Femtosecond Laser-Assisted Cataract Surgery Versus Phacoemulsification Cataract Surgery (FACT): A Randomized Noninferiority Trial.

PURPOSE: To report the 3-month results of a randomized trial (Femtosecond Laser-Assisted Cataract Trial [FACT]) comparing femtosecond laser-assisted cataract surgery (FLACS) with standard phacoemulsification cataract surgery (PCS). DESIGN: Multicenter, randomized controlled trial funded by the UK National Institute of Health Research (HTA 13/04/46/). PARTICIPANTS: Seven hundred eighty-five patients with age-related cataract. METHODS: This trial took place in 3 hospitals in the UK National Health Service (NHS). Randomization (1:1) was stratified by site, surgeon, and 1 or both eyes eligible using a secure web-based system. Postoperative assessments were masked to the allocated intervention. The primary outcome was unaided distance visual acuity (UDVA) in the study eye at 3 months. Secondary outcomes included corrected distance visual acuity, complications, and patient-reported outcomes measures. The noninferiority margin was 0.1 logarithm of the minimum angle of resolution (logMAR). ISRCTN.com registry, number ISRCTN77602616. MAIN OUTCOME MEASURES: We enrolled 785 participants between May 2015 and September 2017 and randomly assigned 392 to FLACS and 393 to PCS. At 3 months postoperatively, mean UDVA difference between treatment arms was -0.01 logMAR (-0.05 to 0.03), and mean corrected distance visual acuity difference was -0.01 logMAR (95% confidence interval [CI], -0.05 to 0.02). Seventy-one percent of both FLACS and PCS cases were within ±0.5 diopters (D) of the refractive target, and 93% of FLACS and 92% of PCS cases were within ±1.0 D. There were 2 posterior capsule tears in the PCS arm and none in the FLACS arm. There were no significant differences between arms for any secondary outcome. CONCLUSIONS: Femtosecond laser-assisted cataract surgery is not inferior to conventional PCS surgery 3 months after surgery. Both methods are as good in terms of vision, patient-reported health, and safety outcomes at 3 months. Longer-term outcomes of the clinical effectiveness and cost-effectiveness are awaited.

Cost-effectiveness of the triple procedure - phacovitrectomy with posterior capsulotomy compared to phacovitrectomy and sequential procedures.

PURPOSE: To evaluate the cost-effectiveness of the triple procedure (phacovitrectomy + posterior capsulotomy, PhacoPPVc) compared to the double- (phacovitrectomy, PhacoPPV) or single sequential procedures. METHODS: Prospective study on 31 eyes from 31 patients (mean age: 72.1 ± 9.1 years; 55% females) was performed with a preoperative decision to undergo only pars plana vitrectomy (PPV) (26%) or PhacoPPV (74%) and/or posterior capsulotomy based upon presence or absence of lens opacification or pseudophakia. Time during and between surgeries, surgical procedure codes, medical and transport costs, outcome and likelihood of complications after surgery were all included in the analysis. Societal perspectives and visual acuity were considered as measures of quality of adjusted life years (QALYs). RESULTS: About 23 eyes underwent triple procedure and eight eyes underwent vitrectomy only (mean surgery times: 35.9 and 24.0 min, respectively). Posterior capsulotomy took on average 30 s, while preparation and cataract procedure took 13.0 min. The patients travelled on average 80km (average cost: $280.12) to the surgery unit. The average reimbursement fee for the day procedures ranged between $174.17 (YAG capsulotomy; Diagnosis Related Group (DRG): 0.034), $1045.48 (Phaco + intraocular lens (IOL); DRG: 0.204) and $1701.32 (PPV; DRG: 0.332). The combined procedures excluded lens and laser reimbursements, while the calculated reimbursements for the double/triple procedures were $2713.08/$2901.45, respectively, without significant loss of QALYs. PhacoPPVc was found to be unequivocally cost-effective, while PhacoPPV remained cost saving compared to sequential procedures. CONCLUSION: This study confirms that the triple procedure has benefits to the patients, health institution and surgeon. For patients, it saves them travel and healing time; for health institution, it justifies the calculated higher costs and need for higher reimbursement for the double/triple procedures, which are cost saving.

Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial.

BACKGROUND: Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. METHODS: We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006. FINDINGS: Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. INTERPRETATION: Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. FUNDING: French Ministry of Social Affairs and Health.

