ABSTRACT
Objetivo: O objetivo do estudo foi realizar uma análise de custo-utilidade da retinografia digital portátil como tecnologia auxiliar na triagem da retinopatia da prematuridade (ROP) no Brasil, sob a perspectiva do Sistema Único de Saúde (SUS). Introdução: A ROP é uma das principais causas de cegueira infantil evitável no mundo e no Brasil. Os recém-nascidos (RN) prematuros e de baixo peso estão em risco de desenvolver ROP grave que, quando não precocemente tratada, leva a cegueira irreversível. A triagem atual da ROP no Brasil é realizada com a oftalmoscopia binocular indireta, por um oftalmologista especializado, mas com cobertura incompleta dos RN em risco. A nova estratégia de triagem é a combinação da retinografia digital portátil, realizada por técnicos de enfermagem, com a oftalmoscopia indireta, em casos suspeitos. Métodos: Um modelo de árvore de decisão foi criado para estimar a razão de custo-utilidade do manejo da ROP (triagem, tratamento e acompanhamento oftalmológico). As duas estratégias de triagem comparadas foram: 1. oftalmoscopia indireta; 2. retinografia digital portátil para toda a população elegível e oftalmoscopia indireta para confirmação de casos suspeitos. A população de referência incluiu RN com idade gestacional inferior ou igual a 32 semanas e/ou peso de nascimento inferior ou igual a 1.500 gramas. O horizonte temporal foi toda a vida. A perspectiva adotada foi a do SUS. Parâmetros e pressupostos foram incorporados ao modelo a partir da revisão da literatura, consulta aos especialistas e técnica de microcusto. A utilidade foi estimada a partir da acuidade visual decimal e os benefícios foram estimados em quality-adjusted life years (QALY). Os custos incluíram insumos, equipamentos e recursos humanos. Duas técnicas de enfermagem foram treinadas para executarem a retinografia e tiveram seus tempos cronometrados antes e ao final do treinamento. Duas oftalmologistas especialistas em ROP tiveram seus tempos de interpretação de imagens cronometrados. Foram realizadas análises de sensibilidade determinística univariada e probabilística. Resultados: Com uma cobertura de 90% da população elegível a estratégia nova se mostrou cost-saving. Os custos estimados por exame foram: 1. Triagem com a oftalmoscopia binocular indireta - R$ 203,18 reais; 2. Triagem com a combinação - R$ 87,10 reais; 3. Tratamento - R$2.529,83 reais. O custo do acompanhamento por RN ao longo da vida variou de R$273,16 a R$1.130,41 reais dependo da função visual desenvolvida pelo RN. A razão de custo por QALY incremental resultou em uma economia de R$ 3.378,18/ QALY ganho por RN triado. Conclusão: A nova triagem da ROP, utilizando a combinação da retinografia com a oftalmoscopia, foi custo-efetiva e pode universalizar o acesso dos recém-nascidos em risco de ROP à assistência neonatal ocular básica. Este estudo poderá contribuir para a tomada de decisão na área da saúde neonatal e fornecer subsídios para outras pesquisas de avaliações econômicas em saúde.
