Trabeculectomy as a first-line procedure to treat glaucoma is more cost-effective than tube shunt surgery for people with elevated intraocular pressure (IOP), but tube shunt surgery may be the better bargain for those with very high pressures.

The findings come from a secondary analysis of the 2022 PTVT Study, which reported no significant differences in the failure rates among 242 patients randomly assigned to tube shunt surgery, also known as drainage device surgery, or trabeculectomy.

“These economic findings should be considered alongside other individual factors when selecting the initial surgical approach,” Adam Rothman, MD, glaucoma specialist at Bascom Palmer Eye Institute at the University of Miami, Plantation, Florida, said in presenting results at the American Glaucoma Society (AGS) 2026 Annual Meeting.

The cost-utility analysis aimed to compare the costs and the outcomes of the two treatments and arrive at an incremental cost-effectiveness ratio (ICER), he said.

Third-Party and Societal Costs

The cost analysis consisted of two components, Rothman said: third-party costs that accounted for clinic visits, medications, surgery, and anesthesia; and societal costs for direct costs, travel, missed work, and caregiver burden. The utility analysis included quality-adjusted life years (QALYs), a measure of lifespan and quality of health, including visual function, symptoms, and treatment burden. An intervention is considered cost-effective if the ICER is less than $50,000 per QALY, Rothman said.

The analysis used a disease simulation model that randomized eyes to one procedure or the other and then performed microsimulation calculations with five 1-year cycles and 100,000 individual eyes for each procedure, he said.

“We ran the numbers from the third-party perspective, and we see that the trabeculectomies cost less and they brought more utility, giving us a negative ICER of -$11,167 per QALY,” he said. Likewise, trabeculectomy costs less from a societal perspective, with an ICER of -$4864 per QALY, he said.

The study included a sensitivity analysis that applied a 20% variation in costs and found that the model favored trabeculectomy for both third-party and societal costs 81% and 78% of the time, respectively.

The study further broke out societal cost by range of IOP before surgery. For patients with pressures < 21 mm Hg, trabeculectomy is cost-saving, Rothman said, with an ICER of -$11,266 per QALY. For pressure readings in the 21-25 mm Hg range, trabeculectomy is not cost-effective, with an ICER of $70,573 per QALY, well above the $50,000 threshold. In the group with pressures > 21 mm Hg, tube shunt surgery is cost-saving with an ICER of -$31,266 per QALY, he reported.

“The third-party and societal costs are just one consideration when selecting the appropriate first incisional surgery for glaucoma,” Rothman told Medscape Medical News.

Other considerations include the surgeon’s comfort level with the procedure and ability to provide appropriate postoperative care, he said. So, too, are individual patient considerations.

“The patient may require less topical medication with a trabeculectomy, which is especially important for patients with medication intolerances,” Rothman said. “On the other hand, trabeculectomies often require more postoperative visits to ensure success, which may be challenging for patients with complex social factors.”

The greatest strength of the study is its use of data from PTVT, “which is the highest quality data available regarding the outcomes of initial incisional glaucoma surgery,” he said. A limitation is the study’s reliance on utility estimates from other published research to assign QALY values for the different glaucoma stages. “We try to account for this in the sensitivity analysis by varying the inputted utilities over a range of values, but external model validation would be helpful to confirm our findings,” Rothman added.

Inas Aboobakar, MD, retina specialist at Mass Eye and Ear and Harvard Medical School in Boston, said the use of the PTVT Study for the analysis was noteworthy because it found no significant differences in failure rates between the two procedures.

“The results of this study suggest that patient-specific clinical factors, such as baseline IOP, can help provide insights into what would be the most cost-effective approach for a given patient, enabling personalized glaucoma care,” she said.

Limitations were the study’s nature as a secondary analysis and its use of simulation models, Aboobakar added. “Therefore, the results would need to be validated in real-world settings,” she said.

The study was independently supported. Rothman and Aboobakar reported having no relevant financial relationships.

Richard Mark Kirkner is a medical journalist based in Philadelphia.