Why is Research So Important?

For over 20 years, Associate Professor Gordon Doig worked with NSW Health as an epidemiologist across all areas of medicine. Now Head of Research at the Centre for Eye Health, he has no doubt about the role of research in guiding optimal care for our patients in the eye health space. When I interviewed him for this article, here’s what he had to say.

I hope to see optometry move more towards the objective interpretation of research evidence and away from the opinion-based influence of experts with vested interests

Q. Why is research important? 

Fundamentally, research is essential to find out which treatments work best for patients.

Research plays an important role in discovering new treatments, and making sure that we use existing treatments in the best possible ways. It can find answers to things that are unknown, filling gaps in knowledge and changing the way that we, as healthcare professionals, work.

Some of the common aims for conducting research studies are to:

• Diagnose diseases and health problems,
• Prevent the development or recurrence ofdisease, and reduce the number of peoplewho become ill,
• Treat illness to improve survival rates orincrease the number of people who aremanaged more appropriately, or ‘cure’, and
• Improve the quality of life for people livingwith their health conditions or eye disease.

Research and clinical trials underpin our health care system. People being cared for benefit from past research, and continue to benefit from research that is currently being carried out. Ultimately, high-quality clinical research helps the health care profession, including optometry and ophthalmology, to improve future healthcare.

Q. What should optometrists realise about eye research? 

I think the first step is to realise there are different types of research:

Pre-clinical research, also called lab or bench research, is most often conducted in animals, but can also be conducted in tissue cultures or simulated physical systems. This type of research gives researchers insights into whether a new intervention holds any promise of helping patients.

Then there are two types of research that are more useful to clinicians:

Clinical research is conducted in patients with a disease. The primary purpose is to understand how patients benefit from a novel treatment or diagnostic process, thus clinical research helps to inform clinical decisions.

Health services research is also extremely useful to clinicians, because its primary purpose is to understand how clinical practice can become more efficient. Health services research focuses on costs, workload or time, with patient outcomes often playing a secondary role. For example, health services research would ask a question such as, ‘Which record keeping system saves more time, and thus costs your practice less money after accounting for the purchase cost and maintenance?’

Today, all health care professions accept that clinical decisions should be guided by the best available evidence from objective clinical research. So, a vital part of our thinking becomes learning how to tell the difference between reliable clinical research and unreliable clinical research. Luckily, there are several credible Users’ Guides developed by clinicians to help other clinicians identify the most reliable clinical research studies and inform decisions regarding treatments and diagnoses.^1-5

Q. Where do you see the state of eye research at the moment in the optometry space? 

The practice of optometry is increasingly being guided by evidence from large-scale clinical research studies, but there is still a long way to go. For example, the Age Related Eye Disease Study (AREDS) is a landmark study that should define supplements as a standard of care for people with intermediate age-related macular degeneration (AMD).⁶ To understand the importance of AREDS, we can look back at this evidence through the eyes of other health professionals.

It is unfortunate that we still come across patients who are misinformed, and they are advised ‘there is no treatment for your macular degeneration’

The US National Institute of Health (NIH) is tasked with producing fact sheets to guide health professionals on the use of medicines and dietary supplements. For example, two NIH fact sheets address the use of zinc supplements⁷ and vitamin A (beta-carotene).⁸ They were written by physicians, pharmacists and dieticians for use by all health professionals, and each fact sheet considers all pertinent research evidence while ignoring dogma and irrelevant personal opinions.

These NIH fact sheets recognise AREDS as the most influential randomised controlled trial (RCT), defining a zinc dose for people with AMD while acknowledging that AREDS2 further refines our understanding by showing that lutein and zeaxanthin may be more beneficial than beta-carotene (a vitamin A precursor) for some people with AMD.⁹ Both fact sheets end with clear recommendations that individuals who have AMD should talk to their healthcare provider about taking an eye health supplement containing zinc.

It is unfortunate that we still come across patients who are misinformed, and they are advised ‘there is no treatment for your macular degeneration’.¹⁰ Just like there is no cure for diabetes, it is important to acknowledge that currently there is no cure for AMD. However, it is important for clinicians to communicate that there is a well-tested treatment that can prevent progression to advanced AMD and also prevent worsening vision loss.

In the future, I hope to see optometry move more towards the objective interpretation of research evidence and away from the opinion-based influence of experts with vested interests. Framing our communications with patients, based on the best available evidence, helps patients participate in their own treatment decisions.

Clear communication, emphasising the proven health benefits of effective treatments, empowers patients to actively improve their own health outcomes, thus reducing anxiety and improving overall confidence and wellbeing.

Q. Some of us don’t see the benefits of eye research guiding practical aspects of patient care, and think that it’s too theoretical to be of practical benefit. How can eye research help us to improve the way we manage patients in optometry? 

