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We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of these services will make for more efficient productivity at referral centers, and the patients will avoid having to spend the time and expense to travel to secondary and tertiary centers for basic eye care.3 Practical training of primary care providers is needed to ensure the transfer of skills, but for this training to have long-term impact on service delivery, primary health centers need to be properly equipped and training programs need to be well integrated into the health systems and, in particular, the referral networks, to ensure that patients with more serious conditions are accessing specialists.3-5
Health systems, therefore, need to have adequate financing available, but the costs of universal eye health are a barrier to remote and resource-limited communities in nearly all countries. For example, the burden of out-of-pocket costs of cataract surgery hits the middle-class populations of higher income countries the hardest.6 Innovative, cost-effective solutions must be employed to better tailor the universal access of eye care to a local population. In developing countries, the provision of phacoemulsification and the maintenance of the required equipment are too expensive for most of the patients and facilities. In these settings, manual small-incision cataract surgery (MSICS) is the more appropriate surgical technique, having the same advantages of phaco in terms of outcomes and faster surgical time and recovery, but MSICS also has a shorter learning curve and drastically lower costs.7-9
At the primary care level, cost-effective technology, such as the use of artificial intelligence and smart phones in telemedicine for the purposes of examination and diagnosis, appears to be an appropriate solution to overcoming financial barriers, again saving patients both the time and the expense of traveling to secondary and tertiary care centers.10-13 The diagnostic accuracy of telemedicine models has been validated; however, for the models to work, attention is again placed on the referral network, which has to be strengthened to be able to manage the increase in caseload.12
References
1. Resnikoff S, Lansingh VC, Washburn L, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology Update): will we meet the needs? Br J Ophthalmol 02 July 2009. doi:10.1136/bjophthamol-2019-314336 [Epub ahead of print]
2. World Health Organization. Universal eye health: a global action plan 2014–2019. [A66/11 – 28 March 2013]. 2013. Available: http://www.who.int/blindness/EyeHealthActionPlanWHA66.pdf. [Accessed September 5, 2019].
3. Mafwiri MM, Jolley E, Hunter J, Gilbert CE, Schmidt E. Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania. BMC Nurs 2016;15:41.
4. Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Serv Res 2017;17(1):823.
5. Yip JLY, Bright T, Ford S, Mathenge W, Faal H; Rwanda Primary Eye Care Process evaluation group. Process evaluation of a National Primary Eye Care Programme in Rwanda. BMC Health Serv Res 2018;18:950.
6. Lansingh VC, Carter MJ, Eckert KA, Winthrop KL, Furtado JM, Resnikoff S. Affordability of cataract surgery using the Big Mac prices. Rev Mex Oftalmol 2015;89:21–30.
7. Singh K, Misbah A, Saluja P, Singh AK. Review of manual small-incision cataract surgery. Indian J Ophthalmol 2017;65:1281–88.
8. Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. Middle East Afr J Ophthalmol 2015;22:362–9.
9. Ruit S, Gurung R, Vyas S. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol 2018;29:105–9.
10. Delgoshaei B, Mobinizadeh M, Mojdekar R, Afzal E, Arabloo J, Mohamadi E. Telemedicine: a systematic review of economic evaluations. Med J Islam Repub Iran 2017;31:113.
11. Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol 2015;99:823–31.
12. Wong TY, Sabanayagam C. Strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence. Ophthalmologica. 2019 Aug 13:1-12. doi: 10.1159/000502387. [Epub ahead of print]
13. Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017;10:1909–18.
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge in ophthalmology. Over the years, the number of doctors unsure in dealing with the most basic eye problems increases. Therefore, we should focus on basic ophthalmology education so that doctors working in the primary care of the population can routinely refer patients to ophthalmologists.
The use of artificial intelligence may be another alternative that can identify ophthalmic diseases with as good accuracy as experts. Artificial intelligence algorithms can be used in telemedicine programs to serve populations of countries that have an irregular distribution of ophthalmologists on their territory, facilitating access to eye examinations with consequent early identification of disease.3
REFERENCE
1. Resnikoff S, Lansingh VC, Washburn L, Felch W, Gauthier TM, Taylor HR, Eckert K, Parke D, Wiedemann PEstimated number of ophthalmologists worldwide (International Council of Ophthalmologyupdate): will we meet the needs? Br J Ophthalmol. 2019 Jul 2. pii: bjophthalmol-2019-314336.
2. Quillen DA, Harper RA, Haik BG. Medical student education in ophthalmology: Crisis and opportunity. Ophthalmology. 2005;112(11):1867–8.
3. Surendran TS, Raman R. Teleophthalmology in diabetic retinopathy. J
Diabetes Sci Technol. 2014; 8: 262-6.
I read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Study Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60 ...
