I wanted to tell you about an article that I read in the journal Ophthalmology, known informally as “the Blue Journal.” Going cover to cover on each month’s edition has been a great benefit to my clinical thought process, and hopefully to my patients. Perhaps I don’t read every word of every article, but I’ve found that most current topics in eye care are covered by at least reading the abstracts.
Our article in question is an editorial entitled, “Dry Eye Research—Still Regressing?” (Footnote 1) It really got me thinking about how we do things, and why. The opinion is a bit of a send-up on our efforts in treating patients troubled by dry eye, but it can be generalized to many areas of care. The over-riding thesis is that treatment results matter less about what we’ve done, and more about the fact that we’ve done SOMETHING.
Does this ring a bell?
For example, ODs on Facebook posters show table-pounding passion about WHICH OMEGA 3 supplement is best for the dry eye patient. Yet, the DREAM study showed that omega 3 supplements were no better than placebo. (Footnote 2) Yes, the placebo was unfortunately chosen as olive oil. (Study chief Dr. Penny Asbell argues that 1000 grams of olive oil is 12x LESS than you’d get in a daily Mediterranean diet, so it’s fine as a placebo. I’m uncertain.) Point being, colleagues report patient improvement with this supplementation, but is the improvement due to the nature of the supplement itself, or the fact that we’ve made an intervention on the patient’s behalf?
Worse yet, a follow-up “extension” study on DREAM showed that patients who stopped taking omega 3 DID NO WORSE than the placebo group. (Footnote 3) If you are confused at this point, join the club!
Should I pound the table regarding olive oil, instead?
To some degree, we lack repeatability in our subjective studies. Here are some basic bullet points from the article, and I think we should take them to heart:
* ”We know dry eye signs do not correlate with symptoms.” This leads to a plethora of other reasons why our treatments work, or they don’t.
* “As physicians, we want to believe our actions are directly responsible for our patients’ improvements.” Yes, I’m pretty confident that my treatments will go far to improve the patient’s quality of life. Maybe it’s unfounded?
What kind of an idiot would I be if I paid all of these copayments, made all of the visits, took all of these pills, and got NO improvement? So, yes, I am going to score better.
*If patients are selected for a dry eye study based on high test scores, “chances are the scores will be lower upon reassessment even without any intervention.” You don’t have to agree, but it does lead me to question the value of written dry eye surveys. In my hands, a dry eye score never drives home a clinical point as well as a face to face discussion with the patient.
I’d add that common-sensically, there are many variations that can enter the picture when we are treating an organ or organ system REMOTELY. Oral medications for dry eye are subject to the body’s modification from mouth to endpoint. It can be challenging to assume mechanisms of action when our physiologies can vary.
I’m a big believer that patients get better from our touch and reassurance. Treatment endpoints can be vague, if they are ever reached at all. Do we have some great methods and medicines, honed by research and clinical experience? Of course we do. However, if you look at the relatively small objective gains in dry eye, it’s clear that we have a long way to go.
- Seitzman, G. et al, “Dry Eye Research—Still Regressing?” Ophthalmology, Volume 126 Number 2, February 2019 pp. 192-194
- Asbell, P. et al, “The Dry Eye Assessment and Management Study Research Group,” New England Journal of Medicine, April 2018
- Hussain M et al, “The Dry Eye Assessment and Management extension study: A randomized clinical trial of withdrawal of supplementation with omega-3 fatty acid in patients with dry eye disease.” Ocular Surface, 16 August 2019