dry eye

To Read or Not to Read?

Is it time to rethink our approach to peer-reviewed scientific articles?

Kelly Nichols, O.D., M.P.H., Ph.D.

In early 2011, the report of the International Meibomian Gland Dysfunction Workshop will be published in Investigative Ophthalmology & Visual Science, and the publication, to some degree, ushers in a new “brand” of manuscript. However, for many optometrists, it will be challenging to find value in reading this survey report because scientific peer-reviewed articles: are 1) hard to read, 2) hard to gain access to and 3) hard to translate into clinical care. We may well ask, then, why do we try to read scientific journals then in the first place?

Peer-what?

We read peer-reviewed journals because we hold them in high regard, as they possess articles on original research that has undergone a high level of editorial scrutiny.

When an article is submitted to such a journal, the publication's editorial board and topical editors select one-to-three reviewers. Reviewers are invited based on their expertise and availability. The reviewers critique the manuscript, and the critiques are provided to the authors without disclosure as to the identity of the reviewer.

The manuscript is either accepted as is (rarely occurs), rejected, or invited to be re-submitted with major or minor modifications. Once the manuscript is re-submitted, the process begins again.

Many instances exist in which articles are rejected. For example, Investigative Ophthalmology & Visual Science (IOVS) receives more than 4,000 manuscripts each year, and clearly all do not get published in the journal.

We all can name top peer-reviewed journals, such as Optometry & Vision Science, IOVS, Archives of Ophthalmology and The Ocular Surface, but the truth is, most of us don't read the peer-reviewed scientific literature. Instead, we often rely on our peers (e.g. those who lecture or write on eyecare topics) to distill the information and present it in an accessible format.

Time is everything

But perhaps the most important reason we don't read peer-reviewed journals is that we just don't have the time. And if we were to find the time, one article in and of itself doesn't generally provide the depth of a topic to convince us to change our patterns in clinical care.

Usher in the review article. A review article does provide the scope needed to paint a picture of the topic area — historical aspects, new research and emerging trends. However, here is the big caveat in selecting a review article: The quality is only as good as the ability of the author(s) in assimilating all the parts to tell a complete, non-biased story.

Because of the opinion involved in a review article on the part of the author(s), which can be considered bias, most peer-reviewed journals do not publish review articles or meeting proceedings as a policy. If you think of the last review article you read, it likely appeared in a trade journal, and as such did not necessarily undergo peer review. In other words, it might be biased. Now, that doesn't mean that such articles aren't well written and/or provide quality information. In fact, some of the best summary articles I've read are product-related pieces that have been published in trade journals.

Is a policy change needed?

Peer-reviewed journal editorial boards are often faced with issues including the re-assessment of manuscript policies. All journals, trade or peer-reviewed, want to publish articles that will be read, which increases readership, citations and sales — all of which are indications of quality. And I would argue that all periodicals strive to provide the highest level of quality, which is the fundamental underpinning of peer-review. The tradeoff in this level of quality is that peer-reviewed journals may continue to be inaccessible (for the reasons described earlier) to most optometrists.

However, often scientific work is made more accessible when presented at meetings, such as the Association for Research in Vision and Ophthalmology, the American Academy of Optometry or the annual meeting of the American Optometric Association. While some would say that the abstracts have been peer-reviewed, others would argue that the abstract review process is more of an acceptance process, and that full-vetted assessment of the poster/presentation requires that the manuscript be prepared and submitted for publication in a peer – reviewed journal.

In short, it doesn't really count until it is published.

Dry eye from the podium

Why am I writing about all this? The answer is that the field of dry eye disease is in a state of flux. We hear a lot of hype from the podium and in trade journals about dry eye and meibomian gland dysfunction, and the peer-reviewed literature is trying to catch up. What that means is that clinical experience, in-office experimentation with new products, case studies (published or not) and open-label studies of emerging therapies are the primary data that are used in continuing education. Anyone who has heard me lecture before has heard me say, “many future therapies and new diagnostic instruments and/or techniques start with ideas generated from the clinic.” This translational approach — clinical observation to basic and/or clinical research and back to clinical care — is the reason we do research, to change clinical care patterns for the better.

Dry eye, while not a blinding eye disease, is a very prevalent condition, affecting up to 15% of your patients (depending on your patient population). It's certainly a condition that can be “owned” by optometry. It takes chair time, can be frustrating with a challenging patient, but ultimately is rewarding personally and financially. Hearing this from the podium may inspire you to start a dry eye clinic, ask a few more questions or just start looking at the ocular surface more carefully.

Can a review article replace the “real thing”?

If you are inspired to research ocular surface disease more carefully, you may ask: Can a review article, such as the report of the International Meibomian Gland Dysfunction Workshop, replace the “real thing” (original research)? One of my favorite colleagues at the College of Optometry at The Ohio State University, in Columbus, has the perfect answer with the mantra, “It depends.” I agree with him — “It depends” on this controversial topic.

Peer-reviewed journals pride themselves on original scientific research. However, a recent discussion with the editor of a top peer-reviewed journal gave me a moment of pause. The editor said that publishing quality, evidence-based reviews of a topical area, without bias, was definitely a consideration by the board. Why? In today's fast-paced electronic world, the idea of this “one-stop-shop” is attractive. And, you heard it here, we are experiencing the slow demise of the “text book,” and this from a self-proclaimed book lover. We used to go to a book for answers, and now we go to the Internet. Book information is outdated long before it is printed.

That doesn't mean that concepts can't be transmitted in print material; they certainly can, and this will continue. The formatting of this material — that is, how books present recent research — is what will likely change.

Inside the report on MGD

When the report of the International Meibomian Gland Dysfunction Workshop is published in its full length, it will run close to 200 pages, or perhaps more. Recognizing that the full text may not be of interest to all readers, a 10-page executive summary is also included. So, while it took 50 individuals from around the world two years to assimilate this information, I am confident reading the article is not an activity a clinician, even with the highest level of interest, would attempt on his/her own. Is there value in the report if it's not widely read? I would answer “yes,” as it will certainly provide a direction for future research.

Having said that, a review article can never take the place of quality science. However, a review article should embody quality science. In my opinion, a good review article should be:

► evidence-based (the level of evidence should be identified);
► complete with full disclosure (of the author and sponsor);
► comprehensive, including the historical perspective of the field;
► inclusive of forward-thinking statements and directions for future research;
► transparent to the reader (and journal editorial board) as to why the review is needed.

Our patients

Many believe in attending continuing education classes or reading clinical information that gleaning a single “pearl” that can be used in practice tomorrow is the rubber-meets-the-road evaluation of the worth of the time spent. I'll challenge that: The “pearl” looks different to every individual. For example, for some, the single pearl may be a starting point to research the concepts they plan to incorporate into their practices.

I have a much more broad, complex, thoughtful and integrated understanding of ocular surface disease, including meibomian gland dysfunction, after spending the last two years of my life working with individuals around the world on the MGD Workshop project as chair (www.tearfilm.org/mgdworkshop/). Spending time with the material in a topic area allows for thoughts and ideas that might not originally seem apparent.

Therefore, get your “pearl” from continuing education class, but support this pearl by spending time reviewing and thinking about the material and concepts presented in the peer-reviewed literature. By doing so, your patients will see that you have put thought into your decisions related to managing their dry eye/meibomian gland disease, and they will greatly appreciate it. OM