„Value-based medicine“ in der Augenheilkunde

Treatment of congenital and early childhood cataract

The successful outcome of treatment for infant and childhood cataract depends on many factors. It is crucial that the treatment falls into a phase in which neither the eye nor the visual pathway and visual cortex are fully developed. This review summarizes the current state of knowledge and provides an overview of the epidemiology, causes and clinical forms, early detection and, above all, treatment options. Special attention is paid to time-critical stages of development, according to which the therapeutic concepts are based. Complications, such as amblyopia and glaucoma are discussed in detail. In addition to surgical aspects, much emphasis is placed on orthoptic-refractive aftercare, the quality and execution of which is the essential predictor of a good functional outcome.

[Treatment of congenital and early childhood cataract]

The successful outcome of treatment for infant and childhood cataract depends on many factors. It is crucial that the treatment falls into a phase in which neither the eye nor the visual pathway and visual cortex are fully developed. This review summarizes the current state of knowledge and provides an overview of the epidemiology, causes and clinical forms, early detection and, above all, treatment options. Special attention is paid to time-critical stages of development, according to which the therapeutic concepts are based. Complications, such as amblyopia and glaucoma are discussed in detail. In addition to surgical aspects, much emphasis is placed on orthoptic-refractive aftercare, the quality and execution of which is the essential predictor of a good functional outcome.

Screening and Treatment in Retinopathy of Prematurity

BACKGROUND

More than 11 000 children are examined for possible retinopathy of prematurity in Germany each year, and 2-5% of them are treated for it. Even though screening and treatment programs are in place, the affected children can still suffer visual impairment.

METHODS

In this article, we summarize the pathogenesis, screening, and treatment of retinopathy of prematurity on the basis of a selective review of pertinent literature, retrieved by a PubMed search. The article centers on publications from 2011 to 2015 on the new option of treatment with VEGF inhibitors and discusses it in comparison to laser therapy.

RESULTS

All premature neonates with a low gestational age at birth, low birth weight, or prolonged exposure to supplemental oxygen must undergo screening by an ophthalmologist. Laser therapy is effective for stages 1-3 and for aggressive posterior retinopathy of prematurity. Its disadvantages are the induction of scarring and the development of severe myopia in 17-40% of the children so treated. Anti-VEGF treatment (VEGF = vascular endothelial growth factor) does not induce any visible scarring and seems to cause less myopia, but long-term data on safety, dosing, and the choice of anti-VEGF drug are still lacking.

CONCLUSION

The available evidence for anti-VEGF treatment is on a much lower level than the evidence for laser therapy. Anti-VEGF may be a way to avoid the disadvantages of laser therapy (scarring and severe myopia). Unlike laser therapy, however, the intravitreal injection of VEGF inhibitors may suppress systemic VEGF levels and potentially harm the developing brain, lungs, or other organs. The currently open questions about anti-VEGF treatment concern its dosing, choice of drug, and long-term safety.

[Value-based medicine for glaucoma]

The application of value-based medicine (VBM) tenets in the area of glaucoma research requires valid and reliable data concerning the quality of life with glaucoma. A multitude of instruments for measuring quality of life of patients with glaucoma have been employed in the past. Any instrument used would need to capture peripheral vision loss and its influence on patient-reported quality of life as this is one of the hallmarks of this disease. Cost-utility analyses can then be based on the reported quality of life and the cost of glaucoma therapy. Several cost-utility analyses have been applied in the field of glaucoma screening as well as treating ocular hypertension and based on this a recommendation regarding population subgroups which can be treated cost efficiently can be made.

[Blindness in Germany: dimensions and perspectives]

Blindness and visual impairment in Germany and the Western world will increase further over the coming years and decades. This is primarily due to current demographic trends leading to increased visual impairment, mainly in the elderly. In Germany the current situation of the blind and visually impaired is less well documented than in other European countries. The impact of this development can be differentiated into individual and societal dimensions, of which quality of life, morbidity, mortality, and cost are the best-documented aspects. Because of the socioeconomic and cultural importance of vision in Western society, the negative effects of an increase in blindness and visual impairment in a continuously aging population are considerable. Healthcare policy makers need to consider this when discussing future planning and resource allocation. Preventive and rehabilitative services should be given a much higher priority.

The value of vision

BACKGROUND

The value of vision is assumed to be very high. To verify this assumption and to assign resources in medical care accordingly, it is necessary to quantify the value of vision. Although the value of vision is difficult to measure, visual quality of life can be quantified as a surrogate criterion. The measured value gains even more relevance if a comparison can be made between visual quality of life and systemic diseases. Multidisciplinary comparisons are only possible by using utility analysis. Two established methods to measure utility values are the standard gamble method and the time trade-off method. The purpose of this review is to find ophthalmologic utility values, and utility values affected by systemic diseases that correlate to the ophthalmologic ones.

METHODS

A literature search was conducted through PubMed of the National Library of Medicine ( http://www.ncbi.nlm.nih.gov ; date: 06.02.2006). The search terms were: "time trade-off / standard gamble" [text word] and "eye / vision / visual" [text word]; results 24. A report was classified as relevant if visually impaired persons were tested by the time trade-off method or the standard gamble method, or if information was provided on the reliability and validity of these measurements in a group of visually impaired persons. Additional searches were done to find associated publications. A total of 42 publications were found to be of interest.

RESULTS

Results showed that patients, with 20/30-20/50 visual acuity would be willing to pay 19% of their lifetime to get back normal visual acuity. Patients with 20/200-20/400 visual acuity would give up 48% of their lifetime, and blind people would give 60% of their lifetime to regain normal visual acuity. Comparable utility values are seen in patients with AIDS (21%), patients after a stroke who are unable to walk and wash themselves without assistance (46%), and bedridden and incontinent patients following a stroke (66%).

CONCLUSION

Patients attach great value to vision. The time trade-off method appears to be an appropriate tool to quantify visual quality of life, and one that can be used to compare utility values of different diseases.