We thank Drs Hanovar and Ali for their comments. The main impetus for
publishing this data was to show that children are NOT prone to infections
with this strategy. In fact while steroid injections were given in cases
of severe corneal neovascularisation such as K.I.D. syndrome and
ectodermal hypoplasia , the fact that no child got a canaliculitis or
other infection even when steroids were used, re-affirms that infection i...
We thank Drs Hanovar and Ali for their comments. The main impetus for
publishing this data was to show that children are NOT prone to infections
with this strategy. In fact while steroid injections were given in cases
of severe corneal neovascularisation such as K.I.D. syndrome and
ectodermal hypoplasia , the fact that no child got a canaliculitis or
other infection even when steroids were used, re-affirms that infection is
not a risk that should prevent the clinician from using silicone punctal
plugs if appropriate.
Furthermore , clinically if spontaneous extrusion occurred after 6 months
we often found that the symptoms had improved. We really wanted to know if
using the plugs was a redundant manouevre , hence discussing the rate of
extrusion within 6 months of placement , which we considered to be high in
any case ( 19%).
Perhaps the most striking fact is that we were unable to cite any other
article dedicated to children with respect to the use of punctal plugs .
We hope this article will encourage Drs Ali and Hanovar and others to
share their experiences.
We welcome the latest estimates of global visual impairment (VI). (1)
Posterior segment eye diseases (PSED): Glaucoma; Age-Related Macular
Degeneration (ARMD); and Diabetic Retinopathy (DR) are now recognised as a
major cause of VI worldwide and are more prevalent than infectious causes
of VI such as trachoma and corneal ulcers. The majority of data collated
in the last ten years from which these figures are estimated like...
We welcome the latest estimates of global visual impairment (VI). (1)
Posterior segment eye diseases (PSED): Glaucoma; Age-Related Macular
Degeneration (ARMD); and Diabetic Retinopathy (DR) are now recognised as a
major cause of VI worldwide and are more prevalent than infectious causes
of VI such as trachoma and corneal ulcers. The majority of data collated
in the last ten years from which these figures are estimated likely
underestimate the true prevalence of PSED for three reasons: (a) The
majority of surveys used the WHO coding instructions, which use the
"principal disorder responsible for visual loss in the individual after
considering disorders in either eye which are most amenable to treatment
or prevention"(2), i.e. if a patient has co-existent PSED with cataract it
will be deemed that cataract is the primary cause of VI. Therefore most VI
prevalence data available in which cataract is the primary cause will
underestimate the actual prevalence of PSED; (b) The Rapid Assessment of
Avoidable Blindness (RAAB) methodology, which forms one of the most
employed methods of gathering VI data in the last ten years (20 published
from Africa, Latin America and Asia) does not allow for accurate diagnosis
of PSED or differentiation between PSED; and (c) VI surveys have been
designed to diagnose the cause of disease in those with varying degrees of
visual impairment (?6/18 Snellen acuity) and thus pre-visually impairing
disease is not detected. This is particularly important in the detection
of PSED where cessation rather than cure is currently our only realistic
management option. If VISION 2020: The Right to Sight's aims of
alleviating suffering from avoidable blindness is to be met, the growing
impact of PSED needs to be a focus of policy makers.
We thank Dr. Shoaib for his interest in our article.1 We agree that
there are various causes of graft rejection and that performing an
endothelial keratoplasty (EK) would not resolve the rejection. To clarify
our wording for the article, patients who developed endothelial graft
rejection with subsequent endothelial failure were offered EK under their
penetrating keratoplasty (PK). The rejection episode was resolved at...
We thank Dr. Shoaib for his interest in our article.1 We agree that
there are various causes of graft rejection and that performing an
endothelial keratoplasty (EK) would not resolve the rejection. To clarify
our wording for the article, patients who developed endothelial graft
rejection with subsequent endothelial failure were offered EK under their
penetrating keratoplasty (PK). The rejection episode was resolved at the
time of the EK. There were a total of 9 patients that fulfilled this
requirement and were included in the study. These patients did not have
any epithelial or stromal rejection and did not have stromal opacities. We
do feel that EK under PK for immunological endothelial failure is a viable
treatment option that should be considered in cases where there are not
any stromal opacities.
Jennifer Nottage, MD
Verinder Nirankari, MD
Eye Consultants of Maryland, Owings Mills, MD
1. Nottage JM, Nirankari VS. Endothelial keratoplasty without
Descemet's stripping in eyes with previous penetrating corneal
transplants. Br J Ophthalmol. 2012 Jan;96(1):24-7
Article "Endothelial keratoplasty without Descemet's stripping in
eyes with previous penetrating corneal transplants" by Nottage JM and
Nirankari VS1, is very informative and the authors deserve appreciation
for their wonderful work. However one point requires discussion. Authors
mentioned that endothelial keratoplasty (EK) was done either for graft
rejection (n = 9) or endothelial failure (n = 24). It seems logical to...
