Incremental Cost-Utility Analysis of Deep Anterior Lamellar Keratoplasty Compared with Penetrating Keratoplasty for the Treatment of Keratoconus

Purpose This study sought to determine the cost effectiveness of deep anterior lamellar keratoplasty (DALK) compared with penetrating keratoplasty (PK) for the treatment of keratoconus. DALK is associated with lower rates of postoperative complications compared with PK, but is a more expensive procedure; whether it is cost effective compared with PK is unknown. Design The study was an incremental cost-utility analysis from a health systems perspective using retrospective data on a cohort of patients with severe keratoconus. Methods The analysis was conducted using 1-year cost and outcomes data from 148 keratoconus patients, representing 102 PK and 46 DALK cases, seen for corneal grafts between January 1991 and January 2009 at the Singapore National Eye Center. The main outcome assessed was the incremental cost-utility ratios associated with PK and DALK for the treatment of keratoconus. Results Over a 20-year period, PK was the lower cost procedure and had an incremental cost-utility ratio of $3750 per quality-adjusted life-year compared with no surgical treatment. Compared with PK, DALK has an incremental quality-adjusted life-year gain of 0.8 and an incremental cost of $2420, for an incremental cost-utility ratio of $3025 per quality-adjusted life-year. Conclusions Compared with PK, DALK has a favorable cost-effectiveness ratio and, resources permitting, should be considered as a first-line treatment for keratoconus. Additional studies are needed to confirm the expected advantages of DALK over PK when it comes to long-term graft failure rates.