Purpose: The present study was aimed to evaluate the cost-utility of wide-field imaging as a complementary technology for retinopathy of prematurity (ROP) screening from the Brazilian Public Health Care system perspective. Introduction: ROP is a leading cause of avoidable childhood blindness worldwide, especially in middle income countries, such as Brazil. It affects preterm and low birth weight newborns. The current ROP screening involves indirect binocular ophthalmoscopy by an experienced ophthalmologist. It has been suggested the insufficient ROP screening coverage with this current practice. An alternative screening strategy, which could enhance preterm access, is the combination of DR by two nurse technicians with ophthalmoscopy for suspected images. Methods: Deterministic decision-tree simulation model was built to estimate cost-utility ratio for ROP management (screening, treatment and follow-up). Two screening strategies were compared: 1. indirect binocular ophthalmoscopy; 2. wide-field imaging of all eligible preterm babies and indirect ophthalmoscopy of suspected cases. The eligible population included preterm under 32 weeks of gestational age or birth weight equal to or less than 1.500 grams. The temporal horizon was lifetime. The perspective was from Brazilian Public Health Care System. Parameters and assumptions were based on published literature, observational experience or specialist's opinion. Visual outcome data was converted to utility based on published literature and the health benefits were estimated in quality-adjusted life years (QALY). Costs were estimated considering staff, equipment, maintenance and inputs. It was used a microcost technique for wide-field imaging. Two technician's nurses were trained for wide-field imaging execution and had their time evaluated before and after the training. Two ROP specialists' ophthalmologists had their time evaluated for imaging interpretation. One-way sensitivity analysis and probabilistic sensitivity analysis were performed. Results: The new ROP screening strategy resulted in a cost-saving program considering 90% ROP screening coverage. The costs per exam were: 1. Screening with ophthalmoscopy: R$ 203,18. 2. Screening with combination: R$ 87,1. 3. Treatment: R$2.529,83. 4. Long term follow-up: from R$273,16 to R$1.130,41 according to the newborn´s visual function. The incremental cost per QALY gained was R$3.378,18 saved per infant with the new screening strategy. Conclusion: The combined strategy for ROP screening showed a cost-effective result. It could enhance preterm access for appropriate ROP management in middleincome countries and diminish opportunity cost of ophthalmologists. This study enables others economic evaluations and could help public health managers in sustainable and appropriate decision making.
Subject(s)
Humans , Infant, Newborn , Health Evaluation , Unified Health System , Retinopathy of Prematurity/diagnostic imaging , Neonatal Screening , Cost-Benefit Analysis/economics , Quality-Adjusted Life Years , Ophthalmoscopes , Retinoscopes , BrazilABSTRACT
RESUMEN Objetivo: Identificar las características del astigmatismo en los niños. Métodos: Se realizó un estudio descriptivo y transversal en pacientes atendidos en el Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer en el período de junio del año 2016 a diciembre de 2017. La muestra estuvo conformada por 61 niños (122 ojos) con astigmatismo, quienes cumplieron los criterios de inclusión y exclusión. Las variables del estudio fueron la edad, el sexo, el tipo de astigmatismo, los síntomas, la agudeza visual sin y con corrección, el cilindro refractivo, el cilindro topográfico y el equivalente esférico. Resultados: El astigmatismo mixto fue el más relevante en todas las edades, y el sexo no fue significativo. El síntoma más referido fue la dificultad para ver de cerca (33 pacientes) para un 54,9 por ciento y en edades de 6 a 9 años. La media más baja de la agudeza visual fue 0,22 para el astigmatismo miópico compuesto y la mejor agudeza visual corregida fue para el astigmatismo miópico simple (0,94). La media del cilindro refractivo y topográfico fue de 2,71 y 2,45 dioptrías respectivamente. Los valores topográficos y refractivos mostraron diferencias significativas en los astigmatismos miópico compuesto y mixto (p= 0,002). Los equivalentes esféricos más cercanos a la emetropía (-0,5 a 0,5) presentaron la media más alta de agudeza visual sin corrección. Conclusión: El astigmatismo miópico compuesto afecta más la agudeza visual sin corrección y presenta diferencias entre el cilindro refractivo y topográfico, al igual que el astigmatismo mixto(AU)
