A recent report stated it might be prudent to delay paediatric
cataract surgery, at least for bilateral cases, until 4 weeks of age to
lower the risk of later glaucoma,[1] and this suggestion was fully
supported in an accompanying editorial [2]. Such a suggestion that could
have an impact on the practice patterns of ophthalmologists and
consequently the care of children with cataract should have stron...
A recent report stated it might be prudent to delay paediatric
cataract surgery, at least for bilateral cases, until 4 weeks of age to
lower the risk of later glaucoma,[1] and this suggestion was fully
supported in an accompanying editorial [2]. Such a suggestion that could
have an impact on the practice patterns of ophthalmologists and
consequently the care of children with cataract should have strong data to
back it. For the following reasons, the data presented in the report do
not seem to rise to that level.
First, as postcataract surgery glaucoma is often a delayed
complication, it is critical to know how long study patients were
followed; and aside from what can be inferred from the presented
statements and survival analyses, such data are not provided. Second,
study patients with glaucoma often presented with the isolated finding of
elevated intraocular pressure, but no mention is made of whether all study
patients were screened for glaucoma using intraocular pressure measurement
(or other means) at any time postoperatively, let alone for the duration
of follow-up. This is important given the challenges of detecting
glaucoma in young children, which the authors acknowledge. Ultimately,
glaucoma was diagnosed if a study clinician elected to treat for glaucoma;
but specific, reliable, and mutually agreed upon parameters for making the
diagnosis were not defined. Third, from a study design perspective, the
decision to include a subgroup of patients (those with persistent
hyperplastic primary vitreous) in the study solely on the basis of the
glaucoma frequency within that subgroup (as determined from a preliminary
analysis) is problematic. Fourth, while other risk factors aside from a
young age at surgery have been associated with the development of aphakic
glaucoma, such as microcornea and secondary membrane surgery, no mention
is made of whether any patients in the study had such features. It might
be assumed that patients with microcornea were excluded from the study
since patients with “other ocular malformations” were excluded; if this is
the case, however, it would seem unusual that the authors would elect to
include patients with persistent hyperplastic primary vitreous (who
generally have microphthalmos, not to mention other abnormalities). In
any case, no multivariable statistical technique was employed that would
take into account other important potential risks for glaucoma aside from
simply an early age at cataract surgery; without such a multivariable
analysis, the validity of the authors’ conclusions would rest on the
presumption that other potential risks for glaucoma aside from age at
surgery were equally distributed among all age groups studied. Fifth, the
study purports to compare the glaucoma frequencies among those patients
operated on in the first month of life to those operated on later during
the first year of life, yet relatively few patients were operated on after
3 months (and especially after 5 months) of age.
A review of presently available reports tends to implicate early
cataract surgery in the pathogenesis of aphakic glaucoma, but exactly what
“early” is has not been absolutely established. In their discussion, the
authors cite prior studies indicating a higher risk of glaucoma when
surgery is performed in the first month of life; these studies, as well as
others indicating a high risk of glaucoma extending up to a later age at
surgery or indicating no relationship to age at surgery at all, have been
briefly reviewed elsewhere [3]. In each of these prior studies, at least
one shortcoming from among the following limit the certainty of any
conclusion relating age at surgery for isolated cataract to later
glaucoma: limited follow-up, small sample size, inclusion of patients
with ocular anomalies aside from cataract that might independently
predispose to glaucoma, inclusion of patients operated on with various
techniques, and lack of information regarding whether all study patients
were actually screened for glaucoma.
A recent study on a large group of cataract patients who lacked other
ocular anomalies aside from microcornea, who were operated on with modern
and standard technique, who were all screened for glaucoma, and who all
had a minimum of 5 years’ postcataract surgery follow-up found that
glaucoma was frequent when the cataract surgery was performed during the
first 9 months of life (37% of 272 patients’ eyes), without seeming matter
if the surgery was performed earlier or later within this timeframe [3].
(Of further note, the frequency of glaucoma was 24% of 25 patients’ eyes
in a subgroup undergoing surgery in the first month of life [previously
unpublished data, Peter K. Rabiah, 2004].) Multivariable analysis
confirmed young age at surgery as a predictor of later glaucoma. Like all
studies on the subject, this study is not without its flaws, but along
with other available reports, it calls into question the usefulness of
delaying surgery until 4 weeks of age. Admittedly, this study may not
have been available to the report’s authors during their manuscript
preparation, though importantly was available to the writer of the
editorial.
The balance of available data does not clearly support a
recommendation to delay cataract surgery until 4 weeks, or even 6 weeks,
of age if the expectation is a reduced risk of later glaucoma; in fact, a
far longer delay might very well be required, in which case the problem of
amblyopia would then weigh more heavily. Further study is required to
learn the optimal time to perform cataract surgery on an infant, with an
important goal being to achieve the most favorable balance between the
risks of later glaucoma and amblyopia.
Sincerely,
Peter K. Rabiah, M.D.
The author has no relevant financial interest in the subject matter of this
letter or the article/editorial on which he comments.
References
(1) Vishwanath M, Cheong-Leen R, Taylor D, Russell-Eggitt I, Rahi J. Is
early surgery for congenital cataract a risk factor for glaucoma? Br J
Ophthalmol 2004;88:905-910.
