We read with interest the article Full thickness eyelid
transsection (blepharotomy) for upper eyelid lengthening in lid retraction
associated with Graves’ disease by Hintschich.[1] This prospective
study showed that full thickness eyelid transsection with preservation of
central conjunctival bridge leaded to perfect or acceptable surgical
results in 57 of 60 lids after one or two surgical procedures....
We read with interest the article Full thickness eyelid
transsection (blepharotomy) for upper eyelid lengthening in lid retraction
associated with Graves’ disease by Hintschich.[1] This prospective
study showed that full thickness eyelid transsection with preservation of
central conjunctival bridge leaded to perfect or acceptable surgical
results in 57 of 60 lids after one or two surgical procedures.
It becomes increasingly common, as in this study, to cut the lateral
horn of levator aponeurosis to relieve the temporal flare of upper eyelid
retraction in Graves' disease.[2] The lateral horn, however, bears close
anatomical relationship with the palpebral lobe of lacrimal gland that may
be damaged during upper eyelid surgery without careful dissection. We are
concerned that the risk may become more significant during full thickness
eyelid transsection because the anatomical details of the lateral horn and
its surrounding structure may be relatively less defined. Furthermore, it
has been shown that lacrimal production may be reduced after mullerectomy
by the conjunctival approach.[3] Despite no patients complained of dry eye
symptoms in this study, which may be partly attributable to improvement in
symptoms related to eyelid retraction, more objective assessment in this
respect seems warranted.
Upper eyelid retraction is frequently accompanied by prominent
preaponeurotic fat in Graves’ ophthalmopathy. Levator recession by the
transcutaneous approach can simultaneously manage both of these by opening
the orbital septum. Since no patient in this study received fat removal,
we would like to know if the authors would recommend, if required,
simultaneous fat removal by opening the orbital septum or staged surgery.
We congratulate the valuable work by Hintschich and associate and
hope that further discussion would broaden our understanding of this
remarkable surgical technique for upper eyelid retraction.
References
1. Hintschich C, Haritoglou C. Full thickness eyelid transsection
(blepharotomy) for upper eyelid lengthening in lid retraction associated
with Graves’ disease. Br J Ophthalmol 2005;89:413-6.
2. Mourits MP, Sasim IV. A single technique to correct various degrees of
upper lid retraction in patients with Graves’ orbitopathy. Br J
Ophthalmol 1999;83:81-4.
3. George JL, Tercero ME, Angioi-Duprez K, Maalouf T. Risk of dry eye
after mullerectomy via the posterior conjunctival approach for thyroid-
related upper eyelid retraction. Orbit 2002;21:19-25.
I read with interest the article about combined plaque radiotherapy
and transpupillary thermotherapy in choroidal melanoma written by
Bartlema
et al.
The authors do not state in the method section the amount of power
deployed through their infrared laser. Since spot diameter and duration
of
treatment are not enough to reproduce the treatment method, it would be
scientifically correct and much appreci...
I read with interest the article about combined plaque radiotherapy
and transpupillary thermotherapy in choroidal melanoma written by
Bartlema
et al.
The authors do not state in the method section the amount of power
deployed through their infrared laser. Since spot diameter and duration
of
treatment are not enough to reproduce the treatment method, it would be
scientifically correct and much appreciated to have a statement about
the
number of Watts chosen or the total amount of Joules delivered.
Dr. Fernandez Rubio raised an interesting issue of "climatic factor" as a risk for delayed onset endophthalmitis after glaucoma surgery. He asked whether
the onset of endophthamitis due to Hemophilus influenzae and
Streptococcus
pneumonia took place around a particular part of the year in our study.[1]
We did not look into the issue of climatic factor during our review.
However, charts of those pati...
Dr. Fernandez Rubio raised an interesting issue of "climatic factor" as a risk for delayed onset endophthalmitis after glaucoma surgery. He asked whether
the onset of endophthamitis due to Hemophilus influenzae and
Streptococcus
pneumonia took place around a particular part of the year in our study.[1]
We did not look into the issue of climatic factor during our review.
However, charts of those patients who developed endophthalmitis caused
by
H. influenzae and S. pneumonia organisms were reviewed recently, and it appears they did not take place during a particular part of the year.
