Aptel et al. [1] presented the prevention and management of postoperative ocular inflammation after cataract surgery based on randomised controlled trials, while after trabeculectomy, vitrectomy and combined phacovitrectomy in a two-round Delphi survey.
The Delphi survey is a technique applied mainly to develop healthcare quality indicators. [2] In this study not only was it applied to evaluate practice patterns among ophthalmologists, but to obtain information on inflammatory potential of a surgical procedure that can be assessed by objective methods.
It should be underlined that even within the formerly mentioned indications there is little recommendation among researchers to use the Delphi method. [2] The use and reporting of the method needs to be improved, while a panel composition of experts in one field significantly influences ratings. [2,3] Several issues regarding the selection of the panel members is critical if the group consensus technique is to work properly. Two hundred and twenty surgeons from Europe (35%) and the USA (59%) were invited to participate in this Delphi survey. The response rate among the invited experts should be thoroughly explained, as finally 82% of the participating experts were from Europe and the balance was from the USA. This discrepancy might have a high risk of bias and should be thoroughly discussed. Of record, in the United States retinal surgeons do not routinely perform cataract surgery, thus including them in the e...
Aptel et al. [1] presented the prevention and management of postoperative ocular inflammation after cataract surgery based on randomised controlled trials, while after trabeculectomy, vitrectomy and combined phacovitrectomy in a two-round Delphi survey.
The Delphi survey is a technique applied mainly to develop healthcare quality indicators. [2] In this study not only was it applied to evaluate practice patterns among ophthalmologists, but to obtain information on inflammatory potential of a surgical procedure that can be assessed by objective methods.
It should be underlined that even within the formerly mentioned indications there is little recommendation among researchers to use the Delphi method. [2] The use and reporting of the method needs to be improved, while a panel composition of experts in one field significantly influences ratings. [2,3] Several issues regarding the selection of the panel members is critical if the group consensus technique is to work properly. Two hundred and twenty surgeons from Europe (35%) and the USA (59%) were invited to participate in this Delphi survey. The response rate among the invited experts should be thoroughly explained, as finally 82% of the participating experts were from Europe and the balance was from the USA. This discrepancy might have a high risk of bias and should be thoroughly discussed. Of record, in the United States retinal surgeons do not routinely perform cataract surgery, thus including them in the expert panel comparing the inflammatory potential of the former is debatable.
Finally, the manuscript has several editorial errors, including references not adjusted to the journal requirements. As of high interest of the pharmaceutical industry in broadening the use of topical non-steroidal anti-inflammatory drugs, we believe financial disclosures of all authors, as well as the interest of the sponsor should be disclosed.
References
1. Aptel F, Colin C, Kaderli S, et al. Management of postoperative inflammation after cataract and complex ocular surgeries: a systematic review and Delphi survey. Br J Ophthalmol. August 2017. doi:10.1136/bjophthalmol-2017-310324.
2. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS One. 2011;6(6):e20476.
3. Campbell SM, Hann M, Roland MO, Quayle JA, Shekelle PG. The Effect of Panel Membership and Feedback on Ratings in a Two-Round Delphi Survey. Med Care. 1999;37(9):964-968.
We read with interest the insightful comments in the e-letter submitted by Dr. Gain, Dr. He, Dr. Garcin, and Dr. Thuret on our recently published article.1 As stated in their letter, they previously reported that by using a similar triple staining (i.e., Hoechst 33342, ethidium homodimere and calcein-AM) on the endothelium of whole donor corneas stored in long-term organ culture, the endothelial cell (EC) density in the whole pool of viable ECs in the cornea is routinely, and quite substantially, overestimated.2,3 We completely agree with the authors regarding the importance of assessing the whole pool of viable ECs in corneal grafts.
We first reported at the 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) that triple-staining a donor graft with propidium iodide, calcein-AM, and Hoechst 33342 allowed for a distinct discrimination between living cells and dead cells. In that report, we hypothesized that the existence of dead cells on the endothelium of the donor cornea suggests an association with the rapid loss of corneal ECs, at least at the early phase, post keratoplasty. However, Gauthier and associates reported3 that there was no difference between the density of viable ECs at day 0 and at day 5 postoperative, thus suggesting that very early EC loss in the host recipient is almost negligible. However, similar to Gain and associates, we believed that it was quite important to measure viable ECD, not to calculate just ECD by...
