We congratulate the authors Ghazi-Nouri et al. to their recently
published study “Visual function and quality of life following vitrectomy
and epiretinal peel surgery”. It mainly confirms our results on a very
similar consecutive cohort of 20 patients followed for three months which
was published August 2005 in the Medline indexed German “Ophthalmologe”
[1] and therefore represents the first paper...
We congratulate the authors Ghazi-Nouri et al. to their recently
published study “Visual function and quality of life following vitrectomy
and epiretinal peel surgery”. It mainly confirms our results on a very
similar consecutive cohort of 20 patients followed for three months which
was published August 2005 in the Medline indexed German “Ophthalmologe”
[1] and therefore represents the first paper on this subject. The first
oral presentation was at the 2004 annual meeting of the German
Ophthalmological Society (DOG).
For assessing the benefit in visual quality of life after
vitreoretinal surgery for epiretinal membranes, we used the commonly
accepted Visual Function 14 (VF-14) test. A larger patient series using
the NEI-VFQ 25 is ongoing. Similarly as in the recent study of Ghazi-Nouri
et al., a significant increase in visual quality of life 3 months after
surgery was observed. The VF-14 values increased significantly from 72.8
preoperatively to 83.3 postoperatively (p<0.05) - although the fellow
eye had good visual acuity (visual acuity of –logMAR 0.2 or better was an
inclusion criteria), so that every patient underwent surgery on the worse
seeing eye. In contrast to Ghazi-Nouri et al., visual acuity increased
significantly from –logMAR 0.55 to 0.4 (p=0.018), which is approximately
1.5 Snellen lines and consistent with most previously reported results in
the literature (2, 3). However, all surgery had been performed by only one
experienced surgeon.
We performed statistic analyses on the data in order to isolate
predictive factors for surgery. When splitting our 20 patients in the two
halves with lowest and highest preoperative VF-14 values, it could be
shown that patients with preoperatively low VF-14 values benefited from
surgery in visual quality of life, while those with preoperatively high VF
-14 values did not. In an analysis of variance model it could be further
shown, that the increase in visual quality of life could better be
estimated than the increase of visual acuity. If in such modelling only
the preoperative VF-14 values and preoperative visual acuity were used to
assess the increase in visual quality of life, those two parameters had a
surprisingly high predictive value (R2=0.80). Cataract surgery did not
influence results significantly. Thus in addition to the later published
results of Ghazi-Nouri et al., we can give practical recommendations for
patient selection: a patient with preoperatively low VF-14 values (i.e.
the patient is highly bothered by the visual performance) and a
preoperatively low visual acuity is very likely to benefit from surgery.
Together with the information that the increase in visual acuity will
probably be not very high, this allows for best consulting and patient
selection for epiretinal membrane surgery.
C. Hirneiss, MD
A.S. Neubauer, MD
A. Kampik, MD
Dept. of Ophthalmology
Ludwig-Maximilians University
Mathildenstr. 8
80336 Muenchen
Germany
References
1. Hirneiss C, Rombold F, Kampik A, Neubauer AS. Visual quality of
life after vitreoretinal surgery for epiretinal membranes. Ophthalmologe
2005 Aug 3 [Epub ahead of print]
2. Michels RG. Vitrektomy for macular pucker. Ophthalmology
1984;91:1384-1388
3. Haritoglou C, Eibl K, Schaumberger M et al. Functional outcome
after trypan blue-assisted vitrectomy for macular pucker: a prospective,
randomized, comparative trial. Am J Ophthalmol 2004;138:1-5
We read with great interest the clinical report by Pate et al. in which bacterial conifection in keratomycosis was reported by smear, culture or
both. We have seen in our own practice in a series of 110 cases of
infectious keratitis (unpublished data) between year 2001-2005, six
cases
of bacterial co infection in keratomycosis. Five of them were smear
positive and one case was only culture positive...
We read with great interest the clinical report by Pate et al. in which bacterial conifection in keratomycosis was reported by smear, culture or
both. We have seen in our own practice in a series of 110 cases of
infectious keratitis (unpublished data) between year 2001-2005, six
cases
of bacterial co infection in keratomycosis. Five of them were smear
positive and one case was only culture positive for bacteria. In
all
these cases, the mycotic element was septate fungus - Fusariunm sps
and
not yeast as reported by these authors. We had suspected polymicrobial
keratitis clinically in all these cases due to certain distinctive
features at presentation. The typical raised dry infiltrate with hyphate margins which is so characteristic of keratomycosis was modified into
wet
looking necrotic infiltate in some areas; epithelial defect overlying
the
infiltrate showed extension beyond the infiltrate in some areas.
