Chauhan and co-workers [1] have provided Table 1, showing times taken to detect significant field progression with 80% power, based on a number of modelling parameters: frequency of examinations, rate of field progression, intrasession variability of field assessment. They have also provided Table 2 showing the number of annual eye examinations required to detect different total visual field changes, for different time periods, and for moderate variability. I have checked the calculations of Chauhan and co-workers, using Monte Carlo modelling, assuming a one-tailed significance value of 0.025. Of the 36 outcome values in Table 1, 33 are incorrect. Of the 12 outcome values in Table 2, 11 are incorrect.
Chauhan and co-workers have made 2 main errors in their calculations for Table 1. The first is in applying their estimates of power. The curves shown in Figure 2 (statistical power plotted against number of field examinations) are appropriate for the case of 2 field examinations per year, but Chauhan and co-workers appear to have incorrectly also used them for the cases of 1 examination per year and 3 examinations per year. Separate sets of curves should have been calculated for those conditions. The effect on Table 1 is that the time taken to detect a field change is incorrectly reported as being inversely proportional to the number of examinations per year. This anomalous relationship was commented on by Albert Alm in his 2008 Rapid Response, “Is a field every 4...
Chauhan and co-workers [1] have provided Table 1, showing times taken to detect significant field progression with 80% power, based on a number of modelling parameters: frequency of examinations, rate of field progression, intrasession variability of field assessment. They have also provided Table 2 showing the number of annual eye examinations required to detect different total visual field changes, for different time periods, and for moderate variability. I have checked the calculations of Chauhan and co-workers, using Monte Carlo modelling, assuming a one-tailed significance value of 0.025. Of the 36 outcome values in Table 1, 33 are incorrect. Of the 12 outcome values in Table 2, 11 are incorrect.
Chauhan and co-workers have made 2 main errors in their calculations for Table 1. The first is in applying their estimates of power. The curves shown in Figure 2 (statistical power plotted against number of field examinations) are appropriate for the case of 2 field examinations per year, but Chauhan and co-workers appear to have incorrectly also used them for the cases of 1 examination per year and 3 examinations per year. Separate sets of curves should have been calculated for those conditions. The effect on Table 1 is that the time taken to detect a field change is incorrectly reported as being inversely proportional to the number of examinations per year. This anomalous relationship was commented on by Albert Alm in his 2008 Rapid Response, “Is a field every 4 month a significant improvement over a field every 6 months?”. He wrote, “… increasing the duration is much more efficient than increasing the frequency of examinations. Thus, 5 examinations in 1.7 years will not be able to detect the same slope as 5 examinations in 5 years!” My calculations for the values in Table 1 show that increasing examination frequency, from once per year to 3 times per year, reduces time to detect a field change to between 71% and 50%, not 33% as implied by the original paper.
The second error made by Chauhan and co-workers is in converting from the number of fields (S) required to the duration required (D) for a given annual frequency of testing (f). From equation 5 in another paper,[2] this relationship is: D=(S-1)/f. Chauhan and co-workers appear to have used D=S/f.
In Table 1, three values are correct. One of those correct values, that it takes 2 years to detect fast progression (MD rate =-2dB/Year) with moderate field variability (SD=1dB) with 3 examinations/year, seems to be the basis for the paper’s recommendation that “six visual field examinations should be performed in the first 2 years.” This is slightly incorrect. A testing frequency of 3 examinations per year over 2 years will yield 7 examinations.
Table 2 contains significant errors. For example, its results imply that detecting a total field change of 1 dB will require between 15 and 21 measurements with SD= 1dB, depending on the number of years measurements are spread over. My calculations give an estimate of 95 total measurements required (irrespective of the time span).
This paper has been, and continues to be, influential. For example, Table 1 has been included in clinical glaucoma management guidelines.[3] The journal’s article metrics show 371 citations for the paper at the time of writing. Yet, the paper incorrectly overemphasises the value of increasing visual field test frequency. That is a core message for the paper. Given the paper’s influence those errors should be corrected.
References
1. Chauhan BC, Garway-Heath DF, Goñi FJ, et al. Practical recommendations for measuring rates of visual field change in glaucoma. Br J Ophthalmol 2008;92(4):569-73. doi: 10.1136/bjo.2007.135012 [published Online First: 2008/01/24]
2. Schlesselman JJ. Planning a longitudinal study. II. Frequency of measurement and study duration. J Chronic Dis 1973;26(9):561-70. doi: 10.1016/0021-9681(73)90061-1
3. NHMRC. NHMRC Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma 2010: National Health and Medical Research Council, Canberra., 2010.
Shang et al. conducted a prospective study to examine the effect of ophthalmic and systemic conditions on incident dementia (1). The adjusted hazard ratios (HRs) (95% confidence intervals [CIs]) of age-related macular degeneration (AMD), cataract, diabetes-related eye disease (DRED), and glaucoma at baseline for incident dementia were 1.26 (1.05 to 1.52), 1.11 (1.00 to 1.24), 1.61 (1.30 to 2.00), and 1.07 (0.92 to 1.25), respectively. Diabetes, heart disease, stroke and depression at baseline were also significantly associated with an increased risk of dementia. In addition, some combinations of ophthalmic and systemic conditions were at the higher risk for incident dementia. I have a comment about the study.
Vision impairment is a risk factor of dementia, and poor vision is independently associated with a decline in cognitive function (2). Shang et al. clarified that AMD, cataract, and DRED were risk of incident dementia, and some combinations with systemic conditions accelerated risk of incident dementia. Although glaucoma was not significantly associated with increased risk of al-cause dementia, it was significantly associated with increased risk of vascular dementia. The authors also conducted analysis by excluding data in the first 5 years of follow-up, consistent results were also specified on the combined effects of ophthalmic and systemic conditions on incident dementia. Although the mechanism of increased risk of dementia in combinations with ophthalmic and...
Shang et al. conducted a prospective study to examine the effect of ophthalmic and systemic conditions on incident dementia (1). The adjusted hazard ratios (HRs) (95% confidence intervals [CIs]) of age-related macular degeneration (AMD), cataract, diabetes-related eye disease (DRED), and glaucoma at baseline for incident dementia were 1.26 (1.05 to 1.52), 1.11 (1.00 to 1.24), 1.61 (1.30 to 2.00), and 1.07 (0.92 to 1.25), respectively. Diabetes, heart disease, stroke and depression at baseline were also significantly associated with an increased risk of dementia. In addition, some combinations of ophthalmic and systemic conditions were at the higher risk for incident dementia. I have a comment about the study.
Vision impairment is a risk factor of dementia, and poor vision is independently associated with a decline in cognitive function (2). Shang et al. clarified that AMD, cataract, and DRED were risk of incident dementia, and some combinations with systemic conditions accelerated risk of incident dementia. Although glaucoma was not significantly associated with increased risk of al-cause dementia, it was significantly associated with increased risk of vascular dementia. The authors also conducted analysis by excluding data in the first 5 years of follow-up, consistent results were also specified on the combined effects of ophthalmic and systemic conditions on incident dementia. Although the mechanism of increased risk of dementia in combinations with ophthalmic and systemic conditions might be difficult to be explained, medical care on both ophthalmic and systemic conditions will be indispensable to avid acceleration of cognitive decline.
