Professional judgement in the era of evidence based practice

Why is traditional lid hygiene still one of the alternative recommended options for treating blepharitis?

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Author: Daniel Hardiman-McCartney MCOptom, Clinical Adviser
Date: 15 February 2016

As clinical adviser I often get asked why traditional lid hygiene is still one of the alternative recommended options in our Clinical Management Guidelines (CMGs). With the recent release of the new Clinical Management Guideline for blepharitis it is a timely point to consider why. The College’s updated CMG still recommends practitioners consider recommending both traditional and commercial products as lid hygiene methods for the management of blepharitis.

Why do so many experts still recommend diluted baby shampoo when there are other specifically designed alternatives available? Well in short, it is safe and it works. Many patients across the world have used it and managed their blepharitis successfully without harm in the days before evidence based practice. Since then studies have shown diluted baby shampoo to be an effective intervention. Although there are concerns baby shampoo may destabilise the tear film, there is still no high quality evidence that show that it does so in a clinically significant way.

It is our role as optometrists to use our clinical expertise in partnership with our patients to decide which intervention is most appropriate.

There are some short-term studies that suggest lid cleaning products and traditional methods are comparable; so why not recommend dedicated lid cleaning products alone? We are told by their manufacturers they are more gentle, less disruptive to the tear film and much easier to use? The primary reason for me has to be cost. Lid cleaning wipes could cost a patient around £250 a year, if used daily, whereas baby shampoo and a supply of cotton buds for a year will cost very significantly less. For an intervention that is likely to be life long, cost is a very important consideration, especially when there is no good quality evidence that the lid cleaning product is more clinically effective than the cheaper alternative. Of course the NHS does not currently pay for either lid hygiene regime, but our patients do, so surely they are the ones best placed to make an informed decision as to which recommended treatment regime they use?

There are a number of convincing reasons to recommend lid cleaning products. The strongest in my opinion is convenience and, consequently, compliance. Patients prefer easy to administer interventions and are, quite frankly, more likely to comply and benefit from the treatment if it is easy to use. The process of boiling water, waiting for it to cool, measuring out a 1:10 mixture, then using it to clean their eyelid margins with cotton pads or cotton buds is without doubt inconvenient. For many of our patients it probably is an easy decision to choose the more expensive but more convenient treatment option. I suspect that is why so many optometrists feel strongly about this. As passionate patient advocates, it seems unhelpful to recommend baby shampoo when there are much simpler and more patient friendly alternatives, despite their being comparable in their clinical effectiveness. Other reasons for recommending cleaning products include the risk posed by compliance errors such as not using boiled water or using the incorrect concentration, treatment inconsistency - in that there are many different formulations of baby shampoo with different preservatives and cleaning agents - and finally the argument that baby shampoo is simply not designed for eyelids, it’s designed for scalp hair.

This conflict between evidence based practice and what is in the patients best interest, is a recurring theme in medicine and one addressed in a 2002 BMJ paper which I would thoroughly recommend reading. The paper proposes that practitioners should balance clinical circumstances, patients’ preference and research in an expanded role of clinical expertise, which must encompass and balance the patient’s clinical state, the research evidence and the patient preference. This judgement involves making individual patient focused trade-offs and discussing them with the patient, so they can make an informed choice. In partnership with patients, optometrists have the professional judgement to weight their recommendation according to their patients’ needs.

It is our role as optometrists to use our clinical expertise in partnership with our patients to decide which intervention is most appropriate. Going back to our original discussion about blepharitis, for some that may be lid cleaning products and for others that may be traditional lid hygiene. It would be interesting to consider what proportion of our patients would choose either option, when presented with all the information to make an informed choice in relation to convenience, cost and clinical effectiveness. The college leaflet on blepharitis lists both options, giving the practitioner the professional freedom to use their clinical expertise to make either recommendation, accordingly enabling our patients to make an informed decision.

The new College CMG on blepharitis gives you the latest research evidence to draw upon. How will you use it to influence your clinical expertise and empower your patient to make a truly informed decision?

Useful link:

Interventions for chronic blepharitis (Cochrane Library, Lindsley et al, published 16 May 2012).

Daniel Hardiman-McCartney MCOptom
Clinical Adviser, College of Optometrists

Daniel graduated from Anglia Ruskin University, where he won the Haag Strait prize for best dissertation. Before joining the College, he was Managing Director of an independent practice in Cambridge and a visiting clinician at Anglia Ruskin University. He has also worked as a senior glaucoma optometrist with Addenbrooke’s Hospital in Cambridge and as a diabetic retinopathy screening optometrist. Daniel was a member of Cambridgeshire LOC from 2007 to 2015 and a member of the College of Optometrists Council, representing its Eastern region, from 2009 to 2014.  

Daniel has an interest in the effects of vision in art and is known throughout the industry as a passionate advocate of iconic and artisan eyewear. He currently practises part time in independent practice, is a locum, a glaucoma specialist optometrist across East Anglia with Newmedica and is clinical adviser to the College of Optometrists.

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