Retrospective assessment of accuracy of nine intraocular lens power calculation formulae in eyes with axial myopia.

PURPOSE: To compare the accuracy of nine conventional and newer-generation formulae in calculating intraocular lens power in eyes with axial myopia. SETTING: Tertiary eye care center, Bengaluru, India. DESIGN: Retrospective cross-sectional, comparative study conducted in India. METHODS: Patients undergoing uneventful phacoemulsification in eyes with axial length >26 mm were included. Preoperative biometry was done using Lenstar LS 900 (Haag-Streit AG, Switzerland). Single eye of patients undergoing bilateral implantation was randomly selected. Optimized lens constants were used to calculate the predicted postoperative refraction of each formula, which was then compared with the actual refractive outcomes to give the prediction errors, following which subgroup analysis was performed. The Kane formula, Barrett universal II, Emmetropia Verifying Optical (EVO) 2.0, Hill Radial Basis Function (Hill RBF) 3.0, Olsen formula, along with Wang Koch-adjusted four formulae, that is, Sanders Retzlaff Kraff/Theoretical (SRK/T), Holladay 1, Haigis, and Hoffer Q formula, were compared for intraocular lens power calculations. RESULTS: One hundred and sixty-five eyes that fulfilled all the inclusion criteria were studied. Hill RBF 3.0 had the lowest mean and median absolute prediction errors (0.355 and 0.275, respectively) compared to all formulas. In subgroup analysis (26-28, >28-30, and >30 mm), significant difference was seen only in extremely long eyes (>30 mm). The Hill RBF 3.0 formula generated the maximum percentage of eyes with refractive errors within ±0.25, ±0.5, ±0.75, and ±1 D (46%, 76.2%, 89.9%, and 95.8%, respectively). CONCLUSION: This is the first study evaluating all the formulas exclusively in the myopic eyes. Hill RBF 3 was found to be superior in accuracy to all other formulas.

Cost-effectiveness of the ADVISE trial: An intraoperative OCT protocol in DMEK surgery.

The intraoperative optical coherence tomography (iOCT) is recently introduced in Descemet membrane endothelial keratoplasty (DMEK) surgery, which aims to increase clinical performance and surgery safety. However, the acquisition of this modality is a substantial investment. The objective of this paper is to report on the cost-effectiveness of an iOCT-protocol in DMEK surgery with the Advanced Visualization in Corneal Surgery Evaluation (ADVISE) trial. This cost-effectiveness analysis uses data 6 months postoperatively from the multicentre prospective randomized clinical ADVISE trial. Sixty-five patients were randomized to usual care (n = 33) or the iOCT-protocol (n = 32). Quality-Adjusted Life Years (EQ-5D-5L), Vision-related Quality of Life (NEI-VFQ-25) and self-administered resources questionnaires were administered. Main outcome is the incremental cost-effectiveness ratio (ICER) and sensitivity analyses. The iOCT protocol reports no statistical difference in ICER. For the usual care group compared with the iOCT protocol, respectively, the mean societal costs are €5027 compared with €4920 (Δ€107). The sensitivity analyses report the highest variability on time variables. This economic evaluation learned that there is no added value in quality of life or cost-effectiveness in using the iOCT protocol in DMEK surgery. The variability of cost variables depends on the characteristics of an eye clinic. The added value of iOCT could gain incrementally by increasing surgical efficiency, and aiding in surgical decision-making.

Role of artificial intelligence in determining factors impacting patients' refractive surgery decisions.

Purpose: To create a predictive model using artificial intelligence (AI) and assess if available data from patients' registration records can help in predicting definitive endpoints such as the probability of patients signing up for refractive surgery. Methods: This was a retrospective analysis. Electronic health records data of 423 patients presenting to the refractive surgery department were incorporated into models using multivariable logistic regression, decision trees classifier, and random forest (RF). Mean area under the receiver operating characteristic curve (ROC-AUC), sensitivity (Se), specificity (Sp), classification accuracy, precision, recall, and F1-score were calculated for each model to evaluate performance. Results: The RF classifier provided the best output among the various models, and the top variables identified in this study by the RF classifier excluding income were insurance, time spent in the clinic, age, occupation, residence, source of referral, and so on. About 93% of the cases that did undergo refractive surgery were correctly predicted as having undergone refractive surgery. The AI model achieved an ROC-AUC of 0.945 with an Se of 88% and Sp of 92.5%. Conclusion: This study demonstrated the importance of stratification and identifying various factors using an AI model which could impact patients' decisions while selecting a refractive surgery. Eye centers can build specialized prediction profiles across disease categories and may allow for the identification of prospective obstacles in the patient's decision-making process, as well as strategies for dealing with them.

