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Recent eLetters

Displaying 1-10 letters out of 485 published

  1. Ketorolac does prevent retinal thickening and CME in routine cataract surgery

    Your study actually confirms the data that we reported in the lead article of the AJO in October 2008 showing the benefit of ketorolac in preventing CME and retinal thickening after routine cataract surgery. To demonstrate statistical significance for CME, it requires a sample size of close to 400 patients per group. Your data clearly shows a trend to decreased retinal thickening when a NSAID is used in conjunction with steroids. You failed to reach statistical significance because you failed to have a large enough sample size. It requires approximately 80 to 100 patients to demonstrate definite statistical advantage with an approximately 95% chance of showing the correct result. Looking at your graphs there is a definite trend especially for ketorolac. In fact, your percentages for ketorolac are very similar to the percentages we reported. Similarly, your placebo group also is not far off the percentages we reported. However, our were statistically significant because there were over 260 patients in each group.

    Conflict of Interest:

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  2. LETTER TO EDITOR

    We Read with great interest the article Topical bromfenac reduces the frequency of intravitreal bevacizumab in patients with branch retinal vein occlusion by Masahiko Shimura et al.(1) We congratulate the authors for the concept and well conducted pilot study . Repeated intravitreal injections are known to have various complications(2) and it would be safer if noninvasive intervention like topical bromfenac can help to reduce the number of intravitreal injections .However, we would like to make an observation in the study design. Fundus Flourescein Angiography (FFA) of the enrolled patients was not performed at any time during the study. It is known that patients with branch retinal vein occlusion can develop CNP areas(Capillary Nonperfusion Areas) and the size of CNP areas is positively correlated with the amount of (Vascular Endothelial Growth Factor)VEGF(3,4). VEGF release is one of the important factors responsible for macular edema. Non availability of FFA can lead to the bias between the two groups because there is a chance of patients with larger CNP areas and thereby more VEGF at the baseline to be present in one group. We would like to suggest that CNP areas need to be considered while randomising patients to remove this bias.

    References

    1.Shimura M, Yasuda K. Topical bromfenac reduces the frequency of intravitreal bevacizumab in patients with branch retinal vein occlusion. Br J Ophthalmol. 2015 Feb;99(2):215-9.

    2. Gunther JB, Altaweel MM. Bevacizumab (Avastin) for the treatment of ocular disease. Surv Ophthalmol 2009;54:372-400. 3.Fujikawa, Masato et al. Correlation between Vascular Endothelial Growth Factor and Nonperfused Areas in Macular Edema Secondary to Branch Retinal Vein Occlusion. Clinical Ophthalmology (Auckland, N.Z.) 7 (2013): 1497- 1501. 4.Noma H, Funatsu H, Yamasaki M, et al. Pathogenesis of macular edema with branch retinal vein occlusion and intraocular levels of vascular endothelial growth factor and interleukin-6. Am J Ophthalmol. 2005;140:256 -261.

    Conflict of Interest:

    None declared

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  3. Is larger endothelial graft size appropriate for Fuchs endothelial dystrophy?

    We read with interest the results reported by Romano et al. The authors speculated the reason for lower endothelial failure in larger grafts (9.5mm) compared to smaller ones is due to the additional endothelial cells being transplanted.

    It has been reported that the host peripheral endothelium in Fuchs endothelial dystrophy (FED) has some capacity towards restoring corneal deturgescence in denuded posterior stroma where the Descemet membrance endothalial keratoplasty (DMEK) did not attached.(1,2) This observation was seen in all 7 eyes with FED that had partial graft detachment but not in any of the 5 eyes with aphakic or pseudophakic bullous keratopathy (PBK).(1) In an eccentrically positioned DMEK, the area between the edge of the descemetorhexis and the edge of the graft often showed faster clearance in a fashion that starts from the recipient endothelium edge towards the graft.(2) In fact, this gap clears faster than the area over the attached DMEK.(2)

    The above findings suggest the peripheral endothelium in FED may have migrated to cover the bare posterior stroma. Interestingly, the peripheral endothelium may have regenerative capacity as the endothelium cell density (ECD) appeared similar in the repopulated area and in eyes with completed attached graft.(2)

    To accommodate a larger endothelial graft, the surgeon is likely to perform a larger descemetorhexis, hence removing more of the host's peripheral endothelium. Should some of latter remains, a large graft is likely to overlap hence damage the cells. Whether one should always aim to insert a larger graft in eyes with FED requires more thoughts.