References
1. Shang X, Zhu Z, Huang Y, et al. Associations of ophthalmic and systemic conditions with incident dementia in the UK Biobank. Br J Ophthalmol 2021 Sep 13. doi: 10.1136/bjophthalmol-2021-319508
2. Lim ZW, Chee ML, Soh ZD, et al. Association Between Visual Impairment and Decline in Cognitive Function in a Multiethnic Asian Population. JAMA Netw Open 2020;3(4):e203560.
I read with interest the article by Jonas et al 1. The main purpose of the authors was to explore associations between a disc size change and other morphological parameters. Indeed, many non-ophthalmic and game-changing parameters are associated with disc size change and other morphological parameters, such as the serum lipids 2 dietary factors (such as lutein, zeaxanthin, and omega-3 fatty acids) 2-4, medications (such as lipid-lowering agents) 2, genetic susceptibility, body mass index, age and sex 3, among which only age and sex are addressed in their retrospective analysis.
According to the authors, decrease in the ophthalmoscopic disc size in the myopic eyes during the 10-year follow up, is likely related to a shift of the Bruch’s membrane opening as the inner of the three optic nerve head canal layers into the direction of the fovea. While their interpretations can be partly true, their attributed mechanism is subject to many biases.
Firstly, changes in ophthalmoscopical optic disc size and Bruch’s membrane are a function of macular pigment optical density 5-7, which in turn is a function of dietary carotenoid intake 8;9. Tong et al 10 have shown before that macular pigment optical density (MPOD) is inversely associated with axial length in Chinese subjects with myopia, suggesting that carotenoid intake, particularly lutein, is associated to axial length as well. Another study with a smaller sample size (45 eyes of 32 patients) with a different mean a...
I read with interest the article by Jonas et al 1. The main purpose of the authors was to explore associations between a disc size change and other morphological parameters. Indeed, many non-ophthalmic and game-changing parameters are associated with disc size change and other morphological parameters, such as the serum lipids 2 dietary factors (such as lutein, zeaxanthin, and omega-3 fatty acids) 2-4, medications (such as lipid-lowering agents) 2, genetic susceptibility, body mass index, age and sex 3, among which only age and sex are addressed in their retrospective analysis.
According to the authors, decrease in the ophthalmoscopic disc size in the myopic eyes during the 10-year follow up, is likely related to a shift of the Bruch’s membrane opening as the inner of the three optic nerve head canal layers into the direction of the fovea. While their interpretations can be partly true, their attributed mechanism is subject to many biases.
Firstly, changes in ophthalmoscopical optic disc size and Bruch’s membrane are a function of macular pigment optical density 5-7, which in turn is a function of dietary carotenoid intake 8;9. Tong et al 10 have shown before that macular pigment optical density (MPOD) is inversely associated with axial length in Chinese subjects with myopia, suggesting that carotenoid intake, particularly lutein, is associated to axial length as well. Another study with a smaller sample size (45 eyes of 32 patients) with a different mean age did not show the same association 5. A detailed explanation of the reasons justifying these differences is provided elsewhere 11.
Secondly, in many medical situations (such as obesity, diabetes, etc.), MOPD is reduced dramatically 12;13. Jonas et al 1 report that only 89 highly myoptic eyes (i.e., 43.6%) were re-examined after 10 years. Although the authors report that the age of cases in 2011 did not differ significantly from the age of their controls in the survey of 2011, no other dietary or medical information is provided in their study. Thus, it is very difficult to draw a firm conclusion.
One can certainly question whether there were any changes in carotenoid intakes and/or any medical situation during a decade-long longitudinal study. In support of this argument, MOPD is reported to significantly increase within 3 months in healthy Japanese individuals supplemented with daily 10 mg of orally administered lutein or zeaxanthin 14. Interestingly, in high myopia, it has been shown that even after a shorter period of lutein supplementation (20 to 40 days), MPOD began to rise uniformly at an average rate of 1.13+/-0.12 milliabsorbance units/day. During this same period, the serum lutein concentration increased tenfold, and then approached a steady state plateau. Most critically, the optical density curve eventually levelled off some 40 to 50 days after the participants discontinued the supplement. Thus, even a modest period of dietary carotenoid intake may produce a 30 to 40% reduction in blue light reaching the photoreceptors, Bruch's membrane, and the retinal pigment epithelium 6.
Substantial differences are reported in terms of dietary carotenoid/lutein intake among Chinese population 15;16. This issue may be even more pronounced in a small sample size a low rate of re-participation.
We agree that geometrical reasons may lead to a decrease in the size of the ophthalmoscopically visible optic disc. However, their presumed mechanism 17 may simply be partially a byproduct of MOPD changes over time.
Reference List
1. Jonas JB, Zhang Q, Xu L et al. Change in the ophthalmoscopical optic disc size and shape in a 10-year follow-up: the Beijing Eye Study 2001-2011. Br.J Ophthalmol. 2021.
2. Renzi LM, Hammond BR, Jr., Dengler M et al. The relation between serum lipids and lutein and zeaxanthin in the serum and retina: results from cross-sectional, case-control and case study designs. Lipids Health Dis. 2012;11:33.
3. Bone RA, Landrum JT, Guerra LH et al. Lutein and zeaxanthin dietary supplements raise macular pigment density and serum concentrations of these carotenoids in humans. The Journal of nutrition 2003;133:992-8.
4. Lin KH, Tran T, Kim S et al. Advanced Retinal Imaging and Ocular Parameters of the Rhesus Macaque Eye. Transl.Vis.Sci Technol. 2021;10:7.
5. Benoudis L, Ingrand P, Jeau J et al. Relationships between macular pigment optical density and lacquer cracks in high myopia. J Fr.Ophtalmol. 2016;39:615-21.
6. Landrum JT, Bone RA, Joa H et al. A one year study of the macular pigment: the effect of 140 days of a lutein supplement. Exp.Eye Res. 1997;65:57-62.
7. Zarubina AV, Huisingh CE, Clark ME et al. Rod-Mediated Dark Adaptation and Macular Pigment Optical Density in Older Adults with Normal Maculas. Curr.Eye Res. 2018;43:913-20.
8. Ajana S, Weber D, Helmer C et al. Plasma Concentrations of Lutein and Zeaxanthin, Macular Pigment Optical Density, and Their Associations With Cognitive Performances Among Older Adults. Invest Ophthalmol.Vis.Sci 2018;59:1828-35.
9. Berendschot TT, Plat J, de JA et al. Long-term plant stanol and sterol ester-enriched functional food consumption, serum lutein/zeaxanthin concentration and macular pigment optical density. Br.J Nutr. 2009;101:1607-10.
10. Tong N, Zhang W, Zhang Z et al. Inverse relationship between macular pigment optical density and axial length in Chinese subjects with myopia. Graefes.Arch.Clin.Exp.Ophthalmol. 2013;251:1495-500.
11. Tong N, Zhang W, Wu X. Reply to the letter by Xing-Ru Zhang and Zhen-Yong Zhang: Comments on "Inverse relationship between macular pigment optical density and axial length in Chinese subjects with myopia". Graefes.Arch.Clin.Exp.Ophthalmol. 2013;251:2287.