Trial-based cost-effectiveness analysis of Descemet membrane endothelial keratoplasty (DMEK) versus ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK).

PURPOSE: To evaluate the cost-effectiveness of Descemet Membrane Endothelial Keratoplasy (DMEK) versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK). METHODS: A cost-effectiveness analysis using data from a multicenter randomized clinical trial was performed. The time horizon was 12 months postoperatively. Patients with Fuchs' endothelial dystrophy were randomized to DMEK (n = 29) or UT-DSAEK (n = 24). Relevant resources from healthcare and societal perspectives were included in the cost analysis. Quality-Adjusted Life Years (QALYs) were determined using the Health Utilities Index Mark 3 (HUI3) and the EuroQol EQ-5D-5L questionnaires. The main outcome was the incremental cost-effectiveness ratio (ICER; incremental societal costs per QALY). RESULTS: Societal costs averaged €8851 (US$11 406) for DMEK and €8320 (US$10 722) for UT-DSAEK. Higher costs in the DMEK group were mainly caused by higher rebubbling and regraft rates (21% and 7%, vs. 4% and 0% in the UT-DSAEK group). HUI3 QALYs were 0.70 (DMEK) and 0.79 (UT-DSAEK). EQ-5D-5L QALYs were 0.83 (DMEK) and 0.86 (UT-DSAEK). The ICER indicated DMEK was dominated by UT-DSAEK in both analyses. The cost-effectiveness probability for DMEK ranged from 21% to 5% (HUI3 QALYs) and 27%-14% (EQ-5D-5L QALYs), assuming the maximum acceptable ICER ranged from €2500 to €80.000 (US$3222-US$103 093) per QALY. CONCLUSION: The base case cost-effectiveness analysis favoured UT-DSAEK over DMEK, as costs of DMEK were higher while QALYs were lower. Further studies are required to assess long-term rebubbling and regraft rates and graft survival.

Economic evaluation of prevention of cystoid macular edema after cataract surgery in diabetic patients: ESCRS PREMED study report 6.

PURPOSE: To investigate the cost-effectiveness of prophylactic treatments against cystoid macular edema after cataract surgery in diabetic patients. SETTING: 7 ophthalmology clinics in the Netherlands and Belgium. DESIGN: Prospective trial-based cost-effectiveness analysis using data from a European multicenter randomized clinical trial. METHODS: Diabetic patients (n = 163) undergoing uneventful cataract surgery were randomized to perioperative subconjunctival triamcinolone acetonide (n = 36), perioperative intravitreal bevacizumab (n = 36), combination treatment (n = 45), or no additional treatment (control group, n = 46). The cost analysis was performed from a healthcare perspective within a 12-week postoperative time horizon. The main effectiveness outcome was quality-adjusted life years (QALYs). The main cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER; cost per QALY). RESULTS: The mean total healthcare costs and QALYs were as follows: triamcinolone group €1827 (U.S. dollars [$] 2295)/0.166; bevacizumab group €2050 ($2575)/0.144; combination group €2027 ($2546)/0.166; and control group €2041 ($2564)/0.156. Bevacizumab and control treatment were most costly and least effective. The ICER was €321 984 ($404 503) per QALY for the combination group compared with that of the triamcinolone group. Assuming the willingness-to-pay as €20 000 ($25 126) per QALY, the cost-effectiveness probability was 70% and 23% in the triamcinolone and combination groups, respectively. No patient who received triamcinolone developed clinically significant macular edema (CSME). A secondary cost-effectiveness analysis based on this outcome showed a clear preference for triamcinolone. CONCLUSIONS: In diabetic patients, subconjunctival triamcinolone was effective in preventing CSME after cataract surgery. The cost-effectiveness analysis showed that triamcinolone is also cost-effective.

Cost analysis of mydriasis strategies in cataract surgery care in the Netherlands.