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Study Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60
MSRE = manifest spherical refractive equivalent; D = diopters;
The conclusion of this study is that both SMILE and FS-LASIK were safe and equally effective for myopic and astigmatic correction. Short -term studies have reached similar conclusions, and no long-term studies show that FS-LASIK has better refractive outcomes than SMILE.2, 6
In this study, the Visumax system was used to make corneal flaps. While different machines may have different refractive outcomes, studies have reported that the Vismax and Intralase system have similar refractive results.7, 8 Moreover, a large number of basic and clinical studies comparing SMILE and FS-LASIK also used the same platforms (as in our study). 9-13 We also look forward to the comparison of SMILE and FS-LASIK with other platforms, but this does not affect the significance of our research.
We appreciate this opportunity to clarify these questions.
References
1. Han T., Xu Y., Han X., Zeng L., Shang J., Chen X. and Zhou X. Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism. Br J Ophthalmol. 2019;103:565-568.
2. Kobashi H., Kamiya K., Igarashi A., Takahashi M. and Shimizu K. Two-years results of small-incision lenticule extraction and wavefront-guided laser in situ keratomileusis for Myopia. Acta Ophthalmol. 2018;96:e119-e126.
3. Alio J. L., Muftuoglu O., Ortiz D., Perez-Santonja J. J., Artola A., Ayala M. J., Garcia M. J. and de Luna G. C. Ten-year follow-up of laser in situ keratomileusis for myopia of up to -10 diopters. Am J Ophthalmol. 2008;145:46-54.
4. Zalentein W. N., Tervo T. M. and Holopainen J. M. Seven-year follow-up of LASIK for myopia. J Refract Surg. 2009;25:312-318.
5. O'Doherty M., O'Keeffe M. and Kelleher C. Five year follow up of laser in situ keratomileusis for all levels of myopia. Br J Ophthalmol. 2006;90:20-23.
6. Xia L. K., Ma J., Liu H. N., Shi C. and Huang Q. Three-year results of small incision lenticule extraction and wavefront-guided femtosecond laser-assisted laser in situ keratomileusis for correction of high myopia and myopic astigmatism. Int J Ophthalmol. 2018;11:470-477.
7. Rosman M., Hall R. C., Chan C., Ang A., Koh J., Htoon H. M., Tan D. T. and Mehta J. S. Comparison of efficacy and safety of laser in situ keratomileusis using 2 femtosecond laser platforms in contralateral eyes. J Cataract Refract Surg. 2013;39:1066-1073.
8. Ang M., Mehta J. S., Rosman M., Li L., Koh J. C., Htoon H. M., Tan D. and Chan C. Visual outcomes comparison of 2 femtosecond laser platforms for laser in situ keratomileusis. J Cataract Refract Surg. 2013;39:1647-1652.
9. Dong Z., Zhou X., Wu J., Zhang Z., Li T., Zhou Z., Zhang S. and Li G. Small incision lenticule extraction (SMILE) and femtosecond laser LASIK: comparison of corneal wound healing and inflammation. Br J Ophthalmol. 2014;98:263-269.
10. Riau A. K., Angunawela R. I., Chaurasia S. S., Lee W. S., Tan D. T. and Mehta J. S. Early corneal wound healing and inflammatory responses after refractive lenticule extraction (ReLEx). Invest Ophthalmol Vis Sci. 2011;52:6213-6221.
11. Ang M., Ho H., Fenwick E., Lamoureux E., Htoon H. M., Koh J., Tan D. and Mehta J. S. Vision-related quality of life and visual outcomes after small-incision lenticule extraction and laser in situ keratomileusis. J Cataract Refract Surg. 2015;41:2136-2144.
12. Liu M., Chen Y., Wang D., Zhou Y., Zhang X., He J., Zhang T., Sun Y. and Liu Q. Clinical Outcomes After SMILE and Femtosecond Laser-Assisted LASIK for Myopia and Myopic Astigmatism: A Prospective Randomized Comparative Study. Cornea. 2016;35:210-216.
13. Hou J., Wang Y., Lei Y. and Zheng X. Comparison of effective optical zone after small-incision lenticule extraction and femtosecond laser-assisted laser in situ keratomileusis for myopia. J Cataract Refract Surg. 2018;44:1179-1185.
We have read with interest the article by Han et al.,1 in which the authors compare the outcomes of myopia correction using small incision lenticule extraction (SMILE) versus laser in situ keratomileusis (LASIK) using the VisuMax® femtosecond laser (FS) to cut the corneal flap, and we have some concerns regarding this study we would like to share with the authors.