We read with interest the insightful comments in the e-letter submitted by Dr. Gain, Dr. He, Dr. Garcin, and Dr. Thuret on our recently published article.1 As stated in their letter, they previously reported that by using a similar triple staining (i.e., Hoechst 33342, ethidium homodimere and calcein-AM) on the endothelium of whole donor corneas stored in long-term organ culture, the endothelial cell (EC) density in the whole pool of viable ECs in the cornea is routinely, and quite substantially, overestimated.2,3 We completely agree with the authors regarding the importance of assessing the whole pool of viable ECs in corneal grafts.
We first reported at the 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) that triple-staining a donor graft with propidium iodide, calcein-AM, and Hoechst 33342 allowed for a distinct discrimination between living cells and dead cells. In that report, we hypothesized that the existence of dead cells on the endothelium of the donor cornea suggests an association with the rapid loss of corneal ECs, at least at the early phase, post keratoplasty. However, Gauthier and associates reported3 that there was no difference between the density of viable ECs at day 0 and at day 5 postoperative, thus suggesting that very early EC loss in the host recipient is almost negligible. However, similar to Gain and associates, we believed that it was quite important to measure viable ECD, not to calculate just ECD by using specular microscope.
In our reported case series, we assessed the relationship between the number of dead cells and the EC density post surgery, in both the early phase and late phase post keratoplasty, as it possibly affects the longevity of the cells over the long-term follow-up. We are currently conducting further investigation on this matter.
References
1. Kitazawa K, Inatomi T, Tanioka H, et al. The existence of dead cells in donor corneal endothelium preserved with storage media. Br J Ophthalmol. 2017;101:1725-1730.
2. Pipparelli A, Thuret G, Toubeau D, et al. Pan-corneal endothelial viability assessment: application to endothelial grafts predissected by eye banks. Invest Ophthalmol Vis Sci. 2011;52:6018-6025.
3. Gauthier AS, Garcin T, Thuret G, et al. Very early endothelial cell loss after penetrating keratoplasty with organ-cultured corneas. Br J Ophthalmol. 2017;101:1113-1118.
We noticed the article entitled “The existence of dead cells in donor corneal endothelium preserved with storage media” by Kitazawa with interest (Br J Ophthalmol 2017. Oct 5).
Authors clearly demonstrated, using a triple staining with Hoechst, Propidium Iodide and Calcein-AM, that corneas stored at 4°C in Optisol-GS for 3 to 7 days, the technic most used worldwide, bear a significant number of dead endothelial cells (ECs). They underlined that these non-viable ECs are not recognized by specular cell count done by the eye bank and that this could explain the “cell loss” inevitably noticed post graft. Our team applied, for the first time in 2011 [1] and again in 2016 [2], a similar triple staining on the endothelium of whole corneas stored in long-term organ culture at 31°C, the dominant technic in Europe. We made the same findings as Kitazawa et al. and defined the notion of viable ECD (vECD) as the number of viable ECs per surface unit. Areas without ECs (especially in Descemetic folds), dead and dying EC (that will not survive the storage) clearly explain the important discrepancy between the cell count done by the eye bank (unable to spot them) and the very early postoperative ECD. Our team also demonstrated long ago that vital Trypan blue staining used by certain eye bank is unable to spot all dying cells because its time window of positivity is very narrow, corresponding only to ECs near to desquamate [3]. Viable ECD determined by triple staining therefore appea...
We noticed the article entitled “The existence of dead cells in donor corneal endothelium preserved with storage media” by Kitazawa with interest (Br J Ophthalmol 2017. Oct 5).
