eLetters

666 e-Letters

  • COVID-19 and immunosuppression in ophthalmic disorders

    The review article by Thng ZX, De Smet MD, Lee CS, et al 1highlights the most intriguing aspects on use of immunosuppressants during and post COVID-19 pandemic. The authors have presented evidences based on various reports in a very well-structured manner and we would like to first thank and congratulate the authors for their work. The review covers the wide range of faculties of medicine where immune suppression is likely to be the main stay of treatment. At the same time, they have also very neatly presented with the “clear cut “ guidelines on the dosing of these various medications at different scenarios and patient status.

    While the article additionally covers the following aspects very well ;

    1) Does the use of immunosuppressive present as an independent risk factor for contracting COVID -19 in patients under them?
    2) Does it affect the severity of COVID -19 ?

    We have few inquiries to make to the authors regarding the use of immunosuppressive in ophthalmology during this difficult time.

    The authors have used the term “high dose steroids” in their article. Firstly, we are curious to understand what would be the considered the criteria to define a “high dosage” of steroid in ophthalmology. From our understanding, it depends upon the class of steroid used and the body weight2 but should we also need to consider the duration of use and cumulative dosage over a stretch of time to define it?

    Also, referring to various public...

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  • RE : Chi et al : Selective Laser Trabeculoplasty Versus Medication for Open-Angle Glaucoma: Systematic Review and Meta-Analysis of Randomised Clinical Trials

    We read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
    The recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
    The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
    The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
    It is ri...

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  • Retinal involvement in Covid-19 would probably be missed.

    Dear Editor,
    We have read the clinical case report entitled “Ocular manifestations of a patient hospitalized with a new coronavirus disease confirmed in 2019” by Chen L, et al.1 We congratulate the authors for this important work and wish to share our comment concerning the retinal findings. The authors indicated that Spectral-domain optical coherence tomography (SD-OCT) imaging was normal in both eyes. However, we would like to highlight the presence of hyper-reflective focal points at the level of the internal plexiform layer (IPL) and the ganglion cell layer (GCL). The report later published by Marinho PM, et al. in Lancet on May 12, 2020 "Retinal findings in patients with COVID-19" described the presence of focal hyperreflective dots at the IPL and GCL levels in all patients (24 eyes of 12 patients), which was the first report of SD-OCT retinal abnormalities in patients with COVID 19.2 We compared the two SD-OCT images published by Chen L, et al. to those published by Marinho PM, et al. All images were reviewed by two different retina specialists (NM, RTJH), and our analysis was strongly consistent. We have implemented the algorithm using the Python script3 to adjust the size and resolution of the images, and flipped the C by Marinho PM, et al. using fovea as the reference to obtain comparable images. We overlaid the images published by Chen L, et al. with those published by Marinho PM, et al. We were able to demonstrate that the hyperreflective lesions...

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  • Cat scratch disease retintis on spectral domain optical coherence tomography

    Dear Editor,

    We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.

    In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.

    We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.

    The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with...

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  • Neoadjuvant Vismodegib plus Mohs Surgery for Locally Advanced Periocular Basal Cell Carcinoma

    Dear Editor,
    We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.1
    The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
    The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
    We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
    Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
    Several authors discussed thi...

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  • Response to the e-letter to editor by Bonnet et al on “The Central corneal basal cell density and nerve parameters in ocular surface disease and limbal stem cell deficiency: a review and meta-analysis”.

    To the Editor,

    We appreciate the authors' interest in our study. In their letter to the editor regarding our meta-analysis[1], the authors raise an issue regarding the inclusion of the diseases in the two groups i.e. limbal stem cell deficiency (LSCD) and ocular surface disease (OSD). We adhered to the categorization of the diseases as indicated or mentioned in the publications which were included in the meta-analysis. Our literature search based on combinations of various “key-words” or “key-terms” returned results as depicted in the categorization of the diseases in the study.[2,3] LSCD being a sub-set of OSD, has signs and symptoms in common with many other conditions, hence it was important that the term “limbal stem cell deficiency” appeared in the publications for the study participants to be categorized into the LSCD group.[2,3,4]

    The lack of consideration of the severity of LSCD and OSD was unavoidable due to the limited data within the source publications. It is apparent that the severity of the disease may affect the corneal epithelial basal cell density (BCD) and nerve fibre parameters.[5,6] The lack of data is likely explained by the difficulty in imaging in the more severe disease when corneal transparency is reduced; the corneal basal cells and nerves are difficult to image using confocal microscopy when the cornea is not clear. This is an important factor which is highlighted in our study.[1] Furthermore, our analysis did not attempt to c...

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  • Comments on “Long-term functional outcomes of different subtypes of primary congenital glaucoma”

    Dear Editor,

    We read the article published by Chaudhary, et al (1) with great interest and laud them on the quality and design of their study. Primary congenital blindness (PCG) poses a challenge to clinicians, both in terms of diagnosis, and treatment. (2)

    We would like to bring to the authors’ notice a similar study conducted in 2017 (3) of 230 eyes of 121 PCG patients having undergone a primary CTT. This study differed from the present study in the fact that it had a longer average follow-up period of 28.87 years with a more concentrated follow-up range of 21.5-38 years. There were also two main differences in the findings of the two studies.