It is noteworthy that the authors found that only 65% of eyes were within ± 0.50 diopters of the attempted spherical equivalent correction after FS-LASIK, these results are clearly worse that those generally obtained with LASIK. It is accepted that the results obtained with excimer laser ablation, either using a surface ablation approach, or LASIK performed with mechanical microkeratome (MK) or using the Intralase® FS platform to correct myopia are quite similar.2,3 Indeed, our group has that 95% of unselected eyes with myopia of -3.9±1.5D3 and 80% of eyes with high myopia (-8.7±1.2D)4 were within ± 0.5D of emmetropia after LASIK. For this reason, we believe that the main conclusion of the article by Han et al.1 that “long-term outcomes of both SMILE and FS-LASIK are safe and equally effective for myopic and astigmatic correction” is clearly biased. In other words, the results of SMILE should have not been compared with a FS laser platform that does not seem to achieve the benchmark results clearly established for LASIK when correcting myopia.
It should be highlighted that different FS platforms appr...
We have read with interest the article by Han et al.,1 in which the authors compare the outcomes of myopia correction using small incision lenticule extraction (SMILE) versus laser in situ keratomileusis (LASIK) using the VisuMax® femtosecond laser (FS) to cut the corneal flap, and we have some concerns regarding this study we would like to share with the authors.
It is noteworthy that the authors found that only 65% of eyes were within ± 0.50 diopters of the attempted spherical equivalent correction after FS-LASIK, these results are clearly worse that those generally obtained with LASIK. It is accepted that the results obtained with excimer laser ablation, either using a surface ablation approach, or LASIK performed with mechanical microkeratome (MK) or using the Intralase® FS platform to correct myopia are quite similar.2,3 Indeed, our group has that 95% of unselected eyes with myopia of -3.9±1.5D3 and 80% of eyes with high myopia (-8.7±1.2D)4 were within ± 0.5D of emmetropia after LASIK. For this reason, we believe that the main conclusion of the article by Han et al.1 that “long-term outcomes of both SMILE and FS-LASIK are safe and equally effective for myopic and astigmatic correction” is clearly biased. In other words, the results of SMILE should have not been compared with a FS laser platform that does not seem to achieve the benchmark results clearly established for LASIK when correcting myopia.
It should be highlighted that different FS platforms approved for LASIK have been shown to obtain different refractive results, even using the same excimer laser.5 Thus, we do believe that the sound validation of new technology (SMILE) needs the comparison with the “benchmark” i.e. the results obtained with the “gold standard”, which is excimer ablation, in this case FS-LASIK performed with the Intralase.®
REFERENCES
1. Han T, Xu Y, Han X, et al. Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism. Br J Ophthalmol 2019; 103:565-8.
2. Farjo AA, Sugar A, Schallhorn SC et al. Femtosecond lasers for LASIK flap creation. A report by the American academy of ophthalmology. Ophthalmology 2013; 120:e5-e20.
3. De Benito-Llopis L, Teus MA, Gil-Cazorla R, et al. Comparison between femtosecond laser assisted sub-bowman keratomileusis versus laser sub-epithelial keratectomy to correct myopia. Am J Ophthalmol 2009; 148:830-6.
4. De Benito-Llopis L, Teus MA, Sánchez-Pina JM. Comparison between LASEK with mitomycin C and LASIK for the correction of myopia of -7.00 to -13.75 D. J Refract Surg 2008; 24:516-23.
5. Garcia-Gonzalez M, Bouza-Miguens C, Parafita-Fernandez A, et al. Comparison of visual outcomes and flap morphology using 2 femtosecond-laser platforms. J Cataract Refract Surg 2018; 44:78-84.
Dear editor, we received with interest the comments by Wambier et al.1 They provided interestingly new insights in possible adverse effects of silicone oil on the human body. If enlarged lymph nodes and skin nodules assumed as sarcoidosis, and lumps in the abdomen of diabetic patients diagnosed as insulin fat hypertrophy are proved to be secondary to the silicone oil released by the syringes, a remarkable paradigm shift will be achieved. Incidentally, the idea of an inflammatory/immunological association to the presence of silicone oil droplets is in agreement with our yet unproven hypothesis that agitation of the syringe, silicone oil and a susceptible drug may cause non-infectious endophthalmitis after intravitreal injections.2
However, we have to disagree with two other comments by the authors. Firstly, we employed two complementary techniques of assessing the presence of silicone oil from the syringes: light microscopy and Fourier-transform infrared spectroscopy.3-5 While the former allowed us to state that agitation of the syringe leads to a much higher release of silicone oil droplets with consistent and reproducible data, the latter showed that all models analysed have silicone oil in their interior, except for the oil-free one. Additionally, although it seems more reasonable, the use of a staining method might yield false-positivity, as we saw in our preliminary study.4
Secondly, we believe that flushing the syringes with saline before drawing the drug...