12. Hammond BR, Jr., Ciulla TA, Snodderly DM. Macular pigment density is reduced in obese subjects. Invest Ophthalmol.Vis.Sci 2002;43:47-50.
13. Scanlon G, Connell P, Ratzlaff M et al. MACULAR PIGMENT OPTICAL DENSITY IS LOWER IN TYPE 2 DIABETES, COMPARED WITH TYPE 1 DIABETES AND NORMAL CONTROLS. Retina. 2015;35:1808-16.
14. Tanito M, Obana A, Gohto Y et al. Macular pigment density changes in Japanese individuals supplemented with lutein or zeaxanthin: quantification via resonance Raman spectrophotometry and autofluorescence imaging. Jpn.J Ophthalmol. 2012;56:488-96.
15. Ng ALK, Leung HH, Kawasaki R et al. Dietary habits, fatty acids and carotenoid levels are associated with neovascular age-related macular degeneration in Chinese. Nutrients 2019;11:1720.
16. Takata Y, Xiang YB, Yang G et al. Intakes of fruits, vegetables, and related vitamins and lung cancer risk: results from the Shanghai Men's Health Study (2002G_ô2009). Nutrition and cancer 2013;65:51-61.
17. Zhang Q, Xu L, Wei WB et al. Size and Shape of Bruch's Membrane Opening in Relationship to Axial Length, Gamma Zone, and Macular Bruch's Membrane Defects. Invest Ophthalmol.Vis.Sci 2019;60:2591-8.
The paper advises that the population inspected was predominately of white background and is looking to find ways of expanding its knowledge of non-white ethnicity within the sphere of retina testing. Within the following paper : Ethnicity and Type 2 diabetes in the UK by
L. M. Goff; it states that the prevalence of Type 2 diabetes within the non-white community is particularly high. a quote from this paper:
"Among minority ethnic communities, the prevalence is alarmingly high, approximately three to five times higher than in the white British population. "
Which brings me to my response: All UK Type 2 diabetics are offered eye screening during which the retina is photographed every year. These digital photographs are examined by medical staff looking for vein bleeding and are held by the NHS. Given the hign incidence of Type 2 diabetes in non-white citizens a very large number of these records will be available and so allow a useful extension to the work done by Professor Rudnicka.
Martel et al. report the prevalence, features and risk factors of visual hallucinations following eye removal (1). The findings indicate that visual hallucinations may be a significant and prevalent association of eye amputation, occurring in around one-third of cases. Throughout the paper, visual hallucinations are referred to as phantom visions, and categorised under the broad catchment of the phantom eye syndrome that includes pain and tactile sensations as well as visual hallucinations. Although the authors speculate phantom visions could be considered a subtype of Charles Bonnet syndrome (CBS) they are reluctant to refer to them as CBS, perhaps because of the longstanding debate as to whether CBS should be used to refer to a specific type of visual hallucination or a specific underlying cause (2,3). Where CBS is used to refer to a specific hallucination type, it is typically reserved for complex hallucinations and excludes the simple, ‘elementary’ hallucinations described as the most common experiences following enucleation. The consequence is that a range of terms have evolved to describe symptoms that have the same cause, adding confusion to the literature and hindering research and extensive efforts to raise awareness and establish appropriate patient management pathways for people with visual hallucinations (4-6).
It is our opinion that both the simple and complex visual hallucinations described in the study should be referred to as Charles Bonnet syndrome....
Martel et al. report the prevalence, features and risk factors of visual hallucinations following eye removal (1). The findings indicate that visual hallucinations may be a significant and prevalent association of eye amputation, occurring in around one-third of cases. Throughout the paper, visual hallucinations are referred to as phantom visions, and categorised under the broad catchment of the phantom eye syndrome that includes pain and tactile sensations as well as visual hallucinations. Although the authors speculate phantom visions could be considered a subtype of Charles Bonnet syndrome (CBS) they are reluctant to refer to them as CBS, perhaps because of the longstanding debate as to whether CBS should be used to refer to a specific type of visual hallucination or a specific underlying cause (2,3). Where CBS is used to refer to a specific hallucination type, it is typically reserved for complex hallucinations and excludes the simple, ‘elementary’ hallucinations described as the most common experiences following enucleation. The consequence is that a range of terms have evolved to describe symptoms that have the same cause, adding confusion to the literature and hindering research and extensive efforts to raise awareness and establish appropriate patient management pathways for people with visual hallucinations (4-6).
It is our opinion that both the simple and complex visual hallucinations described in the study should be referred to as Charles Bonnet syndrome. In fact, irrespective of eye condition or visual pathway disease, surveys that include both simple and complex hallucinations find a similar ratio of simple to complex as that described by the authors following eye removal (see for example 7,8) and it has been argued previously that restriction of the use of CBS to denote complex hallucinations only should be revisited (3). Broadening the term to include simple and complex phenomena reflects current practice (9,10) and has become particularly pressing as the International Classification of Diseases (ICD-11) now includes CBS for the first time, using it to refer to the specific causal mechanism of visual release.
Inconsistent terminology in the visual hallucination literature threatens to widen the gap between patients and appropriate referral to support services. This problem is particularly acute in CBS due to low awareness of the condition among physicians (7, 11). There is need for unity to ensure all patients receive accurate and clear messaging about visual hallucinations and can be signposted to relevant organisations, such as Esme’s Umbrella, for advice and support.
References
1. Martel A, Baillif S, Thomas P, et al. Phantom vision after eye removal: prevalence, features and related risk factors. British Journal of Ophthalmology, Published Online First: 12 May 2021. doi: 10.1136/bjophthalmol-2021-319091
2. ffytche DH. Visual hallucinatory syndromes: past, present, and future. Dialogues in Clinical Neuroscience. 2007;9(2):173-189.
3. ffytche DH. Visual hallucinations and the Charles Bonnet syndrome. Current Psychiatry Reports. 2005;7(3): 168-79.
4. O'Brien J, Taylor JP, Ballard C, Barker RA, Bradley C, Burns A, Collerton D, Dave S, Dudley R, Francis P, Gibbons A. Visual hallucinations in neurological and ophthalmological disease: pathophysiology and management. Journal of Neurology, Neurosurgery & Psychiatry, 2020; 91(5): 512-519.
5. Carpenter K, Jolly JK, Bridge H. The elephant in the room: understanding the pathogenesis of Charles Bonnet syndrome. Ophthalmic and Physiological Optics, 2019; 39(6): 414-421.
6. Best J, Liu PY, ffytche D, Potts J, Moosajee M. Think sight loss, think Charles Bonnet syndrome. Therapeutic Advances in Ophthalmology, 2019. doi:10.1177/2515841419895909
7. Cox TM, ffytche DH. Negative outcome Charles Bonnet Syndrome, British Journal of Ophthalmology, 2014; 98: 1236-9.
8. Santhouse AM, Howard RJ, ffytche DH. Visual hallucinatory syndromes and the anatomy of the visual brain. Brain. 2000;123: 2055-64
9. Jones L, Moosajee M. Visual hallucinations and sight loss in children and young adults: a retrospective case series of Charles Bonnet syndrome. British Journal of Ophthalmology, Published Online First: 15 September 2020. doi: 10.1136/bjophthalmol-2020-317237
10. Jones L, Ditzel-Finn L, Potts J, Moosajee M. Exacerbation of visual hallucinations in Charles Bonnet syndrome due to the social implications of COVID-19. BMJ Open Ophthalmology, 2021; 6(1), p.e000670.
