Recent eLetters

Dear Editor, We read the paper by Chadha and Wright on small margin excision of periocular basal cell carcinoma (BCC) with interest. (1)The authors justify the use of small margins, without margin control (excision and closure without confirmation of histologically clear margins) by their low recurrence rates over a follow up period ranging from 37-59 months.

There has been extensive debate on the ideal approach to the patient with a suspicious skin lesion. We consider the issues here to be two fold: complete tumour removal and reduced recurrence rate and these two have been linked in most studies.(2) The next dilemma for most of us is to determine factors affecting subclinical tumour extension to achieve a complete removal with minimum excision of healthy tissue. Mohs micrographic surgery is considered the gold standard as it is shown to achieve a 98% 5-year cure rate (1773 cases of BCC).(3) Modifications have been sought due to the stringent training and processing requirements of the original technique and acceptable results have been achieved with staged ‘Slow Mohs’ (4) and multi-stage fast paraffin sections; (5)with maybe a varying of the margins based on tumour morphology.(6)

Data from this study would suggest a tumour debulking (excision and closure without margin control) would be equally effective in terms of final outcomes of recurrence rates, as the authors make no attempt to ensure complete removal. Recurrence in patients reported to have complete excision (2.6%, 2/78) is the other argument for this being an acceptable approach. However, interestingly their data also shows an incomplete excision rate ranging from 11.9% (single stage) and 17.4% (two stage excision group presumed to be larger lesions) and a clinical recurrence rate of 2.6% for complete excision versus 14.3% in incomplete excision group (followed up only) and 0% having undergone further excision to ensure complete removal. Also, these recurrence rates stated are for less than 5 years and survival curves may help in estimating the true incidence.

There is good evidence to support a policy of retreatment of incompletely excised tumours especially when they present at critical sites, the deep surgical margins are involved, histology shows a more aggressive subtype and surgical defect is repaired using flaps and grafts.(7) We must not forget recurrences put the patient in a higher risk group being more difficult to evaluate, with more aggressive and larger invasive tumours needing more extensive excision second time round. Recurrence rates of 10% are not considered acceptable in routine primary eyelid tumours where the functional and cosmetic outcomes have much more significant implications than elsewhere in the body.(8)

We understand the service pressure in the National Health Service or elsewhere but quality of care to the patients should be our ultimate aim. A service adaptation to increase efficiency with more appropriate use of the minor outpatient theatres for small lesions not needing major reconstruction, discharge from eye clinics earlier than the mandatory 5 years with follow-up in primary care clinics/ even GP surgeries can ensure complete tumour removal without increasing the service load. The added advantage of reduced patient anxiety and surgeon confidence cannot be under-estimated as these may actually increase the follow up visits much more than the already higher number proposed by the authors in presence of an incomplete excision.

References: 1. Chadha V, Wright M. Small margin excision of periocular basal cell carcinomas. Br J Ophthalmol 2009; 93: 803-806. 2. Cook BE, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies. An evidence-based update. Ophthalmology 2007; 108: 2088-2100. 3. Mohs FE. Micrographic surgery for the microscopically controlled excision of eyelid cancers. Arch Ophthalmol 1986; 104: 901-909. 4. Morris DS, Elzaridi E, Clarke L, Dickinson AJ, Lawrence CM. Periocular basal cell carcinoma: 5 year outcome following Slow Mohs surgery with formalin-fixed paraffin-embedded sections and delayed closure. Br J Ophthalmol 2009; 5. Khandwala MA, Lalchan SA, Chang BYP, Habib M, Chakrabarty A, Cassels Brown A. Outcome of periocular basal cell carcinoma managed by overnight paraffin section. Orbit 2005; 24: 243-247. 6. Hsuan JD, Harrad RA, Potts MJ, Collins C. Small margin excision of periocular basal cell carcinoma: 5 year results Br J Ophthalmol 2004; 88: 358-360. 7.Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermat 2008; 159: 35-48. 8. Anderson RL. Micrographic technique Arch Ophthalmol 1986; 104: 818-819.

Dear editor,

We have read with great interest the article by Unoki N et al Randomised controlled clinical trial of sub-tenon triamcinolone as an adjunct to panretinal photocoagulation for the treatment of diabetic retinopathy 1. We wish to make few comments. The p value of the primary outcome as documented is 0.04. But if calculated from the results documented, applying parametric tests as used in the study it comes out to be highly significant 0.001. We would like to know whether authors might have used a non-parametric test for the analysis. In the retinal thickness analysis, the p values mentioned are significant for the foveal and perifoveal thickness. Again we calculated the p values applying the parametric tests and it came out to be without statistically significant difference. We feel the use of non-parametric test for the analysis could have been more appropriate because the data especially of that of retinal thickness is a continuous variable.

References 1. N Unoki, K Nishijima, M Kita, K Suzuma, D Watanabe, H Oh, T Kimura, A Sakamoto and N Yoshimura. Randomised controlled trial of posterior sub- Tenon triamcinolone as adjunct to panretinal photocoagulation for treatment of diabetic retinopathy. Br. J. Ophthalmol. 2009; 93; 765-770.

2. Techniques for scatter and local photocoagulation treatment of diabetic retinopathy: Early Treatment Diabetic Retinopathy Study Report no. 3. The Early Treatment Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin, 1987 Winter;27(4):254-64.

