Cost-effectiveness of Descemet's stripping endothelial keratoplasty versus penetrating keratoplasty

Ophthalmology. 2013 Mar;120(3):464-470. doi: 10.1016/j.ophtha.2012.08.024. Epub 2012 Nov 20.


Purpose: Selective endothelial transplantation in the form of Descemet's stripping endothelial keratoplasty (DSEK) is rapidly replacing traditional full-thickness penetrating keratoplasty (PK) for endothelial disease. An incremental cost-effectiveness analysis was performed to determine whether the benefits of DSEK are worth the additional costs.

Design: Retrospective cohort study.

Participants: Patients at the Singapore National Eye Center, a tertiary eye center in Singapore, with Fuchs' dystrophy or bullous keratopathy who underwent either PK or DSEK.

Intervention: Patients underwent either PK (n = 171) or DSEK (n = 93) from January 2001 through December 2007. Data were collected from inpatient and outpatient notes corresponding to the time immediately before the procedure to up to 3 years after.

Main outcome measures: Improvements in best spectacle-corrected visual acuity were used to calculate the increase in quality-adjusted life years (QALYs) 3 years after the procedure. This was combined with hospital charges (a proxy for costs) to determine incremental cost-effectiveness ratios (ICERs) comparing PK with no intervention and DSEK with PK.

Results: Three-year charges for DSEK and PK were $7476 and $7236, respectively. The regression-adjusted improvement in visual acuity for PK relative to no intervention was -0.613 logarithm of the minimum angle of resolution (logMAR) units (P<0.001), and for DSEK relative to PK, it was -0.199 logMAR units (P = 0.045). The regression-adjusted marginal gain in utility for PK relative to no intervention was 0.128 QALYs (P<0.001) and for DSEK relative to PK was 0.046 QALYs (P = 0.031). This resulted in ICERs of $56 409 per QALY for PK relative to no intervention and $5209 per QALY for the more expensive DSEK relative to PK.

Conclusions: If the goal is to maximize societal health gains given fixed resources, DSEK should be the preferred strategy. For a fixed budget, it is possible to achieve greater QALY gains by providing DSEK to as many patients as possible (and nothing to others), rather than providing PK.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Blister / economics
  • Blister / surgery
  • Corneal Diseases / economics
  • Corneal Diseases / surgery
  • Cost-Benefit Analysis
  • Descemet Stripping Endothelial Keratoplasty / economics*
  • Ethnicity
  • Female
  • Follow-Up Studies
  • Fuchs' Endothelial Dystrophy / economics
  • Fuchs' Endothelial Dystrophy / surgery
  • Health Care Costs*
  • Humans
  • Intraoperative Complications
  • Keratoplasty, Penetrating / economics*
  • Male
  • Postoperative Complications
  • Quality-Adjusted Life Years
  • Retrospective Studies
  • Visual Acuity / physiology