    In their study, Romano et al mentioned that graft failure is associated with ECD and graft size. One wonders whether there is an association between failure with combined graft size and diagnosis (PBK/FED).

    1) Dirisamer M, Yeh RY, van Dijk K, Ham L, Dapena I, Melles GRJ. Recipient endothelium may relate to corneal clearance in Descemet membrane endothelial transfer. Am J Ophthalmol 2012; 154: 290-296. 2) Dirisamer M, Dapena I, Ham L, van Dijk K, Oganes O et al. Patterns of endothelialization and corneal clearance after Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy. Am J Ophthalmol 2011; 152: 543-555.

    Conflict of Interest:

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  4. Clinical features and treatment outcome of canaliculitis associated with the use of Smartplug

    Dear Editor; We read with great interest the article entitled "Prevalence of canaliculitis after smartplug insertion during long-term follow-up" by Klein-Theyer et al.(1) I would like to contribute to the article with our clinical expeience.

    Among 11 cases of canaliculitis after lacrimal plug insertion between 2007 and 2013 in a tertiary medical center, seven cases (64%) were noted to be associated with the use of Smartplug. All these patients were women with a mean age of 53-year-old. This propensity could be related to hormonal influence during menopause,(2) use of makeup,(3) or female predominance of dry eye requiring lacrimal plug insertion. The average time interval from plug insertion to the onset of symptoms was 4.7 years, which is in consistent with most published studies.(1) This means that the prevalence of lacrimal-plug canaliculitis may be underestimated if follow- up is not really long enough. The most common isolated microorganism in our study was Pseudomonas aeruginosa(29%), followed by Actinomyces(14%) and Staphylococcus aureus(14%). All canaliculitis resolved after canaliculotomy with removal of plug, and there was no recurrence was noted during a mean post-operative follow-up period of 11 months. In the study by Klein-Theyer and colleagues, the canaliculitis was resolved by topical antibiotics and "repeated" lacrimal irrigations, and one of them with persistent canaliculitis finally required canaliculotomy. Although they did not find any plug in the lacrimal drainage system by high-resolutional ultrasound, physicians should always keep in mind that lacrimal irrigation may cause dislodgement of an inflamed plug into the deep lacrimal drainage system, inciting infection or permanent blockage of the lacrimal drainage passages.(4) Canaliculotomy with removal of plug may be an effect and safe treatment option for these patients.

    References

    1. Klein-Theyer A, Boldin I, Rabensteiner DF, Aminfar H, Horwath- Winter J. Prevalence of canaliculitis after smartplug insertion during long-term follow-up. Br J Ophthalmol. 2015 Feb 26. pii: bjophthalmol-2014- 306290. doi: 10.1136/bjophthalmol-2014-306290.

    2. Struck HG, H?hne C, Tost M. Diagnosis and therapy of chronic canaliculitis. Ophthalmologe. 1992; 89: 233-236.

    3. Brazier JS. Hall V. Propionibacterium propionicum and infections of the lacrimal apparatus. Clin Infect Dis. 1993; 17: 892-893.

    4. SmartPlug Study Group. Management of complications after insertion of the SmartPlug punctal plug: a study of 28 patients. Ophthalmology. 2006 Oct;113(10):1859.e1-6.

    Conflict of Interest:

    None declared

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  5. Video glass based vision testing for Home / School vision testing may make testing complete

    Vision testing is a very tedious process. If a complete testing including contrast testing,colour testing,amsler test,glare test,speed of reading and other tests are undertaken it may take a lot of time.It is a reality that even today visual acuity testing alone is the deciding factor for undertaking cataract surgery. It has been noted by some authors that lack of government-funded routine eye examinations is associated with a reduced incidence of self-reported glaucoma and cataracts, probably due to reduced detection rates (1) this only means that some method of home testing may be essential.It is also possible that many kids would not go blind due to amblyopia if vision was to be tested .So it may be useful to test vision at home or school, which can be reported to the eye surgeon. Some authors have envisaged a lay person administered vision test which may be valid for identifying amblyopia in a controlled environment thus making a cost-effective and easily accessible vision screening performed by lay people a reality (2). A school vision screening program involving only school teachers was found to have resulted in more efficient screening than a program including professionals with the costs being a third of what would have been spend and it was found to also improve compliance with regards to hospital referral (3). Many authors have tried mobile app based methods for vision and concluded that while the results are not interchangeable with paper-based charts, mobile app tablet-based tests of reading speed are reliable and rapid to perform, with the potential to capture functional visual ability in research studies and clinical practice(4). Such apps can be easily incorporated into video glasses routinely used by children in video games.