Health policy regulations pertaining to advanced surgical devices-their socio-economic effects on ophthalmology practice.

The Israel Ministry of Health enacted regulations that aim to reduce private expenditure on healthcare services and mitigate social inequality. According to the modified rules, which went into effect in the second half of 2016, patients who undergo surgery in a private hospital and are covered by their healthcare provider's supplemental insurance (SI) make only a basic co-payment.The modified regulations limited the option of self-payment for advanced devices not covered by national health basket, meaning that patients for whom such devices are indicated had to pay privately for the entire procedure. These regulations applied to all medical and surgical devices not covered by national health insurance (NHI).Toric intraocular lenses (IOLs) are a case in point. These advanced lenses are implanted during cataract surgery to correct corneal astigmatism and, in indicated cases, obviate the need for complex eyeglasses postoperatively. Toric IOL implantation has been shown to be highly cost-effective in both economic and quality-of-life terms. Limitations of the use of these advanced IOLs threatened to increase social inequality.In 2017, further adjustments of the regulations were made which enabled supplemental charges for these advanced IOLs, performed through the SI programs of the healthcare medical organizations (HMOs). Allowing additional payment for these lenses at a fixed pre-set price made it possible to apply a supplemental part of the insurance package to the surgery itself. In mid 2018 these IOLs were included without budget in the national health basket, allowing for self-payment for the additional cost in addition to the basic coverage for all patients with NHI.This case study suggests that, in their efforts to enhance health care equity, policymakers may benefit if exercising due caution when limiting the extent to which SI programs can charge co-payments. This is because, when a service or product is not available via the basic NHI benefits package, limiting SI co-payments can sometimes result in a boomerang effect - leading to an increase in inequality rather than the sought-after decrease in inequality.

Trial-based cost-effectiveness analysis of toric versus monofocal intraocular lenses in cataract patients with bilateral corneal astigmatism in the Netherlands.

PURPOSE: To evaluate the cost-effectiveness of toric versus monofocal intraocular lens (IOL) implantation in cataract patients with bilateral corneal astigmatism. SETTING: Two ophthalmology clinics in the Netherlands. DESIGN: Prospective cost-effectiveness analysis. METHODS: Resource-use data were collected over a 6-month postoperative period. Consecutive patients with bilateral age-related cataract and 1.25 diopters or more of corneal astigmatism were included in the economic evaluation. Patients were randomized to phacoemulsification with bilateral toric or monofocal IOL implantation. All relevant resources were included in the cost analysis. The base-case analysis was performed from a societal perspective based on quality-adjusted life years (QALYs). The main outcome was the incremental cost-effectiveness ratio. RESULTS: The analysis comprised 77 consecutive patients (33 toric IOL; 44 monofocal IOL). Societal costs were higher in the toric IOL group (€3203 [$3864]) than in the monofocal IOL group (€2796 [US$3373]). QALYs were slightly lower in the toric IOL group (0.30 versus 0.31; P = .75). Toric IOLs were therefore inferior to monofocal IOLs from a cost-effectiveness perspective. The cost-effectiveness probability ranged from 1% to 15%, assuming a ceiling ratio for the incremental cost-effectiveness ratio of €2500 to €20 000 per QALY. CONCLUSIONS: From a societal perspective, bilateral toric IOL implantation in cataract patients with corneal astigmatism was not cost-effective compared with monofocal IOL implantation. Copayment by patients should therefore be considered.

Pseudophakic mini-monovision: high patient satisfaction, reduced spectacle dependence, and low cost.

