Trusted evidence for eye health decisions

Trusted evidence.
Informed decisions.
Better health.
Meeting or Conference
Location
Date
Cochrane &
Cochrane Eyes and Vision

Cochrane’s central functions are funded by royalties from its
publishers, John Wiley and Sons Limited, which come from
the sales of subscriptions to The Cochrane Library.
The individual entities of Cochrane, such as Centers and Review
Groups, are funded by a large variety of governmental, institutional
and private funding sources and are bound by organization-wide
policy limiting uses of funds from corporate sponsors.
Funding and support for CEV
National Eye Institute - United States
National Health Service (NHS) Research and
Development Programme - UK

Table of Contents for Slide Set
Section Topic Slide numbers
A Introduction to Cochrane 4-11
B Introduction to Cochrane Eyes and Vision 12-31
C Elements to a Cochrane Review 32-40
D Roadmap to Completing a Cochrane Review 41-75
E Example of a Cochrane Eyes and Vision
Review
76-82
F Cochrane Tools 83-91
G CEV@US Research Projects 92-102

Cochrane : A little background
Cochrane’s vision: a world of improved health where
decisions about health and health care are informed by
high-quality, relevant, and up-to-date synthesized research
evidence
Cochrane’s mission: to promote evidence informed health
decision-making by producing high-quality, relevant,
accessible systematic reviews and other synthesized
research evidence

Why “Cochrane”?
Archibald Leman Cochrane
(1909-1988)
"It is surely a great criticism of our
profession that we have not
organised a critical summary, by
specialty or subspecialty, adapted
periodically, of all relevant
randomised controlled trials.”
 His challenge led to the establishment
during the 1980s of an international
collaboration to develop the Oxford
Database of Perinatal Trials.
 Inspired the first Ophthalmic
epidemiological study – the Ferndale
Glaucoma Study in the Rhondda
Valley, Wales

What is a Systematic Review?
A review of existing knowledge that uses explicit, scientific methods
• Structured and transparent process
• Comprehensive search for relevant articles
• Explicit methods of appraisal and synthesis
Synthesizes methods and results of similar but separate studies
May or may not combine results quantitatively (meta-analysis)

Types of Review Articles
All reviews
Systematic
reviews with
meta-analyses
Individual patient
data (IPD) meta-
analyses
Pai M, McCulloch M, Gorman JD, et al. Systematic reviews and meta-analyses: An illustrated, step-by-step guide. Natl Med J India 2004;17(2):86-95.
Systematic
reviews
Reviews that are not
systematic (traditional,
narrative reviews)

Central Editorial Unit
Editorial Board
Cochrane Central Executive

Cochrane is a not-for-profit international network of 37,000 contributors
from over 130 countries.
Over 70% of these people are authors of Cochrane Reviews.
The number of contributors has increased by about 20% each year for the
last five years
The increase in the number of contributors from low, lower-middle and
upper-middle income countries has been even greater, increasing by
42% since 2013.
(http://www.community.Cochrane.org, accessed May, 2015)

World map showing locations of all Cochrane Centers (blue) and
Branches (red)
(http://www.community.Cochrane.org, accessed May, 2015)

“The Cochrane Collaboration is an enterprise
that rivals the Human Genome Project in its
potential implications for modern medicine”
-- CD Naylor. The Lancet, April 1995
The Cochrane Library Impact factor was 6.035 in 2014

Cochrane Eyes and Vision
Cochrane Eyes and Vision (CEV) is an
international network of individuals working to
prepare, maintain and promote access to
systematic reviews of interventions to treat or
prevent eye diseases or visual impairment.
http://eyes.cochrane.org/

CEV is one of 53 Cochrane Review Groups
and has an editorial base and 2 satellites
CEV-UK Editorial
Base:
London School of
Hygiene and Tropical
Medicine,
International Centre
for Eye Health
Diagnostic Test
Accuracy
Satellite:
University of
Florence, Italy
CEV-US
Satellite:
Johns Hopkins
Bloomberg
School of Public
Health, Baltimore,
Maryland
Who we are

Richard Wormald
Coordinating Editor
Iris Gordon
Trials Search Coordinator
Anupa Shah
Managing Editor
Jennifer Evans
Deputy Coordinating Editor
CEV Editorial Base