Treatment in all these cases is incomplete if thorogh microbiological
work
up is not done. Clinical judgement does suffice to treat microbial
keratitis in many cases, rather we advocate laboratory support.
We read with great interest the article titled 'Characteristic
clinical features as an aid to the diagnosis of suppurative keratitis caused by filamentous fungi' by Thomas and associates1. We would like to congratulate the authors on this attempt to validate the signs of fungal keratitis, which would be helpful to the ophthalmologists of developing
nations. We would like to make following comments:...
We read with great interest the article titled 'Characteristic
clinical features as an aid to the diagnosis of suppurative keratitis caused by filamentous fungi' by Thomas and associates1. We would like to congratulate the authors on this attempt to validate the signs of fungal keratitis, which would be helpful to the ophthalmologists of developing
nations. We would like to make following comments:
In the light of the fact that in the tropics laboratory facilities
are
rare and the diagnosis and treatment of cases is based on clinical
characteristics, the authors conclusion that "the probability of fungal
etiology in a case of microbial keratitis is 63% if one of the 3
clinical
signs are present (serrated margin, raised slough and coloration other
than yellow) and at least 85% if all of three are present" becomes very
important. However, before applying this conclusion in clinical practice
we will have to take into account following facts of the study:
In this study the authors excluded cases with mixed infection (1.4%
and 5.5% in Ghana and India respectively), acanthamoeba keratitis (0.3%
& 0.9%), unconfirmed laboratory diagnosis (49.7% & 31.1%), and
small infiltrates (11.7% overall) 2. Since the score is designed for
application in community practice, it would have been better to apply
the scores to all cases (290) from Ghana rather than a subset of
patients.
Since this study aims at ophthalmologists at the primary health
care
level, including cases that had small infiltrate i.e. less than 4 mm
would
have been very useful because clinicians at the primary care level are
likely to see early cases.
The predictive value of a positive test depends on relative pretest probability or prevalence of the disease in the group of individuals
tested. Therefore, the "score" will be useful only in countries with a
high prevalence of fungal keratitis. At a prevalence of 30% the positive predictive value of even a high score will not allow a conclusive
diagnosis.
Therefore, the statement that the three signs described by the
authors allow the diagnosis of fungal keratitis with 85% confidence can
be
misleading. Rather, this study further highlights that there are no
exclusive clinical signs in microbial keratitis to diagnose the
etiological
agent.
To address this difficulty, addition of simple, cost effective
microbiology tests such as microscopic examination of smears using 10%
potassium hydroxide or lactophenol cotton blue will help ophthalmologist to be surer of diagnosis and to start initial treatment with more
certainty.
References
1 Thomas P A, Leck A K and Myatt M. Characteristic clinical
features
as an aid to the diagnosis of suppurative keratitis caused by
filamentous
fungi. Br. J. Ophthalmol 2005;89;1554-1558
2 Leck AK, Thomas PA, Hagan M, et al. Aetiology of suppurative
corneal ulcers
in Ghana and south India, and epidemiology of fungal keratitis.
Br J Ophthalmol 2002;86:1211-15.
The article by Bernauer et al. takes a new focus on the topic of
corneal calcification related to the phosphate content of
eye medications. This topic has been addressed previously by our group,
first with the observation in glaucoma patients published by Huige et
al. (1) then on the normal eye (2), and finally on patients with eye
burns receiving phosphate buffer treatment(3).
Other reports of non ph...
The article by Bernauer et al. takes a new focus on the topic of
corneal calcification related to the phosphate content of
eye medications. This topic has been addressed previously by our group,
first with the observation in glaucoma patients published by Huige et
al. (1) then on the normal eye (2), and finally on patients with eye
burns receiving phosphate buffer treatment(3).
Other reports of non physiologic elements being applied to the cornea,
from silver deposits after accidental high exposure with silver (4), to
particulate matter being observed from trauma and therapy on in eye
burns (5), to corneal calcification in the case of damaged epithelium,
have supported our recent study on phosphate-containing buffer therapy
following eye burns (6).