Competing Interest: None

Dear editor,

I was interested to read the editorial on vision screening by Evans, Smeeth and Fletcher [1]. I share their concern that, despite the availability of free eye tests for the older population, over 50% of vision impairment is due to easily correctable conditions.

I recently audited an elderly person health check; an annual assessment of the medical, social, and physical needs of all patients over 75 years at a GP practice in Wirral.

Whilst an assessment of vision formed part of the pro forma carried out by the health care assistant, this was self reported and recorded broadly; no visual symptoms, provision of spectacles, profound impairment one eye, and profound impairment both eyes.

As part of the audit cycle, for one month, all patients attending their health check had their visual acuity measured (with and without pinholes) using a Snellen chart. Additionally, attendance at optician for regular eye check was recorded.

24 patients attended for their elderly person health check, excluding 4 patients who had significant ocular pathology (3 with age related macular degeneration, 1 had recent cataract surgery), 55% were female and mean age of 80.2 years.

13 patients (65%) had some visual impairment, 4 patients (20%) improved with pinholes. Similarly, van der Pols et al [2] reported that vision improved with pinholes in 22.6% of a national sample of British elderly, and Wormald et al [3] reported improvement in 27% of their subjects (elderly people living in central London). Full refraction and revised prescription may be of benefit to these patients. 19 patients (95%) had regular eye tests at their optician. The one patient who did not attend regularly was found to have a vision impairment that improved with pinholes. This patient was advised to see their optician for refraction.

The editorial concluded that complementary approaches, facilitated around a primary care hub, may reduce the levels of treatable vision impairment in older people. This small audit suggests that, despite the findings of recent clinical trials, primary care may still have a role in the prevention of treatable vision impairment, albeit a small one; essentially to educate patients and remind them to attend their opticians regularly.

Competing interests: None.

References

1) Evans J, Smeeth L, Fletcher A. Vision screening. British Journal of Ophthalmology 2009; 93: 704-705.

2)van der Pols JC, Bates CJ, McGraw PV, et al. Visual acuity measurements in a national sample of British elderly people. British Journal of Ophthalmology 2000; 84:165-170.

3)Wormald RP, Wright LA, Courtney P, Beaumont B, Haines AP. Visual problems in the elderly population and implications for services. British Medical Journal 1992; 304: 1226-9.

Dear Editor

Ramadan (the month of fasting for muslims) is approaching at the end of August 2009. As ophthalmologists in a centre with a large muslim population we read Kumar and Jivan's study with interest [1].

We agree that poor compliance with treatment can be improved with patient education. A major proportion of chronic ophthalmological disease monitoring is for glaucoma, first line treatment for which is latanoprost, administered in the evening. This does not interfere with fasting which ends after sunset. With the support of the ophthalmologist to remind the patient, drops that require twice daily use can be instilled before sunrise as patients who wish to fast are awake for an early breakfast (Suhur) and after sunset.

During Ramadan, muslim patients attend the eye clinic if they have an acute problem and will therefore comply with emergency treatment administered but are more likely to miss a routine eye clinic appointment for monitoring of chronic conditions [1-2]. This may be due to drops administered in the clinic essential for complete assessmen; according to the majority of muslim patients, eye drops constitute a breaking of the Ramadan fast [1-4]. Working in partnership with patients, asking when Ramadan is likely to be and arranging an appropriate follow up interval taking this into account has many advantages. It serves to strengthen the doctor-patient relationship and is outlined as a duty according to good medical practice [5].

Due to a large local muslim population it has been our practice for many years to consider the month of fasting when planning follow up appointments. As a result our "did not attend" (DNA) rates for muslim patients in the month of fasting are shown to be comparable to any other random month in the year. In 2008 the month of fasting was the month of September, facilitating data collection. The DNA rate in the glaucoma clinic for muslim patients was 27.3% in this month compared to 31.25% in the month of June 2008. For another glaucoma clinic the DNA rate was 25.7% compared to 34.7% (Ramadan September 08, June 08 respectively). In the diabetic clinic DNA rates were found to be 43.2% compared to 41.4%, showing poor attendance but that Ramadan is not significantly higher than another month of the year.

Our data suggests that a practical approach to booking routine follow up appointments for muslim patients, so they do not fall within the month of Ramadan, will have a positive impact on the DNA rate, an important way of increasing the efficiency of the ophthalmic service for all patients.

References

1. Kumar N, Dherani M, Jivan S. Ramdan and eye drops: perspective of Muslims in the UK. British Journal of Ophthalmology 2009; 93: 551

2. Kumar N, Jivan S. Ramadan and Eye Drops: the Muslim Perspective. Ophthalmology 2007; 114:2356-60

3. Moradi P. Ramadan and eyedrops: the muslim perspective. Ophthalmology. 2008 Aug;115(8):1440; author reply 1440-1.

4. Saha N. The attitudes and practice of Muslim patients using guttae medication during Ramadan. Eye. 2007;21(6):878-9.

5. Good Medical Practice. November 2006. (http://www.gms-uk.org)

Dear Editor

Out of ignorance, I am surprised that the lenses in a stereoscope should be described as "plus" lenses. They may be so, but I would have expected the more important property to be prism, to aid superimposition of the paired images.

Please clarify the optics involved.

BLC