The “Landmark Studies” column will focus on the main findings of historic studies in glaucoma and how their results should change physicians' practices.
WHAT IS A LANDMARK STUDY?
A landmark study asks a compelling clinical question, and the answer significantly affects our judgment and delivery of clinical care as physicians. These studies represent our best efforts at addressing tough questions such as when to treat and when not to treat glaucoma suspects, whether to administer medicine or perform surgery first, implant a tube or perform filtering surgery, or perform laser or incisional surgery. These thought-provoking studies are usually prospective, randomized, multicenter, and masked (when feasible), and they are characteristically known as randomized clinical trials. I specifically remember reading an article by Paul Palmberg, MD, PhD, about a decade ago that placed landmark studies in perspective. It was a meaningful editorial aimed at helping physicians gain insight into organizing the studies to obtain the big clinical picture. Paul Lichter, MD, also wrote an enlightening article on the various aspects of glaucoma clinical trials and what they mean to patients.1 We must revisit these landmark studies and strive to incorporate their teachings into our practice of medicine by continuing that admirable tradition.
WHY DO I NEED TO KNOW ABOUT A LANDMARK STUDY?
Our immediate and long-term care of patients is suboptimal if we lack knowledge of a landmark study. Its findings are important because they guide physicians through uncertainty. Should we turn right or left? Significant research points us in the right direction, and we become better caregivers when armed with evidence. If we have a knowledge gap, we should fill it by seeking advice from colleagues who are informed on the subject. I ask my four glaucoma colleagues for their advice all the time and believe it fosters the development of two-way communication that enhances patients' care. I do not let egos get in the way. Discussions of studies that change clinical care usually spark a flurry of controversy, which culminates in editorials from interested and experienced readers. These exchanges further clarify what the study means and how it might affect clinical care. Were the recommendations from the study consistent with current medical practice? If not, why, and what does that mean? Treating physicians should communicate to patients the pertinent facts that influence and guide the treatment algorithm. Revealing study data to patients often enforces the goal of therapy, helps them better understand the problem, and increases their adherence to prescribed therapy.
WHAT QUESTION IS THE STUDY DESIGNED TO ANSWER?
Landmark glaucoma studies came about through critical thought concerning patients' care, responses to socioeconomic pressures, and important observations. The giants in glaucoma care put these studies together, and I thank them. One key to remembering a given study is to ask ourselves what it was designed to answer.
For example, what question was the Ocular Hypertension Treatment Study (OHTS) designed to answer? Does lowering IOP in glaucoma suspects prevent or delay the onset of glaucoma? If we cannot ask the question, much less answer it, it is unlikely that we or our patients will receive the full benefit of this research. Answering that targeted question should prompt our analytical minds to understand how the study was set up to answer the question. That leads to understanding the results and what they mean. Then, the sparks fly, and the controversy begins!
In addition, we should be thinking about the best way to incorporate these studies' findings into our practices. Do we need to consider a new piece of equipment? Does our ophthalmic society need to obtain a new CPT or ICD code to transition the new knowledge into the ophthalmic community?
CONCLUSION
This column will focus on glaucoma studies that change the way we practice medicine. It will emphasize take-home messages by focusing initially on what question the research was designed to answer. The organizational approach of how each study fits into the broad spectrum of clinical care will then become more apparent. Ultimately, this column should help us all to become better thinkers regarding glaucoma decision making. These skills, once translated into clinical practice, will improve glaucoma care in a meaningful, evidence-based way.
Section Editor Ronald L. Fellman, MD, is a glaucoma specialist at Glaucoma Associates of Texas in Dallas and clinical associate professor emeritus in the Department of Ophthalmology at UT Southwestern Medical Center in Dallas. Dr. Fellman may be reached at (214) 360-0000; rfellman@glaucomaassociates.com.
