The article "Oral rifampin utilisation for the treatment of chronic
multifocal central serous retinopathy(CSR)"1 by Steinle NC et al is very
informative. However a few points require further elaboration. We were
told that patient is an African -American but for how long he stayed in
Africa and how frequently he or any of his close family members visit any
tuberculosis (TB) endemic area? As both CSR and ocular TB are poor...
The article "Oral rifampin utilisation for the treatment of chronic
multifocal central serous retinopathy(CSR)"1 by Steinle NC et al is very
informative. However a few points require further elaboration. We were
told that patient is an African -American but for how long he stayed in
Africa and how frequently he or any of his close family members visit any
tuberculosis (TB) endemic area? As both CSR and ocular TB are poorly
understood diseases, there is a possibility that these were confused with
each other or TB was the underlying pathology in this condition which
resembled CSR. Furthermore Rifampin did not cure the disease and its
discontinuation led to recurrence which is also true in incomplete TB
treatment. Recommendations in this case include an appropriate test like
QuantiFERON-TB Gold2 or polymerase chain reactions (PCR) of vitreous, to
rule out TB and a full six month course of anti TB3 to avoid recurrences.
References:
1. Steinle NC, Gupta N, Yuan A, Singh RP. Oral rifampin utilisation for
the treatment of chronic multifocal central serous retinopathy. Br J
Ophthalmol. 2012 Jan;96(1):10-3.
2. Gineys R, Bodaghi B, Carcelain G, Cassoux N, Boutin le TH, Amoura Z,
Lehoang P, Trad S. QuantiFERON-TB gold cut-off value: implications for the
management of tuberculosis-related ocular inflammation. Am J Ophthalmol.
2011 Sep;152(3):433-440.e1
3. Sanghvi C, Bell C, Woodhead M, Hardy C, Jones N. Presumed tuberculous
uveitis: diagnosis, management, and outcome. Eye (Lond). 2011
Apr;25(4):475-80.
A Mataftsi et al1 published an interesting article regarding punctal
plugs in children. One of their aim was to establish the efficacy however
they have not mentioned any test (Schirmer, Tear film break-up time, Rose
Bengal staining, osmolarity) to confirm the diagnosis of dry eye and to
calibrate the tear deficiency. It was only the clinical impression
(flouresein staining is not specific for dry eyes and therefore cann...
A Mataftsi et al1 published an interesting article regarding punctal
plugs in children. One of their aim was to establish the efficacy however
they have not mentioned any test (Schirmer, Tear film break-up time, Rose
Bengal staining, osmolarity) to confirm the diagnosis of dry eye and to
calibrate the tear deficiency. It was only the clinical impression
(flouresein staining is not specific for dry eyes and therefore cannot be
used as diagnostic). In the follow up also, there was no yardstick to
measure and compare the post procedure improvement with the pre procedure
status. Only subjective feelings (patients or parents) are difficult to
gauge and therefore a scientific test at this stage would have established
the exact positive role of the plugs which could have been counterchecked
and verified by other workers. These tests could have been done in the
same sitting/ anesthesia and would not have required any additional visit
or anaesthesia.
A few points of this article differed markedly from previous articles. In
"Blepharokeratoconjunctivitis in children: diagnosis and treatment"2 by M
Viswalingam et al in which patients in Moorfields Eye Hospital, London,
UK, were analyzed, there is no mention of dry eye in either the text or
Table 1- Classification of the severity of blepharokeratoconjunctivitis
(BKC) in children and Table - 3 Clinical symptoms and signs. Punctate
erosions were present in only 9 % (all Asian) of their patients. Their
patients improved without any dry eye treatment. Similarly in "Visual
Outcome and Corneal Changes in Children with Chronic
Blepharokeratoconjunctivitis"3 by Jones SM et al, in patients analyzed in
Great Ormond Street Hospital for Children, London, UK, from1999 to 2005
(same hospital and almost same time period as is of the present article),
there was no mention of dry eye and punctate epithelial erosions (PEE)
were found in 31% of eyes. "In the authors' experience, effective
treatment for BKC should include a combination of both systemic and
topical antimicrobial therapy, along with topical steroids" was the
authors' recommendation in the above mentioned article and no punctal
plugs were mentioned. Now in the present article, authors have found a
lot of dry eyes (out of which 14 required punctual plugs) in BKC (and PEE
in 100%) among the almost same record which was used for the above
mentioned article and now they claim "plugs were successful in treating a
variety of causes of dry eye in our cohort, with more than half of the
children presenting with lipid deficiency secondary to meibomian gland
dysfunction".