11. Gordon KD, Felfeli T. Family physician awareness of Charles Bonnet syndrome, Family Practice, 2018; 35(5): 595-8.
We would like to congratulate Uwaydat et al. on their large series of spontaneously closed macular holes (MH), which adds new information to the literature.(1) It reinforces the observation that traumatic MH can spontaneously close and that a period of observation in these eyes, where the results of surgery are not clear, is a worthwhile option. However, we disagree with their conclusion that eyes with recent onset small primary MHs should also be observed. The authors don’t suggest a time period for observation but found that the median time for closure for these small holes was 4.4 months.
The report by Uwaydat et al. has 40 authors and the 60 cases of idiopathic MH were collected over at least a two-year period. Assuming a conservative number of 25 MH cases seen per surgeon per annum, this would give a spontaneous closure rate of ~3%, which is similar to the published literature as the authors review in their article.
MH are known to enlarge with time, even in the short term. Madi et al, reported that 83% enlarged, by a median of 105 microns in 8 weeks. (2) Similarly, Berton et al recently estimated that holes less than 250 microns enlarge by a mean of 1.67 microns per day, resulting in a similar 100-micron increase in 2 months.(3)
The anatomical and visual outcomes of surgery are dependent on MH diameter and duration. Holes greater than 300 microns, and with a duration more than four months are less likely to regain 0.3 logMAR or better.(4)...
We would like to congratulate Uwaydat et al. on their large series of spontaneously closed macular holes (MH), which adds new information to the literature.(1) It reinforces the observation that traumatic MH can spontaneously close and that a period of observation in these eyes, where the results of surgery are not clear, is a worthwhile option. However, we disagree with their conclusion that eyes with recent onset small primary MHs should also be observed. The authors don’t suggest a time period for observation but found that the median time for closure for these small holes was 4.4 months.
The report by Uwaydat et al. has 40 authors and the 60 cases of idiopathic MH were collected over at least a two-year period. Assuming a conservative number of 25 MH cases seen per surgeon per annum, this would give a spontaneous closure rate of ~3%, which is similar to the published literature as the authors review in their article.
MH are known to enlarge with time, even in the short term. Madi et al, reported that 83% enlarged, by a median of 105 microns in 8 weeks. (2) Similarly, Berton et al recently estimated that holes less than 250 microns enlarge by a mean of 1.67 microns per day, resulting in a similar 100-micron increase in 2 months.(3)
The anatomical and visual outcomes of surgery are dependent on MH diameter and duration. Holes greater than 300 microns, and with a duration more than four months are less likely to regain 0.3 logMAR or better.(4)
Surgery achieves closure rates of over 98% for small and medium sized holes, and a risk of a worse visual outcome than preoperatively is very low.(4)
Taking this information together, observing a 200 micron hole with a 2-month duration, for even 2 months would likely result in a 100-micron size increase, and a four-fold reduction in the chances of achieving 0.3logMAR or better, set against a 5% chance of observing spontaneous closure.
The spontaneous closure rate in smaller holes is likely to be higher than previously stated however, it is not a common observation, and delaying surgery carries real risks for the patient. Although the options should be discussed with the patient, we advocate prompt surgery for all primary macular holes, including small ones, as the best means of achieving good functional results.
1. Uwaydat, S. H. et al. Clinical characteristics of full thickness macular holes that closed without surgery. Br. J. Ophthalmol. (2021) doi:10.1136/bjophthalmol-2021-319001.
2. Madi, H. A., Dinah, C., Rees, J. & Steel, D. H. W. The Case Mix of Patients Presenting with Full-Thickness Macular Holes and Progression before Surgery: Implications for Optimum Management. Ophthalmol. J. Int. d’ophtalmologie. Int. J. Ophthalmol. Zeitschrift fur Augenheilkd. 233, 216–221 (2015).
3. Berton, M., Robins, J., Frigo, A. C. & Wong, R. Rate of progression of idiopathic full-thickness macular holes before surgery. Eye (Lond). 34, 1386–1391 (2020).
4. Steel, D. H. et al. Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort. Eye (Lond). 35, 316–325 (2021).
Dear Editor,
With great excitement, we read the original article titled “Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study” by Bulirsch et al.1 We congratulate the authors on their detailed analysis and on adding another important real world data related to brolucizumab usage. As we are still trying to understand the pathogenesis of brolucizumab related immunogenicity and the population at risk,2-4 it would be very helpful for the readers if the authors could share the following information.
1. Were the 7 eyes in which IOI was recorded have history of any other autoimmune systemic diseases such as arthritis, thyroid abnormalities etc ?
2. It would be helpful if the authors could clarify if the 4 eyes that had intermediate uveitis and vitreous cells underwent fluorescein angigraphy or wide filed imaging to rule out the possibility of peripheral retinal vasulilits.
3. It would be helpful for the readers if we could know the indication of using subconjunctival dexamethasone in four cases?
4. After treatment, were all the patients who had vitritis completely free of cells/inflammation on clinical examination or were they asymptomatic?
Ashish Sharma, Nilesh Kumar, Nikulaa Parachuri
Lotus Eye Hospital and Institute, Coimbatore, TN, India
References
1. Bulirsch LM, Saßmannshausen M, Nadal J, et al Short-term real-world outcomes following intravitreal brolucizumab for neovas...
Dear Editor,
With great excitement, we read the original article titled “Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study” by Bulirsch et al.1 We congratulate the authors on their detailed analysis and on adding another important real world data related to brolucizumab usage. As we are still trying to understand the pathogenesis of brolucizumab related immunogenicity and the population at risk,2-4 it would be very helpful for the readers if the authors could share the following information.
1. Were the 7 eyes in which IOI was recorded have history of any other autoimmune systemic diseases such as arthritis, thyroid abnormalities etc ?
2. It would be helpful if the authors could clarify if the 4 eyes that had intermediate uveitis and vitreous cells underwent fluorescein angigraphy or wide filed imaging to rule out the possibility of peripheral retinal vasulilits.
3. It would be helpful for the readers if we could know the indication of using subconjunctival dexamethasone in four cases?
4. After treatment, were all the patients who had vitritis completely free of cells/inflammation on clinical examination or were they asymptomatic?
Ashish Sharma, Nilesh Kumar, Nikulaa Parachuri
Lotus Eye Hospital and Institute, Coimbatore, TN, India
References
1. Bulirsch LM, Saßmannshausen M, Nadal J, et al Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study British Journal of Ophthalmology Published Online First: 12 April 2021. doi: 10.1136/bjophthalmol-2020-318672
2. Sharma A, Kumar N, Parachuri N, Singh S, Bandello F, Regillo CD, Boyer D, Nguyen QD. Understanding Retinal Vasculitis Associated with Brolucizumab: Complex Pathophysiology or Occam's Razor? Ocul Immunol Inflamm. 2021 May 20:1-3. doi: 10.1080/09273948.2021.1897628.
