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Innovations | Jun 2015

Subjective Objectivity

When is it time to implement objective testing versus relying only on clinical experience?

There has been a lot of discussion during meetings, in publications, and at forums about innovations in diagnostic technology. From clinical refraction, to the ocular surface, to the retina, there are numerous resources in our toolbox to help us become better clinicians.

Traditionally, eye care physicians have been trained to perform comprehensive visual examinations using the SOAP format: subjective testing, objective testing, making an assessment, and formulating a plan. With strong educational backgrounds in ocular disease and wide clinical experience, we continually improve our differential diagnostic abilities. When a patient presents with a pathology, we know the importance of not just treating the patient, but scheduling follow-up appointments to ensure he or she adheres to proper ongoing therapy and management.

The question is: When is it time to implement objective testing versus relying only on clinical experience? We are all aware of the various innovative diagnostic technologies, and we may question whether these tests will change the way we treat patients. Some of us say yes, and others say no, for a variety of reasons. Let me be clear: I am not trying to downplay the role of clinical experience. Rather, I am asking the question: When do we need to implement more objective testing?

Glaucoma is a classic example of a disease in which we traditionally evaluated the patient’s risk factors, checked the IOPs, studied the optic nerves, performed a visual field test, took fundus photographs, and treated the condition if warranted. Most of these measures involve some degree of subjectivity. In current practice, the standard of care in glaucoma management includes those same examinations plus numerous objective tests such as OCT, pachymetry, and electrodiagnostics. We take the objective findings and use evidence-based medicine to more accurately treat and follow patients. We can always debate the pros and cons of different technologies, but the fact is that we need objective data to effectively manage our patients.

At a Glance

• Traditionally, eye care physicians have been trained to perform comprehensive visual examinations using the SOAP format: subjective testing, objective testing, making an assessment, and formulating a plan.
• Point-of-care testing and advanced dry eye diagnostics, such as tear osmolarity; levels of matrix metallopeptidase 9, lactoferrin, and IgE; meibography; and blink

Let us compare the management of glaucoma (as outlined above) to ocular surface disease, which includes allergy, dry eye disease (DED), and blepharitis. All three conditions have overlapping signs and symptoms, and they are not always easy to distinguish. We ask patients about their symptoms, evaluate the ocular surface (including the lids), use standard tests such as Schirmer and vital dye staining, and treat patients with over-the-counter or prescription medications. All of our traditional tests for DED are subjective, and, to make matters worse, patients’ signs do not always correlate with their symptoms. Multiple questions come to mind in diagnosing and treating ocular surface disease, including these:

• Is the dry eye inflammatory?
• Is it allergy or dry eye?
• When do I use a steroid? For how long?
• Is it aqueous-deficient or evaporative dry eye?
• When should I use plugs?
• How do I manage a patient with chronic dry eye who is using topical medications?

We need to continually find better ways to understand and improve our diagnostic and management capabilities for patients who experience ocular surface conditions. In the past few years, point-of-care testing and advanced dry eye diagnostics have become hot topics. There are numerous tests now available to supplement the traditional subjective exams, including tear osmolarity; levels of matrix metallopeptidase 9, lactoferrin, and IgE; meibography; blink rate; and more. These tests provide objective data, rather than the subjective data we have traditionally relied upon. Many of us have adopted these diagnostics; however, most of our colleagues have been slower to do so. The question might be asked: Why is objective testing crucial in a disease such as glaucoma, but not so relevant for ocular surface disease?

The accompanying sidebar to this article showcases some of the objective testing devices currently in clinical use. It is my hope that this partial listing, in combination with the results of further research, will spark an interest in you to add some form of objective testing to your daily practice. n

Walter O. Whitley, OD, MBA
• Director of Optometric Services, Virginia Eye Consultants, Norfolk, Virginia
wwhitley@vec2020.com
• Financial disclosure: Clinical Advisory Board (TearLab), Speaker (TearScience)

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