The most important type of research to look for is clinical research that reports patient focused outcomes. For example, loss of visual acuity is very meaningful to patients. So, quality of life (reduced anxiety, increased confidence, improved wellbeing), and for people with major loss of vision, formal measures of disability and daily function (safely managing steps, being able to shop, or independently pour a hot cup of tea) are also important. To help identify clinical research that guides practical aspects of patient care, look for studies that demonstrate significant improvements in patient focused outcomes.

Q. Where do you see eye research growing in optometry in the next few years? 

I hope we move towards more large-scale clinical trials conducted in community settings that focus on documenting improvements in patient outcomes. This type of focus will help tie clinical research directly back to influencing patient care, ultimately leading to improvements in health and quality of life for our patients.

PRACTISE BACKED BY RESEARCH: A CASE STUDY

Damien,* a 55-year-old-male who works as a business analyst, came to see me for the first time. He was looking for a new optometrist as his previous optometrist was no longer in practice. Damien had noticed blurry vision and attributed it to his prescription changing.

Testing showed that Damien was a very high hyperope and a presbyope. Multifocals, digital lenses and contact lenses were prescribed. At this visit, Damien corrected to RE 6/7.5 and LE 6/7.5 and 6/6 together. Mild-to-moderate signs of dry AMD were detected.

I told Damien that established research has demonstrated the best way to prevent sight loss from occurring due to AMD is to take a daily AREDS-based multivitamin. I also provided education about diet and lifestyle changes that could help prevent disease progression, and the importance of regular check-ups. Armed with this evidence-based advice, Damien agreed to take these preventative measures and we booked him in to return for review six months’ later.

However, COVID arrived, and Damien admitted that despite the clear advice he’d been given, he’d found it difficult to come back to the practice during lockdown. He had deferred his appointments and returned not six, but 18 months later, prompted by the perception that his prescription had worsened. As it turned out, Damien had stopped taking his AREDS formula once the initial six month supply had finished.

At this visit we found that Damien’s deteriorating vision was only partly due to a changed prescription. His AMD was progressing from dry to wet; and his vision had been reduced to 6/12 in the left eye.

I recommended an urgent appointment with a retinal ophthalmologist and explained the need for immediate treatment of his wet AMD to reduce further vision loss. Fortunately, Damien acted on this recommendation, and ongoing anti-VEGF treatment eventually returned his vision to 6/7.5 in his left eye.

Damien is now vigilant when it comes to attending appointments with his ophthalmologist, receiving regular anti- VEGF injections as required, and taking his daily dose of AREDS-based multivitamins.

He wishes he had continued with the AREDS tablets in case it could have helped, but is grateful for the urgent referral and ongoing education I was able to provide. Damien maintains a close relationship with our practice and his ophthalmologist to ensure he retains as much of his eyesight as possible.

POWER OF COMMUNICATION

Effective communication between researchers, clinicians and patients is critical to ensure we are all ‘on the same page’ working together to reduce vision loss. Clinical research must form the basis of all communication, so that our advice achieves the best outcomes possible.

By working collaboratively, we can empower patients to take proactive steps to protect their vision and, in doing so, we can prevent vision loss.

Dr Margaret Lam is the National President of the Cornea and Contact Lens Society of Australia, Deputy President of Optometry Australia and a Director of Optometry NSW/ACT. She teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer and works as the Head of Optometry Services for George and Matilda Eyecare. 

Associate Professor Gordon Doig grew up and trained in Canada before being recruited to the Royal North Shore Hospital in 2001. He has 19 years’ experience working with NSW Health as an epidemiologist across all areas of medicine. Assoc/ Prof Doig works with Centre for Eye Health, where he contributes his wealth of research expertise and passion for improving care so that patients can achieve their best possible health outcomes. 

References 

1. Oxman AD, Sackett DL, Guyatt GH. Users’ guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA 1993;270:2093-2095. 
2. Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994;271:389-391. 
3. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994;271:703-707. 
4. Guyatt GH, Sackett DL, Cook DJ. Users’ guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1993;270:2598-2601. 
5. Guyatt GH, Sackett DL, Cook DJ. Users’ guides to the medical literature. II. How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. JAMA 1994;271:59-63. 
6. A randomised, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119:1417-1436. 
7. National Institute of Health, Office of Dietary Supplements. Zinc: Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/ Updated: 26-3-2021. Visited: 2-11-2021. 
8. National Institute of Health, Office of Dietary Supplements. Vitamin A: Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/VitaminAHealthProfessional/ Updated: 26-3-2021. Visited: 2-11-2021.9. 
9. Age-Related Eye Disease Study Research Group. Effect of Omega-3 Fatty Acids, Lutein/Zeaxanthin, or Other Nutrient Supplementation on Cognitive Function: The AREDS2 Randomized Clinical Trial. JAMA 2015;314:791-801. 
10. Taylor DJ, Jones L, Binns AM, Crabb DP. ‘You’ve got dry macular degeneration, end of story’: a qualitative study into the experience of living with non-neovascular age-related macular degeneration. Eye (Lond) 2020;34:461-473.