    We used a video glass available for playing video games and projected vision charts at an appropriate distance into the glass and tested vision at home. The fact that the glass had covers on the side, nullified the effect of ambient light. Also some homes in India may be actually cubicles and so may not have the requisite distance for testing and so in such cases a mobile app based visual testing with charts projected into the video glass helps in such situations. Following the ease of testing and the improved ability of patients or care takers who are now being able to test vision at home; different aspects of vision are now being tested by patients or care takers. When this becomes more common even eye surgeons will begin to do more tests.

    References:-

    1) Chan CH, Trope GE, Badley EM, Buys YM, Jin YP. The impact of lack of government-insured routine eye examinations on the incidence of self- reported glaucoma, cataracts, and vision loss. Invest Ophthalmol Vis Sci. 2014 Dec 9;55(12):8544-9. doi: 10.1167/iovs.14-15361. 2) Longmuir SQ, Pfeifer W, Shah SS, Olson R. Validity of a layperson- administered Web-based vision screening test. J AAPOS. 2015 Feb;19(1):29- 32. doi:10.1016/j.jaapos.2014.10.021 3) Priya A, Veena K, Thulasiraj R, Fredrick M, Venkatesh R, Sengupta S, BassettK. Vision screening by teachers in southern Indian schools: testing a new "all class teacher" model. Ophthalmic Epidemiol. 2015 Feb;22(1):60- 5. doi:10.3109/09286586.2014.988877. 4) Kingsnorth A, Wolffsohn JS. Mobile app reading speed test. Br J Ophthalmol.2014 Oct 29. pii: bjophthalmol-2014-305818. doi:10.1136/bjophthalmol-2014-305818.

    Conflict of Interest:

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  6. Indirect ophthalmoscope , will it get replaced by smart phones in some settings?- Serial video recording of retinal conditions in ICCU setting with indirect ophthalmoscopy with inexpensive smart phones

    Indirect ophthalmoscopy has advanced since its inception. We now recognize the importance of video imaging of the retina. Authors deviced various slit lamp adaptors to capture retinal image(1) Many authors have used smartphones coupled with indirect ophthalmoscopy and some even identified an iPhone application that can control the flash and reduce the intensity to levels that do not damage the retina.(2,3,4,5)

    Some authors described a lightweight, compact, user-friendly, 3D printed attachment which enabled high quality fundus photos achieved by coupling smartphones to indirect ophthalmoscopy lens. (6)

    In January 2013, the FDA approved the iExaminer (Welch Allyn), the first smartphone-based imaging adaptor system that attaches an iPhone 4 (Apple Inc, Cupertino, CA) to Welch Allyn's Panoptic Ophthalmoscope to capture images of the retina in combination with the iExaminer App.(7)

    But all of the methods with adapters and iPhones are expensive or bulky and impossible to use in ICCU setting.

    We used a blackberry Z 3 mobile phone to capture serial video recordings of cases in ICCU setting in patients on ventilator support and recorded various cases like Terson's syndrome and papillodema and other retinal conditions that need serial follow up. The smartphone allowed us to use 1080 p HD recording and the autofocus and ambient light sensors in recent cameras as well as the other features allow better evaluation of the retina.

    The audio video combine recording allows for simultaneous commentary too which is important for Medical records and to save time in ICCU setting. The audio and video format supported are 3GP, 3GP2, M4A, M4V, MOV, MP4, MKV, MPEG-4, AVI, ASF, WMV, WMA, MP3, MKA, AAC, AMR, F4V, WAV, AWB, OGG, FLAC and these allow viewing in any setting,transfer over any media and storage and editing with ease so as to create a time compressed view of the condition for patient education and counselling.