Despite these observations, authors deserve appreciation for
introducing the new concept of punctal plug use in children.
References:
1. Mataftsi A, Subbu RG, Jones S, Nischal KK. The use of punctal plugs in
children. Br J Ophthalmol 2012;96:90-92.
2. Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunctivitis
in children: diagnosis and treatment. Br J Ophthalmol. 2005 Apr;89(4):400-
3.
3. Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual
Outcome and Corneal Changes in Children with Chronic
Blepharokeratoconjunctivitis. Ophthalmology 2007;114:2271-2280
We read the article 'Bevacizumab and ranibizumab tachyphylaxis in the
treatment of choroidal neovascularisation' with interest.
We congratulate the authors for trying to establish the efficacy of a
promising treatment strategy for Tachyphylaxis to Anti-VEGF drugs in
Exudative AMD.
We agree with the authors that this could be a useful option in patients
who develop tachyphylaxis. However, there are s...
We read the article 'Bevacizumab and ranibizumab tachyphylaxis in the
treatment of choroidal neovascularisation' with interest.
We congratulate the authors for trying to establish the efficacy of a
promising treatment strategy for Tachyphylaxis to Anti-VEGF drugs in
Exudative AMD.
We agree with the authors that this could be a useful option in patients
who develop tachyphylaxis. However, there are some unanswered questions .
Firstly,the total number of Exudative ARMD patients treated with
Lucentis or Avastin in the study period was not provided in the article.
This would be useful for calculating the incidence of tachyphylaxis, thus
providing information on the magnitude of the problem.
Secondly,although 80-81% subjects responded to switching to the
alternate Anti-VEGF group, most of these required multiple injections post
intervention. Also, at the end of the study period 11 of the 26 treated
eyes had persistent exudation and continued to need therapy. Could this be
attributed to tachyphylaxis to the second drug after switching? This may
be due to either these subjects being predisposed to developing
tachyphylaxis or ill sustained effect of the second anti VEGF drug as a
response to chronic blockade of signaling mediated by VEGF. All these
issues lead us to question the efficiency and feasibility of switching a
patient from one anti-VEGF to another.
We also noted a difference in the response to the two anti-VEGFs. The
group switched from bevacizumab to ranibizumab therapy subsequently
required a higher number of ranibizumab injections with a mean of 7(1-16)
versus 2.75 (1-6) bevacizumab injections in the other group. Though this
difference may not be significant due to the relatively small size in each
group, it is contrary to expectations since ranibizumab has a much higher
binding efficacy to VEGF?.
The long term sustenance of positive effect of switching needs to be
studied prospectively before recommending it.
References
1.Gasperini JL, Fawzi AA, Khondkaryan A, Lam L, Chong LP, Eliott D,
Walsh AC, Hwang J, Sadda SR. Bevacizumab and ranibizumab tachyphylaxis in
the treatment of choroidal neovascularisation. Br J Ophthalmol. 2012
Jan:96(1):14-20.
2.Ferrara N, Damico L, Shams N, Lowman H, Kim R. Development of
Ranibizumab, An Anti-vascular endothelial growth actor antigen binding
fragment, as therapy for neovascular age-related macular degeneration.
Retina2006;26 (8):859-870
We read with great interest the article by Mataftsi A et al.1
We congratulate the authors for providing insights into the use of
punctal plugs in children. We would like to articulate a few of
our observations.
In seven cases where a secondary procedure was undertaken like a
subconjunctival steroid injection or placement of contact lens, we
believe these would be confounding...
We read with great interest the article by Mataftsi A et al.1
We congratulate the authors for providing insights into the use of
punctal plugs in children. We would like to articulate a few of
our observations.