Authors clearly demonstrated, using a triple staining with Hoechst, Propidium Iodide and Calcein-AM, that corneas stored at 4°C in Optisol-GS for 3 to 7 days, the technic most used worldwide, bear a significant number of dead endothelial cells (ECs). They underlined that these non-viable ECs are not recognized by specular cell count done by the eye bank and that this could explain the “cell loss” inevitably noticed post graft. Our team applied, for the first time in 2011 [1] and again in 2016 [2], a similar triple staining on the endothelium of whole corneas stored in long-term organ culture at 31°C, the dominant technic in Europe. We made the same findings as Kitazawa et al. and defined the notion of viable ECD (vECD) as the number of viable ECs per surface unit. Areas without ECs (especially in Descemetic folds), dead and dying EC (that will not survive the storage) clearly explain the important discrepancy between the cell count done by the eye bank (unable to spot them) and the very early postoperative ECD. Our team also demonstrated long ago that vital Trypan blue staining used by certain eye bank is unable to spot all dying cells because its time window of positivity is very narrow, corresponding only to ECs near to desquamate [3]. Viable ECD determined by triple staining therefore appears as the only reliable measure of the “useful graft endothelial capital” that is, in our opinion, a major determinant of graft survival. As a reminder, fresh grafts done in the 80’s (that the first author of this e-letter aged over 55 years knows…), contained virtually only viable ECs and were known to have a prolonged survival, around 20-25 years, largely better than the corneas stored today.
Authors conclude that the decreased EC viability may be due partly to the storage conditions. Without pleading for the return of fresh grafts, we are convinced that its improvement will require a profound change in storage process because the two current methods (4 and 31°C) are passive (simple immersion in storage medium). We recently developed the notion of active storage using a corneal bioreactor that restores the intraocular pressure, which is essential for corneal physiology. It naturally limits stromal oedema[4] and significantly improves EC viability[5].
Reference List
1. Pipparelli A, Thuret G, Toubeau D, et al. Pan-corneal endothelial viability assessment: application to endothelial grafts predissected by eye banks. Invest. Ophthalmol. Vis. Sci. 2011;52:6018-25.
2. Gauthier AS, Garcin T, Thuret G, et al. Very early endothelial cell loss after penetrating keratoplasty with organ-cultured corneas. Br J Ophthalmol 2017;101:1113-18.
3. Gain P, Thuret G, Chiquet C, et al. Value of two mortality assessment techniques for organ cultured corneal endothelium: trypan blue versus TUNEL technique. Br J Ophthalmol 2002;86:306-10.
4. Guindolet D, Crouzet E, He Z, et al. Storage of porcine cornea in an innovative bioreactor. Invest. Ophthalmol. Vis. Sci. 2017;in press.
5. Garcin T, Forest F, Verhoeven P, et al. Preclinical randomized controlled study comparing long-term stored human corneas in an innovative bioreactor versus standard organ-culture. Invest. Ophthalmol. Vis. Sci. 2017;58:ARVO E-Abstract 3793.
We read with interest the recently published study by Kim et al, which the authors described as a cross-sectional, observational, case-control study. As a single study such a design is not possible since cross-sectional and case-control studies are two distinct types of study designs. The authors compared the percent with lower lid epiblepharon between those with and without congenital glaucoma and reported that controls were matched on age and date of outpatient visit to the cases, which would suggest this is a matched case-control study. However, the statistical analysis employed did not account for the matched nature of the study design and therefore was not appropriate. Statistical procedures that account for the matched nature of the study should have been employed. The authors are urged to conduct a reanalysis of their study, amending their interpretation as warranted.
Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Cicinelli et al. Br J Ophthalmol 2017; http: /dx.doi. org/ 10.1136/bjophthalmol-2017-310242.
Dear Editor
We would like to address several challenges that have arisen from the study by Cicinelli et al (1), which can be specifically summarized below.
1. The study was retrospectively conducted, with a selection bias attributable to the heterogeneity of the patients included, for example, six patients were affected by the type 1 diabetes mellitus; eighteen eyes were phakic; twenty seven eyes underwent cataract extraction and intraocular lens implant; and thirteen eyes received grid macular photocoagulation for diabetic macular oedema (DME) prior to ranibizumab (RNB).