BACKGROUND: Cataract surgery with pseudophakic mini-monovision has lower out-of-pocket patient expense than premium multifocal intraocular lenses (IOL). The purpose of this study was to evaluate patient-reported satisfaction and spectacle dependence for key activities of daily living after cataract surgery with pseudophakic mini-monovision. The study also examined statistical relationships between patient demographic variables, visual acuity and satisfaction. METHODS: Prospective cohort study of 56 patients (112 eyes) who underwent bilateral cataract surgery with pseudophakic mini-monovision. Mini-monovision corrects one eye for distance vision and the other eye is focused at near with - 0.75 to - 1.75 D of myopia. All patients with 1 diopter or greater of corneal astigmatism had a monofocal toric IOLs implanted or limbal relaxing incision. The main study outcomes were assessed at the last follow-up appointment and included refraction, visual acuity, patient reported spectacle use, and patient satisfaction. Descriptive statistics, correlation matrixes and Pearson's chi-square tests were examined. RESULTS: Uncorrected visual acuity was significantly better post-operatively. Most patients reported the surgery met their expectations for decreased dependence on spectacles (93%). Most patients report little or no use of spectacles post-operatively for computer use (93%), distance viewing (93%) and general use throughout the day (87%). A small number of patients report spectacle use for reading (9%) and night driving (18%). There were no relationships detected between demographic variables and visual acuity or patient satisfaction. CONCLUSIONS: Aging of the population presents one of the biggest challenges in the health sector, which includes a rising number of individuals with chronic vision impairment and increased demand for accessible treatment strategies. Cataract surgery with pseudophakic mini-monovision results in high patient satisfaction and considerable reduction in spectacle dependence. Pseudophakic mini-monovision technique is a low-cost, valuable option for patients who would like to reduce dependence on spectacles post-operatively and should be considered along with premium multifocal IOLs in options available for patients based on their needs, preferences and clinical indicators. Reducing spectacle dependence with the pseudophakic mini-monovision technique could improve the functionality, independence and quality of life for many patients who are unsuitable or are unable to pay additional fees associated with premium multifocal IOLs.

Budget impact model of Mydrane®, a new intracameral injectable used for intra-operative mydriasis, from a UK hospital perspective.

BACKGROUND: During cataract surgery, maintaining an adequate degree of mydriasis throughout the entire operation is critical to allow for visualisation of the capsulorhexis and the crystalline lens. Good anaesthesia is also essential for safe intraocular surgery. Mydrane® is a new injectable intracameral solution containing two mydriatics (tropicamide 0.02% and phenylephrine 0.31%) and one anaesthetic (lidocaine 1%) that was developed as an alternative to the conventional topical pre-operative mydriatics used in cataract surgery. This study aimed to estimate the budget impact across a one year time frame using Mydrane® instead of topical dilating eye drops, for a UK hospital performing 3,000 cataract operations a year. METHODS: A budget impact model (BIM) was developed to compare the economic outcomes associated with the use of Mydrane® versus topical drops (tropicamide 0.5% and phenylephrine 10%) in patients undergoing cataract surgery in a UK hospital. The outcomes of interest included costs and resource use (e.g. clinician time, mydriasis failures, operating room time, number of patients per vial of therapy etc.) associated with management of mydriasis in patients undergoing cataract surgery. All model inputs considered the UK hospital perspective without social or geographical variables. Deterministic sensitivity analyses were also performed to assess the model uncertainty. RESULTS: Introduction of Mydrane® is associated with a cost saving of £6,251 over 3,000 cataract surgeries in one year. The acquisition costs of the Mydrane® (£18,000 by year vs. £3,330 for eye drops) were balanced by substantial reductions in mainly nurses' costs and time, plus a smaller contribution from savings in surgeons' costs (£20,511) and lower costs associated with auxiliary dilation (£410 due to avoidance of additional dilation methods). Results of the sensitivity analyses confirmed the robustness of the model to the variation of inputs. Except for the duration of one session of eye drop instillation and the cost of Mydrane®, Mydrane® achieved an incremental cost gain compared to tropicamide/phenylephrine eye drops. CONCLUSIONS: Despite a higher acquisition cost of Mydrane®, the budget impact of Mydrane® on hospital budgets is neutral. Mydrane® offers a promising alternative to traditional regimes using eye drops, allowing for a better patient flow and optimisation of the surgery schedule with neutral budget impact.

Improved utilization of operating room time for trainee cataract surgery in a public hospital setting.