3. Singer M, Albini TA, Seres A, Baumal CR, Parikh S, Gale R, Kaiser PK, Lobach I, Feltgen N, Joshi MR, Ziemssen F, Bodaghi B. Clinical Characteristics and Outcomes of Eyes with Intraocular Inflammation after Brolucizumab: Post Hoc Analysis of HAWK and HARRIER. Ophthalmol Retina. 2021 May 7:S2468-6530(21)00162-7. doi: 10.1016/j.oret.2021.05.003.
4. Sharma A, Kumar N, Parachuri N, Kuppermann BD, Bandello F, Regillo CD, Boyer D, Nguyen QD. Brolucizumab-foreseeable workflow in the current scenario. Eye (Lond). 2021 Feb 2. doi: 10.1038/s41433-020-01324-w.
To the editor
We read the article published by Patel et al. with considerable interest [1]. The authors have provided interestingly novel insights into the prevalence and risk factors for chalazion. In their large case-control study comprising 3,453,944 older veteran participants with/without chalazion, the risk factors for chalazion included smoking, conditions of the tear film, conjunctivitis, dry eye, conditions affecting periocular skin, rosacea, allergic conditions, and systemic disorders, such as anxiety. Considering the relationship between chalazion and anxiety, a similar trend as reported in the previous study by Nemet et al. was observed [2]. Moreover, anxiety is generally considered as a psychological reaction to stress [3, 4]. Alsammahi et al. reported that stress is associated with the development of chalazion [5]. In real-world settings, we realize that patients with the onset of chalazion are likely to have anxiety or stress (such as work and examination).
Incidentally, in the c...
To the editor
We read the article published by Patel et al. with considerable interest [1]. The authors have provided interestingly novel insights into the prevalence and risk factors for chalazion. In their large case-control study comprising 3,453,944 older veteran participants with/without chalazion, the risk factors for chalazion included smoking, conditions of the tear film, conjunctivitis, dry eye, conditions affecting periocular skin, rosacea, allergic conditions, and systemic disorders, such as anxiety. Considering the relationship between chalazion and anxiety, a similar trend as reported in the previous study by Nemet et al. was observed [2]. Moreover, anxiety is generally considered as a psychological reaction to stress [3, 4]. Alsammahi et al. reported that stress is associated with the development of chalazion [5]. In real-world settings, we realize that patients with the onset of chalazion are likely to have anxiety or stress (such as work and examination).
Incidentally, in the coronavirus disease 2019 (COVID-19) pandemic era, Silkiss et al. reported that the incidence of chalazion increased with widespread mask wear, possibly resulting from eye dryness and changes in the eyelid microbiome associated with wearing face coverings [6]. Moreover, the widespread COVID-19 vaccinations provide many opportunities to examine the chalazion of patients who had recently received the vaccination at our institution, and most of these patients had anxiety or stress regarding the vaccination. To the best of our knowledge, the association between chalazion and COVID-19 vaccination has not been debated. Moreover, determining whether the chalazion occurred immediately after the vaccination was causation or coincidence is difficult because this disease is common and often observed in unvaccinated patients as well. However, we believe that these cases confirmed the result of Patel et al.’s study, wherein anxiety was associated with the risk of chalazion development. The need for vaccination against COVID-19 will continue because of the increased supply of COVID-19 vaccines for developing nations, recommendation of the third dose of vaccine, and the lowering of the age for vaccination against COVID-19, mainly in developed countries. Therefore, to elucidate the mechanism of chalazion after the vaccination, increasingly reliable care of this symptom following vaccination is warranted.
References
1. Patel S, Tohme N, Gorrin E, Kumar N, Goldhagen B, Galor A. Prevalence and risk factors for chalazion in an older veteran population. Br J Ophthalmol. 2021 Mar 31; bjophthalmol-2020-318420.
doi: 10.1136/bjophthalmol-2020-318420. Online ahead of print.
2. Nemet AY, Vinker S, Kaiserman I. Associated morbidity of chalazia. Cornea 2011; 30: 1376-1381.
3. Robinson L. Stress and anxiety. Nurs Clin North Am 1990; 25: 935-943.
4. American Psychological Association. Stress won’t go away? Maybe you are suffering from chronic stress. Available online: https://www.apa.org/topics/stress/chronic. Accessed March 15, 2022.
5. Alsammahi A, Aljohani Z, Jaad N, Daia OA, Aldayhum M, Almutairi M, Basendwah M, Alzahrani R, Alturki M. Incidence and predisposing factors of chalazion. Int J Community Med Public Health 2018; 5: 4979-4982.
6. Silkiss RZ, Paap MK, Ugradar S. Increased incidence of chalazion associated with face mask wear during the COVID-19 pandemic. Am J Ophthalmol Case Rep 2021; 22: 101032.
Randomized controlled trials (RCTs) are considered to be the best method for evaluating the effectiveness of medical interventions.1 Despite their strengths, RCTs have substantial limitations.1 Although RCTs have strong internal validity, they occasionally lack external validity and generalizations of findings outside the study population may be invalid. More specifically in retinal surgery, there are many obstacles to conducting RCTs to address the specific questions asked, so the analysis using real-world data is useful.2 Drs Anguita and Charteris wrote an editorial in the British Journal of Ophthalmology (BJO) on the merits and limitations of studies using real-world data.3 They cited our papers that were recently published in BJO which used the data collected in the Japan Retinal Detachment Registry (J-RD registry), and I would like to comment on with a focus on the retinal surgery.4,5
As correctly stated by Drs Anguita and Charteris, studies using the propensity score matching method cannot be performed well if one is not familiar with the limitations of this technique. 3 However, this is also true for those who do not have a deep understanding of the disease and may make incorrect interpretations. This would be the case for our paper4 cited in the editorial. This study compared pars plana vitrectomy (PPV) and scleral buckling for superior RD without macula detachment using the data from the J-RD registry. The results which were analyzed using propensity score...
