Author Affiliations: Department of Ophthalmology (Drs Seider, Keenan, and Han) and Francis I. Proctor Foundation (Dr Keenan), University of California, San Francisco.
Topical medications are the mainstay of glaucoma therapy and are responsible for most of the dollars spent on glaucoma management.1 However, a randomized clinical trial suggested that a single administration of 360° of selective laser trabeculoplasty (SLT) may be as effective as a prostaglandin analog for the reduction of intraocular pressure.2 Given the recent introduction of generic latanoprost, we were interested in comparing the costs of topical medications vs SLT.
We assumed a societal perspective for this analysis. We estimated the costs of topical glaucoma medications from the median value of the average wholesale prices listed in the online Red Book database.3 We assumed that bilateral treatment would require 2.5 mL for medications dosed once daily and 5 mL for medications dosed 2 or 3 times daily. As a sensitivity analysis, we also estimated the lower limit of medication costs using the lowest price listed in the Red Book.
We estimated the costs of SLT from the national average Medicare fee schedule for Current Procedural Terminology code 65855, assuming the nonfacility reimbursement.4 Based on a previous trial in which 50% of eyes developed transient uveitis and 27% of eyes developed elevated intraocular pressure, we assumed that 50% of SLTs required one 5-mL bottle of prednisolone acetate, 1%, and that 27% of SLTs required one 5-mL bottle of timolol maleate, 0.5%.2 We assumed that any additional clinic visits for adverse events following SLT would be covered by the Medicare reimbursement given the transient nature of these adverse events.
We calculated the time threshold at which bilateral SLT would become less costly than bilateral use of each topical medication by dividing the total costs of SLT by the monthly costs of each medication.
The Table shows the monthly costs of bilateral treatment with several topical glaucoma therapies. As a simple sensitivity analysis, we also report the costs for each medication assuming the least expensive Red Book price (Table). In comparison, we estimated the total cost of bilateral SLT to be $675.76, which includes the costs of the procedure ($328.55/eye), prednisolone acetate ($4.74/eye), and timolol ($4.59/eye).3,4 We found that SLT would become less costly than generic latanoprost after 13.1 months. Assuming that repeated SLT is as effective as the initial SLT treatment, SLT could be repeated as frequently as every 13.1 months and cost the same as treatment with generic latanoprost. Similar analyses are shown in the Table for each medication.
Selective laser trabeculoplasty has been shown to be effective both as a monotherapy and as additive treatment for lowering intraocular pressure in glaucoma, and it is likely effective when repeated.5 Our study shows that SLT becomes less costly than most brand-name medications within 1 year and less costly than generic latanoprost and generic timolol after 13 and 40 months, respectively. Although no study to date has specifically evaluated the duration of efficacy of SLT monotherapy, a single SLT treatment has been shown to be effective for 3 to 5 years when used in addition to topical medications.5,6 Thus, glaucoma treatment is probably less expensive with SLT compared with most brand-name medications. Selective laser trabeculoplasty may even be less expensive than a generic medication such as latanoprost, although the value of SLT is less clear when compared with generic timolol. Not surprisingly, this analysis is sensitive to the cost of the medications: for a patient using the least expensive formulation of generic latanoprost, 56 months are required for SLT to become less expensive than latanoprost.
Our cost analysis has several limitations. We did not model many aspects that would affect the costs of glaucoma therapy, including complications after SLT, need for subsequent surgery, or transportation costs for patients. We acknowledge that the clinical decision to initiate treatment for glaucoma with either SLT or a topical glaucoma medication depends on many factors aside from cost, including angle architecture, patient's ability to effectively administer eyedrops, patient's choice, and adverse effects profile.
This cost analysis provides information for clinicians deciding between SLT and topical treatment. Assuming equal efficacy between SLT and latanoprost, SLT may ultimately be less expensive.
Correspondence: Dr Han, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, Room K301, San Francisco, CA 94143-0730 (firstname.lastname@example.org).
Author Contributions: Dr Han had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This work was supported in part by Core Grant for Vision Research EY002162 from the National Eye Institute, by an unrestricted grant from Research to Prevent Blindness, and by That Man May See, Inc.
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The Rational Clinical Examination
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The Rational Clinical Examination
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