Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification

Shefali Sood, Noah Heilenbach, Victor Sanchez, Sherry Glied, Sien Chen, Lama A. Al-Aswad

Research output: Contribution to journalArticlepeer-review


Purpose: To investigate the costs and effects of implanting trabecular meshwork bypass stents during cataract surgery from a societal perspective in the United States. Design: Cost-utility analysis using Markov models and efficacy/safety data from published pivotal or randomized control trials (RCTs) of devices investigated. Participants: Patients aged 65 years and older with mild to moderate primary open-angle glaucoma with or without visually significant cataract. Methods: With the use of Markov models, glaucoma progression through 4 glaucoma states (mild, moderate, advanced, severe/blind) and death were simulated over 35 years. The cohort with cataract entered the model and received cataract surgery with or without device implantation. We included a medication management only reference group to calculate total costs and outcomes for those without cataract. Intraocular pressure (IOP) reductions from RCTs were converted to glaucoma state transition probabilities using visual field (VF) mean deviation (MD) decline rates from the Early Manifest Glaucoma Trial. Progressive thinning of the retinal nerve fiber layer (RNFL) on OCT imaging related to IOP control warranted further intervention, including adding medication, selective laser trabeculoplasty (SLT), or incisional glaucoma surgery. We estimated whole costs at Medicare rates and obtained utility values for glaucoma states from previous studies. Incremental costs per quality-adjusted life-year (QALY) gained were evaluated at a QALY threshold of $50 000. One-way deterministic sensitivity analysis, scenario analyses, and probabilistic sensitivity analyses addressed parameter uncertainty and demonstrated model robustness. Main Outcome Measures: Total costs, QALY, and incremental cost-effectiveness ratio (ICER). Results: Over 35 years in the base case, the Hydrus (Ivantis, Inc.) implanted with cataract surgery arm cost $48 026.13 and gained 12.26 QALYs. The iStent inject (Glaukos Corp.) implanted with cataract surgery arm cost $49 599.86 and gained 12.21 QALYs. Cataract surgery alone cost $54 409.25 and gained 12.04 QALYs. Initial nonsurgical management cost $57 931.22 and gained 11.74 QALY. The device arms dominated or were cost-effective compared with cataract surgery alone within 5 years and throughout sensitivity analyses. The iStent inject arm was cost-effective in 94.19% of iterations in probabilistic sensitivity analyses, whereas the Hydrus arm was cost-effective in 94.69% of iterations. Conclusions: Implanting the Hydrus Microstent or iStent inject during cataract surgery is cost-effective at a conservative QALY threshold.

Original languageEnglish (US)
Pages (from-to)284-296
Number of pages13
JournalOphthalmology Glaucoma
Issue number3
StatePublished - May 1 2022


  • Cost-effectiveness analysis
  • Economic burden of glaucoma
  • Hydrus
  • Markov Model
  • Minimally invasive glaucoma surgery
  • Phacoemulsification
  • QALY
  • Structure and function progression
  • Treatment cost
  • iStent inject

ASJC Scopus subject areas

  • Ophthalmology


Dive into the research topics of 'Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification'. Together they form a unique fingerprint.

Cite this