Randomized controlled trials (RCTs) are considered to be the best method for evaluating the effectiveness of medical interventions.1 Despite their strengths, RCTs have substantial limitations.1 Although RCTs have strong internal validity, they occasionally lack external validity and generalizations of findings outside the study population may be invalid. More specifically in retinal surgery, there are many obstacles to conducting RCTs to address the specific questions asked, so the analysis using real-world data is useful.2 Drs Anguita and Charteris wrote an editorial in the British Journal of Ophthalmology (BJO) on the merits and limitations of studies using real-world data.3 They cited our papers that were recently published in BJO which used the data collected in the Japan Retinal Detachment Registry (J-RD registry), and I would like to comment on with a focus on the retinal surgery.4,5
As correctly stated by Drs Anguita and Charteris, studies using the propensity score matching method cannot be performed well if one is not familiar with the limitations of this technique. 3 However, this is also true for those who do not have a deep understanding of the disease and may make incorrect interpretations. This would be the case for our paper4 cited in the editorial. This study compared pars plana vitrectomy (PPV) and scleral buckling for superior RD without macula detachment using the data from the J-RD registry. The results which were analyzed using propensity score matching showed that there was no significant difference in the best-corrected visual acuity at 6 months after surgery, but there were significantly fewer surgical failures with scleral buckling than with PPV. Thus, we concluded that, “Although the indications for PPV are becoming broader, PPV may not be the optimal approach for repairing all types of RDs. Therefore, careful considerations are needed when selecting the appropriate surgical technique in treating uncomplicated phakic macula-on RD case”, knowing the limitation of evidence level obtained from real-world data study.4 The editorial by Drs Anguita and Charteris indicated that a major problem with this study was the lack of adjustments for the presence or absence of a posterior vitreous detachment (PVD) which is the most important factor in selecting the surgical method.3 Traditionally, the presence of a PVD has been determined by echography, but its accuracy is inferior to that of optical coherence tomography, and above all, it was found to vary from operator to operator.6 On the other hand, it is widely accepted that almost all cases of retinal tears are caused by a PVD,7 so we decided it would be more objective to adjust the evaluations of PVD by using retinal tear or hole instead. We believed that this analysis, in which preoperative factors were adjusted for retinal tear and/or hole, adjusted for PVD to an acceptable level. Without understanding this background, the findings of this paper might be misinterpreted. On the other hand, we mention in the paper by Funatsu et al, which was also cited in the editorial, on the potential toxic effects of silicone.5 There was a misunderstanding of the intent of our study, however because of space limitation, we will not discuss it here.
We agree that the analysis of real-world data using propensity score matching has its limitations.3 However, there are major problems in implementing RCTs in retinal surgery. First, RCTs are very costly, and the overall cost of an RCT study has skyrocketed to a level that cannot be borne by the surgeons or researchers. In recent years, RCTs are no longer conducted unless they are sponsored by large pharmaceutical companies that can profit from the results of RCTs.8 Additionally, if the drug is not effective, it will not necessarily be published.8 Studies in which the company's profit is not clear, such as retinal surgical treatments, are less likely to be adopted as a topic of study. Second, RCT is time-consuming. It usually takes only a few weeks to complete a study using registry data, but it generally takes years to complete RCT studies from planning, implementation, and analyzation. If prospective RCTs were performed for comparing PPV and scleral buckling for superior RD as in our study, it would have taken several years to accomplish the project. Furthermore, it has been noted that RCTs are virtually impossible to perform to compare existing and new surgical methods because surgeons’ preferences already exist and enrollment does not work.9 In general, surgeons want to know how to save the patient in front of them, often an individual problem, as soon as possible. Not only is it extremely difficult to recruit patients for an RCT who meet the inclusion criteria of individual problem of retinal surgery, and it can take several years to obtain the results.9 Thus, it is not practical to use an RCT for this purpose.
The editorial by Drs Anguita and Charteris is very important and I congratulate that. As they stated, we do not believe that the results obtained from real-world data analysis can replace the evidence of RCTs, either. On the other hand, it is true that RCTs cannot answer all of the surgical questions. Most importantly, RCTs are essentially experimental trials of humans. It is unclear whether it will continue to be ethically acceptable to put a large number of subjects at risk even for medical purposes. In contrast, real-world data analyses are basically retrospective studies so it does not expose patients to any new risks. Until better analysis methods are developed, real-world data analysis will provide certain answers to many problems which surgeons have. Nevertheless, I fully agree with them that the researchers and the readers need to recognize the validity and limitations of propensity score matching studies as well as to know the background of the treatment.
REFERENCES
1. Frieden TR. Evidence for Health Decision Making - Beyond Randomized, Controlled Trials. N Engl J Med 2017;377:465-75.
2. Ryan EH, Ryan CM, Forbes NJ, et al. Primary Retinal Detachment Outcomes Study Report Number 2: Phakic Retinal Detachment Outcomes. Ophthalmology 2020;127:1077-85.
3. Anguita R, Charteris D. Could real-world data replace evidence from clinical trials in surgical retinal conditions? Br J Ophthalmol 2022:bjophthalmol-2022-321759. doi: 10.1136/bjophthalmol-2022-321759. Epub ahead of print. PMID: 35580995.
4. Kawano S, Imai T, Sakamoto T; Japan-Retinal Detachment Registry Group. Scleral buckling versus pars plana vitrectomy in simple phakic macula-on retinal detachment: a propensity score-matched, registry-based study. Br J Ophthalmol 2022:857-62.
5. Funatsu R, Terasaki H, Koriyama C, et al. Silicone oil versus gas tamponade for primary rhegmatogenous retinal detachment treated successfully with a propensity score analysis: Japan Retinal Detachment Registry. Br J Ophthalmol 2021:bjophthalmol-2021-319876. doi: 10.1136/bjophthalmol-2021-319876. Epub ahead of print. PMID: 34373251.
6. Moon SY, Park SP, Kim YK. Evaluation of posterior vitreous detachment using ultrasonography and optical coherence tomography. Acta Ophthalmol 2020;98:e29-e35.
7. Michaels RG, Wilkinson CP, Rice TA. Vitreoretinal precursors of retinal detachment. In Retinal detachment, eds Michaels RG, Wilkinson CP, Rice TA, The CV Mosby Company, St Louis, 1990, pp 29-100.
8. Flacco ME, Manzoli L, Boccia S, et al. Head-to-head randomized trials are mostly industry sponsored and almost always favor the industry sponsor. J Clin Epidemiol 2015;68:811-20.
9. Lonjon G, Boutron I, Trinquart L, et al. Comparison of treatment effect estimates from prospective nonrandomized studies with propensity score analysis and randomized controlled trials of surgical procedures. Ann Surg 2014;259:18–25.
In your interesting paper dealing with the incidence of rhegmatogenous retinal detachment in France, you report the highest incidence rate so far together with Gout et al 1. It is almost twice as high as the incidence found in our area 2. You also report that this incidence was highest in Guadeloupe (28.30±2.74 per 100000 population) and lowest in French Guiana (15.51±3.50 per 100000 population).
Peters 3 investigated the incidence of RRD in black people and found that it was much lower (0.46/100,000 inhabitants) than in whites. Foos et al. 4 also found that there were no differences in the number of breaks or the proportion/ percentage of vitreous detachments between black and white people, suggesting a stronger adherence in their retinal pigmentary epithelium in the former. Given the fact that black subjects present higher levels of melanin, they have greater resistance against solar radiation, in the same way that they present a lower incidence of non-melanoma skin cancer due to this protective factor 5. Similarly, there is a lower risk of RRD in very dark-colored iris 6 subjects, possibly due to the same reason, as a smaller amount of solar radiation, which has been found to be associated with RRD 7 enters the eye. Taking into account that 70-90% of the population in the French Antilles are mulattoes or creoles (source: indexmundi.com), the lower incidence detected in this geographical location is not surprising. However, we encourage the authors to investigate...
In your interesting paper dealing with the incidence of rhegmatogenous retinal detachment in France, you report the highest incidence rate so far together with Gout et al 1. It is almost twice as high as the incidence found in our area 2. You also report that this incidence was highest in Guadeloupe (28.30±2.74 per 100000 population) and lowest in French Guiana (15.51±3.50 per 100000 population).