    The blackberry at a cost of Indian currency of 13,000 rupees is a very cheap piton for such video recording of the retina. It was very easy to train ICU residents and the ability to transfer data through encrypted messengers like Telegram allows for excellent management of such patients in the follow up period especially in ICCU setting in rural areas where Superspeciality may not be available round the clock in a country like India. The ease with which even residents and non ophthalmologists can acquire images and transfer the images ,makes smart phones replace indirect ophthalmoscopes in these settings. Besides the use of these methods by those screening for diabetic retinopathy in rural outreach settings makes it all the more exciting.The ability to see the video in slow motion allows for better screening as well as in better assessment in telepath alkaloid from rural areas as has been our experience.

    Considering all these developments the traditional indirect ophthalmoscope may need to be modified and made less expensive and less bulkier and easier to use and learn even in emergency rooms and ICCU settings to withstand the competition from smart phones.

    References:- 1) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 2) Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology 2010;117(6):1274. e3 3) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 4) Haddock LJ, Kim DY, Mukai S. Simple, Inexpensive Technique for High- Quality Smartphone Fundus Photography in Human and Animal Eyes. Journal of Ophthalmology 2013;2013. http://dx.doi.org/10.1155/2013/518479 5) Chhablani J, Kaja S, Shah VA. Smartphones in ophthalmology. Indian J Ophthalmol 2012;60(2):127 6) David Myung, Alexandre Jais, Lingmin He.Mark S. Blumenkranz, Robert T. Chang, 3D Printed Smartphone Indirect Lens Adapter for Rapid, High Quality Retinal Imaging. Journal MTM 3:1:9-15, 2014 7) Teichman JC, Sher JH, Ahmed IIK. From iPhone to eyePhone: A technique for photodocumentation. Canadian Journal of Ophthalmology/Journal Canadien d'Ophtalmologie 2011;46(3):284-6.

    Conflict of Interest:

    None declared

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  7. Endoscopic suturing of flaps in endonasal DCR with stenting further improves results

    Endoscopic suturing of lacrimal sac flap to the nasal mucosa flap in Dacryocystorhinostomy ( DCR) was described by us as early as 2004 and a video of the procedure was published in textbook of oculoplasty (1) The audits done showed that the short term results were excellent and the only concern was the time taken to do the surgery. Three years later another paper described excellent results with suturing of the flaps and it was reported to have a primary success rate of 96 percent and ultimate success rate of 100 percent and the authors contemplated replacement of external DCR with endonasal DCR (2) Traumatic Dacryocystitis has been treated often by external DCR and some authors have suggested external DCR with stenting in such cases (3) We have noted in our audits that doing an endonasal DCR with suturing of the flaps and stenting both leads to 100 percent results even in cases with trauma where in there is Dacryocystitis with coexisting orbital fracture too. The endoscopy procedure does not disturb the lacrimal pump and the suturing of the flap causes healing by primary intention and makes the procedure 100 percent successful especially when combined with stents.

    Reference

    1) Sunil Moreker, Sneha K, Kirtane MV, Mankekar G. Endoscopic Dacrocystorhinostomy :Recent advances. Oculoplasty and reconstructive surgery , Jaypee publications 2010, page 286 2) Kirtane MV, Lall A, Chavan K, Satwalekar D. Endoscopic dacryocystorhinostomy with flap suturing. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl):236-41. doi: 10.1007/s12070-011-0354-z. 3) Rizvi SA, Sharma SC, Tripathy S, Sharma S. Management of traumatic Dacryocystitis and failed dacryocystorhinostomy using silicone lacrimal intubation set. Indian J Otolaryngol Head Neck Surg. 2011 Jul;63(3):264-8. doi:10.1007/s12070-011-0230-x.

    Conflict of Interest:

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  8. Re: Intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series

    Dear Editor; I have read the article entitled "Intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series" by Kalaiselvi et al. with interest.1 The authors investigated the efficacy of intrastromal voriconazole injection in the management of deep recalcitrant fungal keratitis and found it safe and effective. I would like to contribute to the article in terms of clinical practice.