CEV US Satellite – Baltimore, Maryland (CEV@US)
Kay Dickersin, PhD, MA Principal Investigator
Kristina Lindsley, MS Project Director
Roberta Scherer, PhD Co-Investigator & Handsearching Unit Director
Tianjing Li, MD, PhD Co-Investigator
Barbara Hawkins, PhD Co-Investigator
Ian Saldanha, MD, PhD Co-Investigator
Sonal Singh, MD Co-Investigator
Andrew Hua Law, MHS Methodologist
Elizabeth Clearfield, MHS Methodologist
Nan Zhang, MHS Methodologist
Sueko Ng, MHS Methodologist
Lori Rosman, MLS, AHIP
Claire Twose, MLIS
Reva Datar, MPH
Informationist
Informationist
Coordinator

CEV@US serves as a methodological “hub” to train and assist
content experts and consumers with methodology of
systematic reviews, Review Manager (RevMan), searching
for studies, screening titles and abstracts, data abstraction,
and write-up and publication.

CEV@US is funded by the National Eye Institute,
National Institutes of Health, US

• Expand awareness of evidence-based health care
• Develop a critical mass of vision researchers who are able to
perform and interpret systematic reviews, and train others to do
the same
• Develop a critical mass of clinicians who use the results of
systematic reviews as an evidence base to guide their practice
and to train others to do the same
• Generate an increased number of systematic reviews in priority
vision research areas, published in The Cochrane Library and in
the traditional vision research literature
Aims of CEV@US

In-person workshops:
1. Developing a Cochrane Systematic Review
Takes place twice a year in Baltimore, Maryland
• Purpose: To guide participants through the steps of developing a
systematic review
• Target Audience: Cochrane review authors
• Includes: Presentations about Cochrane methodology & hands-on
practice using the Cochrane Collaboration’s RevMan software
2. Evidence-based Ophthalmology
Takes place as requested
• Purpose: To teach participants how to find, appraise and apply the best
research evidence to clinical practice
• Target Audience: Ophthalmologists
• Includes: a mix of both didactic and small group sessions; small groups
provide experience using specific patient cases as a basis for
evaluating research evidence for clinical care

1. Understanding Evidence-based Healthcare
Course Developers: Kay Dickersin, MA, PhD and Musa Mayer, MS,
MFA
Designed to help consumer advocates understand the fundamentals
of evidence-based healthcare concepts and skills. A complementary
course adapted for clinicians with Steve Goodman, MD, PhD
2. Translating Critical Appraisal for a Manuscript into Meaningful Peer Review
An acclaimed team of Cochrane scientists and clinicians with research interests in
evidence-based healthcare have developed an online course on journal peer review of the
biomedical literature.
3. Cochrane Handsearching Training Course
Course Developer: Roberta Scherer, PhD
This short distance education course will prepare participants for
manually screening peer-reviewed biomedical journals, conference
proceedings, and other publications for the best-available evidence.
Online training:

US Contributors’ meeting
at the 2014 Cochrane
Colloquium
Doctoral student Ian
Saldanha wins ‘Best Oral
Presentation’ award
CEV members check out
the sights in Hyderabad,
India in September 2014
Cochrane Colloquium:
• Methodological workshops and training
• Dissemination of research
• Networking opportunities

Systematic Reviews in Eyes and Vision
“The ultimate goal of Cochrane reviews is to
organize medical research information in a
systematic way that allows end-users to reach
practical conclusions in the interests of
evidence-based medicine”
Allen C, Richmond K. The Cochrane Collaboration: international activity within Cochrane Review Groups in
the first decade of the twenty-first century. J Evid Based Med 2011, 4:2-7.

• We aim to prepare, maintain and promote access to systematic reviews of
all the interventions used to prevent, treat, or diagnose eye diseases
and/or visual impairment.
• Our reviews focus on randomized or quasi-randomized controlled trials
and provide descriptive syntheses where such data are lacking.
• The main outcome for our reviews is visual function, which can be
assessed in a variety of ways including measurement of visual acuity,
assessment of visual field, and assessment of vision related quality of life.
• Other outcomes are included as necessary within individual reviews.
Scope of CEV Systematic Reviews