PURPOSE: To examine the effect of group goal and group performance theories on operating room efficiency in resident-performed cataract surgery. SETTING: Zuckerberg San Francisco General Hospital and Trauma Center, Department of Ophthalmology, University of California, San Francisco, California, USA. DESIGN: Prospective case series. METHODS: This study assessed 4 specific segments of operating room utilization identified as room-to-incision time, incision-to-close time, close-to-exit time, and room turnover time. The time segments were measured for resident-performed cataract cases before the proposed intervention. Then, group goals were set for ideal times of each utilization segment. Behaviors of the surgery, anesthesia, nursing, pharmacy, and housekeeping teams that would improve group performance were identified. Utilization segments were measured again after the intervention. RESULTS: The time segments were measured for 134 resident-performed cataract cases before the proposed intervention and again after the intervention for 136 resident-performed cataract cases. Before the intervention, the mean overall case time was 55 minutes, allowing for 10 cases in a 10-hour day. After the intervention, the mean overall case time was 46 minutes, allowing for 13 cases in a 10-hour day. The decrease in postintervention times for overall case time, room-to-incision time, and close-to-exit time were statistically significant. CONCLUSIONS: Operating room utilization for resident-performed cataract surgery was enhanced by setting group goals. A multidisciplinary effort to enhance group performance through behavior modification can be implemented immediately and improve efficiency without compromising patient safety or resident teaching.

An evaluation of intracameral mydriasis for routine cataract surgery.

BACKGROUND: Intracameral Mydrane might facilitate a more streamlined cataract service and improve the patient experience. There is limited 'real-world' evidence of its use in a UK setting. METHODS: As part of a local evaluation of cataract surgery using intracameral Mydrane (group 2; n=60), data were collected on intraoperative pupil size and postoperative visual acuity (VA), as well as the rate of mechanical pupil dilation, intraoperative floppy iris syndrome (IFIS) and complications. Preoperative and theatre turnaround time was recorded and patients completed a validated measure of satisfaction postoperatively. Data were compared with a previous cohort subjected to the existing standard regime of preoperative topical mydriatics (group 1; n=60). RESULTS: Postoperative VA was comparable between groups (0.09±0.16 vs 0.08±0.15; p=0.59). Pupil size in group 2 was 7.0±1.0 mm prior to capsulorhexis and 6.5±0.29 mm after cortical aspiration, with a smaller pupil in patients on alpha-antagonists (4.7±1.1 mm; p=0.004) at this later time point. Comparing group 2 with group 1, preoperative waiting was less (87 vs 146 min; p<0.0001) and satisfaction was higher (76.0±11.2 vs 66.3±8.6; p<0.0001), although theatre turnaround time was longer (25 min vs 22 min). CONCLUSION: Intracameral mydriasis was clinically effective in most patients undergoing cataract surgery and might be associated with an improved patient experience and a more streamlined preoperative flow. Mydrane represents a licensed alternative to the off-label use of other intracameral mydriatic agents, but was not judged to be a cost-effective intervention for routine use in this particular setting.

[Cost of teaching cataract surgery in a public hospital]. / Évaluation du coût de l'enseignement de la chirurgie de la cataracte dans un établissement public de santé.

INTRODUCTION: The gold standard of cataract surgery, phacoemulsification is the most commonly performed surgical procedure in France. Surgical instruction often takes place in the operating room where residents and fellows perform real surgery, supervised by an experienced surgeon. The goals of this study were double: evaluate surgical times according to the person performing the surgery, in order to quantitate the cost incurred by teaching and compare complication rate between surgeons. METHODS: A retrospective single center study was performed at Simone-Veil Hospital, Eaubonne-Montmorency, France. Over a period of 13 consecutive weeks from January to March 2016, all patients who underwent phacoemulsification for cataract extraction were included. Patients were separated into three groups, according to the primary surgeon: group S for Senior was composed of two experienced surgeons who typically performed over 500 procedures per year; group A for assistant was composed of three residents who performed less than 500 procedures per year; 2 inexperienced interns constituted group I. Surgery duration was recorded by the OR nurse in minutes between the first incision and removal of the lid speculum. The cost of operating room time was estimated at seven euros per minute. The occurrence of complications was determined from the operative report. RESULTS: 408 cataract surgeries were performed during the study period, divided into 156 eyes in group S, 142 in group A and 110 surgeries in group I. The mean age at surgery was 74.1±9 years (39-95), comparable in the 3 groups. The operative time was significantly shorter in group S (11.7min) than in A (18.7min; P<0.001) and in I (18.8min; P<0.001). The complication rate was higher in group I than in group S (P=0.03). The average additional cost related to the lengthening of the teaching procedure was 49 euros for Group A and 49.7 euros for Group I. DISCUSSION: The hospital reimbursement for cataract surgery is higher in the public sector than in the private sector; it can absorb the cost of university training. CONCLUSION: Teaching cataract surgery entails an additional financial cost for the hospital. It is also responsible for a higher human cost due to a greater number of operative complications with interns.

