To the Editor:
As a member of the Wilderness Medical Society (WMS) for many years and a supporter of evidence-based medicine, I appreciate the effort that the WMS has made to develop practice guidelines regarding different aspects of wilderness medicine. Recently, I was reading the guideline for eye injuries and illnesses. 1 Although the attempt at making this guideline conform to the American College of Chest Physicians (ACCP) Grading Recommendations is admirable, I believe the authors may have gone too far with their recommendations in most cases when many of the recommendations may be expert opinions that hold little evidence to support them.
The authors state the “data … are sparse … therefore we evaluated the data regarding eye injuries and illness … and adapted these to the wilderness setting” and “evidence … is limited to case reports and extrapolation of clinical and hospital care.” Because of the scarce evidence for many of these illnesses or injuries in wilderness settings, I argue that several of these recommendations should be downgraded. Further, evaluating evidence from the nonwilderness setting and adapting them to the wilderness decreases the certainty of the treatment within this setting. I, however, do not know whether the existing ACCP recommendations can sufficiently handle the complexity of the wilderness medicine guidelines with the paucity of evidence for these conditions in this setting.
Should wilderness practitioners abide by any grade 1 recommendation in these guidelines? There is not enough room to express the appropriate uncertainty with these recommendations; they do not offer an “insufficient evidence” or even an “expert opinion” for any grade or description. The strength of recommendation taxonomy (SORT) might be considered as an alternative grading system 2 in the future as it can further differentiate the strength of the evidence and the recommendations and it has more flexibility within its system to work within the wilderness medicine field.
There are several other concerns with this guideline I would like to bring to the attention of the authors. The first issue regarding this guideline is the inclusion of treatments that cannot be done in the wilderness setting. Two specific examples follow. Under central retinal artery occlusion (CRAO), the authors discuss counterpulsation, which is unavailable in the field. Why would it be discussed? Pentoxifylline is an option if available, but counterpulsation is not. The second example is the recommendation of surgical management of acute angle-closure glaucoma as grade 1A. Again, this is not an available field option, so why would it be mentioned? I would think the authors could make a stronger recommendation for emergent evacuation for definitive treatment (ie, surgery) rather than have a treatment option that cannot be done in the wilderness setting.
In the central retinal vein occlusion section, the article states “although the treatments … are complicated … it is nevertheless reasonable to start … with topical steroids.” The authors did not reference any studies to support this. Without even referencing a case report, I would think this is likely expert opinion, and without any studies I would propose this would be very weak evidence on the ACCP system (2C). Although topical steroid drops are unlikely to harm anyone, the risk-benefit analysis cannot be judged in this instance without any studies as there is surely some possible harm from topical steroids such as allergies, irritation, or pain.
In their discussion of conjunctivitis, I would disagree with the 1A recommendation for systemic antibiotics. I would argue that the recommendation should be “do not give systemic antibiotics unless Trachoma present: 1A.” Single dose azithromycin has been shown to be effective for trachoma. 3 As the WMS guideline states, conjunctivitis is self-limited, and systemic antibiotics would be a waste of a potentially valuable wilderness resource, and could potentially cause significant harm through Clostridium difficile colitis, antibiotic-induced diarrhea, rash, or anaphylaxis, not to mention future long-term concerns for resistance. Further, there is some evidence suggesting that some antibiotics may increase the mortality rate. 4 I believe the harms do outweigh the benefits on this recommendation and hence my choice for 1A recommendation against systemic antibiotics for conjunctivitis unless trachoma is present.
Regarding orbital fractures, the bulleted recommendation should read “Avoid nose blowing”; the word avoid is missing and if someone just read the recommendations, they would recommend nose blowing, which is recommended against in the guidelines.
Under corneal abrasion, the review of cycloplegics, the review cited used combination nonsteroidal anti-inflammatory drugs and cycloplegics; however, the review did not look at cycloplegics alone. There is some evidence that suggests cycloplegics alone do not help for pain control. 5 From this citation, cycloplegics have no role in the treatment of corneal abrasions, although the Cochrane group will undoubtedly be looking at this issue in the future.
Regarding corneal frostbite, as there are case reports (not even case series), I again would not say 1C would be appropriate. 1C is a strong recommendation; however, I cannot see how this could be a strong recommendation as there is not sufficient strength in the methodology of the studies. I agree there may be little harm, but I cannot agree that there are benefits as there is not enough evidence to support a recommendation as there have been too few cases treated. Again the ACCP grading system fails the WMS practice guidelines.
I do encourage the authors of this and other wilderness guidelines to make them available in the National Guideline Clearinghouse (