    The authors' choice was voriconazole as an antifungal agent, and it seems reasonable because of its' safety and potency on various fungal species especially aspergillus spp. On the other hand, itraconazole could also be studied due to a distinct characteristic of it. Goktas et al. revealed that itraconazole can reduce corneal neovascularization.2 Recalcitrant corneal infections usually result in corneal scars and sometimes corneal neovascularizations. Therefore; intrastromal administration of itraconazole would be more beneficial in which cases the infectious agents are found sensitive to itraconazole.

    Zeng et al. have recently reported that amniotic membrane covering (AMC) may enhance cornea epithelial regeneration after debridement of fungal keratitis.3 I suppose that AMC could be helpful alone or in combination with intrastromal administration of antifungal agents. It will promote wound healing, support corneal integrity and decrease the risk of perforation due to such persistent fungal infections.

    Conflict of Interest:

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  9. Ranibizumab for neovascular AMD in eyes with good baseline visual acuity.

    We read with interest and congratulate Lee et al1 on publishing the largest study to date on visual outcomes reported upto 36 months, with intravitreal ranibizumab treatment for neovascular age related macular degeneration (AMD). However we do not agree with their conclusion that this is the first publication to focus on the visual outcomes on this subgroup of patients, excluded from treatment by the NICE UK criteria. Our group2 was the first to publish, in this journal, the 12-month treatment outcomes in a retrospective small case series of fourteen patients. Subsequently, Williams and Blyth3 reported the outcomes from Wales, UK. Other investigators have published good treatment outcomes with earlier treatments at good baseline visual acuity 4,5. Surprisingly, none of these investigators seem to have been acknowledged or referenced in the discussion section by Lee et al1. We agree with the authors that earlier treatment in neovascular age related macular degeneration has the potential to maintain good visual function for longer duration and await the cost effectiveness analysis the authors wish to publish in future. Clinical experience and logic does dictate that once there is clinical and/or OCT based imaging evidence of disease activity in neovascular age related macular degeneration, commencing treatment earlier rather than waiting for visual acuity to deteriorate to 6/12 and below, is the best course of action. REFERENCES

    1. Lee AY, Lee CS, Butt T , et al. UK AMD EMR USERS GROUP REPORT V : benefits of initiating therapy for neovascular AMD in eyes with vision better than 6/12. Br J Ophthalmol. 2015 Feb 13. Pii:bjophthalmol-2014- 306229. Doi: 10.1136/bjophthalmol-2014-306229. Epub ahead of print.

    2. Raja MS, Saldana M, Goldsmith C, Burton BJ: Ranibizumab treatment for neovascular age- related macular degeneration in patients with good baseline visual acuity (better than 6/12): 12-month outcomes. Br J Ophthalmol 2010; 94:1543-1545.

    3. Williams TA, Blyth CP: Outcome of ranibizumab treatment in neovascular age related macular degeneration in eyes with baseline visual acuity better than 6/12. Eye (Lond) 2011;25:1617-1621.

    4. Saito M, Iida T, Kano M: Intravitreal ranibizumab for exudative age-related macular de- generation with good baseline visual acuity. Retina 2012;32:1250-1259.

    5. Kato A, Yasukawa T, Suga K, et al. Intravitreal ranibizumab for patients with neovascular age related macular degeneration with good baseline visual acuity. Ophthalmologica . 2015;233(1):27-34.

    Conflict of Interest:

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  10. Prevalence of canaliculitis after smartplug insertion during long-term follow-up

    In the recently published study by Klein-Theyer and colleagues, the authors conducted a retrospective case series study to evaluate the number of eyes (and patients) that develop canaliculitis over time after having SmartPlugs inserted into the eye for underlying dry eye syndrome. The authors described the measure of disease occurrence as prevalence; however, this is incorrect. Prevalence is the proportion of the population that has the disease at a particular time. In this study, disease-free eyes were followed over time to determine the occurrence of new cases of canaliculitus during the observation period. This describes a measure of incidence, not prevalence. This error has implications for the appropriate interpretation of the observed results. The authors reported a cumulative probability of the event during the observation period; however, this assumes none of the patients had been lost to follow -up. Patients were followed for a median of 7.9 years, which means some of the patients were censored and their limited participation must be accounted for in the denominator. Therefore, an incidence rate based on person-time should have been calculated. Authors are strongly encouraged to conduct a reanalysis of their study data and provide readers with the appropriate measure of incidence, amending their interpretation as warranted.

    Conflict of Interest:

    None declared

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