Dear editor, we received with interest the comments by Wambier et al.1 They provided interestingly new insights in possible adverse effects of silicone oil on the human body. If enlarged lymph nodes and skin nodules assumed as sarcoidosis, and lumps in the abdomen of diabetic patients diagnosed as insulin fat hypertrophy are proved to be secondary to the silicone oil released by the syringes, a remarkable paradigm shift will be achieved. Incidentally, the idea of an inflammatory/immunological association to the presence of silicone oil droplets is in agreement with our yet unproven hypothesis that agitation of the syringe, silicone oil and a susceptible drug may cause non-infectious endophthalmitis after intravitreal injections.2
However, we have to disagree with two other comments by the authors. Firstly, we employed two complementary techniques of assessing the presence of silicone oil from the syringes: light microscopy and Fourier-transform infrared spectroscopy.3-5 While the former allowed us to state that agitation of the syringe leads to a much higher release of silicone oil droplets with consistent and reproducible data, the latter showed that all models analysed have silicone oil in their interior, except for the oil-free one. Additionally, although it seems more reasonable, the use of a staining method might yield false-positivity, as we saw in our preliminary study.4
Secondly, we believe that flushing the syringes with saline before drawing the drug introduces an additional risk for bacterial contamination. Since endophthalmitis is a vision-threatening condition, any additional step should be avoided.
In conclusion, we advocate that the manufacturers develop syringes previously tested and approved for intraocular use. We also recommend that no agitation of the syringe be performed at the time of intravitreal injections.
1. Wambier CG, Wambier SPF, Beltrame FL. Here is your injection: would you like with or without silicone oil? Br J Ophthalmol. [eLetter] 3 June 2019. https://bjo.bmj.com/content/early/2019/03/24/bjophthalmol-2019-313823.re...
2. Melo GB, Figueira ACM, Batista FAH, Lima Filho AAS, Rodrigues EB, Belfort Jr R, et al. Inflammatory reaction after aflibercept intravitreal injections associated with silicone oil droplets released from syringes: a case-control study. Ophthalmic Surg Lasers Imaging Retina. 2019;50(5):288-294. doi: 10.3928/23258160-20190503-05.
3. Melo GB, Emerson GG, Dias Jr CS, Morais FB, Lima Filho A de S, Ota S, et al. Release of silicone oil and the off-label use of syringes in ophthalmology. Br J Ophthalmol. 2019. doi:10.1136/bjophthalmol-2019-313823.
4. Melo GB, Dias Jr CS, Carvalho MR, Cardoso AL, Morais FB, Figueira ACM, et al. Release of silicone oil from syringes. Int J Retina Vitreous. 2019;5:1.
5. Agra LLM, Melo GB, Lima Filho AAS, Ota S, Maia M. Silicone oil found in syringes commonly used for intravitreal injections. Arq Bras Oftalmol. 2019;82(4):354-5.
Dear Editor,
With great interest, we have read the article by Feihui et al.[1]
This study has investigated the sensitivities and specificities of different diagnostic criteria based on the OCT for glaucoma detection. According to the article abnormal superotemporal and inferotemporal RNFLT attained a higher sensitivity than abnormal superotemporal and inferotemporal BMO-MRW to detect mild glaucoma. However, our query arises when “Integration of RNFLT / BMO-MRW assessment was done”. The author stated, integrating RNFLT and BMO-MRW assessment did not change the sensitivity and specificity of RNFLT but increased the sensitivity of BMO-MRW for detection of glaucoma. To quote the author, the author paradoxically stated “ Our finding underscores the importance of RNFL imaging and measurement in the diagnostic evaluation of glaucoma”. We are interested to know if sensitivity and specificity on combination is increased, why would the diagonostic performance not increased? Reis et al stated, Bruch's membrane opening minimum rim width (BMO‐MRW) reproducibility were comparable and excellent in both healthy subjects and patients with glaucoma to that of RNFLT measurements.[2]
The article also did not include head tilt in the confounding covariates, as it was previously stated, head tilt significantly affects OCT image orientation as measured by the FoBMO angle.[3]
The article has also not mentioned dimensions of the optic nerve head (ONH) as stated previo...