Long-term efficiency of cataract surgery with hydrophilic acrylic Ioflex intraocular lens.

OBJECTIVE: To evaluate the efficiency of long-term cataract surgery using low-cost intraocular lens implantation in community campaigns. METHODS: Fifty-eight randomly selected patients were evaluated four years after phacoemulsification and Ioflex intraocular lens implantation. Causes of low visual acuity related to the intraocular lens were evaluated, and treatment costs were calculated. RESULTS: The mean age of patients was 72±10.2 years. Four years after surgery, 25 eyes (43.0%) had decreased visual acuity related to the intraocular lens: posterior capsule opacification was noted in 24 eyes (41.3%), and intraocular lens opacification was noted in one eye (1.7%). The total cost of the post-surgical complication treatments represented 6.3% of the initial budget of the entire surgical patient group. CONCLUSIONS: The efficiency of cataract surgery with low-cost Ioflex intraocular lens implantation was significantly reduced in a long-term follow-up study because postoperative complications related to intraocular lenses emerged at higher rates than when the gold-standard treatment was used.

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.

Long-term efficiency of cataract surgery with hydrophilic acrylic Ioflex intraocular lens

OBJECTIVE: To evaluate the efficiency of long-term cataract surgery using low-cost intraocular lens implantation in community campaigns. METHODS: Fifty-eight randomly selected patients were evaluated four years after phacoemulsification and Ioflex intraocular lens implantation. Causes of low visual acuity related to the intraocular lens were evaluated, and treatment costs were calculated. RESULTS: The mean age of patients was 72±10.2 years. Four years after surgery, 25 eyes (43.0%) had decreased visual acuity related to the intraocular lens: posterior capsule opacification was noted in 24 eyes (41.3%), and intraocular lens opacification was noted in one eye (1.7%). The total cost of the post-surgical complication treatments represented 6.3% of the initial budget of the entire surgical patient group. CONCLUSIONS: The efficiency of cataract surgery with low-cost Ioflex intraocular lens implantation was significantly reduced in a long-term follow-up study because postoperative complications related to intraocular lenses emerged at higher rates than when the gold-standard treatment was used.

Immediately sequential bilateral cataract surgery: advantages and disadvantages.

PURPOSE OF REVIEW: The number of cataract surgeries performed globally will continue to rise to meet the needs of an aging population. This increased demand will require healthcare systems and providers to find new surgical efficiencies while maintaining excellent surgical outcomes. Immediately sequential bilateral cataract surgery (ISBCS) has been proposed as a solution and is increasingly being performed worldwide. The purpose of this review is to discuss the advantages and disadvantages of ISBCS. RECENT FINDINGS: When appropriate patient selection occurs and guidelines are followed, ISBCS is comparable with delayed sequential bilateral cataract surgery in long-term patient satisfaction, visual acuity and complication rates. In addition, the risk of bilateral postoperative endophthalmitis and concerns of poorer refractive outcomes have not been supported by the literature. ISBCS is cost-effective for the patient, healthcare payors and society, but current reimbursement models in many countries create significant financial barriers for facilities and surgeons. SUMMARY: As demand for cataract surgery rises worldwide, ISBCS will become increasingly important as an alternative to delayed sequential bilateral cataract surgery. Advantages include potentially decreased wait times for surgery, patient convenience and cost savings for healthcare payors. Although they are comparable in visual acuity and complication rates, hurdles that prevent wide adoption include liability concerns as ISBCS is not an established standard of care, economic constraints for facilities and surgeons and inability to fine-tune intraocular lens selection in the second eye. Given these considerations, an open discussion regarding the advantages and disadvantages of ISBCS is important for appropriate patient selection.

Manchester iStent study: 3-year results and cost analysis.