Organisms causing endophthalmitis following glaucoma drainage implant (GDI) surgery in children are H. influenzae or S. pneumonia or both. In our series,[1] cultures revealed S. pneumonia in 2 eyes, H. influenzae in 1 eye, and both organisms in 1 eye. Gedde et al,[2] and Al-Torbaq and
Edward[3] reported H.influenzae caused endophthalmitis following GDI surgery in 2 separate paediatric patients. This is not surprising as H. influenzae and S. pneumonia are part of the normal bacterial flora of the conjunctiva
and upper respiratory tract, and a common cause of infection in both tissues.[4,5] Presence of conjunctival erosion which is common in paediatric shunts (10-13%),[6] is a major risk factor for endophthalmitis. Prompt surgical revision of an exposed GDI tube is highly recommended.
Abdullah A. Al-Torbak, MD, FRCS
King Khaled Eye Specialist Hospital
P.O. Box 7191 Riyadh 11462
Saudi Arabia
Tel: +966-1-482-1234 Ext. 3771
Fax: +966-1-482-9311
Email: atorbaq{at}health.net.sa
References
1. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, et al. Endophthalmitis
associated with the Ahmed glaucoma valve implant. Br J Ophthalmol
2005;89:454-458.
2. Gedde SJ, Scott IU, Tabandeh H, et al. Late endophthalmitis
associated
with glaucoma drainage implants. Ophthalmology 2001;108:1323-1327.
3. Al-Torbaq A, Edward DP. Delayed endophthalmitis in a child
following an
Ahmed glaucoma valve implant. JAAPOS 2002;6:123-125.
4. Osata MS. Normal Ocular flora. In: Pepose JS, Holland GN,
Wilhelmus KR,
eds. Ocular infection and immunity. St. Louis: Mosby;1996:191-199.
5. Kaplan SL, Feigin RD. Haemophilus influenzae. In: Behrman RE,
Kliegman
RM, eds. Nelson Textbook of Paediatrics. 14th ed. Philadelphia:
Saunders,1992:711-713.
6. Englert JA, Freedman SF, Cox TA. The Ahmed valve in refractory
paediatric glaucoma. Am J Ophthalmol 1999;127:34-42.
I thank Drs. Bajaj, Pushker, Mehta and Pathak for their interest in
my article
titled, "Finger-tip" Cryoprobe Assisted Orbital Tumor Extraction, that
appeared in the British Journal of Ophthalmology's June 2005 issue.
Their center's extensive experience with cryo-extraction of orbital
tumors is
well noted. However, they have their "considered opinion" that the older
round probes are superior, they have no exp...
I thank Drs. Bajaj, Pushker, Mehta and Pathak for their interest in
my article
titled, "Finger-tip" Cryoprobe Assisted Orbital Tumor Extraction, that
appeared in the British Journal of Ophthalmology's June 2005 issue.
Their center's extensive experience with cryo-extraction of orbital
tumors is
well noted. However, they have their "considered opinion" that the older
round probes are superior, they have no experience with the new "Finger-
tip"
cryoprobes. In contrast, I have used both devices and clearly prefer the
new
spatulated probes.1-3
I invite them to obtain a set of "Finger-tip" probes from MIRA, and
hope they
share their prospective and comparative experience the readers of the
journal.
Best regards,
Paul T Finger, MD
References
1. Finger PT. "Fingertip" cryoprobe assisted orbital tumour
extraction. Br J
Ophthalmol. 2005 ; 89(6):777-8.
2. Finger PT. "Finger-tip" cryoprobe assisted enucleation. Am J Ophthalmol
2005 ; 139: 559-61
3. Finger PT. "Finger-tip" cryotherapy probes: Treatment of squamous and
melanocytic neoplasia. Br J Ophthalmol (In Press).
We read with interest the article by Antcliff and associates.[1] The authors have compared the macular edema, retinal thickness, visual acuity and cyst height in 11 patients of non ischaemic central retinal vein occlusion (niCRVO) randomized to either observation or laser-induced
chorioretinal anastomosis (CRA). Although only 6 patients underwent laser induced CRA, the results are encouraging at six mo...