Dear Editor,
With great interest, we have read the article by Feihui et al.[1]
This study has investigated the sensitivities and specificities of different diagnostic criteria based on the OCT for glaucoma detection. According to the article abnormal superotemporal and inferotemporal RNFLT attained a higher sensitivity than abnormal superotemporal and inferotemporal BMO-MRW to detect mild glaucoma. However, our query arises when “Integration of RNFLT / BMO-MRW assessment was done”. The author stated, integrating RNFLT and BMO-MRW assessment did not change the sensitivity and specificity of RNFLT but increased the sensitivity of BMO-MRW for detection of glaucoma. To quote the author, the author paradoxically stated “ Our finding underscores the importance of RNFL imaging and measurement in the diagnostic evaluation of glaucoma”. We are interested to know if sensitivity and specificity on combination is increased, why would the diagonostic performance not increased? Reis et al stated, Bruch's membrane opening minimum rim width (BMO‐MRW) reproducibility were comparable and excellent in both healthy subjects and patients with glaucoma to that of RNFLT measurements.[2]
The article also did not include head tilt in the confounding covariates, as it was previously stated, head tilt significantly affects OCT image orientation as measured by the FoBMO angle.[3]
The article has also not mentioned dimensions of the optic nerve head (ONH) as stated previously, in small optic discs, BMO-MRW and peripapillary RNFLT (OCT) have similar sensitivity to discriminate glaucoma patients. In glaucomatous patients, BMO-MRW correlates strongest with visual field function, but the diameter of the disc has to be considered.[4]
The article has no mention regarding type of glaucoma, as the OCT scanning parameters BMO-MRW and RNFLT were significantly influenced by papillary leakage in uveitic eyes with and without glaucoma. RNFLT values were also significantly increased while active inflammation was present.[5]
References:
1. Zheng F, Yu M, Leung CK . Diagnostic criteria for detection of retinal nerve fibre layer thickness and neuroretinal rim width abnormalities in glaucoma. British Journal of Ophthalmology Published Online First: 30 May 2019. doi: 10.1136/bjophthalmol-2018-313581
2. Reis, A. S., Zangalli, C. e., et al. Intra‐ and interobserver reproducibility of Bruch's membrane opening minimum rim width measurements with spectral domain optical coherence tomography. Acta Ophthalmol, 95: e548-e555. doi:10.1111/aos.13464
3. Mohammad S , Jarrar FS , Torres LA, et al. Impact of Head Tilt on Optical Coherence Tomography Image Orientation. J Glaucoma. 2018 Dec; 27(12):1042-1045.
4. Enders P, Schaub F, Adler W, et al. The use of Bruch's membrane opening-based optical coherence tomography of the optic nerve head for glaucoma detection in microdiscs British Journal of Ophthalmology 2017; 101:530-535.
5. Kriegel MF, Heiligenhaus A, Heinz C et al. Influence of uveitis on Bruch’s membrane opening minimum rim width and retinal nerve fibre layer thickness measurements. British Journal of Ophthalmology.18 December 2018. doi: 10.1136/bjophthalmol-2018-313016
Dear editor, we have read with great interest the article presented by Melo et al.1 The authors provide good evidence of silicone oil release in injections from lubricated syringes. However, the likelihood of false-negative data may have been high because of lack of a staining method (Sudan III, for example) to differentiate and highlight small droplets, as previously described.2
Although injectable fluid contamination with syringe silicone oil has been known for decades,3,4 the lack of awareness of all medical specialties about this problem is impressive. The most concerning, still controversial long-term effect of silicone oil exposure is the development of an autoimmune/inflammatory syndrome induced by adjuvants, also known as ASIA syndrome.5
Given the massive amount of injections given worldwide, silicone oil injected seems safer than one would imagine, however, it is worth remembering that if the physician is unaware of the fact of the silicone oil injection, the diagnosis is omitted as a possible hypothesis. Enlarged lymph nodes or skin nodules with evidence of granulomas are assumed as sarcoidosis, and lumps in the abdomen of diabetic patients are all diagnosed as insulin fat hypertrophy, and if a biopsy is performed, the likely cause of the granuloma would be the injected therapeutic protein or an autoimmune phenomenon. If the physicians are informed that a patient received silicone oil injections the diagnoses change to silicone oil induced granuloma...
Dear editor, we have read with great interest the article presented by Melo et al.1 The authors provide good evidence of silicone oil release in injections from lubricated syringes. However, the likelihood of false-negative data may have been high because of lack of a staining method (Sudan III, for example) to differentiate and highlight small droplets, as previously described.2
Although injectable fluid contamination with syringe silicone oil has been known for decades,3,4 the lack of awareness of all medical specialties about this problem is impressive. The most concerning, still controversial long-term effect of silicone oil exposure is the development of an autoimmune/inflammatory syndrome induced by adjuvants, also known as ASIA syndrome.5
Given the massive amount of injections given worldwide, silicone oil injected seems safer than one would imagine, however, it is worth remembering that if the physician is unaware of the fact of the silicone oil injection, the diagnosis is omitted as a possible hypothesis. Enlarged lymph nodes or skin nodules with evidence of granulomas are assumed as sarcoidosis, and lumps in the abdomen of diabetic patients are all diagnosed as insulin fat hypertrophy, and if a biopsy is performed, the likely cause of the granuloma would be the injected therapeutic protein or an autoimmune phenomenon. If the physicians are informed that a patient received silicone oil injections the diagnoses change to silicone oil induced granulomas and lymphatic migration of silicone oil.