Glaucoma
14%
Corneal Diseases
10%
Retinal
Degeneration
13%
Retinal Diseases
10%Lens Diseases
8%
Ocular Motility
Diseases
7%
Other*
38%
CEV REVIEWS BY SUBTOPIC
*Other:
• Coexisting Eye
disease
• Conjunctival Diseases
• Eye Haemorrhage
• Eye injuries
• Eye neoplasms
• Eyelid Diseases
• Lacrimal apparatus
diseases
• Optic nerve diseases
• Orbital diseases
• Refractive errors
• Rehabilitation
• Retinal vascular
occlusion
• Uveal and choroid
diseases
Accessed: July 12, 2015 at http://eyes.cochrane.org/our-reviews

A recent study found that CEV reviews “allow, in
approximately half of the cases, the reader to reach a
clinically applicable conclusion.”
…. But how do we improve this?
For ophthalmologic studies, “larger total number of
participants, total number of eyes studied, and number
of rigorous RCTs performed all can improve the
conclusiveness of review findings.”
CEV encourages researchers in the field to conduct
more clinical trials using high-quality research
methods that will yield reliable, trustworthy results.
Mimouni M, Mimouni F, Segev Fani. Conclusiveness of the Cochrane Eye and Vision Group Reviews. BMC
Research Notes 2015, 8:242.

Application and Impact of CEV Reviews
"The commissioners were most
persuaded by the recent
independent Cochrane review of
the evidence for the two drugs,
which said Lucentis was not
superior….That was a Cochrane
review, independent of everything
else, concluding that Avastin is of
comparable efficacy and safety.
From our point of view, that is
good enough.”
-- Julie Wood, NHS Clinical
Commissioners
Published: May 17th, 2015

Accessing CEV Reviews in the Cochrane Library

Recent Publications (2016):
Over the counter (OTC) artificial tear drops for dry eye
syndrome
Pucker AD, Ng SM, Nichols JJ. (February 2016)
Authors’ conclusions:
OTC artificial tears may be safe and effective means for
treating dry eye syndrome; the literature indicates that the
majority of OTC artificial tears may have similar efficacies.
This conclusion could be greatly skewed by the
inconsistencies in study designs and inconsistencies in
reporting trial results. Additional research is therefore needed
before we can draw robust conclusions about the
effectiveness of individual OTC artificial tear formulations.

Peripheral iridotomy for pigmentary glaucoma
Michelessi M, Lindsley K. (February 2016)
Authors’ conclusions:
We found insufficient evidence of high quality on the
effectiveness of peripheral iridotomy for pigmentary glaucoma
or pigment dispersion syndrome. Although adverse events
associated with peripheral iridotomy may be minimal, the
long-term effects on visual function and other patient-
important outcomes have not been established. Future
research on this topic should focus on outcomes that are
important to patients and the optimal timing of treatment in the
disease process (eg, pigment dispersion syndrome with
normal IOP, pigment dispersion syndrome with established
ocular hypertension, pigmentary glaucoma).

Elements of a Cochrane Review
Why Publish a Cochrane Review?
 Identify targeted areas where evidence is needed to answer important, as yet
unresolved clinical questions (e.g., for CEV, authors focus on eyes and vision
research)
 Explore variations in practice
 Highlight a need for further research
 Help patients/consumers and clinicians make well-informed decisions about
healthcare

Sections of a Cochrane Review
1. Abstract
2. Plain Language Summary
3. Background
4. Objective
5. Methods
 Formulation of a focused research question (PICO)
 Definition of inclusion and exclusion criteria
 Description of a comprehensive, exhaustive search for evidence
 Assessment of potentially eligible studies for eligibility
 Data collection and synthesis
6. Results
 Qualitative assessment: how study characteristics and bias may influence
findings and interpretation
 Quantitative assessment: data abstraction and synthesis of study results;
sensitivity analysis
7. Discussion
8. Authors’ conclusions
9. References
10. Tables of characteristics of studies and summary of findings
11. Figures of data and analysis

What the background section addresses
• What is the problem and why is it important?
• Why do people think the intervention might work?
• Is there uncertainty about the effectiveness of the
intervention(s) being tested?
• Why is this review important?
Background

Focused Research Question
Translation of clinical problem into a structured
question and identification of the key concepts (PICO)
Inclusion and exclusion criteria of the systematic
review should specify the following:
• Type of studies
• Type of participants
• Type of interventions and comparisons
• Type of outcomes

Assessment of Potentially Eligible Studies
• A two-stage process often is used to access studies for
the review
–Screening of titles and abstracts to identify possibly
relevant studies (by 2 people, independently)
–Full reports of these studies are read to determine
eligibility (by 2 people, independently)
• Study authors are contacted when questions about
eligibility exist (e.g., studies not yet published)