We read with interest the article by Antcliff and associates.[1] The authors have compared the macular edema, retinal thickness, visual acuity and cyst height in 11 patients of non ischaemic central retinal vein occlusion (niCRVO) randomized to either observation or laser-induced
chorioretinal anastomosis (CRA). Although only 6 patients underwent laser induced CRA, the results are encouraging at six months. There are few issues which we would like to raise.
The incidence of CRAs post CRVO is generally 50% during the natural course and these spontaneously arising CRAs were found to develop at a mean interval of 3.9 months by Fuller et al.[2] Also since the retinal haemorrhages present in a fresh case of CRVO may be partly responsible for decreased visual acuity, an early intervention that does not allow normal recovery may be unjustified. We would recommend reassessment of visual acuity and retinal perfusion at 4 to 6 weeks before resorting to any intervention.
The laser-induced CRAs, as described by McAllister et al have been found to improve macular edema in patients of niCRVO.[3] They could successfully create CRAs in only 33% of the cases with one attempt [3],
54% of cases in more than one attempt [4] and in 43% of the cases with mean 1.8 attempts.[5] Since 20% of the eyes also developed the neovascularization at the site of anastomosis [4], it would be interesting to know the total number of attempts required to create a functional anastomosis in all 6 eyes by Antcliff et al.
Also the authors have reported that they could not mask the patients because of the laser surgery, we would suggest a sham procedure on observation group to overcome this limitation. To summarize, the authors are commended for conducting a randomized study for evaluation of this alternative technique to improve vision in CRVO patients. We agree with the authors that a larger trial with longer follow up duration is needed to reach a conclusion. The issues raised by us can also be utilized when planning future studies.
References
1. Antcliff RJ, Mayer EJ, Williamson TH, J S Shilling. Early
chorioretinal anastomosis in non-ischaemic CRVO: a randomised trial. Br.
J.Ophthalmol. 2005;89;780-781.
2. Fuller JJ, Mason JO, White MF, et al. Retinochoroidal Collateral
Veins Protect Against Anterior Segment Neovascularization After Central
Retinal Vein Occlusion. Arch Ophthalmol. 2003;121:332-336.
3. McAllister IL, Constable IJ. Laser-induced chorioretinal venous
anastomosis for treatment of nonischemic central retinal vein occlusion.
Arch Ophthalmol. 1995 Apr;113(4):456-62.
4. McAllister IL, Douglas JP, Constable IJ, Yu DY. Laser-induced
chorioretinal venous anastomosis for nonischemic central retinal vein
occlusion: evaluation of the complications and their risk factors. Am J
Ophthalmol. 1998 Aug;126(2):219-29.
5. Eckstein M, McAllister I. Laser-induced chorioretinal venous
anastomosis for non-ischaemic hemi-central vein occlusion. Clin Experiment
Ophthalmol. 2000 Feb;28(1):18-21.
The growing research implicating smoking with age-related macular
degeneration prompted us to write an editorial in 1999 [1] urging the
Australian government to warn smokers of this little appreciated risk.
In 2000, the Australian National Quit campaign ran an advertisement as part of a series titled "Every cigarette is doing you damage" which explicitly addressed AMD. A website describes the cam...
The growing research implicating smoking with age-related macular
degeneration prompted us to write an editorial in 1999 [1] urging the
Australian government to warn smokers of this little appreciated risk.
In 2006 the Australian government will require new mandatory
pictorial pack warnings, one of which will be about AMD. This warning
was one of the strongest tested among smokers in the research conducted for
the government prior to the announcement. The full report and other
related information can be found at:
http://tobacco.health.usyd.edu.au/site/supersite/resources/docs/gallery_
packwarnings.htm.
Reference
1. Mitchell P, Chapman S, Smith W. "Smoking is a major cause of
blindness": a new cigarette pack warning? Med J Aust 1999;171:173-4.
We read with great interest the article on the new design of a
cryoprobe for removal of Orbital tumors.[1] The concept of providing a
large spatulated surface for better tumour adhesion is commendable.
Cryoextraction greatly facilitates the excision of well-defined, solid,
encapsulated, benign or malignant tumors.[2,3] We have been routinely
employing cryoextraction for orbital tumors at our centre f...
