary: Minimally invasive glaucoma surgery for a surgical take diversion: An economic perspective

Abstract

The authors of the accompanying article investigated, in great detail, the extent to which glaucoma disease process can challenge patients economically.[1] Various factors associated with financial dependence on medical expenditure and total expenditure were explored, and the study concluded that the economic burden of glaucoma was high and burnt a hole in the patient’s pocket. The study also focused on the economic burden of various glaucoma procedures, such as peripheral iridotomy and trabeculectomy, with limited or no information on minimally invasive glaucoma surgeries (MIGSs).[1] Also, as there is minimal literature currently available on the economic burden of MIGS, we have shed light on this grey area with respect to developing countries like India.[2,3] The current MIGS Indian journey - Where we stand MIGS has made slow and steady definitive inroads in the last few years in India. The number of MIGS procedures and devices that are currently available and accessible in India are limited in their type and number [Tables 1 and 2]. However, cost-effective alternatives to their expensive western counterparts are readily available. Prolene suture gonioscopy-assisted transluminal trabeculotomy (GATT) is the cost-effective alternative to the OMNI Surgical System (Sight Sciences Inc., CA, USA). Bent ab-interno needle goniectomy (BANG) is the cost-effective alternative to the Kahook Dual Blade (New World Medical, CA, USA) that was recently granted regulatory approval in India.Table 1: Various types of minimally invasive glaucoma surgery (MIGS) procedures and stenting devices employed for reducing intraocular pressure by increasing trabecular outflow. *MIGS procedure devices currently available and accessible in IndiaTable 2: Various types of minimally invasive glaucoma surgery (MIGS) procedures employed for reducing intraocular pressure by targeting uveoscleral outflow, reduction of aqueous production and sub-conjunctival filtration. *MIGS procedure devices currently available and accessible in IndiaTrabectome and other cycloablative diode procedures, such as endoscopic cyclophotocoagulation (ECP) or micropulse transscleral diode cyclophotocoagulation (MP-TSCPC), are available and require capital expenditure for acquisition. The economic disadvantage of using the electrocautery probe of trabectome and the MP-TSCPC probe are their disposable nature and recurring costs, even after the capital investment is made. On the other hand, the probe of ECP is relatively cost-effective due to its reusable nature and can function effectively for at least 10–12 procedures.[4] Cost per 1 mmHg intraocular pressure reduction/The MIGS conundrum down to every mmHg Recently, it was reported that the cost per 1 mmHg reduction in intraocular pressure (IOP) after one year was approximately $190 (or 15,502) for trabeculectomy, $1,376 (or 1,12,25) for iStent (Glaukos), $635 (or 51,802) for cyclophotocoagulation, and $450 (or 36,705) for Baerveldt glaucoma drainage implant. Trabeculectomy was found to be the most cost-efficient incisional glaucoma surgery, whereas the least cost-efficient was iStent (Glaukos). Other procedures ranked in the middle were cyclophotocoagulation and the Baerveldt glaucoma drainage implant.[5] Among the MIGS procedures, the most cost-efficient one was trabectome (Microsurgical Technology, $498 per 1 mmHg or 40,628 per 1 mmHg), followed by gonioscopy-assisted transluminal trabeculotomy ($719 per 1 mmHg or 58,651 per 1 mmHg).[5] Conventional glaucoma surgeries and selective laser trabeculoplasty (SLT) seemed to be a better option when the cost was a concern for patients.[4] Assuming that no further surgeries were required thereafter, the cost per 1 mmHg reduction in IOP decreased after the first year. This was because the calculations included only the price of the glaucoma medications needed henceforth. With this calculation, the cost per 1 mmHg for various surgeries ranged from $12 (or 979) to $61 (or 4,978).[5] Effective cost of intervention - The MIGS quandary The effective cost of the intervention was calculated as the total fee of intervention minus drop savings (for one year). The lowest cost was for SLT surgery ($571 or 46,596), followed by cyclophotocoagulation ($2,351 or 1,91,855) and trabeculectomy ($2,450 or 1,99,934). As expected, the effective cost of MIGS was high, ranging from $3,762 (or 3,07,001) to $7,138 (or 5,82,502).[4] Take diversion option for MIGS - The economical solution As the authors of the accompanying article rightly pointed out regarding customizing treatment, according to socioeconomic status, suture GATT is the most preferred MIGS procedure of choice from an economic standpoint, as it can be performed using a $4 (or 326) prolene suture rather than a $750 (or 61,220) catheter (OMNI), followed by BANG which only needs a 25-G or 27-G needle to unroof the trabecular meshwork. 25 G or 27 G, 5/8 inch is preferred since 1/2 inch may be too short, and a needle holder is required to bend the tip. Goniectomy can be performed for about 100° using a gonioprism. This results in a reduction of IOP of about 30% and also a reduction of the anti-glaucoma medication load. However, the major advantage of prolene GATT over BANG is that it can access the entire Schlemm’s canal and unroof it 360-degree, rather than target only a small portion. GATT combined with cataract surgery is another cost-effective option that can be safely performed and does not reduce the effectiveness of GATT.[6] Similarly, BANG combined with cataract extraction is another economical option, demonstrating greater than-expected IOP reduction.[7] The challenge - Economic evidence from non-randomized control trials and gray literature The challenging concept about MIGS that remains unclear is whether the cost savings outweigh the cost of using it through decreased medication and the need for further interventions. The currently available studies are retrospective studies, case reports, or industry-sponsored RCTs that can lead to bias, and many studies have only a short follow-up period.[8] Moreover, most of the studies focus on the safety profile and clinical outcomes and fail to evaluate the economic burden of these MIGS devices. Also, a few studies that focused on the economics were only from the United States, and the cost dynamics were reported in USD; the conversion in Rupees () shown in this manuscript is only a rough estimate, and may not reflect the actual market rates in India. Conclusion - breaking the barrier Newer modalities of MIGS have created an impact on the management of open-angle glaucoma, even in developing countries. With cost-effective alternate modalities, MIGS is here to stay and can go a long way in improving the quality of life at a much lower expenditure while maintaining good control of their glaucoma status. With time, more randomized control trials that focus on economics are called for to throw more light on the financial and economic picture surrounding MIGS.

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