650 e-Letters

  • Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?

    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...

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  • Optometrists do not have to refer

    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.

  • Authors' response: Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism

    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

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    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...

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  • Potential hazards of silicone oil released by the syringes

    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...

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  • Reliability of Bruch’s membrane opening minimum rim width (BMO-MRW) and retinal nerve fibre layer thickness (RNFLT) with optical coherence tomography (OCT)

    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...

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  • Here is your injection: would you like with or without silicone oil?

    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...

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  • Letter to Editor

    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...

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  • Re: Choroidal Thickness in Macular Telangiectasia Type 2

    Dear 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.

  • Comment on 'Clinical presentation and management of corneal fistula'

    Dear Editor,
    We have read with great interest the article by Singhal et al 1 on 'Clinical presentation and management of corneal fistula'. The authors have rightly highlighted the point that failure to perform simple test like Seidel test in cases of corneal ulcer, can lead to missing the diagnosis of corneal fistula, which in turn can lead to serious complications like endophthalmitis, panophthalmitis and phthisis bulbi.
    One of the complications of persistent corneal fistula is the formation of anterior capsular cataract. It would have been more insightful if the authors had mentioned as to how many patients had developed anterior capsular cataract during follow up, as this can lead to a change in the future management of the eye.
    Also, the authors have not mentioned the type of anaesthesia for doing the procedure. As creating the grooves around perforation to tuck in the tenons graft is difficult due to the friability of corneal tissue, the type of anaesthesia has a bearing on the intra operative surgical procedure. As doing the technique in topical anaesthesia will be technically challenging and administration of peribulbar block could lead to extrusion of the intraocular contents or extension of the perforation.
    Although the study mentions the surgical technique for closing the fistula with a tenons patch graft, it does not mention the regimen of postoperative medical management.
    In the discussion, the authors have mentioned that...

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