We read with great interest the article on the new design of a
cryoprobe for removal of Orbital tumors.[1] The concept of providing a
large spatulated surface for better tumour adhesion is commendable.
Cryoextraction greatly facilitates the excision of well-defined, solid,
encapsulated, benign or malignant tumors.[2,3] We have been routinely
employing cryoextraction for orbital tumors at our centre for a
considerable period of time and would like to share our experience on this
subject and delve into a few crucial issues.
Indeed, the presently available cryoprobes used for orbital tumour
extraction have rounded tips which may not give a very large area for
tumour adhesion. However, it is our considered opinion that such probes
provide a greater margin of safety when they are applied to masses that
are relatively more friable or are cystic in nature. The rounded edges
lead to lesser trauma to the tumour capsule and the probability of its
rupture is significantly reduced. The spatulated cryoprobe devised by the
authors seems to have a sharp edge which may cause disruption of the
tumour in these situations.
The authors have descried the use of the new probe in just a single
case of a well-encapsulated and circumscribed Cavernous Haemangioma. It
would be interesting to know if they have used this probe in other types
of orbital lesions of varying consistency and diverse etiologies. The
response to the application of a cryoprobe depends on a multitude of
factors such as tumour contents, consistency, friability, encapsulation
and adhesion to surrounding structures. The safety and effectivity of this
newly designed cryoprobe can be objectively assessed only after it has
been successfully used in a wider variety of orbital tumours in a larger
series of patients.
References
1. Finger PT. "Fingertip" cryoprobe assisted orbital tumour
extraction. Br J Ophthalmol. 2005 ; 89(6):777-8.
2. Kiratli H, Bilgic S. Cryoextraction in the management of orbital
tumors. An old technique revisited. Orbit. 1998 ; 17(3):189-194.
3. Hurwitz JJ, Mishkin SK. The value of cryoprobe-assisted removal
of orbital tumors. Ophthalmic Surg. 1988 ; 19(2):94-7.
We read with great interest the results of the pilot study comparing
patients satisfaction between topical and sub-Tenon’s anaesthesia.[1] In
conclusion the authors state that sub-Tenon’s block produces higher
satisfaction scores than topical anaesthesia.[1]
The scores used were obtained using the ISAS score, which has been
used many times during other forms of surgery.[2]
We read with great interest the results of the pilot study comparing
patients satisfaction between topical and sub-Tenon’s anaesthesia.[1] In
conclusion the authors state that sub-Tenon’s block produces higher
satisfaction scores than topical anaesthesia.[1]
The scores used were obtained using the ISAS score, which has been
used many times during other forms of surgery.[2]
However, the ISAS has not been used in the setting of unmonitored
anaesthetic care and has not as yet been fully validated in a purely local
anaesthetic environment. Dexter, who was part of the team that developed
the ISAS, has said that the ISAS is still to be validated in this setting.
Therefore we would suggest that the conclusions that sub-Tenon’s gives
better satisfaction than topical, purely based on this scale, is slightly
premature.
The ISAS is due to be validated soon using local anaesthesia and
sedation [3] however it is still used specifically during monitored
anaesthetic care and is as yet not tested on unmonitored anaesthetic care
which is often found during topical cataract lists.
References
1. Rüschen H, Celaschi D, Bunce C, Carr C. Randomised controlled trial
of sub-Tenon’s block versus topical anaesthesia for cataract surgery: a
comparison of patient satisfaction. Br J Ophthalmol. 2005; 89: 291-293.
2. Dexter F. Aker J. Wright WA. Development of a measure of patient
satisfaction with monitored anesthesia care: the Iowa Satisfaction with
Anesthesia Scale.Anesthesiology. 87(4):865-73, 1997 Oct.
3. Fung D, Cohen M, Stewart S, Davies A. Can the Iowa Satisfaction
with Anesthesia Scale be used to measure patient satisfaction with
cataract care under topical local anesthesia and monitored sedation at a
community hospital? Anesthesia and Analgesia June 01, 2005; 100 (6).
We read with interest the article by J A Montero and J M Ruiz-Moreno
on ‘Optical coherence tomography (OCT) characterization of idiopathic
central serous chorioretinopathy (ICSC)’.[1] We agree that OCT may offer a
new approach to the staging and knowledge of ICSC, and may help the
understanding of the mechanisms of the disease.