ABSTRACT Objective: Describe the characteristics of astigmatism in children. Methods: A descriptive cross-sectional study was conducted of patients cared for at the Pediatric Ophthalmology Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology from June 2016 to December 2017. The sample was 61 children (122 eyes) with astigmatism who met the inclusion and exclusion criteria. The study variables were age, sex, type of astigmatism, symptoms, visual acuity with and without correction, refractive cylinder, topographic cylinder and spherical equivalent. Results: Mixed astigmatism was the most relevant type in all age groups, whereas sex was not significant. The symptom most frequently reported was difficulty to see up close: 33 patients (54.9 percent) in the 6-9 years age group. The lowest visual acuity mean was 0.22 for compound myopic astigmatism, whereas the best corrected visual acuity corresponded to simple myopic astigmatism (0.94). Mean refractive and topographic cylinder was 2.71 and 2.45 diopters, respectively. Topographic and refractive values were significantly different in compound myopic and mixed astigmatism (p= 0.002). The spherical equivalents closest to emmetropia (-0.5 to 0.5) exhibited the highest mean visual acuity without correction. Conclusions: Compound myopic astigmatism affects uncorrected visual acuity more markedly and presents differences between the refractive and the topographic cylinder just like mixed astigmatism(AU)
Subject(s)
Humans , Male , Female , Child , Astigmatism/diagnostic imaging , Retinoscopes/adverse effects , Symptom Assessment/methods , Epidemiology, Descriptive , Cross-Sectional Studies , Observational StudyABSTRACT
PURPOSE: To evaluate the performance of the hand-held and table-top autorefractokeratometer in measuring refractive errors by comparing them with cycloplegic retinoscopy. METHODS: Included in the study were 112 eyes of 112 pediatric patients whose mean age was 6.78 +/- 2.61 years (range, 2 to 12 years). The refractive errors of all the eyes were measured with and without cycloplegia using a hand held autorefractokeratometer (Retinomax K-plus 3), table top autorefractokeratometer (Canon RK-F1) and performing cycloplegic retinoscopy. The spherical equivalent, cylindrical axis and keratometer values were statistically compared. RESULTS: The mean spherical equivalent obtained from the Retinomax K-plus 3 was significantly less hyperopic than that of Canon RK-F1 (p = 0.004) before cycloplegia. When the Bland Altman analysis was performed in comparisons of spherical equivalent values measured with the Retinomax K-plus 3, Canon RK-F1 and cycloplegic retinoscopy, it was seen that almost all of the differences between the measurements remained within the range of +/-2 standard deviation. Good agreement was found between Retinomax K-plus 3 and Canon RK-F1 for the Jackson cross-cylinder values at axis 0degrees and 45degrees; keratometer values respectively. CONCLUSIONS: The refractive error components were highly correlated between the two instruments and cycloplegic retinoscopy.
Subject(s)
Child , Child, Preschool , Female , Humans , Male , Refractive Errors/diagnosis , Retinoscopes , Retinoscopy , Vision ScreeningABSTRACT
PURPOSE: To evaluate the performance of the hand-held and table-top autorefractokeratometer in measuring refractive errors by comparing them with cycloplegic retinoscopy. METHODS: Included in the study were 112 eyes of 112 pediatric patients whose mean age was 6.78 +/- 2.61 years (range, 2 to 12 years). The refractive errors of all the eyes were measured with and without cycloplegia using a hand held autorefractokeratometer (Retinomax K-plus 3), table top autorefractokeratometer (Canon RK-F1) and performing cycloplegic retinoscopy. The spherical equivalent, cylindrical axis and keratometer values were statistically compared. RESULTS: The mean spherical equivalent obtained from the Retinomax K-plus 3 was significantly less hyperopic than that of Canon RK-F1 (p = 0.004) before cycloplegia. When the Bland Altman analysis was performed in comparisons of spherical equivalent values measured with the Retinomax K-plus 3, Canon RK-F1 and cycloplegic retinoscopy, it was seen that almost all of the differences between the measurements remained within the range of +/-2 standard deviation. Good agreement was found between Retinomax K-plus 3 and Canon RK-F1 for the Jackson cross-cylinder values at axis 0degrees and 45degrees; keratometer values respectively. CONCLUSIONS: The refractive error components were highly correlated between the two instruments and cycloplegic retinoscopy.