Peters 3 investigated the incidence of RRD in black people and found that it was much lower (0.46/100,000 inhabitants) than in whites. Foos et al. 4 also found that there were no differences in the number of breaks or the proportion/ percentage of vitreous detachments between black and white people, suggesting a stronger adherence in their retinal pigmentary epithelium in the former. Given the fact that black subjects present higher levels of melanin, they have greater resistance against solar radiation, in the same way that they present a lower incidence of non-melanoma skin cancer due to this protective factor 5. Similarly, there is a lower risk of RRD in very dark-colored iris 6 subjects, possibly due to the same reason, as a smaller amount of solar radiation, which has been found to be associated with RRD 7 enters the eye. Taking into account that 70-90% of the population in the French Antilles are mulattoes or creoles (source: indexmundi.com), the lower incidence detected in this geographical location is not surprising. However, we encourage the authors to investigate the reasons why this is not so in Guadeloupe as it might provide valuable information as to the factors influencing retinal detachment incidence in this region and globally.
1. Gout I, Mellington F, Tah V, Sarhan M, Rokerya S, Goldacre M, et al. Retinal Detachment - An Update of the Disease and Its Epidemiology - A Discussion Based on Research and Clinical Experience at the Prince Charles Eye Unit, Windsor, England, Advances in Ophthalmology 2012; 341-356
2. Sevillano C, Viso E, Moreira-Martínez S, Blanco MJ, Parafita-Fernández A, Sampil M, Gude F. Incidence and epidemiological characteristics of rhegmatogenous retinal detachment in Northwestern Spain.. Eye (Lond). 2021 Jan 8. doi: 10.1038/s41433-020-01200-7
3. Peters AL. Retinal detachment in black South Africans. S Afr Med J. 1995 Mar;85(3):158–9.
4. Foos RY, Simons KB, Wheeler NC. Comparison of lesions predisposing to rhegmatogenous retinal detachment by race of subjects. Am J Ophthalmol. 1983 Nov;96(5):644–9
5. Fajuyigbe D, Young AR. The impact of skin colour on human photobiological responses. Pigment Cell Melanoma Res. 2016 Nov;29(6): 607–18.
6. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case Control Study Group. Am J Epidemiol. 1993 Apr;137(7):749–57.
7. Sevillano C, Viso E, Moreira-Martínez S, Blanco MJ, Gude F. Rhegmatogenous retinal detachment and solar radiation in northwestern Spain. Ophthalmologica 2020;243(1):51-57.
Chauhan and co-workers [1] have provided Table 1, showing times taken to detect significant field progression with 80% power, based on a number of modelling parameters: frequency of examinations, rate of field progression, intrasession variability of field assessment. They have also provided Table 2 showing the number of annual eye examinations required to detect different total visual field changes, for different time periods, and for moderate variability. I have checked the calculations of Chauhan and co-workers, using Monte Carlo modelling, assuming a one-tailed significance value of 0.025. Of the 36 outcome values in Table 1, 33 are incorrect. Of the 12 outcome values in Table 2, 11 are incorrect.
Chauhan and co-workers have made 2 main errors in their calculations for Table 1. The first is in applying their estimates of power. The curves shown in Figure 2 (statistical power plotted against number of field examinations) are appropriate for the case of 2 field examinations per year, but Chauhan and co-workers appear to have incorrectly also used them for the cases of 1 examination per year and 3 examinations per year. Separate sets of curves should have been calculated for those conditions. The effect on Table 1 is that the time taken to detect a field change is incorrectly reported as being inversely proportional to the number of examinations per year. This anomalous relationship was commented on by Albert Alm in his 2008 Rapid Response, “Is a field every 4...
Show MoreShang et al. conducted a prospective study to examine the effect of ophthalmic and systemic conditions on incident dementia (1). The adjusted hazard ratios (HRs) (95% confidence intervals [CIs]) of age-related macular degeneration (AMD), cataract, diabetes-related eye disease (DRED), and glaucoma at baseline for incident dementia were 1.26 (1.05 to 1.52), 1.11 (1.00 to 1.24), 1.61 (1.30 to 2.00), and 1.07 (0.92 to 1.25), respectively. Diabetes, heart disease, stroke and depression at baseline were also significantly associated with an increased risk of dementia. In addition, some combinations of ophthalmic and systemic conditions were at the higher risk for incident dementia. I have a comment about the study.
Vision impairment is a risk factor of dementia, and poor vision is independently associated with a decline in cognitive function (2). Shang et al. clarified that AMD, cataract, and DRED were risk of incident dementia, and some combinations with systemic conditions accelerated risk of incident dementia. Although glaucoma was not significantly associated with increased risk of al-cause dementia, it was significantly associated with increased risk of vascular dementia. The authors also conducted analysis by excluding data in the first 5 years of follow-up, consistent results were also specified on the combined effects of ophthalmic and systemic conditions on incident dementia. Although the mechanism of increased risk of dementia in combinations with ophthalmic and...
Show MoreI read with interest the article by Jonas et al 1. The main purpose of the authors was to explore associations between a disc size change and other morphological parameters. Indeed, many non-ophthalmic and game-changing parameters are associated with disc size change and other morphological parameters, such as the serum lipids 2 dietary factors (such as lutein, zeaxanthin, and omega-3 fatty acids) 2-4, medications (such as lipid-lowering agents) 2, genetic susceptibility, body mass index, age and sex 3, among which only age and sex are addressed in their retrospective analysis.
According to the authors, decrease in the ophthalmoscopic disc size in the myopic eyes during the 10-year follow up, is likely related to a shift of the Bruch’s membrane opening as the inner of the three optic nerve head canal layers into the direction of the fovea. While their interpretations can be partly true, their attributed mechanism is subject to many biases.
Firstly, changes in ophthalmoscopical optic disc size and Bruch’s membrane are a function of macular pigment optical density 5-7, which in turn is a function of dietary carotenoid intake 8;9. Tong et al 10 have shown before that macular pigment optical density (MPOD) is inversely associated with axial length in Chinese subjects with myopia, suggesting that carotenoid intake, particularly lutein, is associated to axial length as well. Another study with a smaller sample size (45 eyes of 32 patients) with a different mean a...
Show MoreThe paper advises that the population inspected was predominately of white background and is looking to find ways of expanding its knowledge of non-white ethnicity within the sphere of retina testing. Within the following paper : Ethnicity and Type 2 diabetes in the UK by
L. M. Goff; it states that the prevalence of Type 2 diabetes within the non-white community is particularly high. a quote from this paper:
"Among minority ethnic communities, the prevalence is alarmingly high, approximately three to five times higher than in the white British population. "
Which brings me to my response: All UK Type 2 diabetics are offered eye screening during which the retina is photographed every year. These digital photographs are examined by medical staff looking for vein bleeding and are held by the NHS. Given the hign incidence of Type 2 diabetes in non-white citizens a very large number of these records will be available and so allow a useful extension to the work done by Professor Rudnicka.