In our personal experience
of OCT evaluation of 56 eyes we observ...
We read with interest the article by J A Montero and J M Ruiz-Moreno
on ‘Optical coherence tomography (OCT) characterization of idiopathic
central serous chorioretinopathy (ICSC)’.[1] We agree that OCT may offer a
new approach to the staging and knowledge of ICSC, and may help the
understanding of the mechanisms of the disease.
In our personal experience
of OCT evaluation of 56 eyes we observed that with-in first two weeks of
onset of symptoms the OCT showed a neurosensory detachment of varied
extent and height in all the eyes which authors refer as optically empty
vaulted area under the neurosensory retina. A clearly demarcated dome
shaped retinal pigment epithelium detachment (RPED) was seen in 40 eyes
where as clinically it could be picked up in 24 eyes-only. Careful
analysis of OCT scan revealed characteristic small bulges similar to what
authors have described were seen protruding from RPE, in 16 eyes and it
related to leaking spots on angiography. We also observed that pick up
rate of these small bulges was enhanced if the OCT was performed
immediately following fluorescein angiography.
OCT performed in the resolving stages of the disease showed either a
complete resolution or a partial resolution of the neurosensory detachment
with persisting RPEDs along with neurosensory thinning. Few eyes showed
decreased height of RPEDs suggestive of collapsing RPEDs.
Thus, we share the same view with the authors that OCT is a useful tool
for diagnosis, monitoring and follow-up of patients with ICSC and offers
valuable information for establishing a new classification for ICSC.
References
1. Montero JA, Ruiz-Moreno JM. Optical coherence tomography
characterization of idiopathic central serous chorioretinopathy. Br J
Ophthalmol 2005;89:562-564.
We read with keen interest the recently published article by Shields
et al.[1] Cholesterol lowering agents may indeed evolve as a
physiological and non-invasive therapeutic modality for this cosmetically
disfiguring entity. We would like to raise a few pertinent issues related
to this article.
We would like to draw your attention to the fact that there is a
marked difference in the quali...
We read with keen interest the recently published article by Shields
et al.[1] Cholesterol lowering agents may indeed evolve as a
physiological and non-invasive therapeutic modality for this cosmetically
disfiguring entity. We would like to raise a few pertinent issues related
to this article.
We would like to draw your attention to the fact that there is a
marked difference in the quality of the pre and post-treatment photographs
of the patient. The pre-treatment picture is grossly underexposed as
compared to the post-treatment one, which is overexposed. In an
overexposed photograph, the patient’s skin complexion appears rather
light, thereby making a yellowish lesion such as a Xanthelasma less
prominent in contrast, and vice versa. Therefore it would be incorrect to
say that the Xanthelasmas have completely resolved after treatment. We
would like to reiterate that extremely stringent standards of clinical
photography and colour reproduction should be adhered to in cosmetic and
ophthalmic plastic surgery for the images to be comparable, credible and
scientifically relevant.[2]
There are various other factors that may contribute to a serial
reduction in prominence of the lesion and should be taken into
consideration. Xanthelasma lesions are known to enlarge and coalesce over
time. This makes the margins indistinct and the lesion could appear to
merge with the surrounding skin, thereby changing its characteristics from
a well demarcated to a somewhat diffuse entity. As there is a long
interval of ten years between the two assessments, one also has to take
into account the changes in texture and pigmentation of the skin that
invariably occur with aging. The surrounding skin pigmentation could
reduce with advancing age due to a decrease in melanocyte density [3],
possible hormonal influences, and a presumed reduction in outdoor
activities leading to lesser exposure to sunlight. Moreover, there is
wrinkling and change in texture of the eyelid skin due to loss of
elasticity, resilience and flexibility of the dermis and thinning of the
epidermis associated with aging.[4] These changes, which are expected in
the patient reported by the authors have to be factored in while
objectively evaluating such a case as they could play a significant role
in the reduction in prominence of the Xanthelasma lesion over time. Once
these concerns are suitably addressed, one could appreciate this article
in a proper perspective.