2. After undergoing three loading-dose intravitreal injections of RNB performed at fixed 4-week intervals for the first 12 weeks, all the patients regardless of functional and anatomical characteristics, were shifted to dexamethasone implant (DEX implant 0.7 mg; Ozurdex; Allergan, Irvine, California, USA) continued at 4-month intervals until stable best-corrected visual acuity (BCVA) was reached. However, nothing was...
Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Cicinelli et al. Br J Ophthalmol 2017; http: /dx.doi. org/ 10.1136/bjophthalmol-2017-310242.
Dear Editor
We would like to address several challenges that have arisen from the study by Cicinelli et al (1), which can be specifically summarized below.
1. The study was retrospectively conducted, with a selection bias attributable to the heterogeneity of the patients included, for example, six patients were affected by the type 1 diabetes mellitus; eighteen eyes were phakic; twenty seven eyes underwent cataract extraction and intraocular lens implant; and thirteen eyes received grid macular photocoagulation for diabetic macular oedema (DME) prior to ranibizumab (RNB).
2. After undergoing three loading-dose intravitreal injections of RNB performed at fixed 4-week intervals for the first 12 weeks, all the patients regardless of functional and anatomical characteristics, were shifted to dexamethasone implant (DEX implant 0.7 mg; Ozurdex; Allergan, Irvine, California, USA) continued at 4-month intervals until stable best-corrected visual acuity (BCVA) was reached. However, nothing was stated as to whether there were patients with complete retinal dryness at week 12 and if so, why they were switched to dexamethasone implant.
3. In the assessment of the final results of this study we considered the current assertion that evaluation of outcomes has to be guided by anatomical measure data with visual changes as a secondary guide [2]. Accordingly, the final outcomes of this series were unsatisfactory. Specifically, despite a significant mean gain of 5.6 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in BCVA score in poorly responding patients and an insignificant improvement of 2.1 ETDRS letters in patients with good visual response, the central macular thickness (CMT) decreased significantly to 363.6 microns and reduced insignificantly to 359 microns, in the poor and good responders, respectively. Of note, the both CMT values were more than the cutoff for the upper level of normal CMT [3], highlighting unresolved DME. Moreover, seven eyes developed intraocular pressure =/> 20 mm Hg, cataract progression was observed in nine among the phakic eyes (50%) during the study period, and two patients underwent cataract extraction after the dexamethasone implant. Importantly, persistence of unresolved macular oedema can permanently damage the outer retinal layers, leading to retinal fibrosis and macular atrophy, indicating that the disease process is still active and progressive, requiring further treatment with antiangiogenic agents.
4. As far as the potential prognosticatours of clinical outcome after dexamethasone implant are concerned, the following baseline characteristics should have been considered and included in a stepwise linear regression analysis along with those already presented, namely the subfoveal choroidal thickness, the qualitative status of the 4 outer retinal layers, the vitreoretinal interface abnormalities (vitreomacular adhesion/traction and epiretinal membrane), the diabetic retinopathy severity, the presence of macular ischemia on fluorescein angiography, and the duration of DME prior to therapy.
5. The specific anti-VEGF drugs (bevacizumab [Avastin; Genentech, South San Francisco, California, USA)/ranibizumab [Lucentis, Genentech]/aflibercept [Eylea; Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA]) represent the front-line therapy for the treatment of DME but only the VEGF inhibition may not be sufficient to decrease inflammatory response. Therefore, addition of a non-specific anti-VEGF substance, ie. a corticosteroid implant, is mandatory. Both groups of anti-VEGF substances provide similar rates of vision improvement but with superior anatomic outcomes and fewer injections in the corticosteroid implant-treated eyes. However, more patients receiving the corticosteroid implant lose vision mainly due to cataract [4].
Altogether, the results of this study can not be validated and extrapolated because a stepwise linear regression analysis of the potential predictors of functional outcome was not carried out. Regardless of the anti-VEGF agents employed (bevacizumab/ranibizumab/aflibercept/ corticosteroid), the efficacy of therapy depends primarily on the promptness of the therapy after DME diagnosis [4,5].
References
1. Cicinelli MV, Cavalleri M, Querques L, et al. Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Br J Ophthalmol 2017; http:/ dx. doi. org/ 10.1136/bjophthalmol-2017-310242.
