The Cost of Glaucoma
Chat Highlights
July 26, 2006

On Wednesday, July 26, 2006, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "The Cost of Glaucoma."

Moderator: Tonight's topic is “The Cost of Glaucoma.” I can think of many aspects of cost: the cost to the individual, to society, and of treating and not treating glaucoma.  There’s the cost of screening and prevention, research, drugs, surgery, and insurance.  There’s also the cost to health care systems and the cost of mental health care to patients and their families.  Where would you like to start?

Dr. Rick Wilson:     You are correct with your iteration of the costs of glaucoma, which come in so many forms.  I am not an expert in the economics of health care, so I only have a few statistics to call forth. I am happy to start wherever you wish.

P: Why is treating the disease in early stages less costly than in later stages?

Dr. Rick Wilson:   The target IOP (intraocular pressure) for patients with early glaucoma is in the upper teens in most of those who do not have normal-tension glaucoma.  As the disease progresses and there is more disc damage, it seems the optic nerve has become softened up by the damage.

Because sustaining additional disc damage increases at a lower IOP, the target IOP for someone with mild to moderate glaucoma would be around 15 mm Hg.  The target pressure depends upon the IOP level the patient was getting worse at before. Therefore, treating someone with advanced damage, when the target IOP is around 12 mm Hg, must be more aggressive to reach that low level with medicines, laser, and often surgery.  Consequently, it is more expensive.

P: How important is it economically that glaucoma patients are well monitored?

Dr. Rick Wilson:   Luckily, central vision is lost last in glaucoma, so most patients with serious glaucoma can still work, even if they can't drive.  However, because central vision is lost last and the vision loss is slow and gradual, a lot of damage often occurs before the patient seeks medical help.

Last Monday I operated on a patient who had been told 20 years ago that he might have glaucoma.  But he did not seek medical help again until his vision was reduced to hand motion in one eye and advanced damage in the other eye.  He can no longer work.

P: What a sad story. I guess that shows the economic burden that delaying treatment can place on people with glaucoma.

Dr. Rick Wilson:   It does. It also shows how important it is for the doctor to make sure the patient understands there are no symptoms with glaucoma, and the patient will not notice that he or she is losing vision until the loss is advanced.  Otherwise, the patient may end up with advanced disease and be unaware of it.

P: What reason did your patient give for not seeking medical help all those years?

Dr. Rick Wilson:   He said he didn't notice anything wrong with his vision until it was real blurred. He thought he needed a change in glasses.

P: Does the cost of medications make up a large percentage of the total cost for glaucoma?

Dr. Rick Wilson:   When the cost of multiple drugs is added to those of medical visits, tests and occasional laser or cutting surgery, the average cost per year in 1999 was $806, when a beta blocker like timolol was chosen as the first-line drug.

P: Take a look at these costs:  "Glaucoma costs the U.S. health care system an estimated $2.5 billion annually: $1.9 billion in direct costs and $0.6 billion in indirect costs."  (January issue of Archives of Ophthalmology, one of the JAMA/Archives journals)

Dr. Rick Wilson:   That certainly makes sense.  There are approximately 130,000 Americans who are blind from glaucoma.

P: In your experience, what's the greatest emotional cost with glaucoma?

Dr. Rick Wilson:   I think the fear of losing vision is the greatest emotional cost. In cost-benefit accounting, when trying to equate a certain number of years of shorter lifespan with vision versus a longer lifespan with poor vision, vision is valued very highly by patients, compared to a number of other diseases or disabilities.

P: Do you have any data comparing the costs of glaucoma in different countries?

Dr. Rick Wilson:   I know that in Brazil congenital glaucoma is present in much higher numbers per population than here.  In China, where the ratio of open-angle glaucoma to closed-angle glaucoma is almost the opposite of here, the rate of blindness is much higher because of the increased morbidity with closed-angle glaucoma compared to open-angle glaucoma.

P: My two-year-old daughter has primary open-angle glaucoma.  The medical expenses for her were over $30,000 (the allowed amount paid to doctors and hospitals).  That was three operations ago, and doesn’t include our out-of-pocket expenses, which average $5,000 a year.

Dr. Rick Wilson:   That's a good example of the expensive nature of healthcare in America.  We spend far more of our gross national product on health care, but usually aren't in the top seven in terms of population health in developed countries.

P: Do you know how much laser surgery, a trabeculectomy, or a shunt would cost out-of-pocket?

Dr. Rick Wilson:   I don't remember off-hand, but ball-park numbers are low $300’s for a laser, about $860 for a trabeculectomy, and just over $1,000 for a shunt.

P: My sister's bill for a recent trabeculectomy was almost $10,000. Insurance covered most of it.  The surgeon got about $1,000.

Dr. Rick Wilson:   You always have to differentiate between what is billed and what is paid by the insurance.  Amazingly, a $10,000 bill may only be reimbursed 20 to 40%.

P: Amazing, all right.  What if you didn’t have insurance?

P: I don't understand the large difference between what my insurance carrier pays my glaucoma specialist and my rheumatologist.  I think the reimbursement is low for a glaucoma specialist.

P: I got stuck with the entire bill on my first set of SLT’s (selective laser trabeculoplasty). The insurance company went defunct.

P: Earlier this evening I had a lengthy long-distance phone call from a glaucoma patient who was upset and crying.  She's had many eye operations and has seen excellent specialists.  She has always enjoyed an active social life and has many good friends.  Now she can't force herself to go out or see her friends.  The quality of her life has changed drastically.  I just let her talk and cry and talk.  She was laughing when she hung up, but I knew the mood elevation would only be temporary.  Talk about the cost of glaucoma!

Dr. Rick Wilson:   I agree.  Have a good week everyone.

Moderator: Thank you, Dr. Wilson.  You are a true champion and greatly appreciated. Have a good night and a great week.

On August 2, Dr. Wilson discussed "Glaucoma Medications" in the Chat room. Click here for highlights of that meeting.

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