PURPOSE: To investigate the economic impact of an intracameral mydriatics and anesthetic agent (ICMA), topical mydriatics, and a mydriatic ocular insert in cataract patients. SETTING: One public hospital in the Netherlands. DESIGN: Prospective cohort study. METHODS: Resource use data were collected from a healthcare and societal perspective on the day of surgery. Other outcome parameters included pupil size, surgeon satisfaction, postoperative pain, and Catquest-9SF scores. RESULTS: A total of 368 patients were included, the mean costs per patient were €506 in the ICMA group (n = 122), €474 in the ocular insert group (n = 115), and €451 in the topical group (n = 131). The acquisition cost of ICMA was highest and resulted in longer surgical time. After correction for an imbalance in the distribution of fast and slow surgeons, the mean costs in the ocular insert and topical groups were comparable (€450 vs €444). There was no statistically significant difference in the use of additional mydriatics intraoperatively (P = .521). The mean ratio of pupil size to white-to-white distance was lower in the ICMA group during all intraoperative measurements (P < .001) but similar between the topical and ocular insert groups (P range .11-.82). CONCLUSIONS: In the investigated setting in the Netherlands, ICMA was the most costly strategy. In addition, pupil size was lowest in the ICMA group but did not result in more additional mydriasis measures intraoperatively. The ocular insert was comparable with topical mydriatics in costs and pupil size. Implementation of ICMA could be considered when availability of nurses or physical space for perioperative care is limited.

Economic evaluation of prevention of cystoid macular edema after cataract surgery in patients without diabetes: ESCRS PREMED study report 4.

PURPOSE: To investigate the cost-effectiveness of prophylactic treatments against cystoid macular edema (CME) after cataract surgery in patients without diabetes. SETTING: Seven ophthalmology clinics in the Netherlands and Belgium. DESIGN: Prospective cost-effectiveness analysis using data from a European multicenter randomized clinical trial (ESCRS PREMED). METHODS: Patients without diabetes planned for expected uneventful cataract surgery were randomized to topical bromfenac (Yellox, n = 242), topical dexamethasone (n = 242), or a combination treatment (n = 238). All relevant resources from a healthcare perspective were included in the cost analysis within a time horizon of 12 weeks postoperatively. The main effectiveness outcome was quality-adjusted life years (QALYs). The main cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER) based on the cost per QALY. RESULTS: The study comprised 722 patients without diabetes. Total healthcare costs and QALYs were € 447 (US $562) and 0.174 in the bromfenac group, €421 (US $529) and 0.179 in the dexamethasone group, and €442 (US $565) and 0.182 in the combination group. Bromfenac was most costly and least effective (ie, strongly dominated). The ICER was €6544 (US $8221) per QALY for the combination group compared with the dexamethasone group. Assuming that the willingness to pay is € 20 000 (US $25 126) per QALY, the cost-effectiveness probability was 3%, 32%, and 65% in the bromfenac, dexamethasone, and combination groups, respectively. CONCLUSIONS: In patients without diabetes, combination treatment with topical bromfenac and dexamethasone was effective and cost-effective in preventing CME after cataract surgery compared with treatment with either drug alone.

Trial-based cost-effectiveness analysis of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) versus DSAEK.

PURPOSE: To evaluate the cost-effectiveness of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) versus standard DSAEK. METHODS: A cost-effectiveness analysis using data from a multicentre randomized clinical trial was performed. The time horizon was 12 months postoperatively. Sixty-four eyes of 64 patients with Fuchs' endothelial dystrophy were included and randomized to UT-DSAEK (n = 33) or DSAEK (n = 31). Relevant resources from healthcare and societal perspectives were included in the cost analysis. Quality-adjusted life years (QALYs) were determined using the Health Utilities Index Mark 3 questionnaire. The main outcome was the incremental cost-effectiveness ratio (ICER; incremental societal costs per QALY). RESULTS: Societal costs were €9431 (US$11 586) for UT-DSAEK and €9110 (US$11 192) for DSAEK. Quality-adjusted life years (QALYs) were 0.74 in both groups. The ICER indicated inferiority of UT-DSAEK. The cost-effectiveness probability ranged from 37% to 42%, assuming the maximum acceptable ICER ranged from €2500-€80 000 (US$3071-US$98 280) per QALY. Additional analyses were performed omitting one UT-DSAEK patient who required a regraft [ICER €9057 (US$11 127) per QALY, cost-effectiveness probability: 44-62%] and correcting QALYs for an imbalance in baseline utilities [ICER €23 827 (US$29 271) per QALY, cost-effectiveness probability: 36-59%]. Furthermore, the ICER was €2101 (US$2581) per patient with clinical improvement in best spectacle-corrected visual acuity (≥0.2 logMAR) and €3274 (US$4022) per patient with clinical improvement in National Eye Institute Visual Functioning Questionnaire-25 composite score (≥10 points). CONCLUSION: The base case analysis favoured DSAEK, since costs of UT-DSAEK were higher while QALYs were comparable. However, additional analyses revealed no preference for UT-DSAEK or DSAEK. Further cost-effectiveness studies are required to reduce uncertainty.