Severe changes of the cornea as observed by Bernauer et al. are
very likely due to high dosing. The application of Hylo Comod more than
100 times daily as reported in this paper might be sufficient to be
declared at least "off label use" or misuse of
artificial tears. Mostly astonishing is the fact that the
appearance of white plaques on the cornea did not lead to a change in
the
management in any of the 6 patients described. The combination of
norfloxacin (Floxal Edo), known to form precipitates itself as cited
above, dexamethasone phosphate (Dexa sine) and Hylo comod in patient 1
of the study might have caused the calcified plaques, with the
artificial tears being only contributory in this case. Case 3, 4, 5, and
6 received dexamytrex eye drops containing phosphate buffer with Hylo
Comod. This might be an additional factor causative for the
calcification.
The authors to warning that phosphate containing drugs may lead to
corneal epithelial damage is very important. The other important aspect
is that recommended dosing (10), must be taken into
account. The old wisdom that "the dose makes the poison" applies to the
need to advise our patients to use eye drops as
well as oral medications under recommended dosing.
References
(1) Huige WM, Beekhuis WH, Rijneveld WJ, Schrage N, Remeijer L. Deposits in the superficial corneal stroma after combined topical corticosteroid
and beta-blocking medication. Eur J Ophthalmol. 1991 Oct-Dec;1(4):198-9.
(2) Schrage NF, Flick S, Redbrake C, Reim M. Electrolytes in the
cornea: a therapeutic challenge.
Graefes Arch Clin Exp Ophthalmol. 1996 Dec;234(12):761-4. Erratum in:
Graefes Arch Clin Exp Ophthalmol 1997 Apr;235(4):262.
(3) Schrage NF, Schlossmacher B, Aschenbernner W, Langefeld S:
Phosphate buffer in alkali eye burns as an inducer of experimental
corneal
calcification. Burns. 2001 Aug;27(5):459-64.
(4) Schirner G, Schrage NF, Salla S, Teping C, Reim M, Burchard WG,
Schwab B. Corneal silver deposits following Crede's prophylaxis an
examination with electron dispersive x-ray analysis (EDX-analysis) and
scanning electron microscope (SEM). Lens Eye Toxic Res. 1990;7(3-4):445-
57.
(5) Schrage NF, Reim M, Burchard WG. Particulate matter
contamination
in the corneal stroma of severe eye burns in humans. Lens Eye Toxic Res.
1990;7(3-4):427-44.
(6) Schrage NF, Kompa S, Ballmann B, Reim M, Langefeld S.
Relationship of eye burns with calcifications of the cornea? Graefes
Arch
Clin Exp Ophthalmol. 2005 Aug;243(8):780-4. Epub 2005 Mar 9.
(7) Tanhehco TY, Chiavetta SV 3rd, Lee PP, Fowler AM, Afshari NA. "Cracked-mud" ciprofloxacin precipitates on a corneal graft. Ophthalmic
Surg Lasers Imaging. 2005 May-Jun;36(3):252-3.
(8) Castillo A, Benitez del Castillo JM, Toledano N, Diaz-Valle D,
Sayagues O, Garcia-Sanchez J. Deposits of topical norfloxacin in the
treatment of bacterial keratitis. Cornea. 1997 Jul;16(4):420-3.
(9) Lopez JD, del Castillo JM, Lopez CD, Sanchez JG. Confocal
microscopy in ocular chrysiasis. Cornea. 2003 Aug;22(6):573-5.
Financial statement: The Aachen Center of Technologytransfer in
Ophthalmology "ACTO.de" is involved in research on corneal trauma with
phosphate containing eye drops since 10 years and received several
research funds from pharmaceutical industry.
We read with interest the paper by Hamada et al 1, which draws a
number of conclusions from a five year follow up study of 69 periocular
BCCs treated by conventional surgery, and in particular suggests that
there is no place for Mohs micrographic surgery (MMS) in patients with
periocular BCCs. MMS is the serial saucerisation excision with mapped
horizontal tissue sections examining 100% of the surg...
We read with interest the paper by Hamada et al 1, which draws a
number of conclusions from a five year follow up study of 69 periocular
BCCs treated by conventional surgery, and in particular suggests that
there is no place for Mohs micrographic surgery (MMS) in patients with
periocular BCCs. MMS is the serial saucerisation excision with mapped
horizontal tissue sections examining 100% of the surgical margins to
produce histological evidence of tumour negative margins. Unfortunately,
the data included in the paper are incomplete and if such conclusions are
to be considered, then further clarification is required.