In seven cases where a secondary procedure was undertaken like a
subconjunctival steroid injection or placement of contact lens, we
believe these would be confounding factors in the final analysis
even if we presume that this was a combination effect and not
replacing one another?
30/64 (46.8%) of the plugs had spontaneous extrusion and these
figures should have been highlighted in a clearer way. It would
be of interest to know the additive effects of bipunctal versus
monopunctal occlusion as well as the results of those who
underwent a repeat punctal occlusion.
We once again congratulate the authors for highlighting the beneficial
effects of this therapeutic modality and for their commendable
work.
I would like to congratulate the authors for this wonderful effort,
which throws some light on some of the time trends in the therapeutic
area. However, while interpreting long term observational studies, some of
the potential sources of bias should be kept in mind.
One such potential confounding factor, is the observation of the end-
points for Latanoprost, in the two distinct time-periods. The results for
both the end-po...
I would like to congratulate the authors for this wonderful effort,
which throws some light on some of the time trends in the therapeutic
area. However, while interpreting long term observational studies, some of
the potential sources of bias should be kept in mind.
One such potential confounding factor, is the observation of the end-
points for Latanoprost, in the two distinct time-periods. The results for
both the end-points were somewhat different in these two time-periods. It
was apparently superior in the period of 1997-2001, than in the period of
2002 onwards. This could be attributed to the availability of newer PG
analogs in the period after 2002, which could be a confounding factor for
treatment discontinuation or treatment change for latanoprost.
Persistence itself is a surrogate end-point for the tolerability profile
of the anti-glaucoma drugs. This surrogate end-point may be a subject of
confounding factors, if measured in different time-periods, and hance, may
give a false impression about the tolerability profile of different
medications.
Conflict of Interest:
I am a medical advisor, working at Pfizer India. I declare that the response posted here is my personal opinion on the topic, and does not endorse the views of my institution.
Simon Kelly is to be congratulated for his work to increase awareness
of patient safety issues in ophthalmology. His studies analysing safety
incidents recorded in the NPSA database have led to descriptions of
incidents related to intravitreal injections and wrong lens insertion and
suggestions on how to improve patient safety. Many of the patient safety
incidents analysed resulted from poor documentation described in the...
Simon Kelly is to be congratulated for his work to increase awareness
of patient safety issues in ophthalmology. His studies analysing safety
incidents recorded in the NPSA database have led to descriptions of
incidents related to intravitreal injections and wrong lens insertion and
suggestions on how to improve patient safety. Many of the patient safety
incidents analysed resulted from poor documentation described in the
following terms: transcription errors, handwriting misinterpretations,
patient identification issues, misfiled biometry, wrong or missing patient
notes, wrong appointment or scheduling problems. This led him to suggest
that electronic health records (EHRs), computerised physician order entry
(CPOE), and electronic audit tools may have a role to play in preventing
such incidents.(Kelly, Barua 2011, Kelly, Jalil 2011) This is demonstrably
true(Bates, Teich et al. 1999), however it is important to note that there
is growing evidence of problems induced by the application of EHRs dubbed
e-Iatrogenesis.(Weiner, Kfuri et al. 2007) A website alarmingly entitled
"bad informatics can kill" (http://tinyurl.com/oxx9r9) collates several
examples of incidents originating from health informatics systems
themselves (e.g. radiotherapy dose errors, incorrect or missing data, data
display for the wrong patient) to chaos ensuing from system downtime due
to crashes, maintenance or hacking attempts (e.g. misdirected ambulances
and torch lit operations). Some studies even reported a negative effect on
mortality(Ammenwerth, Talmon et al. 2006). Although CPOE has been shown to
reduce medication errors it does so at the cost of facilitating a range of
other errors (Koppel, Metlay et al. 2005) and system engineers must pay
attention to both the errors they facilitate and those they
prevent.(Patterson, Cook et al. 2002) In the spirit of "error wisdom"
espoused by Professor James Reason(Reason 2004) ophthalmic health care
practitioners should be vigilant for errors resulting from the increased
use of EHRs in ophthalmology and should report them along with incidents
of missing case notes in theatre and clinic as advised by the College
guidelines. (Kelly 2009)
AMMENWERTH, E., TALMON, J., ASH, J., BATES, D., BEUSCART-ZEPHIR, M.,
DUHAMEL, A., ELKIN, P., GARDNER, R. and GEISSBUHLER, A., 2006. Impact of
CPOE on Mortality Rates - Contradictory Findings, Important Messages.