2. Freund KB, Korobelnik JF, Devenyi R, et al. Treat-and-extend regimens with anti-VEGF agents in retinal diseases. Retina 2015;35(8):1489-1506.
3. Gover S, Murthy RK, Brar VS, Chalam KV.Normative data for macular thickness by high-definition spectral-domain optical coherence tomography (spectralis). Am J Ophthalmol 2009;148(2):266-271.
4. Calugaru D, Calugaru M. Real-world outcomes of ranibizumab treatment for diabetic macular edema in a United Kingdom National Health Service setting. Am J Ophthalmol 2017;174(2):175-176.
5. Calugaru D, Calugaru M. Comments to: Long-term efficacy and safety of intravitreal dexamethasone implant for the treatment of diabetic macular edema. Eur J Ophthalmol 2016;26(6):171-172.
We warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
We agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the...
We warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
We agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the text.
The analysis of central macular thickness (CMT) at 12 months on optical coherence tomography disclosed that the poor and good responders reached CMT of 363 microns and of 359 microns, respectively. Despite being more than the cutoff for the upper level of normal CMT, as suggested by the Authors, for DME eyes a CMT of ~350um should be considered as a good outcome, as values inferior to this cut-off would indicate impending atrophy of the neurovascular tissue. As a validation of our approach, we referred to the latest Diabetic Retinopathy Clinical Research Network (DRCR.net) guidelines about persistent macular thickening after ranibizumab treatment, according to which CMT appeared to be a less important prognostic factor in DME outcomes. In fact, persistent macular edema was associated with similar long-term improvement in visual acuity showed by patients in which DME did not persist.2 Finally, we would like to specify that we analyzed data of included patients until 12-months follow-up; these patients did not conclude treatment for DME, and most of them continued to receive injections for their condition.
We perfectly agree that, along with CMT, other OCT biomarkers (as disorganization of the retinal inner layers, integrity of the ellipsoid zone and of the cone outer segment tips, presence of taut internal limiting membrane or epiretinal membrane, and vitreomacular traction) should be analyzed in order to predict the prognostic outcome of diabetic patients.3-4 A specific analysis of these parameters was beyond our purposes, but we will include them in a future more complete stepwise linear regression analysis of the data presented in the present study.
We listed the complications of treatment experienced by patients who underwent dexamethasone (DEX) implant, with particular attention to intraocular pressure increase as well as cataract worsening. These two are well-known side-effects of dexamethasone implant and their rate did not exceed the expectations in our study.5 Despite these complications, intravitreal steroids have shown a good safety profile in long-term prospective studies, especially in those cases when anti-VEGF are contraindicated, or fewer intravitreal injections regimen is required.
In conclusion, we kindly disagree with the conclusion of the Authors and we further demonstrated the usefulness of switching the therapeutic drug in diabetic patients non-responders to anti-VEGF the by replying to this letter.
References:
1. Cicinelli MV, Cavalleri M, Querques L, et al. Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Br J Ophthalmol 2017; http:/ dx. doi. org/ 10.1136/bjophthalmol-2017-310242.
2. Bressler SB, Ayala AR, Bressler NM, Melia M, Qin H, Ferris FL 3rd, Flaxel CJ, Friedman SM, Glassman AR, Jampol LM, Rauser ME; Diabetic Retinopathy Clinical Research Network. Persistent Macular Thickening After Ranibizumab Treatment for Diabetic Macular Edema With Vision Impairment. JAMA Ophthalmol. 2016 Mar;134(3):278-85. doi: 10.1001/jamaophthalmol.2015.5346.
3. Sun JK, Lin MM, Lammer J, Prager S, Sarangi R, Silva PS, Aiello LP. Disorganization of the retinal inner layers as a predictor of visual acuity in eyes with center-involved diabetic macular edema. JAMA Ophthalmol. 2014 Nov;132(11):1309-16.
4. Iacono P, Parodi MB, Scaramuzzi M, Bandello F. Morphological and functional changes in recalcitrant diabetic macular oedema after intravitreal dexamethasone implant. Br J Ophthalmol. 2016 Sep 13. pii: bjophthalmol-2016-308726. doi: 10.1136/bjophthalmol-2016-308726.