Data Collection
• Which data were extracted and by whom?
–Develop and pilot data extraction forms
–Extract data by 2 extractors, independently
–Contact study authors when data are unclear or not reported
• Who, what, and how were data entered into a software
package?
–Double data entry: 2 people enter the data into a database
to avoid bias and errors
–Data entry verification: 1 person enters data into the
software and a 2nd person verifies the data entered after
duplicate data extraction and adjudication

Qualitative Synthesis of Included Studies
Context of the evidence
• What are the differences in study characteristics among
the studies? How might study characteristics affect the
results?
• Are studies at risk of bias? How might potential bias affect
our confidence in the results?
• Is heterogeneity assessed? Is it appropriate to combine
the studies in a meta-analysis?

Quantitative Synthesis of Included Studies
Meta-analysis
• Statistical pooling of study results to obtain a single
summary estimate of treatment effect
Meta-analysis is appropriate when …
• Study outcomes and treatment effects have been
measured in similar ways, and
• Heterogeneity (clinical, methodological, and statistical)
is considered within limited of acceptability

Discussion and Conclusions
Discussion
• Summary of main results
• Overall completeness and applicability of the evidence
• Quality of the evidence
• Potential biases in the review process
• Agreements and disagreements with other studies or reviews
Conclusions
• Implications for practice
• Implications for research

Interactive Roadmap
to completing a
Cochrane systematic review
Updated 7 August 2015

Welcome to CEV
This interactive roadmap provides a step by step
reference for completing a review with CEV.
Our editorial team is available to assist authors at every
stage of the review process. Ms. Anupa Shah, the CEV
Managing Editor, maintains communication between the
editorial team, authors, and other group members.
Members in the United States are additionally supported
by our satellite team, the CEV US Satellite (CEV@US).
There also is a CEV DTA Satellite, which provides editorial
and methodological support for systematic reviews of
diagnostic test accuracy (DTA).

The Cochrane Systematic Review
Process
 Review proposal
 Title registration
 Protocol preparation
 Editorial and peer review of the protocol
 Publication of the protocol
 Systematic review preparation
 Editorial and peer review of the systematic review
 Publication of the systematic review
 Updating the systematic review

Preparing to do a Cochrane Review
Things to consider before undertaking a Cochrane review:
Time: It takes about 18 months to complete the steps in the systematic
review process.
Topic: Consider what area interests you and what question you would like
to answer. Check current reviews and consult with CEV to ensure that your
topic is not already registered.
We recommend familiarizing yourself with The Cochrane Handbook for
Systematic Reviews of Interventions (updated March 2011)

Timeline for Cochrane Reviews
Protocol
Submission
Protocol Publication
Review Submission
Review Publication
6-8 weeks 9-12 months 15-18 months

CEV Timeline
55
68
41
39.1
183
132
84
39.3
45
33
36
38.7
0 50 100 150 200 250 300
15 or more Studies (n=4)
5-7 Included Studies (n=5)
Time (weeks)
PublishedCEVReviews(n)Grouped
byNumberofIncludedStudies
Average Timelines of Published CEV Reviews (N=25)
Time from protocol submission to protocol publication Time from protocol publication to review submission
Time from review submission to review publication

Topics for Cochrane Reviews
• Cochrane reviews focus on evidence from randomized
controlled trials (RCTs) and quasi-randomized controlled
trials (CCTs)
• Begin by creating a PICO outline for your topic.
P :
I :
C :
O :
Participants (include population/condition of interest)
Intervention(s) of interest
Comparison(s) of interest (e.g., placebo)
Outcome(s) of interest (e.g., visual acuity at 12 months)

Building Your Review Team
Co-authors: At least one co-author is needed to assist with the
review. The co-author duplicates the main steps of the review
process. All authors are expected to contribute to the review.
Statistician: It is mandatory that the review team have a statistician
as a co-author.
• There must be at least one person on the review team with:
• Content expertise
• Methodological expertise
• Statistical expertise
• CEV can assist with identifying co-authors if needed

Review Proposal Process
Once you have decided on a review topic, you should contact Ms.
Anupa Shah with your interest in initiating a Cochrane review.
If your topic is approved, you will be asked to complete a Review
Proposal Form. Note that there are two Review Proposal Forms, one for
reviews of Treatment Interventions and one for reviews of Diagnostic
Test Accuracy (DTA).
We recommend consulting Chapters 4 and 5 of the Cochrane
Handbook.
The CEV editorial team will review your proposal and either
approve your proposed review topic, respond with
comments, or reject your proposal with reasons.