    Contrary to the results in the present study where the infants with PCG fared better than the neonates (48.9% >6/60), the previous study found that 76.3% newborns with PCG had a vision better than 6/60. Additionally, the previous study, found visual acuity to be better than 6/60 in a greater proportion of patients (76.1%) at the last follow-up, as compared to the proportion in the study by Chaudhary et al (55.3%). Applying the WHO recommendation of measuring vision in the better eye, (4) the results improved to 89.3% in the study by Sood et al. (3)

    A possible reason for these disparities between the studies could be the difference in presentation times of the patients and the study inclusion criteria. While the present study reports late presentation, over half of the patients (53%) in the earlier pub...

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  • Keratoconus in Down syndrome: A diagnostic dilemma

    The recent study by Vega-Estrada et al highlights some of the challenges in diagnosing keratoconus in Down syndrome (DS).[1] Previous studies have shown that the cornea of individuals with DS without evidence of keratoconus appear to be steeper and thinner than the general population, both being features characteristic of keratoconus.[2] Vega-Estrada et al further identified that posterior keratometry was similar in DS to mild keratoconus, however, a lesser degree of posterior elevation was observed in the DS group.[1] This may be related to the younger mean age of the cohort with DS, small sample size or diagnostic criteria. The authors concluded that the corneal features analysed in the DS cohort were in the range of normal to mild keratoconus.[1]

    We would like to further highlight some of the challenges associated with image acquisition when performing corneal topo/tomography in patients with DS. Some of the ophthalmic manifestations such as slanted and small palpebral apertures, nystagmus and strabismus can affect fixation. We have also observed additional common behavioural responses that affect fixation and alignment; patients squeezing the eyes shut in response to the examiner touching the eyelids or involuntarily opening the mouth when asked to keep the eyes wide open.

    Misaligned fixation while acquiring corneal tomography images is known to result in false keratoconus features.[3] In addition to the reported overlap in corneal features in DS and ke...

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  • Repeatability of automated leakage quantification and microaneurysm identification ‎utilising an analysis platform for ultra-widefield fluorescein angiography. Avoid ‎misinterpretation

    Synopsis:‎
    Applying Pearson r to assesses the repeatability of a test is a methodologic mistake which leads to ‎misinterpretation.‎

    Repeatability of automated leakage quantification and microaneurysm identification ‎utilising an analysis platform for ultra-widefield fluorescein angiography. Avoid ‎misinterpretation
    Dear editor, We were interested to read the paper by Jiang A et al. published in Apr 2020 edition of the ‎Br J Ophthalmol.1 Ultra-wide field fluorescein angiography (UWFA) provides unique opportunities for ‎panretinal assessment of retinal diseases. The objective quantification of UWFA features is a labour-intensive ‎manual process, limiting its utility. The authors aimed to assesses the consistency/repeatability of an automated ‎assessment platform for the characterization of retinal vascular features, quantification of microaneurysms (MA) ‎and leakage foci in UWFA images. For each eye, two arteriovenous-phase images and two late-phase images ‎were selected. Automated assessment was performed for retinal vascular features, MA identification and ‎leakage segmentation. Panretinal and zonal assessment of metrics was performed. The authors mentioned a ‎significant correlation between paired time points for retinal vessel area and vessel length on early images ‎‎(Pearson r=0.92, p<0.0001; Pearson r=0.94, p<0.0001) and late images (Pearson r=0.92, p<0.0001; Pearson ‎r=0.92, p<0.0001, respectively). Panretinal and zonal MA counts demonst...

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  • Comment on Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease

    At the outset, we would like to congratulate the authors for determining the presence of the viral RNA over time in conjunctival specimens of a patient with COVID-19, which was much needed.
    The clinical course of viral conjunctivitis is self-limiting. Usually only supportive treatments like cold compress, artificial tears and topical steroids are given. The time duration taken for symptoms to subside without treatment ranges from 4-6 days to 2-3 weeks, depending upon the type of disease.[1] Clinical studies regarding the usage of antivirals for conjunctivitis reveal that they were effective only for DNA viruses and was not free of toxicity.[2]
    In the case report regarding ocular manifestation of patient with 2019 novel corona virus disease,[3] the ocular symptoms of patient resolved after 5 days of its onset and the author claims it to be possibly due to treatment with ribavirin eye drops. As Corona virus is a RNA virus, we believe that antiviral therapy would have been limited use. Adequate corneal tissue levels of antiviral agents are achieved by both topical and systemic administration.[4] If antiviral therapy was the reason for improvement of ocular symptoms, the patient was on three oral antiviral drugs (Umifenovir, lopinavir and ritonavir) in addition to topical ribavirin. Therefore, attributing only topical ribavirin for curing ocular symptoms may not be appropriate with the limited evidence.
    The authors also had mentioned that sterile synthetic f...

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