5. Boyer DS, Yoon YH, Belfort R Jr, et al; Ozurdex MEAD Study Group. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. 2014;121:1904-1914.
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be affected by trauma, and traumatic cataract carries an increased risk of PCR. We would welcome further discussion of this less recognised risk factor for PCR.
References:
1. Salowi MA, Chew FLM, Adnan TH, Ismail M, Goh PP: The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture. The British journal of ophthalmology 2017.
2. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Asaria RH, Galloway P, Sparrow JM: The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye (London, England) 2009, 23(1):31-37.
3. Shalchi Z, Okada M, Whiting C, Hamilton R: Risk of Posterior Capsule Rupture During Cataract Surgery in Eyes With Previous Intravitreal Injections. American journal of ophthalmology 2017, 177:77-80.
4. Chatziralli IP, Peponis V, Parikakis E, Maniatea A, Patsea E, Mitropoulos P: Risk factors for intraoperative floppy iris syndrome: a prospective study. Eye (London, England) 2016, 30(8):1039-1044.
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, f...
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, for example STROBE for observational studies, CONSORT for randomized trials, and PRISMA for systematic reviews and meta-analyses of intervention studies (see https://www.equator-network.org/reporting-guidelines/ for a full list of reporting standards).
Related to this project, CEV is examining the quality of published systematic review methods and maintains a database of systematic reviews in eyes and vision (http://cmr.cochrane.org/?CRGReportID=11343). We classify systematic reviews as “reliable” based on adherence to pre-specified criteria, (3) and send the “reliable” reviews to the American Academy of Ophthalmology for reference when issuing clinical practice guidelines. (4)
We urge all stakeholders to join our effort to ensure that vision science is recognized as evidence-based.
Literature cited
1. Joksimovic L, Koucheki R, Popovic M, Ahmed Y, Schlenker MB, Ahmed IIK. Risk of bias assessment of randomized controlled trials in high-impact ophthalmology journals and general medical journals: a systematic review. Br J Ophthalmol 2017;0:1–6. doi:10.1136/bjophthalmol-2017-310313
2. Institute of Medicine (IOM). Finding what works in health care: Standards for systematic reviews. Washington, DC: The National Academies Press; 2011
3. Lindsley K, Li T, Ssemanda E, Virgili G, Dickersin K. Interventions for age-related macular degeneration: Are practice guidelines based on systematic reviews? Ophthalmol. 2016;123(4):884-97. doi:10.1016/j.ophtha.2015.12.004.
4. Mayo-Wilson E, Ng SM, Chuck RS, Li T. The quality of systematic reviews about interventions for refractive error can be improved: a review of systematic reviews. BMC Ophthalmol.2017; 17:164 doi:10.1186/s12886-017-0561-9.
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These barriers exist from both a patient’s and clinician’s perspective. The most obvious hurdle is the disparity in subject knowledge between both parties and the potential for patients to feel isolated during discussion. Therefore, it is crucial that patient involvement is designed in a way that recognizes this, and provides adequate support either through training schemes or debriefing with expert members prior to meetings(3). There may be resistance from clinicians concerned that the need to accommodate patient understanding may restrict the scope of discussion. Other patient concerns include time commitment and logistical concerns such as travel reimbursements(3), both of which should be adequately addressed. Additionally, care must be taken when defining the patient recruitment criteria in order to ensure the volunteers are truly representative of the patient population concerned.
Ultimately, we applaud the efforts of this article in highlighting what is currently an inadequately tapped resource in the realm of ophthalmology, and we hope to see the ‘patient voice’ become an intrinsic part of future research.
References
1. Dean, S., Mathers, J., Calvert, M., Kyte, D., Conroy, D., Folkard, A., Southworth, S., Murray, P. and Denniston, A. (2017). "The patient is speaking": discovering the patient voice in ophthalmology. The British Journal of Ophthalmology, [online] 101(6), pp.700-708. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28455280 [Accessed 20 Sep. 2017].