Title Registration
Once your title is approved by the CEV editors, we will register your title in
Archie. Archie is Cochrane’s central server and review management system.
CEV will set up an Archie user account for all review authors. The Archie
server will send a welcome email with further instructions on activating your
user account. There also is a Quick start guide to Archie for authors.
All authors must activate their Archie account in order to access and edit their
protocol, update contact information, and submit publication forms. Your
Archie account gives you access to your Review Manager (RevMan) file of
the protocol template. RevMan is the software used by Cochrane to prepare
systematic reviews.

Key Deadlines
A first draft of a protocol should be submitted to the editorial
base by three months after title registration; the protocol
should be published within six months of title registration.
The completed systematic review should be submitted
within 12 months and published within 18 months of the
protocol being published.
It may be helpful to complete the
Cochrane Online Learning Modules for Authors
before undertaking the review process

Protocol Preparation
 We strongly recommend downloading RevMan and
completing the tutorial before you begin work on your
protocol.
 You may access your RevMan file via Archie or RevMan;
however, all editing is done in RevMan. The process of
retrieving, editing, and saving your protocol is explained in
the RevMan tutorial.

Protocol Preparation
 To access your protocol:
 In RevMan, select the option “Check out” from the File
menu or “Go to My Reviews” from the Welcome window.
 In Archie, navigate to the Eyes and Vision Group folder,
click on the subfolder “Reviews” and then look for your
file in the folder “Registered titles” (first time) or
“Protocols”.
 Each time you make a change to your RevMan file, you
should “check it in” to Archie so that the draft is saved on
our central server. This process is explained in the RevMan
tutorial.

Things to Consider While Drafting
Your Protocol
General background information
Description of the condition
Description of the intervention
How the intervention might work
Why is it important to do this review
These items are described in Chapter 4.5 of the Cochrane
Handbook. Also feel free to consult our website for additional
review author resources.

Submitting Your Protocol
• All protocols must be submitted to CEV editors using RevMan. When
you “check in” your protocol, RevMan will offer the additional option of
submitting it for editorial approval.
• Steps in the authoring and editorial processes are tracked using the
Workflows system in Archie. The contact author of the protocol will
receive a Workflow “ticket” (via email) describing the task needed and
the due date to complete the task. When done, the contact author can
click the link in the email to mark the task as done.
Authors and editors can view tasks assigned to them by
logging into Archie and clicking on the Organizer tab.

Editorial and Peer Review of the
Protocol
All Cochrane protocols undergo a multi-step editorial process
1. CEV methodologists and advisors will review your protocol and
may respond with initial comments or forward to the contact
editor.
2. CEV contact editors will review the clinical content of the
protocol and either respond with comments or approve for peer
review.
3. Your protocol will be sent out for external peer review.
4. CEV methodologists and advisors will review your revised
protocol and may respond with additional comments or send to
the Coordinating Editor for approval.

Protocol (continued)
5. The CEV Coordinating Editor will review your protocol and may
respond with comments or approve the protocol for publication.
6. Your protocol will be copy-edited and sent to you for final
approval.
7. Your approved protocol will be submitted for publication in the
Cochrane Library

Publication of the Protocol
Shortly after your protocol is accepted for publication, the
CEV Trials Search Coordinator will run the searches and
send you the search results (a list of titles and abstracts) in
a text file, a reference management file (e.g., EndNote), or
upload the search results to Covidence.
Your protocol file will be saved in Archie and will be used as
the starting point when you begin preparing your review.