References
1. Shields CL, Mashayekhi A, Shields JA, Racciato P. Disappearance of eyelid xanthelasma following oral simvastatin (Zocor). Br J Ophthalmol. 2005 May;89(5):639-40.
2. Bajaj MS, Pushker N, Mahindrakar A, Balasubramanya R. Standardised clinical photography in ophthalmic plastic surgery. Br J Ophthalmol. 2003 Mar;87(3):375-6.
3. Wulf HC, Sandby-Moller J, Kobayasi T, Gniadecki R. Skin aging and natural photoprotection. Micron. 2004;35(3):185-91.
4. Giacomoni PU, Rein G. A mechanistic model for the aging of human skin. Micron. 2004;35(3):179-84.
Dear Editor,
We read with interest the article Full thickness eyelid transsection (blepharotomy) for upper eyelid lengthening in lid retraction associated with Graves’ disease by Hintschich.[1] This prospective study showed that full thickness eyelid transsection with preservation of central conjunctival bridge leaded to perfect or acceptable surgical results in 57 of 60 lids after one or two surgical procedures....
Dear Editor,
I read with interest the article about combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma written by Bartlema et al. The authors do not state in the method section the amount of power deployed through their infrared laser. Since spot diameter and duration of treatment are not enough to reproduce the treatment method, it would be scientifically correct and much appreci...
Dear Editor,
Dr. Fernandez Rubio raised an interesting issue of "climatic factor" as a risk for delayed onset endophthalmitis after glaucoma surgery. He asked whether the onset of endophthamitis due to Hemophilus influenzae and Streptococcus pneumonia took place around a particular part of the year in our study.[1] We did not look into the issue of climatic factor during our review. However, charts of those pati...
I thank Drs. Bajaj, Pushker, Mehta and Pathak for their interest in my article titled, "Finger-tip" Cryoprobe Assisted Orbital Tumor Extraction, that appeared in the British Journal of Ophthalmology's June 2005 issue.
Their center's extensive experience with cryo-extraction of orbital tumors is well noted. However, they have their "considered opinion" that the older round probes are superior, they have no exp...
Dear Editor,
We read with interest the article by Antcliff and associates.[1] The authors have compared the macular edema, retinal thickness, visual acuity and cyst height in 11 patients of non ischaemic central retinal vein occlusion (niCRVO) randomized to either observation or laser-induced chorioretinal anastomosis (CRA). Although only 6 patients underwent laser induced CRA, the results are encouraging at six mo...
Dear Editor,
The growing research implicating smoking with age-related macular degeneration prompted us to write an editorial in 1999 [1] urging the Australian government to warn smokers of this little appreciated risk.
In 2000, the Australian National Quit campaign ran an advertisement as part of a series titled "Every cigarette is doing you damage" which explicitly addressed AMD. A website describes the cam...
Dear Editor,
We read with great interest the article on the new design of a cryoprobe for removal of Orbital tumors.[1] The concept of providing a large spatulated surface for better tumour adhesion is commendable. Cryoextraction greatly facilitates the excision of well-defined, solid, encapsulated, benign or malignant tumors.[2,3] We have been routinely employing cryoextraction for orbital tumors at our centre f...
Dear Editor
We read with great interest the results of the pilot study comparing patients satisfaction between topical and sub-Tenon’s anaesthesia.[1] In conclusion the authors state that sub-Tenon’s block produces higher satisfaction scores than topical anaesthesia.[1]
The scores used were obtained using the ISAS score, which has been used many times during other forms of surgery.[2]
However, th...
Dear Sir,
We read with interest the article by J A Montero and J M Ruiz-Moreno on ‘Optical coherence tomography (OCT) characterization of idiopathic central serous chorioretinopathy (ICSC)’.[1] We agree that OCT may offer a new approach to the staging and knowledge of ICSC, and may help the understanding of the mechanisms of the disease.
In our personal experience of OCT evaluation of 56 eyes we observ...
Dear Editor,
We read with keen interest the recently published article by Shields et al.[1] Cholesterol lowering agents may indeed evolve as a physiological and non-invasive therapeutic modality for this cosmetically disfiguring entity. We would like to raise a few pertinent issues related to this article.
We would like to draw your attention to the fact that there is a marked difference in the quali...
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