Methods Inf Med, 45, pp. 586-594.
BATES, D.W., TEICH, J.M., LEE, J., SEGER, D., KUPERMAN, G.J., MA'LUF,
N., BOYLE, D. and LEAPE, L., 1999. The Impact of Computerized Physician
Order Entry on Medication Error Prevention. Journal of the American
Medical Informatics Association, 6(4), pp. 313-321.
KELLY, S., 2009. Guidance on patient safety in ophthalmology from the
Royal College of Ophthalmologists. Eye, 23(12), pp. 2143-2151.
KELLY, S. and BARUA, A., 2011. A review of safety incidents in
England and Wales for vascular endothelial growth factor inhibitor
medications. Eye, 25(6), pp. 710-716.
KELLY, S. and JALIL, A., 2011. Wrong intraocular lens implant;
learning from reported patient safety incidents. Eye, 25(6), pp. 730-734.
KOPPEL, R., METLAY, J.P., COHEN, A., ABALUCK, B., LOCALIO, A.R.,
KIMMEL, S.E. and STROM, B.L., 2005. Role of computerized physician order
entry systems in facilitating medication errors. JAMA: the journal of the
American Medical Association, 293(10), pp. 1197.
PATTERSON, E.S., COOK, R.I. and RENDER, M.L., 2002. Improving Patient
Safety by Identifying Side Effects from Introducing Bar Coding in
Medication Administration. Journal of the American Medical Informatics
Association, 9(5), pp. 540-553.
REASON, J., 2004. Beyond the organisational accident: the need for
"error wisdom" on the frontline. Quality and safety in health care,
13(suppl 2), pp. ii28.
WEINER, J.P., KFURI, T., CHAN, K. and FOWLES, J.B., 2007. "e-
Iatrogenesis": The most critical unintended consequence of CPOE and other
HIT. Journal of the American Medical Informatics Association, 14(3), pp.
387.
We would like to thank Zaidi et al. for their interest in our
publication titled, "Sustained elevation of intraocular pressure after
intravitreal injections of anti-VEGF agents." [1] As stated in our
publication, we believe anti-VEGF agents revolutionized the treatment of
ocular neovascular disease and their overall safety profile is excellent.
The points by Zaidi et al. are valid and we take this opportunity to
expand...
We would like to thank Zaidi et al. for their interest in our
publication titled, "Sustained elevation of intraocular pressure after
intravitreal injections of anti-VEGF agents." [1] As stated in our
publication, we believe anti-VEGF agents revolutionized the treatment of
ocular neovascular disease and their overall safety profile is excellent.
The points by Zaidi et al. are valid and we take this opportunity to
expand on recent developments related to ocular hypertension (OHTN) post
intravitreal injection of anti-VEGF agents.
Additional evidence has been published regarding the potential causes
of OHTN post anti-VEGF injections. Kahook et al.[2] examined particulate
material in samples of bevacizumab from different compounding pharmacies
and found significantly less functional IgG and correspondingly more large
particulate matter in samples from certain pharmacies. The authors
concluded that large particulate material might result in aqueous outflow
obstruction. The fact that particular compounding pharmacies were more
likely to have contaminants in their syringes could explain why our group
and others have noted clusters of OHTN cases, a phenomenon which then
lessens after switching to a different compounding pharmacy.[3]
A second study by Lui et al. examined the affects of handling
procedures used by pharmacies when repackaging both bevacizumab and
ranibizumab.[4] The repackaged samples of anti-VEGF agents had
significantly higher particle counts after mishandling of syringes. The
contaminants were consistent with silicone droplets. It is important to
note that these silicone droplets are sub-visible leading some to negate
their existence erroneously due to not observing them on slit lamp exam.
