The potential harmfulness of consensus meetings and/or opinion surveys in medicine to determine nosological classifications: The “white dots” case

Dear Editor,

This is a follow-up to the expert opinion published in this journal.[1] We are pleased to be able to mention that our article had a very positive impact inasmuch as the denomination of a major uveitis meeting abandoned the term “white dots.” Moreover, the organizers recently published an article entitled “Is it time to adopt a new nomenclature and classification for ‘white dot syndromes’ using multimodal imaging techniques.”[2] After the decision to abandon this terminology by one of the major textbooks earlier this year,[3] this is indeed another step in the right direction. However, we know how long it takes to get rid of inappropriate encrusted terminologies, if possible, at all.

The urge to define, understand, classify, and name diseases or groups of diseases has naturally always been a major concern for the medical world. This is no different in the field of uveitis. The approach to such questions has evolved according to the times. In the past, the way of apprehending diseases was often limited to the methodology at hand, that is, very often, surveys, consensus meetings, and consensus decisions in the absence of precise and objective means to analyze disease mechanisms and generate disease nomenclatures. This is the methodology chosen by the authors of the article and for their follow-up conference.[2] Nowadays, the availability of evidence-based medicine through technical advances is increasingly able to replace advantageously consensus and opinion-based definitions and classifications of diseases, highlighting the positive evolution of evaluating and understanding diseases and disease groups through much-needed scientific-based approaches.

The content of the article of the International Uveitis Study Group Multimodal Imaging in Uveitis task force concerns the result of a survey on white dot syndromes (WDS) that was launched in view of a consensus meeting on the topic, and the rejoicing result of the survey is the fact that it confirmed that the WDS terminology should be abandoned.[2] However, no need to ask the opinion of ophthalmologists at large, few of them being uveitis specialists and perform a survey to come to this conclusion. The fact that WDS has always been a groundless and useless misnomer and should be replaced by the more adequate term of noninfectious choroiditis was established for more than 20 years relying on evidence-based arguments.[4,5,6,7,8] Therefore, we are astonished that the title of the survey article is only in the interrogative and not in the affirmative form.[2]

The characteristics and mechanisms of most of these diseases are today well determined thanks, essentially, to progress in imaging.[9,10] Nevertheless, as a follow-up of this survey article as announced in it, a meeting has been planned and organized to reestablish the criteria of individual diseases sanctioned by a vote, corresponding to another consensus meeting (https://www.iusg.net/uploads). The sense of such a meeting is somewhat questionable, as reclassification of these diseases has been mostly settled. As already mentioned, consensus decisions can be very problematic.[11] The scheme of such decisions usually consists of expert working groups not always devoid of preconceived ideas that propose their reflections to the international, mostly nonspecialized participants of the meeting who are then asked to vote on a set of criteria that become “marked in the marble” and represent from then on the established doctrine because “internationally promulgated.” Here lies exactly the danger of such processes, as it difficult to avoid biases linked to the promoters of such criteria, mostly active opinion leaders.[11] It can be expected that decisions taken will principally rely on objective elements. If this is the case, the conclusions of such meetings could become acceptable as long as they also cite divergent opinions when applicable either from participants present in the meeting or from relevant publications in the literature.[12] To the best of our knowledge, we are not aware of such a pluralistic and open attitude in consensus meetings. Therefore, such enterprises can be harmful to the progress of medical knowledge because they can end up in the confinement of medical notions and doctrine. This is the reason why we are concerned in this consensus type of re-assessment of mostly already defined diseases.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.