If patients had the option to choose between receiving injections with or without silicone oil, which would they choose? Would the regulatory agencies and manufacturers listen to their option?
The generalized adoption of silicone oil free syringes is likely the future. Meanwhile, the flush technique can be adopted to minimize the possibility of adverse reactions,2 which can occur decades after an injection.
References:
1. Melo GB, Emerson GG, Dias Jr CS, Morais FB, Lima Filho A de S, Ota S, et al. Release of silicone oil and the off-label use of syringes in ophthalmology. Br J Ophthalmol 2019. doi:10.1136/bjophthalmol-2019-313823.
2. Wambier CG, Assis de Andrade E, Cruz LS, et al. Flush technique to minimize adverse reactions from syringe lubricant (silicone oil). J Am Acad Dermatol. December 2018. doi:10.1016/j.jaad.2018.12.014
3. Chantelau EA, Berger M. Pollution of Insulin With Silicone Oil, a Hazard of Disposable Plastic Syringes. Lancet. 1985;325(8443):1459. doi:10.1016/S0140-6736(85)91892-6
4. Baldwin RN. Contamination of insulin by silicone oil: a potential hazard of plastic insulin syringes. Diabet Med. 1988;5(8):789-790.
5. Perricone C, Colafrancesco S, Mazor RD, Soriano A, Agmon-Levin N, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) 2013: Unveiling the pathogenic, clinical and diagnostic aspects. J Autoimmun. 2013;47:1-16. doi:10.1016/j.jaut.2013.10.004
We have read the paper written by Avila MY et al “Randomised prospective clinical trial of platelet-rich plasma injection in the management of severe dry eye” . Authors have evaluated the effectiveness of platelet-rich injection in lacrimal gland plus free-demand topical lubricants drops in Sjögren’s syndrome severe dry eye patients . Diagnosis was based on Schirmer I, break-up time(BUT), ocular surface staining (Oxford grid) and OSDI . Achieved results in interventional group showed a Schirmer I (6,7+/-0,9 vs 9,2+/-1 mm, p<0,002), BUT (6,4+/-0,4 vs 4,4+/-0,3 secs p=0,0005), staining (2,15+/-0,15 vs 1,2+/-0,18 p<0,001) and OSDI (59+/-0,4 VS 34+/-4, p<0,001). Surprisingly authors have not included the lacrimal osmolarity test, the most valuable diagnostic tool to rule in/out this disease (S and Sp >90%) . Unfortunately Schirmer I (without anesthesia) evaluates not just basal lacrimal tearing, it also measures reflex response giving confounding bias in measured result. Surface staining (a qualitative variable) was mistakenly analyzed with a t-paired student test. Regarding OSDI, PRP patients showed a test improvement (pre 59+/- 4,0 vs post 34+/-4,0) without change in disease severity. Finally, this trial enrolled a low number of patients (n=15) that according to authors assumptions we would expect a much greater sample size (Epidat 4.1 n=417 eyes). In conclusion, a novel and interesting new treatment for Sjögren’s dry eye patients that must be confirmed in the f...
We have read the paper written by Avila MY et al “Randomised prospective clinical trial of platelet-rich plasma injection in the management of severe dry eye” . Authors have evaluated the effectiveness of platelet-rich injection in lacrimal gland plus free-demand topical lubricants drops in Sjögren’s syndrome severe dry eye patients . Diagnosis was based on Schirmer I, break-up time(BUT), ocular surface staining (Oxford grid) and OSDI . Achieved results in interventional group showed a Schirmer I (6,7+/-0,9 vs 9,2+/-1 mm, p<0,002), BUT (6,4+/-0,4 vs 4,4+/-0,3 secs p=0,0005), staining (2,15+/-0,15 vs 1,2+/-0,18 p<0,001) and OSDI (59+/-0,4 VS 34+/-4, p<0,001). Surprisingly authors have not included the lacrimal osmolarity test, the most valuable diagnostic tool to rule in/out this disease (S and Sp >90%) . Unfortunately Schirmer I (without anesthesia) evaluates not just basal lacrimal tearing, it also measures reflex response giving confounding bias in measured result. Surface staining (a qualitative variable) was mistakenly analyzed with a t-paired student test. Regarding OSDI, PRP patients showed a test improvement (pre 59+/- 4,0 vs post 34+/-4,0) without change in disease severity. Finally, this trial enrolled a low number of patients (n=15) that according to authors assumptions we would expect a much greater sample size (Epidat 4.1 n=417 eyes). In conclusion, a novel and interesting new treatment for Sjögren’s dry eye patients that must be confirmed in the future with a more robust trial.