This study also highlighted that the existence of silicone droplets was
not exclusive to repackaged bevacizumab but was also observed in
mishandled ranibizumab samples. Our group has acknowledged that other
causes of OHTN in this setting likely exist and require further
exploration.[2,4] Other potential causes include repeated volume changes
with multiple injections or an idiosyncratic response by the trabecular
meshwork.[5]
The design of our study, a retrospective chart review, is a
reflection of the early stage of our understanding of this phenomenon.
Recently, Dr. Sophi Bakri reported, "In the pooled ANCHOR and MARINA
population, those treated with 24 monthly ITV injections of ranibizumab
were more likely than sham injection/PDT patients to have [higher rates of
glaucoma, new glaucoma medications, and OHTN]" and recommended "close
monitoring of IOP in patients receiving intravitreal injections with
Lucentis with special attention paid to those patients who have
preexisting glaucoma or glaucoma risk factors."[6] Dr. Bakri cautioned
that these findings could not be attributed directly to ranibizumab
independent of repeated intravitreal injections being a possible cause. It
appears that cases of OHTN may indeed be linked to intravitreal anti-VEGF
therapy. We hope that our data and recent publications have brought
attention to this phenomenon and that others continue to build upon this
knowledge so that we can better counsel and treat our patients.
References
1. Good TJ, Kimura AE, Mandava N, Kahook MY. Sustained elevation of
intraocular pressure after intravitreal injections of anti-VEGF agents. Br
J Ophthalmol. 2010 Aug 11. Epub ahead of print.
2. Kahook MY, Liu L, Ruzycki P, et al. High-molecular-weight
aggregates in repackaged bevacizumab. Retina. 2010 Jun;30(6):887-92.
3. Carver J, Bouska C, Corey R. Avastin and Risk of Glaucoma
[abstract]. Retina Congress 2009 New York, September 30th-October4th,
2009. New York, NY.
4. Liu L, Ammar DA, Ross LA, et al. Silicone oil microdroplets and
protein aggregates in repackaged bevacizumab and ranibizumab: effects of
long-term storage and product mishandling. Invest Ophthalmol Vis Sci.
2011 Feb 22;52(2):1023-34.
5. Kahook MY, Ammar DA. In vitro effects of antivascular endothelial
growth factors on cultured human trabecular meshwork cells. J Glaucoma.
2010 Sep;19(7):437-41.
6. Bakri SJ. IOP in Eyes Treated with Monthly Ranibizumab (Ran): a
Post-hoc Analysis of Data From the MARINA and ANCHOR Trials. American
Academy of Ophthalmology Annual Meeting 2010, October 16th-19th, 2010,
Chicago, IL.
Conflict of Interest:
MYK has received research support from Genentech in the past.
In your September 2010 issue, I read with interest the article about
amblyopia by D J Hwang.1 The group has also previously published a
similar article in Korean Journal of Ophthalmology 2 but it was not
mentioned in the references. Both articles included their participants
from the same hospital since 2000 and the eligibility criteria were nearly
identical. I was wondering if both articles share the same group of
parti...
In your September 2010 issue, I read with interest the article about
amblyopia by D J Hwang.1 The group has also previously published a
similar article in Korean Journal of Ophthalmology 2 but it was not
mentioned in the references. Both articles included their participants
from the same hospital since 2000 and the eligibility criteria were nearly
identical. I was wondering if both articles share the same group of
participants. If so, a clarification will help to determine the
eligibility of either studies into future systematic reviews.
I look forward to your reply.
Sincerely yours,
Vannarut Satitpitakul, MD
References
1. Hwang DJ, Kim YJ, Lee JY. Effect and sustainability of part-time
occlusion therapy for patients with anisometropic amblyopia aged ? 8
years. Br J Ophthalmol 2010;94(9):1160-4.
2. Lee YR, Lee JY. Part-time occlusion therapy for anisometropic
amblyopia detected in children eight years of age and older. Korean J
Ophthalmol 2006;20(3):171-176.