Systematic Review Preparation
Two authors independently screen the titles and abstracts
from the search results and classify each record as 1)
definitely relevant, 2) possibly relevant, or 3) definitely not
relevant
Authors should retrieve and independently review the full-text
report of all records designated “definitely relevant” or
“possibly relevant” to select a final list of “included studies”

Screening and Selection of Studies
Walline et al, The Cochrane Library 2011

Remember to document reasons for excluding studies from
your review. You will need to enter this information in
RevMan’s Characteristics of Excluded Studies Table.
The CEV editorial team can assist with retrieving full text
articles if needed
Consult Chapter 7 of the Cochrane Handbook for guidance

Check the bibliographies of included studies, conference
proceedings, and the Science Citation Index for other RCTs
and CCTs relevant to your review. Document where you
found any additional references.
Prepare forms for data extraction and risk of bias
assessments. You also will use this information to complete
the Characteristics of Included Studies Table

CEV provides authors with assistance from methodologists
(epidemiologists, statisticians) and informationists (trials
search coordinators)
Methodologists advise and collaborate with researchers
during the preparation of their systematic review

Methodology “Hubs” at CEV@US:
 Provide methodological and administrative assistance to US-
based systematic review authors (“help desk”, office space)
 Coordinate editorial process for CEV@US systematic
reviews (in collaboration with the editorial base)
 Train ophthalmologists, optometrists, other vision
researchers to perform and interpret systematic reviews
o 152 US-based researchers from over 45 US institutions

CEV@US will pair you with a trained methodologist to
assist with the following procedures:
 Two authors independently screen the titles and abstracts
and classify each reference as either:
 Include
 Unsure
 Exclude
 Authors should review the full text of all references
designated “include” or “unsure” to select a final list of
“included studies”
 CEV methodologists also help authors develop and modify data
abstraction forms as appropriate.

 Handsearch journals and conference proceedings for
reports of clinical trials
 Conduct workshops on evidence-based healthcare, peer
review, and handsearching
 Identify new review authors
• CEV Centers for Evidence-based Medicine
–Wilmer Eye Institute (35+ review authors)
–Truhlsen Eye Institute, University of Nebraska
• Advisory Board
 Perform methodological research

Data Extraction and Risk of Bias
Assessments
At least two authors should independently
Assess the risk of bias of the included studies and complete a
Risk of Bias Table for each study
Extract relevant design, conduct, and analysis characteristics
and complete a Characteristics of Included Studies Table for
each study
Extract outcome data (e.g., visual acuity, intraocular pressure)

Data Extraction and Risk of Bias
Assessments
 Contact the authors of included studies for missing or
unclear information
 Resolve disagreements by consensus or with a third
party
 Enter above data into corresponding tables in RevMan
 Consult Chapters 7 and 8 of the Cochrane Handbook
for additional guidance

Data Analysis
 Select the appropriate measure of effect for each
outcome (e.g., dichotomous, continuous)
 Test for heterogeneity
 Perform subgroup analyses if appropriate
 Test for publication bias
 Conduct sensitivity analyses
 Consult Chapters 9 and 10 of the Cochrane Handbook for
additional guidance

Things to Consider While Drafting
Your Systematic Review
Confirm that the review methods are consistent with the published protocol.
Discuss deviations from the protocol with your co-authors and the CEV
editorial team before submitting the review for publication.
Confirm that all required sections of the review are complete:
 Main text: Remember to update verbs from future to past tense where
appropriate (e.g., change protocol text “We will search MEDLINE” to “We
searched MEDLINE”)
 References: Included studies, excluded studies, studies awaiting
assessment, other references
 Tables and figures: Including data tables, risk of bias tables, characteristics
of included and excluded studies tables

Submitting Your Systematic Review
•Before you submit your review, you will need to check that
your review meets the methodological and reporting
standards of Cochrane reviews. Checklists for the
Methodological Expectations of Cochrane Intervention
Reviews (MECIR) are available here. Please note that
there are separate checklists for the conduct of reviews,
reporting of reviews, and the writing of the Plain Language
Summary.
•As with protocols, full reviews must be submitted to CEV
editors using RevMan. When you “check in” your review,
RevMan will offer the additional option of submitting it for
editorial approval.

Systematic Review
The editorial review process for full reviews is
similar to the editorial review process for protocols.
Additionally,
•All reviews will undergo a pre-publication screening
following guidance from the Cochrane Editorial Unit
to ensure the quality of the review.
•The literature searches may need to be updated
prior to publication if the searches are out of date.