Article "Endothelial keratoplasty without Descemet's stripping in
eyes with previous penetrating corneal transplants" by Nottage JM and
Nirankari VS1, is very informative and the authors deserve appreciation
for their wonderful work. However one point requires discussion. Authors
mentioned that endothelial keratoplasty (EK) was done either for graft
rejection (n = 9) or endothelial failure (n = 24). It seems logical to
replace endothelium in endothelium failure. The question is how new
endothelium can correct graft rejection? Authors mention "An allograft
rejection was defined as corneal clouding in association with an
epithelial or endothelial rejection line, keratic precipitates and/or
anterior chamber cells." Endothelial line reflecting endothelial rejection
can qualify as an indication for EK but the rest of the signs can be due
to rejection of the other parts of the graft. A further breakdown of the
frequency of above mentioned signs of allograft rejection would have been
useful.
Other authors have been careful not to include the generalized graft
rejection cases for EK e.g. Chen ES et al2 mentioned in their Protocal
under the heading of Methods, the inclusion criteria "after penetrating
keratoplasty (PK) and without significant stromal haze". Similarly Straiko
et al3 described inclusion criteria "for failed PK grafts from endothelial
failure with minimal stromal Opacities" and "all eyes with a prior
standard PK graft that had failed because of immunologic or nonimmunologic
endothelial failure".
Graft rejection results from host immunologic response against foreign
antigen from donor tissue. Li JY et al 4 observed that it can lead to
decreased endothelial cell survival and graft failure. They reported a
graft rejection rate of 7.3 % and that the greatest number of rejections
occurred between postoperative months 12 and 18.
An initial improvement due to healthy endothelial can be expected in all
cases of EK but antigenic stimulation will continue even after removal of
the rejected graft's endothelium. Especially for the one patient regarding
whom authors1 of the under discussion article wrote "had multiple previous
graft failure, requiring placement of an investigational ciclosporine
implant to prevent further rejection." Should we do EK or PK in PK
rejection cases? Perhaps a longer follow up will answer this question.
References:
1. Nottage JM, Nirankari VS. Endothelial keratoplasty without Descemet's
stripping in eyes with previous penetrating corneal transplants. Br J
Ophthalmol. 2012 Jan;96(1):24-7
2. Chen ES, Terry MA, Shamie N, Hoar KL, Phillips PM, Friend DJ.
Endothelial keratoplasty: vision, endothelial survival, and complications
in a comparative case series of fellows vs attending surgeons. Am J
Ophthalmol. 2009 Jul;148(1):26-31.e2. Epub 2009 Apr 17.
3. Straiko MD, Terry MA, Shamie N. Descemet stripping automated
endothelial keratoplasty under failed penetrating keratoplasty: a surgical
strategy to minimize complications. Am J Ophthalmol. 2011 Feb;151(2):233-
7.e2. Epub 2010 Dec 3.
4. Li JY, Terry MA, Goshe J, Shamie N, Davis-Boozer D. Graft rejection
after descemet's stripping automated endothelial keratoplasty graft
survival and endothelial cell loss. Ophthalmology. 2012 Jan;119(1):90-4.
Epub 2011 Nov 23.
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 thank Drs Hanovar and Ali for their comments. The main impetus for publishing this data was to show that children are NOT prone to infections with this strategy. In fact while steroid injections were given in cases of severe corneal neovascularisation such as K.I.D. syndrome and ectodermal hypoplasia , the fact that no child got a canaliculitis or other infection even when steroids were used, re-affirms that infection i...
We welcome the latest estimates of global visual impairment (VI). (1) Posterior segment eye diseases (PSED): Glaucoma; Age-Related Macular Degeneration (ARMD); and Diabetic Retinopathy (DR) are now recognised as a major cause of VI worldwide and are more prevalent than infectious causes of VI such as trachoma and corneal ulcers. The majority of data collated in the last ten years from which these figures are estimated like...
We thank Dr. Shoaib for his interest in our article.1 We agree that there are various causes of graft rejection and that performing an endothelial keratoplasty (EK) would not resolve the rejection. To clarify our wording for the article, patients who developed endothelial graft rejection with subsequent endothelial failure were offered EK under their penetrating keratoplasty (PK). The rejection episode was resolved at...
Article "Endothelial keratoplasty without Descemet's stripping in eyes with previous penetrating corneal transplants" by Nottage JM and Nirankari VS1, is very informative and the authors deserve appreciation for their wonderful work. However one point requires discussion. Authors mentioned that endothelial keratoplasty (EK) was done either for graft rejection (n = 9) or endothelial failure (n = 24). It seems logical to...
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...
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