OBJECTIVES: EX-PRESS glaucoma filtration device (Alcon Inc, TX) is an alternative treatment to trabeculectomy, a surgery realized in advanced primary open angle glaucoma (POAG). This analysis reports the incremental cost and benefits of EX-PRESS. METHODS: Patients with POAG uncontrolled by maximally-tolerated medical therapies were randomized to receive either the EX-PRESS or a trabeculectomy. Clinical outcomes included intraocular pressure (IOP), use of IOP lowering medications and post-operative eye surgeries. The study follow-up was 5 years. The economic perspective was the one of the French society. EX-PRESS cost was not included. Patients were considered a success if they had an IOP less than or equal to the success thresholds of 15 or 18 mmHg, without IOP lowering medications, and without having undergone further glaucoma surgery. Time to failure was analyzed using a log rank test. Costs were discounted at a 3% rate. RESULTS: 78 patients were analyzed, 39 in each arm. EX-PRESS eyes had better IOP control at 1 (12.0 vs 13.9 mmHg; P=0.02), 2 (11.9 vs 13.8 mmHg; P=0.01) and 3 years (12.0 vs 13.5 mmHg; P=0.04). The five-year failure rate was 41% for EX-PRESS versus 69% for trabeculectomy (P=0.005) using an 18 mmHg IOP target and 46% versus 77% (P=0.001) for 15 mmHg. At year 5, 41.0% of the EX-PRESS patients had an IOP lowering drug prescription versus 53.9% for the trabeculectomy patients. EX-PRESS patients received 0.85 IOP lowering medications versus 1.10 in the trabeculectomy group. EX-PRESS patients required less needling (2 versus 5) and had fewer cataract surgeries (5 versus 8). Without discounting, drug savings with EX-PRESS equaled €277.00, €331.02 as a total. With a 3% discounting, the figures became €260.00 and €342.97, respectively. CONCLUSIONS: At 5 years after surgery, EX-PRESS demonstrated that it better controls IOP than trabeculectomy, resulting in post-operative savings.