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.

Economic evaluation of endothelial keratoplasty techniques and penetrating keratoplasty in the Netherlands.

PURPOSE: To evaluate cost-effectiveness of penetrating keratoplasty (PK), femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Cost-effectiveness analysis based on data from a randomized multicenter clinical trial and a noncomparative prospective study. METHODS: Data of 118 patients with corneal endothelial dysfunction were analyzed in the economic evaluation. Forty patients were included in the PK group, 36 in the FS-DSEK group, and 42 in the DSAEK group. The primary incremental cost-effectiveness ratio (ICER) was the incremental costs per clinically improved patient, defined as a patient with a combined effectiveness of both a clinically improved BSCVA (defined as an improvement of at least 2 lines) and a clinically acceptable refractive astigmatism (defined as less than or equal to 3.0 diopters). Analysis was based on a 1-year follow-up period after transplantation. RESULTS: The percentage of treated patients who met the combined effectiveness measures was 52% for DSAEK, 44% for PK, and 43% for FS-DSEK. Mean total costs per patient were €6674 (US$7942), €12 443 (US$14 807), and €7072 (US$8416) in the PK group, FS-DSEK group, and DSAEK group, respectively. FS-DSEK was less effective and more costly compared to both DSAEK and PK. DSAEK was more costly but also more effective compared to PK, resulting in incremental costs of €4975 (US$5920) per additional clinically improved patient. CONCLUSIONS: The results of this study show that FS-DSEK was not cost-effective compared to PK and DSAEK. DSAEK, on the other hand, was more costly but also more effective compared to PK. Including societal costs, a longer follow-up period and preparation of the lamellar transplant buttons in a national cornea bank could improve the cost-effectiveness of DSAEK.

Economic evaluation of deep anterior lamellar keratoplasty versus penetrating keratoplasty in The Netherlands.

PURPOSE: To evaluate the cost effectiveness of deep anterior lamellar keratoplasty (DALK) versus penetrating keratoplasty (PK) in The Netherlands. DESIGN: Cost-effectiveness analysis alongside a randomized, multicenter clinical trial. METHODS: Fifty-three patients with corneal stromal pathologic features not affecting the endothelium were included with 28 patients in the DALK group and 25 in the PK group. Quality of life was measured before surgery and 3, 6, and 12 months after surgery. The main outcome measures were incremental cost-effectiveness ratios per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and per patient with endothelial cell loss of maximally 20% within the first year. RESULTS: Mean total bootstrapped costs per patient were €7607 (US$10,498) in the DALK group and €6552 (US$9042) in the PK group. The incremental cost-effectiveness ratios were €9977 (US$13,768) per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and €6900 (US$9522) per patient with cell loss of maximally 20%. In patients without perforation of the Descemet membrane, the incremental cost-effectiveness ratio was €5250 (US$7245) per patient. CONCLUSIONS: This study shows that DALK is more costly and more effective as compared with PK. Results on the 25-item National Eye Institute Visual Functioning Questionnaire were in favor of DALK, and endothelial cell loss in DALK patients remained stable after 6 months, whereas cell loss in PK patients continued. Furthermore, DALK procedures performed without perforation of the Descemet membrane were more effective. However, because it is unknown what society is willing to pay for an additional improved patient, cost effectiveness of DALK within a limited follow-up period of 12 months is unclear. Cost effectiveness of DALK may improve over time because of lower graft failure.