Publication of the Systematic Review
Congratulations!
You have completed a Cochrane Review
Your review will be submitted for publication
in the Cochrane Library

Updating the Review
• Once your review is published you will receive a free
subscription to the Cochrane Library
• Your review will be indexed on MEDLINE
• You also may choose to submit your review to another peer
reviewed journal. Please consult Chapter 2 of the Cochrane
Handbook for guidance on co-publication
• You will need to update your review based on post-
publication comments or as new data become available
• The CEV editorial team will send you updated search
results every year for your consideration
• You should plan on updating your review every two years

Now let’s take a look at an
example of a CEV Systematic
Review…

Characteristics of Included Studies

Risk of bias assessment
Methodological quality of
studies included in review
 Random sequence
 Allocation concealment
 Masking of participants
 Masking of outcome assessors
 Masking of data analysts
 Incomplete outcome data
 Selective reporting
 Other bias

Walline et al, The Cochrane Library 2011
Anti-muscarinic agents vs. placebo

Cochrane Tools
Tools and Resources for:
• Review authors
• Handsearchers
• Healthcare users
• Patients/Consumers

Online Cochrane Resources
 Website – www.cochrane.org
• 2 Handbooks:
– Reviews of interventions
– Reviews of diagnostic test accuracy
• RevMan – review authoring software
• Archie – review management database
• Online Learning Modules – training.cochrane.org
• Cochrane Register of Studies
– Specialized registers of individual review groups

Cochrane Tools: Handbook
Higgins, J. P. T., and Green, S. (Eds.). Cochrane handbook for
systematic reviews of interventions version 5.1.0 [updated March
2011]. The Cochrane Collaboration. Available from
www.cochrane-handbook.org

Cochrane Tools: RevMan
 Review Manager (RevMan)
 Mandatory software for writing
and publishing your review
 Available from
http://ims.Cochrane.org/revman
 Free for Cochrane authors
and academic use

Cochrane Tools: Archie
Cochrane’s central database
 Stores all reviews and author contact information
 The Cochrane Library is published directly from
Archie
 Use RevMan to access reviews in Archie
 Requires a user account and password from a
Cochrane Review Group

Cochrane Tools: Review Management
Via Cochrane Training: http://www.slideshare.net/mirandacumpston/12-introduction-to-rev-
man-v10 Accessed on 23 August, 2015

Cochrane Tools: Training
CEV offers two Systematic Review training
workshops each year
Free online courses:
Translating Critical
Appraisal of a
Manuscript into
Meaningful Peer Review
Understanding Evidence-
based Healthcare for
Physicians
Handsearching:
Identifying and
Classifying Controlled
Trial Reports
Understanding Evidence-
based Healthcare: A
Foundation for Action

Web-based course on Peer Review – Launched May 2011
Module 1. Introduction to editorial peer review
 Lec 1. Peer review: What, why, who, and how - Fiona Godlee
 Lec 2. What journal editors expect from peer reviewers - Tom Liesegang
Module 2. How to critically appraise the literature
 Lec 1. What is the study question? - David Friedman
 Lec 2. What is the study design and is it appropriate for the study
question? - Ann Coleman
 Lec 3. Measures of disease frequency, measures of association, and
hypothesis testing - Marie Diener-West
Appraising validity in:
 Lec 4. Studies of intervention effectiveness - Karla Zadnik
 Lec 5. Systematic reviews - Donald Minckler
 Lec 6. Studies of harm - Ann Ervin
 Lec 7. Studies of prognosis - Richard Wormald
 Lec 8. Studies of diagnostic test accuracy and effectiveness- Milo Puhan
 Lec 9. How should we assess claims of causality? - Joanne Katz

Getting Involved with CEV
• Prepare a systematic review
• Peer review our systematic reviews
• Handsearch journals and conference proceedings
• Translate articles into English
• Become a CEV Center for Evidence-based Medicine
• Join our e-mail listserv (visit our homepage)
• Join a Special Interest Group in The Association for
Research in Vision and Ophthalmology (ARVO)
• Join a workshop for guidelines panel members at American
Academy of Ophthalmology (AAO) and the Association of
Vision Science Librarians (AVSL)

What’s new at CEV@US
Current CEV@US
Research Projects

CEV Partnerships
Professional societies
 American Academy of Ophthalmology
 American Academy of Optometry
 American Glaucoma Society, and others
Research groups
 Diabetic Retinopathy Clinical Research Network (DRCRNet)
 Pediatric Investigative Group (PedIG)
 CEV Centers for Evidence-based Medicine (Wilmer, Truhlsen)
Journals
 CEV systematic review editors at American Journal of Ophthalmology,
JAMA Ophthalmology, Ophthalmology, Optometry and Vision Science
 CEV online peer review course acknowledged by American Journal of
Ophthalmology, BMC Ophthalmology, Ophthalmology