Martel et al. report the prevalence, features and risk factors of visual hallucinations following eye removal (1). The findings indicate that visual hallucinations may be a significant and prevalent association of eye amputation, occurring in around one-third of cases. Throughout the paper, visual hallucinations are referred to as phantom visions, and categorised under the broad catchment of the phantom eye syndrome that includes pain and tactile sensations as well as visual hallucinations. Although the authors speculate phantom visions could be considered a subtype of Charles Bonnet syndrome (CBS) they are reluctant to refer to them as CBS, perhaps because of the longstanding debate as to whether CBS should be used to refer to a specific type of visual hallucination or a specific underlying cause (2,3). Where CBS is used to refer to a specific hallucination type, it is typically reserved for complex hallucinations and excludes the simple, ‘elementary’ hallucinations described as the most common experiences following enucleation. The consequence is that a range of terms have evolved to describe symptoms that have the same cause, adding confusion to the literature and hindering research and extensive efforts to raise awareness and establish appropriate patient management pathways for people with visual hallucinations (4-6).
It is our opinion that both the simple and complex visual hallucinations described in the study should be referred to as Charles Bonnet syndrome....
Show MoreWe would like to congratulate Uwaydat et al. on their large series of spontaneously closed macular holes (MH), which adds new information to the literature.(1) It reinforces the observation that traumatic MH can spontaneously close and that a period of observation in these eyes, where the results of surgery are not clear, is a worthwhile option. However, we disagree with their conclusion that eyes with recent onset small primary MHs should also be observed. The authors don’t suggest a time period for observation but found that the median time for closure for these small holes was 4.4 months.
The report by Uwaydat et al. has 40 authors and the 60 cases of idiopathic MH were collected over at least a two-year period. Assuming a conservative number of 25 MH cases seen per surgeon per annum, this would give a spontaneous closure rate of ~3%, which is similar to the published literature as the authors review in their article.
MH are known to enlarge with time, even in the short term. Madi et al, reported that 83% enlarged, by a median of 105 microns in 8 weeks. (2) Similarly, Berton et al recently estimated that holes less than 250 microns enlarge by a mean of 1.67 microns per day, resulting in a similar 100-micron increase in 2 months.(3)
The anatomical and visual outcomes of surgery are dependent on MH diameter and duration. Holes greater than 300 microns, and with a duration more than four months are less likely to regain 0.3 logMAR or better.(4)...
Show MoreDear Editor,
With great excitement, we read the original article titled “Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study” by Bulirsch et al.1 We congratulate the authors on their detailed analysis and on adding another important real world data related to brolucizumab usage. As we are still trying to understand the pathogenesis of brolucizumab related immunogenicity and the population at risk,2-4 it would be very helpful for the readers if the authors could share the following information.
1. Were the 7 eyes in which IOI was recorded have history of any other autoimmune systemic diseases such as arthritis, thyroid abnormalities etc ?
2. It would be helpful if the authors could clarify if the 4 eyes that had intermediate uveitis and vitreous cells underwent fluorescein angigraphy or wide filed imaging to rule out the possibility of peripheral retinal vasulilits.
3. It would be helpful for the readers if we could know the indication of using subconjunctival dexamethasone in four cases?
4. After treatment, were all the patients who had vitritis completely free of cells/inflammation on clinical examination or were they asymptomatic?
Ashish Sharma, Nilesh Kumar, Nikulaa Parachuri
Lotus Eye Hospital and Institute, Coimbatore, TN, India
References
Show More1. Bulirsch LM, Saßmannshausen M, Nadal J, et al Short-term real-world outcomes following intravitreal brolucizumab for neovas...
Clinical features of chalazion following COVID-19 vaccination
Yusuke Kameda, Megumi Sugai, Karin Ishinabe, Nichika Fukuoka
Yotsuya-sanchome Ekimae Eye Clinic, Tokyo, Japan
*Corresponding author: Yusuke Kameda, MD, Yotsuya-sanchome Ekimae Eye Clinic, Tokyo, Japan, 3-7-24 Yotsuya, Shinjuku-ku Tokyo 160-0004, Japan.
Phone: 81-3-6380-4101; Fax: 81-3-6380-4133; E-mail: y09025618059@leaf.ocn.ne.jp
To the editor
Show MoreWe read the article published by Patel et al. with considerable interest [1]. The authors have provided interestingly novel insights into the prevalence and risk factors for chalazion. In their large case-control study comprising 3,453,944 older veteran participants with/without chalazion, the risk factors for chalazion included smoking, conditions of the tear film, conjunctivitis, dry eye, conditions affecting periocular skin, rosacea, allergic conditions, and systemic disorders, such as anxiety. Considering the relationship between chalazion and anxiety, a similar trend as reported in the previous study by Nemet et al. was observed [2]. Moreover, anxiety is generally considered as a psychological reaction to stress [3, 4]. Alsammahi et al. reported that stress is associated with the development of chalazion [5]. In real-world settings, we realize that patients with the onset of chalazion are likely to have anxiety or stress (such as work and examination).
Incidentally, in the c...
Randomized controlled trials (RCTs) are considered to be the best method for evaluating the effectiveness of medical interventions.1 Despite their strengths, RCTs have substantial limitations.1 Although RCTs have strong internal validity, they occasionally lack external validity and generalizations of findings outside the study population may be invalid. More specifically in retinal surgery, there are many obstacles to conducting RCTs to address the specific questions asked, so the analysis using real-world data is useful.2 Drs Anguita and Charteris wrote an editorial in the British Journal of Ophthalmology (BJO) on the merits and limitations of studies using real-world data.3 They cited our papers that were recently published in BJO which used the data collected in the Japan Retinal Detachment Registry (J-RD registry), and I would like to comment on with a focus on the retinal surgery.4,5
As correctly stated by Drs Anguita and Charteris, studies using the propensity score matching method cannot be performed well if one is not familiar with the limitations of this technique. 3 However, this is also true for those who do not have a deep understanding of the disease and may make incorrect interpretations. This would be the case for our paper4 cited in the editorial. This study compared pars plana vitrectomy (PPV) and scleral buckling for superior RD without macula detachment using the data from the J-RD registry. The results which were analyzed using propensity score...
Show MoreIn your interesting paper dealing with the incidence of rhegmatogenous retinal detachment in France, you report the highest incidence rate so far together with Gout et al 1. It is almost twice as high as the incidence found in our area 2. You also report that this incidence was highest in Guadeloupe (28.30±2.74 per 100000 population) and lowest in French Guiana (15.51±3.50 per 100000 population).
Peters 3 investigated the incidence of RRD in black people and found that it was much lower (0.46/100,000 inhabitants) than in whites. Foos et al. 4 also found that there were no differences in the number of breaks or the proportion/ percentage of vitreous detachments between black and white people, suggesting a stronger adherence in their retinal pigmentary epithelium in the former. Given the fact that black subjects present higher levels of melanin, they have greater resistance against solar radiation, in the same way that they present a lower incidence of non-melanoma skin cancer due to this protective factor 5. Similarly, there is a lower risk of RRD in very dark-colored iris 6 subjects, possibly due to the same reason, as a smaller amount of solar radiation, which has been found to be associated with RRD 7 enters the eye. Taking into account that 70-90% of the population in the French Antilles are mulattoes or creoles (source: indexmundi.com), the lower incidence detected in this geographical location is not surprising. However, we encourage the authors to investigate...
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