Treatments for age-related macular degeneration (AMD) are lively
being debated. One controversy is that all randomized controlled studies
published thus far have used placebo or verteporfin in the control group
[1,2]; hence, direct head-to-head comparisons between the newest active
agents are lacking. The only randomised trial comparing ranibizumab vs
bevacizumab (CATT study [3]) is still ongoing and its results are...
Treatments for age-related macular degeneration (AMD) are lively
being debated. One controversy is that all randomized controlled studies
published thus far have used placebo or verteporfin in the control group
[1,2]; hence, direct head-to-head comparisons between the newest active
agents are lacking. The only randomised trial comparing ranibizumab vs
bevacizumab (CATT study [3]) is still ongoing and its results are
eagerly been awaited.
Network meta-analysis (NMA) can carry out indirect comparisons when
head-to-head controlled trials are not available [4]. Another advantage
of this technique is that a single graph can effectively summarise all
information available on comparative effectiveness [5].
We have conducted a simplified NMA to examine all controlled trials
in which all AMD therapeutic options were evaluated. For this purpose, a
standard PubMed search identified a total of 5 studies (acronyms: ANCHOR,
FOCUS, MARINA, VISION and ABC, see Figure 1 below for details) that
shared the end-point of the loss of fewer than 15 letters on the ETDRS
chart at one year. The data of comparative effectiveness were
incorporated in a simplified NMA graph (Figure 1). While these results
confirm that ranibizumab is likely to determine the best outcomes, the
indirect comparison of ranibizumab vs bevacizumab shows no significant
difference.
In conclusion, the evidence currently available indicates that the
class of anti-VEGF agents can significantly improve the outcome of
patients with AMD. However, the choice between bevacizumab and ranibizumab
remains a matter of controversy because current data show no difference in
indirect comparisons, but the former agent is much less expensive than the
latter.
References
1. Takeda A L, Colquitt J, Clegg A J, Jones J. Pegaptanib and
ranibizumab for neovascular age-related macular degeneration: a systematic
review. Br J Ophthalmol 2007;91:1177-1182.
2. Tufail A et al. Bevacizumab for neovascular age related macular
degeneration (ABC Trial): multicentre randomised double masked study. BMJ
2010;340:C2459.
The article by Hennessy and co-authors is important and interesting,
and the last three words of the abstract are essential (The utility of
relative afferent pupillary defect as a screening tool for glaucoma:
prospective examination of a large population-based study in a south
Indian population. BJO Online First, February 24, 2011, DOI: 10.1136/BJO.
2010.194217). Their conclusion is, "The authors...
The article by Hennessy and co-authors is important and interesting,
and the last three words of the abstract are essential (The utility of
relative afferent pupillary defect as a screening tool for glaucoma:
prospective examination of a large population-based study in a south
Indian population. BJO Online First, February 24, 2011, DOI: 10.1136/BJO.
2010.194217). Their conclusion is, "The authors find that APD assessed by
the swinging flashlight test is a poor screening tool for glaucoma in this
setting." The authors state, ". . . the low prevalence of afferent defect
. . . 60/5150 (1.2 percent in those referred for evaluation) led to a
large number of true negatives. It was previously reported by
Ramakrishnan and colleagues15 that "the prevalence of any glaucoma in the
same population was 2.6 percent." However, the authors only found 77
cases of glaucoma in their 5150 referred cases. Thus, the percentage of
patients found with a simple test performed by individuals who are not
expert came up with a percentage of 1.2 percent, and in that study
population the expert glaucoma specialist found a percentage of 1.5
percent with glaucoma, not the 2.6 percent they mention. Furthermore, it
is clear that the technicians screening for afferent pupillary defects
were not highly reliable in recognizing afferent pupillary defects. The
technicians found 11 afferent pupillary defects, but ". . . only one was
verified to have a pupil defect at the time of the comprehensive
examination. . ." My major concern is that clinicians around the world
will generalize unwisely from a comment made by this group of highly-
respected authors. Specifically, they state, "Many academic institutions.
