Comparative efficacy and cost–utility of combined cataract and minimally invasive glaucoma surgery in primary open-angle glaucoma

PURPOSE: To assess the comparative efficacy and the long-term cost–utility of alternative minimally invasive glaucoma surgeries (MIGSs) when combined with cataract surgery in patients with primary open-angle glaucoma (POAG). METHODS: Treatment effects, as measured by the 1-year reduction in intraocular pressure (IOP), were estimated with an adjusted indirect treatment comparison. Evidence from randomized clinical trials was identified for four different MIGS methods. A disease-transition model was developed by capturing clinically relevant POAG stages and the expected natural disease evolution. Outcomes of the disease-transition model were the comparative utility [quality-adjusted life years (QALYs)], cost and cost–utility of included strategies in a lifetime horizon. RESULTS: Estimated 1-year IOP reductions were: cataract surgery − 2.05 mmHg (95% CI − 3.38; − 0.72), one trabecular micro-bypass stent − 3.15 mmHg (95% CI − 5.66; − 0.64), two trabecular micro-bypass stents − 4.85 mmHg (95% CI − 7.71; − 1.99) and intracanalicular scaffold − 2.25 mmHg (95% CI − 4.87; 0.37). Discounted outcomes from the disease-transition model appraised the strategy of two trabecular micro-bypass stents with cataract surgery in the moderate POAG stage as the one providing the greatest added value, with 10,955€ per additional QALY. Improved outcomes were seen when assessing MIGS in the moderate POAG stage. CONCLUSIONS: When indirectly comparing alternative MIGS methods combined with cataract surgery, the option of two trabecular micro-bypass stents showed both a superior efficacy and long-term cost–utility from a German perspective. Moreover, outcomes of the disease-transition model suggest POAG patients to beneficiate the most from an earlier intervention in the moderate stage contrary to waiting until an advanced disease is present.