Reference:
1. Avila MY, et al. Br J Ophthalmol 2019;103(648653)
2. Aqrawi L, Chen X, Jensen J, Morthen M, Thiede B et al. Severity of clinical dry eye manifestations influences protein expression in tear fluid of patients with primary Sjögren’s syndrome. PlosOne. 2018; Oct:1-14
3. Karakus S, Akpek E, Agrawal D, Massof R. Validation of an objective measure of dry eye severity. Trans Vis Sci Tech. 2018;7(5):26
4. Wolffsohn J.S. TFOS DEWS II Diagnostic Methodology Report. The Ocular Surface 15 (2017);539-574
We appreciate the interest in our paper by Kumawat and Kumar, and the opportunity to address their comments. With regards to axial length, it is certainly known to be correlated with choroidal thickness. However, this information was not routinely obtained in our retina clinic and was not available for most patients in the study. We were able to account for spherical equivalent in our multivariate model, which may serve as a proxy for axial length. We agree that accounting for at least one of these variables is required for studies on choroidal thickness. We appreciate the Kumawat and Kumar’s suggestion to categorize patients based on stage of disease (proliferative vs nonproliferative). We had considered this approach, however the small number of patients with proliferative disease (only 4) made this less ideal from a statistical standpoint. Subretinal neovascularization was included in our univariate analysis but was not found to be statistically significant with regard to choroidal thickness, so it was not further considered in our multivariate assessments. Lastly, while inter-ocular asymmetry in choroidal thickness may exist, eye laterality was not found to be a significant variable affecting choroidal thickness in our univariate analysis (p = 0.87) and thus was also not included in multivariate models. We once again thank Dr. Kumawat and Dr. Kumar for their interest in our work.
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Show MoreAlthough the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
Show MoreThe article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
I read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Show MoreStudy Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60
...
We have read with interest the article by Han et al.,1 in which the authors compare the outcomes of myopia correction using small incision lenticule extraction (SMILE) versus laser in situ keratomileusis (LASIK) using the VisuMax® femtosecond laser (FS) to cut the corneal flap, and we have some concerns regarding this study we would like to share with the authors.
Show MoreIt is noteworthy that the authors found that only 65% of eyes were within ± 0.50 diopters of the attempted spherical equivalent correction after FS-LASIK, these results are clearly worse that those generally obtained with LASIK. It is accepted that the results obtained with excimer laser ablation, either using a surface ablation approach, or LASIK performed with mechanical microkeratome (MK) or using the Intralase® FS platform to correct myopia are quite similar.2,3 Indeed, our group has that 95% of unselected eyes with myopia of -3.9±1.5D3 and 80% of eyes with high myopia (-8.7±1.2D)4 were within ± 0.5D of emmetropia after LASIK. For this reason, we believe that the main conclusion of the article by Han et al.1 that “long-term outcomes of both SMILE and FS-LASIK are safe and equally effective for myopic and astigmatic correction” is clearly biased. In other words, the results of SMILE should have not been compared with a FS laser platform that does not seem to achieve the benchmark results clearly established for LASIK when correcting myopia.
It should be highlighted that different FS platforms appr...
Dear editor, we received with interest the comments by Wambier et al.1 They provided interestingly new insights in possible adverse effects of silicone oil on the human body. If enlarged lymph nodes and skin nodules assumed as sarcoidosis, and lumps in the abdomen of diabetic patients diagnosed as insulin fat hypertrophy are proved to be secondary to the silicone oil released by the syringes, a remarkable paradigm shift will be achieved. Incidentally, the idea of an inflammatory/immunological association to the presence of silicone oil droplets is in agreement with our yet unproven hypothesis that agitation of the syringe, silicone oil and a susceptible drug may cause non-infectious endophthalmitis after intravitreal injections.2
Show MoreHowever, we have to disagree with two other comments by the authors. Firstly, we employed two complementary techniques of assessing the presence of silicone oil from the syringes: light microscopy and Fourier-transform infrared spectroscopy.3-5 While the former allowed us to state that agitation of the syringe leads to a much higher release of silicone oil droplets with consistent and reproducible data, the latter showed that all models analysed have silicone oil in their interior, except for the oil-free one. Additionally, although it seems more reasonable, the use of a staining method might yield false-positivity, as we saw in our preliminary study.4
Secondly, we believe that flushing the syringes with saline before drawing the drug...