Risk of BCC recurrence relates directly to the nature of the tumours
treated2. The principle risk factors for recurrence include previous
treatment, large tumour size, and an infiltrative or micronodular
histological growth pattern. No information is given on the first 2
factors and the histological subtype was non-specified in approx 45% of
cases. We calculate from the data provided that the authors experienced a
19% 5 year recurrence rate in patients with a histologically infiltrative
BCC.
If most of the “non-specified” tumours in Hamada’s series were small
nodular tumours, as the paper implies, then Hamada’s series also differs
significantly from other larger series in that it represents a group of
patients with an inherently better prognosis. Other comments hint at this,
in that 76% of BCCs were on the lower eyelid and 72% were amenable to
direct closure. If the majority of the tumours in this series were not in
a high- risk group then only one recurrence would be anticipated. In
contrast, the Australian Mohs’ database series3 reported on a much higher
incidence of high-risk tumours (50% were infiltrative, morphoeic,
basosquamous or superficial), of which only 54% were on the lower eyelid
while 41% affected the medial canthus, a site with a proven higher risk of
recurrence. Despite this, they reported a 0% recurrence rate for primary
BCCs of all histological subtypes treated by MMS surgery.
Hamada also concludes that 4mm margins are justified for well-defined
nodular tumours, on the basis of the 5-year recurrence rates and the fact
that most eyelids can still be directly repaired after such excisions. It
is of interest however that 16% of the patients reported had incomplete
tumour excision at the first attempt, although we do not know what margins
were used for this group. As conventional pathological sectioning examines
less than 1% of the margins4, it is likely that the actual incomplete
excision rate was higher.
Hamada argues that MMS is not necessary for periocular tumours on the
basis that it is difficult to obtain true MMS sections. Unless either
periosteum or anterior orbital septum are breached by the tumour, then
there is no evidence for the former statement. What about cost benefit?
MMS histology costs are greater than routine sections. However, when the
other advantages of MMS are taken into account MMS is cost-effective in
comparison to traditional surgical excision5.
The current best evidence shows that recurrence rates are lower with
MMS than with any other technique, with MMS for recurrent or high-risk
tumours showing the greatest advantage over conventional surgery.
Furthermore, Hamada acknowledges that the tissue sparing quality of MMS is
an important issue in that 36% of patients will develop a second BCC
within 5 years.
Although we believe that MMS is the treatment of choice for optimal
cure rates in periocular BCC, we would agree with Hamada that is currently
impractical for all tumours because of the patchy availability of the
service in the UK. However we believe the current evidence shows that MMS
remains the optimal treatment for all high risk tumours based on treatment
status, site, size and histological subgroup and do not feel that the data
presented warrant a different conclusion.
2. Lawrence CM. Mohs surgery - A critical review. Br J Plast Surg
1993, 46, 599-606
3. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs
Database, part II: Periocular basal cell carcinoma outcome at 5 year
follow up. Ophthalmol 2004, 111, 631-636.
4.Abide JM, Nahai F, Bennet RG. The meaning of surgical margins.
Plast Reconstr Surg 1984;73:492-6
5. Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis. J
Am Acad Dermatol. 1998; 39:698-703.
EA Barnes1, AJ Dickinson1, J AA Langtry2 and CM Lawrence2
1Department of Ophthalmology
Royal Victoria Infirmary
Newcastle-upon-Tyne, NE1 4LP
2Department of Dermatology
Royal Victoria Infirmary
Newcastle-upon-Tyne, NE1 4LP
We read with great interest the paper by Senoo et al1 and we would like to draw your attention to a complication of the approach described. Some years ago, relying on our experience in deep sclerectomy, we tried a similar approach in two cases: we first performed a double scleral flap
exposing Descemet membrane at limbus and then started the dissection. Although in both cases we had a good exposure of D...
We read with great interest the paper by Senoo et al1 and we would like to draw your attention to a complication of the approach described. Some years ago, relying on our experience in deep sclerectomy, we tried a similar approach in two cases: we first performed a double scleral flap
exposing Descemet membrane at limbus and then started the dissection. Although in both cases we had a good exposure of Descemet's membrane at surgery without perforation, in one patient we observed an unusual complication on the first postoperative day: blood was present between the donor cornea and the recipient Descemet's membrane marking a
channel from the sclerotomy site. We had to reopen the scleral flaps and wash out the blood in the interface by
introducing air in the anterior chamber. The patient did not suffer any further complications after this treatment.
