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HOW DO WE KNOW WHAT TO DO?
This issue of the BJO highlights several aspects of the dilemma ophthalmologists face when dealing with a specific clinical problem. What data are they to use in making their therapeutic decisions? Clearly in the past decade the randomised multicentred prospective trial has become the gold standard for assessing therapeutic options in medicine. Regrettably, only a minority of the clinical problems that face ophthalmologists on a daily basis have been submitted to this rigorous format. As a result, therefore, many important questions are still answered by less adequate means: retrospective and poorly controlled studies and even less satisfactorily depending on expert opinions. Far too often one still hears “in my experience” used to justify major medical decisions. See 51
THE PATIENT WITH THYROID DISEASE
Susan Lightman and Peter McCluskey have organised a provocative series of controversies in ophthalmology. In this month's issue they dramatically demonstrate that even in the most common ophthalmic disorders there can still be considerable debate about what is the appropriate therapy. In a case of thyroid orbitopathy some things are clear. Lid surgery, strabismus surgery, treatment of dry eye, and re-establishment of a normal thyroid status are all fundamental keystones to the therapeutic programme in these patients. But some problems surrounding thyroid orbitopathy are much more vexing as this month's controversy shows. Is there a role for radiotherapy in the management of thyroid orbitopathy? Certainly the most recent published papers have an increasingly negative response to that question. Nevertheless, Cockerham and Kennerdel make a strong case that despite the lack of a good controlled study they find the use of external beam radiation to be safe and effective as an intervention in patients with dysthyroid orbitopathy who are not diabetics. In sharp contrast, Mourits reviews the literature carefully and comes to a quite opposite conclusion. Although the tide seems to be turning against the use of radiotherapy in thyroid orbitopathy it is still a well established part of the therapeutic regimen of these patients. As Mourits point out often there is nothing else to offer the patient. Clearly this is an area of ophthalmic management that begs for further clarity. See 102
VALUE ADDED OPHTHALMOLOGY
In a new series of articles Gary and Melissa Brown introduce us to the concept of value oriented ophthalmology. As they state in their editorial on prioritisation and outcome in corneal transplantation “There is little doubt that while evidence based medicine was the buzz phrase of the 1990s moving forward it will be teamed with patient perceived value and cost utility analysis to take healthcare quality to a yet higher level; “value based medicine” will be the paradigm of the 21st century.” In their article “Quality of life and systemic co-morbidities in patients with ophthalmic disease” the authors point out that utility values can be used to assess the value of certain medical procedures. Implicit in the use of utility values is the patient's perception of the importance of a certain diseased state and our ability to treat it may be more important than a third party's evaluation of the procedure. In every medical system those who pay the bills are increasingly asking physicians to justify the cost of the procedures that they perform. Brown and co-workers demonstrate that even when patients have serious co-morbidities like cardiac disease, diabetes, cancer, and other serious systemic disease they still perceive vision threatening ophthalmic disorders as one of the primary healthcare concerns. This, of course, may not be surprising since as increasing disability sets in one might make the case that good vision becomes more important as the patient becomes more dependent on reading and other sedentary activities. Nevertheless, the findings here are important since they suggest that vision threatening ophthalmic diseases are very high on the list of patient concerns. As a result, therefore, patient perception of ophthalmic procedures that might improve these conditions is very positive. These are the kind of data that ophthalmologists will need to collect in the future if they are to make their case to governments, third party insurance companies, individual patients, and other organisations who are involved in paying the ever escalating cost of health care throughout the world. In future articles Brown and Brown will outline and detail this field of evidence based medical economics that we will all have to become familiar with. See 8
THE PLACE OF ANIMAL RESEARCH IN MEDICINE
In the commentary Kevin Dolan presents a thoughtful if not conclusive discussion of the problem facing all physicians with regard to the question of the legitimate use of experimental animals in medicine. As Dolan points out surely we cannot discount the numerous important medical discoveries and developments that have been directly related to animal experimentation. Despite this, it is clear that increasing restrictions are being placed on animal research both by institutions of higher learning as well as external reviewing bodies in different countries.
None the less, the most vexing problem within this discussion of animal research is the question Dolan mentions regarding the use of non-human primates. Restrictions concerning non-human primates appear to be much more severe in the United Kingdom, New Zealand, and countries other than the United States. Nevertheless, there is a growing consensus that non-human primates should only be used in medical research when no other paradigm can answer the essential question being investigated. The editorial committee of the BJO is committed to publishing basic laboratory research in the journal. Nevertheless, each paper that is submitted to the journal in which live animals were used as part of the investigation is carefully reviewed by the editorial committee. We would want to be convinced that a very important question in science is being addressed and can only be addressed by using a non-human primate in a laboratory investigative setting. We realise that the sensitivities concerning animal research vary from one part of the world to the next. We would welcome our readers' comments and their own views about this ethical dilemma. See 5
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