dry eye

Dogma or Truth?

Some treatments are accepted as standard of care—but do they work?

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

Often in writing this dry eye column, I utilize a definition of a word (or common phrase) to illustrate a point. In this column, I will discuss the term dogma, which is often thought to have a negative connotation. The definition of the term dogma has both a faith-based context, as well as an opinion-based one. In medicine, dogma is defined as something held as an established opinion; in particular, an opinion that is considered authoritative. In addition, dogma is defined as a point of view or tenet put forth as authoritative without adequate grounds. I would add to that my opinion that dogma in science, or perhaps medicine, also has the connotation of being something widely believed, or commonly practiced, perhaps without scientific evidence, and with some impression that it just might be (a little bit) wrong.

A healthy dose of doubt

When we seek medical care, I expect that most of us are a bit skeptical and question the advice or treatments recommended to us. How do we know that what has been suggested is the best course of action? The doctor has probably seen the problem before and knows what to do. Some of it is, of course, the doctor's own judgment and our acceptance of that. If the case is more challenging, a doctor might consult a colleague or the scientific literature—most likely through the Internet. After we leave the office, we do the same; we consult colleagues or seek more information online. But how do we know that the Internet source is providing truth and not furthering dogma?

The test of time

If an agent has been used for a long time with good results, it is generally accepted as “safe and effective.” Take, for example, the use of fluorescein dye in our clinical practices. We use it every day as a diagnostic tool to view staining on the ocular surface and to perform tests, such as fluorescein tear breakup time. One of my first IRB applications for a research study was returned with the request for additional information and package labeling (package insert) for fluorescein and lissamine green, because they are classified as therapeutic agents. You probably never thought of this when opening a box of fluorescein strips. If you've ordered liquid fluorescein or lissamine green through a compounding pharmacy, you may have, since these agents require a prescription for compounding. In some states, a Terminal Distributor of Dangerous Drugs (TDDD) license is required if liquid fluorescein is dispensed—even though it's only used in the diagnostic process. This same license requires that liquid fluorescein be kept in a locked cabinet, in this case a locked refrigerator. The TDDD license doesn't distinguish between having benign liquid fluorescein or narcotics, for example. If you were a patient and saw your doctor unlock a refrigerator to remove his liquid fluorescein, what would you think? The point is that while a doctor's thought processes and decisions create and dispel dogma, a patient's perception plays into the scenario as well.

Time is ticking

Many treatments have withstood the test of time because they really work, while some continue to linger despite evidence that they aren't effective. I recently came across information excerpted from a book by David H. Newman, who wrote “Believing in Treatments That Don't Work,” where he explores how medical ideology often gets in the way of evidence-based medicine. He cites many examples of clinical care in which the response is sub-optimal or no better than the absence of treatment, and yet the medical community continues providing that care. Some examples are the use of cough syrup (no better than a placebo, for both children and adults), certain types of back surgeries, and the use of antibiotics to treat ear infections. In the anterior segment arena, one could argue that antibiotics for a nonspecific “pink eye” or lowgrade conjunctivitis might fall into the same category. But how about oral doxycycline for internal or external hordeola or more recently, for MGD? How about lid scrubs or warm compress therapy for anterior blepharitis? For MGD?

Documenting truth

I was recently discussing the use of generics versus branded ocular medications and I realized that even though the results would be useful, some studies will never happen. Why? There are many reasons — first and foremost, financing. If a treatment is already accepted as the “standard of care,” why would a new study be done, unless it was for a pure academic purpose, and furthermore, who (or what agency) would fund it?

Truth in MGD?

Throughout the process of the Meibomian Gland Workshop, it became clear that there was a paucity of evidence on effective treatments for MGD. The clinical trials committee identified only 26 studies that qualified, according to pre-set standards, as trials for MGD. A more in-depth read of the articles demonstrated that not only were studies on treatments lacking, commonality among the studies, including classification of disease and diagnostic testing required, was minimal. Most of the studies were relatively small in nature (less than 40 subjects), lacked consistency in entry and exclusion criteria between studies, and varied significantly in the concomitant use of alternate therapies.

It's important to note that what we currently know IS the truth, even if it's tainted by dogma. Dogma can be right. Remember, all new therapies begin with clinician inquisition, the seed of an idea, the trial of a new concept.

How can we judge what is “truth” and what isn't?

Recently, I learned of a free Internet training program developed by the Cochrane Library, the Cochrane Eyes and Vision Group US Project (CEVG@US Project), a free-of-charge online course on journal peer review, titled Translating Critical Appraisal of a Manuscript into Meaningful Peer Review. The objective of the course is to serve as a resource for health professionals who are serving, or wish to serve, as peer reviewers of the biomedical literature. This project has been funded by the National Eye Institute of the National Institutes of Health. Sure, that sounds scientific, but any clinician with an interest in better understanding scientific literature would find some components of this online course to be valuable (http://trams.jhsph.edu/trams/index.cfm?event=training.launch&trainingID=132).

The bottom line

I believe there are several layers to separating dogma from truth. We must remember that treatment providers (ourselves included) are human, and even as doctors, our core beliefs and learnings are typically not changed all that easily even when there exists evidence to the contrary.

Dogma also persists because of a lack of effective treatments, especially in ocular surface disease. “Ttreatment as usual” at least feels like we're doing something, whether or not it's actually beneficial remains to be seen. Developing new therapies, especially for dry eye, can take years. And in all of the cases that Newman named, as well as those in our own profession, I'm betting medical dogma prevails because no one knows what else to do.

So, before we jettison existing therapies, dogma or not, evaluate whether the therapy seems to work for an individual patient. If we critically assess, even if only in our own clinic, the things that just aren't working, we can begin to make room for the things that might finally make a difference. OM