Subject(s)
Child , Child, Preschool , Female , Humans , Male , Refractive Errors/diagnosis , Retinoscopes , Retinoscopy , Vision ScreeningABSTRACT
PURPOSE: We analyzed the difference in values between noncycloplegic and cycloplegic autorefraction and refraction, as measured by ophthalmologist, in children according to age. METHODS: We classified the 84 children (153 eyes) whose best corrected visual acuity was better than 0.6 into four groups according to age. The first age group ranged from 29 to 57 months (36 eyes); the second age group ranged from 58 to 75 months (47 eyes); the third age group ranged from 76 to 95 months (36 eyes); and the fourth age group ranged from 96 to 121 months (34 eyes). The children were examined with an autorefractometer (Canon Auto Ref RK-2) and a retinoscope before and after cycloplegia. RESULTS: The children in all age groups tend to show more myopia in autorefraction than refraction regardless of cycloplegia. Also, differences in spherical component and spherical equivalents in noncycloplegic autorefraction and cycloplegic refraction were regarded as significant statistically (P<0.05) in all age groups. However, in all groups, none of the refractive values in cycloplegic autorefraction and refraction were statistically significant. CONCLUSION: Refraction measurement should be recommended for cycloplegic refraction in children. It is suggested that cycloplegic autorefraction could be useful for the refraction partially.
Subject(s)
Child , Humans , Myopia , Retinoscopes , Visual AcuityABSTRACT
We analysed the differences between the values of noncycloplegicautomated refraction and manifest refraction by ophthalmologist 150 patients(274 eyes)were studied. We divided these patients into five groups according to the age; Group 1 included patients under 10 yea(n=50 eyes), Group 2 from 10 yrs to 19 yrs(n=74 eyes), Group 3 from 20 yrs to 39 yrs(n=66 eyes), Group 4 from 40 yrs to 49yrs(n=39 eyes), Group 5 over 50 yrs(n=46 eyes); We used Canon Auto Ref R-10 autorefractor and ophthalmologist's refractions were the results of both subjective refraction by retinoscope and objective refraction used by cross cylinder. Between the two examinations, the percentages of eyes of disagreement beyond +/-0.5D were 22%(group 1), 39.2%(group 2), 14.1%(group 3), 15.8%(group 4), 17.4%(group 5) in spherical power; 18%, 23%, 27.3%, 29%, 15.2% in cylindrical power respectively; 20%, 31.9%, 18.2%, 15.8%, 19.6% in spherical equivalent respectively and the percentages of eyes of disagreement beyond +/-10 degrees in cylindrical axis were 25%, 42.6%, 39.2%, 40%, 52.9% respectively. There was no statistic significance between the age groups when we compared the absolute differences of values between two examinations. Conclusively, this study revealed that there were large differences between the values of noncycloplegic automated refraction and manifest refraction by ophthalmologist in the large amout of patients and then our results indicated that automated refraction was dangerous to patient's eyes and subjective refinement was needed by ophthalmologist if patients wanted the spectacle or contact lens.
Subject(s)
Humans , Axis, Cervical Vertebra , RetinoscopesABSTRACT
The aims of the our study are investigation of the average value of the refraction, anterior chamber depth(ACD), axial length(AL), and the interrelationship of refraction, ACD, AL, weight and height of normal newborn infant. Objects of this study are 236 eyes of 118 normal newborn infants that have been examined with retinoscope under the cycloplegia and the axial length and anterior chamber depth have been measured by ultrasonogram. And so we gained following results. The average value of refraction(+1.85 +/- 1.86D), the average value of the AL(17.5 +/- 0.68mm) and the average value of ACD(2.62 +/- 0.21mm) did not show significant difference between male and female newborn infants. The correlation coefficient between AL and ACD. refraction and AL, weight and AL, and height and AL were 0.326(P0.1).
Subject(s)
Female , Humans , Infant, Newborn , Male , Anterior Chamber , Retinoscopes , UltrasonographyABSTRACT
Photorefraction was performed in 96 cases(191 eyes) after instillation of tropicamide and cyclopentolate for the purpose of screening procedure. And then refraction was also carried out by retinoscope. From this comparison study, phtorefraction provided data which were very close to those obtained from the conventional retinoscopy.