. . still teach residents and fellows to consciously look for an APD as
part of any initial clinical examination. . ." The authors are clearly
suggesting that is inappropriate. However, there are few tests that are
as quick and as inexpensive, and whose results are so important. The
presence of an afferent pupillary defect is a sure sign of significant
disease. The clinical significance of its presence, then, is close to 100
percent. To test for an afferent pupillary defect properly requires that
the room be dark, that the light be bright, that the patient be looking in
the distance, and the light be held in each eye for three seconds. The
authors have verified themselves that clearly the testing was not well
done. The overwhelming majority of individuals seen by physicians have
borderline findings, in which it is not clear whether the involved person
is merely a variant of normal or has actual disease. To discard a test
that can quickly and inexpensively solve that common dilemma seems unwise.
The article "Oral rifampin utilisation for the treatment of chronic multifocal central serous retinopathy(CSR)"1 by Steinle NC et al is very informative. However a few points require further elaboration. We were told that patient is an African -American but for how long he stayed in Africa and how frequently he or any of his close family members visit any tuberculosis (TB) endemic area? As both CSR and ocular TB are poor...
A Mataftsi et al1 published an interesting article regarding punctal plugs in children. One of their aim was to establish the efficacy however they have not mentioned any test (Schirmer, Tear film break-up time, Rose Bengal staining, osmolarity) to confirm the diagnosis of dry eye and to calibrate the tear deficiency. It was only the clinical impression (flouresein staining is not specific for dry eyes and therefore cann...
Dear Editor,
We read the article 'Bevacizumab and ranibizumab tachyphylaxis in the treatment of choroidal neovascularisation' with interest. We congratulate the authors for trying to establish the efficacy of a promising treatment strategy for Tachyphylaxis to Anti-VEGF drugs in Exudative AMD. We agree with the authors that this could be a useful option in patients who develop tachyphylaxis. However, there are s...
We read with great interest the article by Mataftsi A et al.1 We congratulate the authors for providing insights into the use of punctal plugs in children. We would like to articulate a few of our observations. In seven cases where a secondary procedure was undertaken like a subconjunctival steroid injection or placement of contact lens, we believe these would be confounding...
I would like to congratulate the authors for this wonderful effort, which throws some light on some of the time trends in the therapeutic area. However, while interpreting long term observational studies, some of the potential sources of bias should be kept in mind. One such potential confounding factor, is the observation of the end- points for Latanoprost, in the two distinct time-periods. The results for both the end-po...
Simon Kelly is to be congratulated for his work to increase awareness of patient safety issues in ophthalmology. His studies analysing safety incidents recorded in the NPSA database have led to descriptions of incidents related to intravitreal injections and wrong lens insertion and suggestions on how to improve patient safety. Many of the patient safety incidents analysed resulted from poor documentation described in the...
We would like to thank Zaidi et al. for their interest in our publication titled, "Sustained elevation of intraocular pressure after intravitreal injections of anti-VEGF agents." [1] As stated in our publication, we believe anti-VEGF agents revolutionized the treatment of ocular neovascular disease and their overall safety profile is excellent. The points by Zaidi et al. are valid and we take this opportunity to expand...
In your September 2010 issue, I read with interest the article about amblyopia by D J Hwang.1 The group has also previously published a similar article in Korean Journal of Ophthalmology 2 but it was not mentioned in the references. Both articles included their participants from the same hospital since 2000 and the eligibility criteria were nearly identical. I was wondering if both articles share the same group of parti...
Treatments for age-related macular degeneration (AMD) are lively being debated. One controversy is that all randomized controlled studies published thus far have used placebo or verteporfin in the control group [1,2]; hence, direct head-to-head comparisons between the newest active agents are lacking. The only randomised trial comparing ranibizumab vs bevacizumab (CATT study [3]) is still ongoing and its results are...
Dear Editor:
The article by Hennessy and co-authors is important and interesting, and the last three words of the abstract are essential (The utility of relative afferent pupillary defect as a screening tool for glaucoma: prospective examination of a large population-based study in a south Indian population. BJO Online First, February 24, 2011, DOI: 10.1136/BJO. 2010.194217). Their conclusion is, "The authors...
Pages