We discontinued this approach not only for the possibility of this complication but also because in our experience the time required to prepare the limbal access is equal to that of a classical mechanical procedure. The high percentage of double anterior chamber reported for the
limbal approach (45%) is another point worth consideration. Since we observe a rate of less than 3% with mechanical dissection, the suspecion arises that the higher rate reported for the new technique may be due to either viscoelastic persistence in the interface or filtration through trabeculodescemetic membrane at the sclerotomy site: in the presence of an intact descemetic membrane and functioning endothelium, percolation of aqueous humor at the sclerotomy site may maintain a double chamber. It would be of interest to verify this hypothesis with ultrasound biomicroscopy.
Finally, we wonder why the author did not try to resolve the long persistence of a double chamber (often a sign of unrecognized perforation) by introducing air in the anterior chamber. In this procedure, the risk of a pseudo Urrets-Zavalia syndrome2 may be controlled by both avoiding overinflation of the chamber and strictly monitoring the
patient over hours.
Marco Nardi, Gianluca Guidi, Marino De Luca
Neuroscience Department, University of Pisa, Pisa, Italy
Correspondence to:
M Nardi MD
Pza Varanini 2
55100 Lucca Italy
marco.nardi@med.unipi.it
References:
1. Senoo T, Chiba K, Terada O et Al. Deep lamellar keratoplasty by deep parenchima detachment from the corneal limbs. Br J Ophthalmol 2005; 89:1597-1600.
2. Maurino V, Allan BD, Stevens JD, Tuft SJ. Fixed dilated pupil (urrets-Zavalia syndrome) after air/gas injection after deep lamellar keratoplasty
for keratoconus. Am J Ophthalmol 2002; 133(2): 266-8.
We want to congratulate Drs. S.L. Liao, et al., on their excellent
paper entitled "Surgical coverage of exposed hydroxyapatite implant with
retroauricular myoperiosteal graft". 1 In the paper they described "a
newly developed technique with an autogenous retroauricular
myoperiosteal
graft" to repair defects with exposed hydroxyapatite implants.
We want to congratulate Drs. S.L. Liao, et al., on their excellent
paper entitled "Surgical coverage of exposed hydroxyapatite implant with
retroauricular myoperiosteal graft". 1 In the paper they described "a
newly developed technique with an autogenous retroauricular
myoperiosteal
graft" to repair defects with exposed hydroxyapatite implants.
However, they did not mention our retrospective, multicentered work
published in 1999 in The American Journal of Ophthalmology. 2 In this
paper we discussed a technique very similar to that of Dr. Liao and
coworkers in which we covered exposed hydroxyapatite implants with a
retroauricular muscle complex graft (complex refers to muscle, fascia,
and
vascular tissues). As with Dr. Liao's, et al., technique, we placed our
retroauricular graft between the implant and the overlying Tenon's
capsule
and conjunctiva and the latter tissues migrated over the graft within
several weeks.
We also used the thicker, stronger, retroauricular tissues
anteriorly
combined with the thinner tissues overlying the pinna for additional
volume post-enucleation. This also facilitated the insertion of the
spicular hydroxyapatite into the orbit post-enucleation. Additionally,
we
used only the thicker tissue between the mastoid and the overlying
dermal
flap anteriorly as a "cap graft" post-enucleation. Our techniques
involved 83 patients with a mean follow-up of 36 months.
One difference in our technique and that of Dr. Liao and associates
was that they used periosteum in their retroauricular complex graft for
added strength and vascularity. We were reluctant to use periosteum in
our grafts for fear of unduly compromising the vascularity of the
underlying mastoid bone and the overlying dermal flap. The authors do
not
state that this occurred in their series of 9 patients in the duration
of
over one year. Accordingly, this may be a non-problem and it would
appear
that both techniques are efficacious. However, incorporation of the
periosteum in the retroauricular myoperiosteal graft may not be
necessary
because of the strong, thick complex of muscle and fascia and vascular
tissues between the underlying periosteum and overlying dermal flap.
Another difference in our technique is that we did not have to
encounter active infections at the time of surgery and did not find it
necessary to burr down the implant anteriorly. By undermining
conjunctiva
and Tenon's capsule the approximate distance of the equator of the
globe,
we have found that there is sufficient space for the graft to fit "flush
tight" in the recipient bed.