Dear Editor,
Show MoreWith great interest, we have read the article by Feihui et al.[1]
This study has investigated the sensitivities and specificities of different diagnostic criteria based on the OCT for glaucoma detection. According to the article abnormal superotemporal and inferotemporal RNFLT attained a higher sensitivity than abnormal superotemporal and inferotemporal BMO-MRW to detect mild glaucoma. However, our query arises when “Integration of RNFLT / BMO-MRW assessment was done”. The author stated, integrating RNFLT and BMO-MRW assessment did not change the sensitivity and specificity of RNFLT but increased the sensitivity of BMO-MRW for detection of glaucoma. To quote the author, the author paradoxically stated “ Our finding underscores the importance of RNFL imaging and measurement in the diagnostic evaluation of glaucoma”. We are interested to know if sensitivity and specificity on combination is increased, why would the diagonostic performance not increased? Reis et al stated, Bruch's membrane opening minimum rim width (BMO‐MRW) reproducibility were comparable and excellent in both healthy subjects and patients with glaucoma to that of RNFLT measurements.[2]
The article also did not include head tilt in the confounding covariates, as it was previously stated, head tilt significantly affects OCT image orientation as measured by the FoBMO angle.[3]
The article has also not mentioned dimensions of the optic nerve head (ONH) as stated previo...
Dear editor, we have read with great interest the article presented by Melo et al.1 The authors provide good evidence of silicone oil release in injections from lubricated syringes. However, the likelihood of false-negative data may have been high because of lack of a staining method (Sudan III, for example) to differentiate and highlight small droplets, as previously described.2
Although injectable fluid contamination with syringe silicone oil has been known for decades,3,4 the lack of awareness of all medical specialties about this problem is impressive. The most concerning, still controversial long-term effect of silicone oil exposure is the development of an autoimmune/inflammatory syndrome induced by adjuvants, also known as ASIA syndrome.5
Given the massive amount of injections given worldwide, silicone oil injected seems safer than one would imagine, however, it is worth remembering that if the physician is unaware of the fact of the silicone oil injection, the diagnosis is omitted as a possible hypothesis. Enlarged lymph nodes or skin nodules with evidence of granulomas are assumed as sarcoidosis, and lumps in the abdomen of diabetic patients are all diagnosed as insulin fat hypertrophy, and if a biopsy is performed, the likely cause of the granuloma would be the injected therapeutic protein or an autoimmune phenomenon. If the physicians are informed that a patient received silicone oil injections the diagnoses change to silicone oil induced granuloma...
Show MoreWe have read the paper written by Avila MY et al “Randomised prospective clinical trial of platelet-rich plasma injection in the management of severe dry eye” . Authors have evaluated the effectiveness of platelet-rich injection in lacrimal gland plus free-demand topical lubricants drops in Sjögren’s syndrome severe dry eye patients . Diagnosis was based on Schirmer I, break-up time(BUT), ocular surface staining (Oxford grid) and OSDI . Achieved results in interventional group showed a Schirmer I (6,7+/-0,9 vs 9,2+/-1 mm, p<0,002), BUT (6,4+/-0,4 vs 4,4+/-0,3 secs p=0,0005), staining (2,15+/-0,15 vs 1,2+/-0,18 p<0,001) and OSDI (59+/-0,4 VS 34+/-4, p<0,001). Surprisingly authors have not included the lacrimal osmolarity test, the most valuable diagnostic tool to rule in/out this disease (S and Sp >90%) . Unfortunately Schirmer I (without anesthesia) evaluates not just basal lacrimal tearing, it also measures reflex response giving confounding bias in measured result. Surface staining (a qualitative variable) was mistakenly analyzed with a t-paired student test. Regarding OSDI, PRP patients showed a test improvement (pre 59+/- 4,0 vs post 34+/-4,0) without change in disease severity. Finally, this trial enrolled a low number of patients (n=15) that according to authors assumptions we would expect a much greater sample size (Epidat 4.1 n=417 eyes). In conclusion, a novel and interesting new treatment for Sjögren’s dry eye patients that must be confirmed in the f...
Show MoreDear Editor,
We appreciate the interest in our paper by Kumawat and Kumar, and the opportunity to address their comments. With regards to axial length, it is certainly known to be correlated with choroidal thickness. However, this information was not routinely obtained in our retina clinic and was not available for most patients in the study. We were able to account for spherical equivalent in our multivariate model, which may serve as a proxy for axial length. We agree that accounting for at least one of these variables is required for studies on choroidal thickness. We appreciate the Kumawat and Kumar’s suggestion to categorize patients based on stage of disease (proliferative vs nonproliferative). We had considered this approach, however the small number of patients with proliferative disease (only 4) made this less ideal from a statistical standpoint. Subretinal neovascularization was included in our univariate analysis but was not found to be statistically significant with regard to choroidal thickness, so it was not further considered in our multivariate assessments. Lastly, while inter-ocular asymmetry in choroidal thickness may exist, eye laterality was not found to be a significant variable affecting choroidal thickness in our univariate analysis (p = 0.87) and thus was also not included in multivariate models. We once again thank Dr. Kumawat and Dr. Kumar for their interest in our work.
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