2. Burns, K., Rizvi, L., Charteris, A., Laskey, S., Batty, S., Chokar, K. and Choong, K. (2017). Characterizing Citizens’ Preferences for Engagement in Patient Care and Research in Adult and Pediatric Intensive Care Units. Journal of Intensive Care, [online] Available at: http://journals.sagepub.com/doi/full/10.1177/0885066617729127[Accessed 20 Sep. 2017].
Chalmers, J., Timothy, A., Polverino, E., Almagro, M., Ruddy, T., Powell, P. and Boyd, J. (2017). Patient participation in ERS guidelines and research projects: the EMBARC experience. European Respiratory Journal, [online] 13(3), pp.194-207. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584721/ - C1[Accessed 20 Sep. 2017].
Kenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the li...
Kenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the literature with regard to how visual acuity relates to increased risk of MVC’s in glaucoma patients,3-5 we suggest that these findings be more clearly emphasized. Furthermore, we would appreciate any commentary from the authors regarding visual acuity as a significant risk parameter for MVCs. Specifically, we are interested to know if further analysis of the data would show a particular threshold for visual acuity to incite a significantly higher risk for simulated collision. Given our role to responsibly report the visual capacity of patients to safely operate a motor vehicle, this information may serve useful to further guide visual acuity parameters for motor vehicle licensing.
Author Affiliations:
1. Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, TX
2. Michael E. Debakey Veterans Affairs Medical Center, Houston, TX
References:
1. Ramulu PY, West SK, Munoz B, Jampel HD, Friedman DS. Driving cessation and driving limitation in glaucoma: the Salisbury Eye Evaluation Project. Ophthalmology. 2009;116(10):1846-1853.
2. Janz NK, Musch DC, Gillespie BW, Wren PA, Niziol LM, Collaborative Initial Glaucoma Treatment Study I. Evaluating clinical change and visual function concerns in drivers and nondrivers with glaucoma. Invest Ophthalmol Vis Sci. 2009;50(4):1718-1725.
3. Yuki K, Awano-Tanabe S, Ono T, et al. Risk Factors for Motor Vehicle Collisions in Patients with Primary Open-Angle Glaucoma: A Multicenter Prospective Cohort Study. PLoS One. 2016;11(11):e0166943.
4. Gracitelli CP, Tatham AJ, Boer ER, et al. Predicting Risk of Motor Vehicle Collisions in Patients with Glaucoma: A Longitudinal Study. PLoS One. 2015;10(10):e0138288.
5. Kwon M, Huisingh C, Rhodes LA, McGwin G, Jr., Wood JM, Owsley C. Association between Glaucoma and At-fault Motor Vehicle Collision Involvement among Older Drivers: A Population-based Study. Ophthalmology. 2016;123(1):109-116.
Aptel et al. [1] presented the prevention and management of postoperative ocular inflammation after cataract surgery based on randomised controlled trials, while after trabeculectomy, vitrectomy and combined phacovitrectomy in a two-round Delphi survey.
The Delphi survey is a technique applied mainly to develop healthcare quality indicators. [2] In this study not only was it applied to evaluate practice patterns among ophthalmologists, but to obtain information on inflammatory potential of a surgical procedure that can be assessed by objective methods.
It should be underlined that even within the formerly mentioned indications there is little recommendation among researchers to use the Delphi method. [2] The use and reporting of the method needs to be improved, while a panel composition of experts in one field significantly influences ratings. [2,3] Several issues regarding the selection of the panel members is critical if the group consensus technique is to work properly. Two hundred and twenty surgeons from Europe (35%) and the USA (59%) were invited to participate in this Delphi survey. The response rate among the invited experts should be thoroughly explained, as finally 82% of the participating experts were from Europe and the balance was from the USA. This discrepancy might have a high risk of bias and should be thoroughly discussed. Of record, in the United States retinal surgeons do not routinely perform cataract surgery, thus including them in the e...