The authors and readers might read with interest an article
entitled
"Variability of the postauricular muscle complex - analysis of 40 hemi-cadaver dissections" by Guerra, et al., including myself. 3 This
article
identifies and analyzes variations in the patterns of the posterior
auricular muscle complex and the relations of the fascial contributions.
In our opinion, a signature thought would be to wrap a
hydroxyapatite
orbital implant with a strong autogenous graft of the surgeon's choice
anteriorly to create a barrier between the implant and the overlying
conjunctiva and Tenon's capsule to significantly decrease the chance of
implant exposure.
Our technique has been discussed in a presentation of the 9th
annual
meeting of the European Society of Ophthalmic Plastic and Reconstructive
Surgery in Dublin, Ireland, 1991, a presentation at the 23rd annual
Scientific Symposium of the American Society of Ophthalmic, Plastic, and
Reconstructive Surgery in Dallas, Texas, 1992, and discussed as a
scientific video presentation at the annual meeting of the American
Academy of Ophthalmology, 1994.
References
1. Liao S.L., Kao S.C.S, Tseng J.H.S., et al. Surgical coverage of
exposed hydroxyapatite orbital implants with retroauricular
myoperiosteal
graft. Br J Ophthalmol 2005;89:92-95.
2. Naugle T.C., Lee A.M., Haik B.G., et al. Wrapping
hydroxyapatite
orbital implants with posterior auricular muscle complex grafts. Am J
Ophthalmol 1999;128:495-501.
3. Guerra A.B., Metzinger S.E., Metzinger R.C., et al. Variability
of the
postauricular muscle complex - analysis of 40 hemicadaver dissections.
Arch Facial Plast 2004;6:324-344.
Thomas C. Naugle Jr, M.D.
Department of Ophthalmology,
Tulane University School of Medicine,
New Orleans, LA, USA.
Dear Editor,
We congratulate the authors Ghazi-Nouri et al. to their recently published study “Visual function and quality of life following vitrectomy and epiretinal peel surgery”. It mainly confirms our results on a very similar consecutive cohort of 20 patients followed for three months which was published August 2005 in the Medline indexed German “Ophthalmologe” [1] and therefore represents the first paper...
Dear Editor,
We read with great interest the clinical report by Pate et al. in which bacterial conifection in keratomycosis was reported by smear, culture or both. We have seen in our own practice in a series of 110 cases of infectious keratitis (unpublished data) between year 2001-2005, six cases of bacterial co infection in keratomycosis. Five of them were smear positive and one case was only culture positive...
Dear Dr. Watson,
I wish to share that I have adopted your technique of limbal sparing LK for keratoglobus patients and am happy with the results.
Dr.Sitalakshmi
Director
Cornea Services
Sankara Nethralaya
Chennai
India
Dear Editor,
We read with great interest the article titled 'Characteristic clinical features as an aid to the diagnosis of suppurative keratitis caused by filamentous fungi' by Thomas and associates1. We would like to congratulate the authors on this attempt to validate the signs of fungal keratitis, which would be helpful to the ophthalmologists of developing nations. We would like to make following comments:...
Dear Editor,
The article by Bernauer et al. takes a new focus on the topic of corneal calcification related to the phosphate content of eye medications. This topic has been addressed previously by our group, first with the observation in glaucoma patients published by Huige et al. (1) then on the normal eye (2), and finally on patients with eye burns receiving phosphate buffer treatment(3). Other reports of non ph...
Dear Editor,
We read with interest the paper by Hamada et al 1, which draws a number of conclusions from a five year follow up study of 69 periocular BCCs treated by conventional surgery, and in particular suggests that there is no place for Mohs micrographic surgery (MMS) in patients with periocular BCCs. MMS is the serial saucerisation excision with mapped horizontal tissue sections examining 100% of the surg...
Dear Editor,
We read with great interest the paper by Senoo et al1 and we would like to draw your attention to a complication of the approach described. Some years ago, relying on our experience in deep sclerectomy, we tried a similar approach in two cases: we first performed a double scleral flap exposing Descemet membrane at limbus and then started the dissection. Although in both cases we had a good exposure of D...
Dear Editor,
We want to congratulate Drs. S.L. Liao, et al., on their excellent paper entitled "Surgical coverage of exposed hydroxyapatite implant with retroauricular myoperiosteal graft". 1 In the paper they described "a newly developed technique with an autogenous retroauricular myoperiosteal graft" to repair defects with exposed hydroxyapatite implants.
However, they did not mention our retrospect...
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