Evidence Gap Project (E-Gap)
CEV@US is examining the evidence underpinning clinical
practice guidelines, and together with professional societies
and patients, are prioritizing the systematic reviews that are
needed:
 Primary open angle glaucoma (Tianjing Li) – completed
 Primary angle closure glaucoma (Tsung Yu) – completed
 Age-related macular degeneration (Kristina Lindsley) – in progress
 Diabetic retinopathy (Kay Dickersin, Jimmy Le) – in progress
 Dry eye syndrome (Ian Saldanha) – in progress
 Cataract (Asieh Golozar) – in progress
 + 12 others

E-Gap: What Evidence Is Needed?
1. Extract recommendations and supporting evidence from the American
Academy of Ophthalmology’s Preferred Practice Patterns (PPP)
2. Transform the recommendations into answerable clinical questions
3. Identify professional organizations and patient groups as partners
4. Conduct surveys asking professional partners to prioritize the questions
to be answered by research
5. Conduct focus groups or survey patients to prioritize and name patient-
important outcomes
6. Map highest ranked priority questions to high quality systematic review
evidence to determine what new evidence is needed

Database of Systematic Reviews in
Eyes and Vision
Aim To identify and assess the quality of systematic reviews in
eyes and vision
Completed
Tasks
1. Searched PubMed, EMBASE, and The Cochrane Library
for systematic reviews in May 2014
2. Identified and classified over 1,500 systematic reviews in
eyes and vision
3. Updated searches in March 2016
In Progress 1. Assess eligibility and classify topic area of records
identified from updated searches
2. Describe the quality of systematic reviews
3. Map high quality systematic reviews to research questions

Network Meta-Analysis
Medical Interventions for Primary Open Angle
Glaucoma (POAG)
 To synthesize direct and indirect evidence from over 500 RCTs
that evaluated 5 classes of eye drops used to lower eye pressure
in patients with POAG
 Funded by the National Eye Institute (PI: Kay Dickersin)
 Collaboration with Brown/Tufts Evidence-based Practice Center to
use the Systematic Review Data Repository (SRDR) for data
collection (14 data abstractors, including CEV methodologists,
faculty, and graduate research assistants)

Progress:
• Completed data abstraction and analysis of
monotherapy interventions
• Published 2 papers
Next steps:
• Complete data analysis for combination therapies
• Publish two CEV reviews using data from this project
• Prepare at least one clinical paper and two methods
papers outside of Cochrane
Medical Interventions for Primary Open Angle
Glaucoma

Application of Network Meta-Analysis for
Clinical Practice Guidelines
Objective: to compare the guideline recommendations in the
American of Ophthalmology’s (AAO) Preferred Practice
Patterns (PPP) for open angle glaucoma from 1989-2010 with
the evidence base determined by network meta-analysis at the
time of each major update of the PPP. [paper in press]

CompARE Project
Comparison of Abstract Reports as Evidence
Background
• Conference abstracts not peer-reviewed
• Not all abstracts get published (45%-60%) (Scherer 2007,
Klassen 2002)
• Concern about data accuracy, consistency with published
reports

Objectives
 Assess concordance of data between conference abstracts and full-
publications of RCTs
 Assess factors associated with discrepancies
 Assess how reliable conference abstracts are for systematic reviewers
Methods
 Identify abstracts from ARVO 2002-2004
 Identify corresponding published reports (through 2010)
 Extract data on funding, author conflicts of interest, study characteristics, risk
of bias, primary outcomes, results for primary outcomes, conclusions – for
both abstracts (completed) and published reports (in process).
 Compare and analyze discrepancies
CompARE Project

Other CEV Methods Research Projects
 Registration of eye trials (Bobbi Scherer, PLoS One 2012)
 Agreement between primary outcomes in conference abstracts and
CT.gov (Bobbi Scherer)
 Investigation and follow-up of eye trials on CT.gov (Stephan Ehrhardt)
 Design, Analysis, and Reporting of Crossover Trials for Inclusion in a
Meta-Analysis (Tianjing Li, Tsung Yu, Barbara S Hawkins, Kay
Dickersin)
 Common outcomes used in trials versus systematic reviews (Ian
Saldanha)
 Wasted data in RCTs of medical treatment for glaucoma (Andrew Law)
 Patient-important outcomes in minimally invasive glaucoma surgery
(MIGS) (Jimmy Le)

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