Show MoreWe read with interest the insightful comments in the e-letter submitted by Dr. Gain, Dr. He, Dr. Garcin, and Dr. Thuret on our recently published article.1 As stated in their letter, they previously reported that by using a similar triple staining (i.e., Hoechst 33342, ethidium homodimere and calcein-AM) on the endothelium of whole donor corneas stored in long-term organ culture, the endothelial cell (EC) density in the whole pool of viable ECs in the cornea is routinely, and quite substantially, overestimated.2,3 We completely agree with the authors regarding the importance of assessing the whole pool of viable ECs in corneal grafts.
We first reported at the 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) that triple-staining a donor graft with propidium iodide, calcein-AM, and Hoechst 33342 allowed for a distinct discrimination between living cells and dead cells. In that report, we hypothesized that the existence of dead cells on the endothelium of the donor cornea suggests an association with the rapid loss of corneal ECs, at least at the early phase, post keratoplasty. However, Gauthier and associates reported3 that there was no difference between the density of viable ECs at day 0 and at day 5 postoperative, thus suggesting that very early EC loss in the host recipient is almost negligible. However, similar to Gain and associates, we believed that it was quite important to measure viable ECD, not to calculate just ECD by...
Show MoreWe noticed the article entitled “The existence of dead cells in donor corneal endothelium preserved with storage media” by Kitazawa with interest (Br J Ophthalmol 2017. Oct 5).
Show MoreAuthors clearly demonstrated, using a triple staining with Hoechst, Propidium Iodide and Calcein-AM, that corneas stored at 4°C in Optisol-GS for 3 to 7 days, the technic most used worldwide, bear a significant number of dead endothelial cells (ECs). They underlined that these non-viable ECs are not recognized by specular cell count done by the eye bank and that this could explain the “cell loss” inevitably noticed post graft. Our team applied, for the first time in 2011 [1] and again in 2016 [2], a similar triple staining on the endothelium of whole corneas stored in long-term organ culture at 31°C, the dominant technic in Europe. We made the same findings as Kitazawa et al. and defined the notion of viable ECD (vECD) as the number of viable ECs per surface unit. Areas without ECs (especially in Descemetic folds), dead and dying EC (that will not survive the storage) clearly explain the important discrepancy between the cell count done by the eye bank (unable to spot them) and the very early postoperative ECD. Our team also demonstrated long ago that vital Trypan blue staining used by certain eye bank is unable to spot all dying cells because its time window of positivity is very narrow, corresponding only to ECs near to desquamate [3]. Viable ECD determined by triple staining therefore appea...
We read with interest the recently published study by Kim et al, which the authors described as a cross-sectional, observational, case-control study. As a single study such a design is not possible since cross-sectional and case-control studies are two distinct types of study designs. The authors compared the percent with lower lid epiblepharon between those with and without congenital glaucoma and reported that controls were matched on age and date of outpatient visit to the cases, which would suggest this is a matched case-control study. However, the statistical analysis employed did not account for the matched nature of the study design and therefore was not appropriate. Statistical procedures that account for the matched nature of the study should have been employed. The authors are urged to conduct a reanalysis of their study, amending their interpretation as warranted.
Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Cicinelli et al. Br J Ophthalmol 2017; http: /dx.doi. org/ 10.1136/bjophthalmol-2017-310242.
Dear Editor
Show MoreWe would like to address several challenges that have arisen from the study by Cicinelli et al (1), which can be specifically summarized below.
1. The study was retrospectively conducted, with a selection bias attributable to the heterogeneity of the patients included, for example, six patients were affected by the type 1 diabetes mellitus; eighteen eyes were phakic; twenty seven eyes underwent cataract extraction and intraocular lens implant; and thirteen eyes received grid macular photocoagulation for diabetic macular oedema (DME) prior to ranibizumab (RNB).
2. After undergoing three loading-dose intravitreal injections of RNB performed at fixed 4-week intervals for the first 12 weeks, all the patients regardless of functional and anatomical characteristics, were shifted to dexamethasone implant (DEX implant 0.7 mg; Ozurdex; Allergan, Irvine, California, USA) continued at 4-month intervals until stable best-corrected visual acuity (BCVA) was reached. However, nothing was...
We warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
Show MoreWe agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the...
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
Show MoreDear Editors,
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, f...
Show MoreWe have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
Show MoreKenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the li...
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