PurposeTo evaluate the safety, efficacy, and the cost of combined phacoemulsification and single iStent insertion in open angle glaucoma (OAG) at 3-years follow-up.MethodsThis was a prospective, uncontrolled, interventional case series. All subjects underwent single iStent implantation combined with cataract surgery by a single surgeon and were followed up over 3 years. Primary outcome measures were the reduction in intraocular pressure (IOP) and number of glaucoma drops at 1, 2, and 3 years. The costs of the procedure vs the cost of continuation of glaucoma drops were calculated and compared in patients who completed 3-years follow-up.ResultsForty-one patients were included in the study and thirty-six patients completed 3-years follow-up. Mean pre-op IOP was 21.2 mm Hg on 2.1 medications. Mean IOP was reduced to 15.9 mm Hg on 0.5 drops, 16.1 mm Hg on 1.0 drops, and 17.1 mm Hg (P<0.001) on 1.3 drops (P<0.001) at 1, 2, and 3 years, respectively. The overall cost of combined cataract surgery and iStent was estimated to be £829.32 more in total than conservative management with brand name eye drops over 3 years (£7.70 per patient per year) and £14 176.9 more if generic drops were used. (£131.3 per patient per year).ConclusionsCombined phaco-iStent proved to be a safe and effective way of managing patients with OAG over our 3-year follow-up period. The cost-effectiveness of the procedure may vary depending on whether brand name or generic eye drops are used.

Cost-Utility Analyses of Cataract Surgery in Advanced Age-Related Macular Degeneration.

PURPOSE: To explore the cost-utility of cataract surgery in patients with advanced age-related macular degeneration (AMD). METHODS: Patients who were diagnosed as having and treated for age-related cataract and with a history of advanced AMD at the Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, were included in the study. All of the participants underwent successful phacoemulsification with foldable posterior chamber intraocular lens implantation under retrobulbar anesthesia. Best-corrected visual acuity (BCVA) and utility value elicited by time trade-off method from patients at 3-month postoperative time were compared with those before surgery. Quality-adjusted life years (QALYs) gained in a lifetime were calculated at a 3% annual discounted rate. Costs per QALY gained were calculated using the bootstrap method, and probabilities of being cost-effective were presented using a cost-effectiveness acceptability curve. Sensitivity analyses were performed to test the robustness of the results. RESULTS: Mean logarithm of the minimum angle of resolution BCVA in the operated eye increased from 1.37 ± 0.5 (Snellen, 20/469) to 0.98 ± 0.25 (Snellen, 20/191) (p < 0.001); BCVA in the weighted average from both eyes (=75% better eye + 25% worse eye) was changed from 1.13 ± 0.22 (Snellen, 20/270) to 0.96 ± 0.17 (Snellen, 20/182) (p < 0.001). Utility values from both patients and doctors increased significantly after surgery (p < 0.001 and p = 0.007). Patients gained 1.17 QALYs by cataract surgery in their lifetime. The cost per QALY was 8835 Chinese yuan (CNY) (1400 U.S. dollars [USD]). It is cost-effective at the threshold of 115,062 CNY (18,235 USD) per QALY in China recommended by the World Health Organization. The cost per QALY varied from 7045 CNY (1116 USD) to 94,178 CNY (14,925 USD) in sensitivity analyses. CONCLUSIONS: Visual acuity and quality of life assessed by utility value improved significantly after surgery. Cataract surgery was a cost-effective intervention for patients with coexistent AMD.

Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States.

PURPOSE: To evaluate the visual and economic benefits of same-day bilateral cataract surgery versus separate-day bilateral cataract surgery in the United States. SETTING: Private practice, Amarillo, Texas, USA. DESIGN: Prospective controlled nonrandomized clinical trial. METHODS: A cohort of patients having same-day bilateral cataract surgery was age-matched with a cohort of control patients who had standard separate-day bilateral cataract surgery. The primary outcome was a comparison of the direct cost for the patient, physician, ambulatory surgery center (ASC), and third-party payer. RESULTS: The same-day cohort (42 patients, 84 eyes) had similar baseline characteristics and postoperative outcomes as the control cohort (42 patients, 84 eyes). The same-day cohort had less total distance traveled for care (P = .0039 and P < .0001 for in-town and out-of-town residents, respectively), less total time spent traveling for care (P = .0008 and P < .0001 for in-town and out-of-town residents, respectively), less total number of visits required for care (P < .0001), and less total time for vision recovery (P < .0001) than the control cohort. The physician and ASC reimbursements were lower in the same-day cohort (P = .0028 and P = .0016, respectively), whereas the total physician time spent caring for the patient in surgery was not different between the 2 groups (P = .7310). The total ASC expenses were higher in the same-day cohort (P < .0001). The total third-party payer cost was significantly less in the same-day cohort (P < .0001). CONCLUSION: Visual and economic benefits for the patient can be achieved with same-day bilateral cataract surgery in the U.S. at the present time. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.