(2) Lambert SR. Treatment of congenital cataract. Br J Ophthalmol
2004;88:854-855.
3 Rabiah PK. Frequency and predictors of glaucoma after pediatric cataract
surgery. Am J Ophthalmol 2004;137:30-37.
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 a recently published article by Chandra et al. the authors have
stated that they conducted a "case-controlled" study to examine the
anticoagulant effectiveness of warfarin in vitreoretinal surgery.(1)
However, this study was conducted on a cohort of patients receiving pars
plana vitrectomy (PPV); 60 patients who received warfarin (exposure) on
the day of PPV were selected. These 'exposed' pati...
In a recently published article by Chandra et al. the authors have
stated that they conducted a "case-controlled" study to examine the
anticoagulant effectiveness of warfarin in vitreoretinal surgery.(1)
However, this study was conducted on a cohort of patients receiving pars
plana vitrectomy (PPV); 60 patients who received warfarin (exposure) on
the day of PPV were selected. These 'exposed' patients were matched to
other patients receiving PPV but not taking warfarin (unexposed) on age,
sex, and presenting complaint. These patients were then followed for
perioperative and long term complications. Thus, this is not a case-
control study rather it is a matched cohort study. As a result, the
statistical analysis raises concerns. Matching in a cohort study does not
necessarily eliminate the need for control of matching factors in the
analysis; censoring (competing risks, death, loss to follow-up) can
produce imbalances thereby limiting the extent of matching only to those
among the original counts of persons for whom matching was applied.(2) In
other words, an association of exposure and the matching factors could be
observed for the remaining persons and the observed person-time.2
Furthermore, even if no censoring occurs and one examines risk, control of
matching factors would still be necessary to obtain valid standard
deviation estimates.(3,4) In contrast, case-control studies require
control of matching factors associated with exposure rather than risk.
Moreover, with variable follow-up duration and censoring a matched
survival (time-to-event) analysis producing hazard ratios would have been
a better strategy than reporting the p-values alone; censoring has not
been mentioned in the article.
REFERENCES
1. Chandra A, Jazayeri F, Williamson T. Warfarin in vitreoretinal
surgery: a case controlled series. Br J Ophthal 2010.
http://bjo.bmj.com/content/early/2010/11/11/bjo.2010.187526.full.html.
2010.
2. Rothman K, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 1998.
3. Greenland S, Robins J. Estimation of a common effect parameter
from sparse follow-up data. Biometrics. 1985;41:55-68.
4. Weinberg C. On pooling across strata when frequency matching has
been followed in a cohort study. Biometrics. 1985;41:103-116.
Regarding the editorial by Khaw et al.[1]
we are surprised that after quite a few years now non-
penetrating filtering surgery (NPFS) remains only
partly understood by many ophthalmologists. There are
at present two main NPFS: viscocanalostomy as
described by Stegmann, in which outflow filtration is at
least in theory not subconjunctival, and deep
sclerectomy with or without an implant or even wi...
Regarding the editorial by Khaw et al.[1]
we are surprised that after quite a few years now non-
penetrating filtering surgery (NPFS) remains only
partly understood by many ophthalmologists. There are
at present two main NPFS: viscocanalostomy as
described by Stegmann, in which outflow filtration is at
least in theory not subconjunctival, and deep
sclerectomy with or without an implant or even with
viscoelastics, the success of which depends on
several outflow routes - an important one being
subconjunctival. Careful postoperative follow up
becomes therefore mandatory and is at least as
important as the procedure itself. If needed
subconjunctival injection of antimetabolites, needling or use of lasers for
goniopuncture, iris
desincarceration and attempts of possible bleb
reduction or closure of possible seidel may be
required. It also becomes evident that
antimetabolites play an important role in high risk
cases for filtration failure undergoing NPFS (apart
from viscocanolostomy as describd by Stegmann).
Furthermore in our hospital we have been using
antimetabolites also in cases requiring low
postoperative IOP such as normal tension glaucoma
since 1994. We do not understand the comment made
stating that greater care should be taken with
antimetabolites used during NPFS, since we
intraoperatively use these agents before the deeper
scleral flap is being excised or even created. Thus
at this stage this does not differ with
trabeculectomy. Later on the anterior chamber is not
entered and furthermore the deep scleral flap which
has been exposed to antimetabolites is being excised
making the danger of intraoperative intraocular
penetration considerably less than with
trabeculectomy (even with unintended macroperforation
during NPFS).
Additional sutures are added in cases of accidental
macroperforaton so that the incidence of early
significant hypotony in the hands of experienced
surgeons with NPFS is not high. Moreover
postoperative suturelysis may then be required in
these cases if the sutures have been made too tight
or too numerous.
References are being made to the article by Brart et al. However how
reliable is it to compare the
efficacy of two procedures without giving the same
chances of success to both? Intraoperative
antimetabolites were used for all trabeculectomies
and yet never with NPFS. Yet strangely enough,
postoperative antimetabolites as well as needling
with an attempt to lift the scleral flap in some,
were used in both groups. The author also writes in
the discussion that patients with successful drainage
at 6 and 12 months following viscocanalostomy had
evidence of subconjunctival drainage of aqueous as
opposed to eyes without successful drainage. Later on
he further states that 'with our viscocanalostomy
technique, the subconjunctival route is the main
pathway' and 'observation of the disappearance of
subconjunctival blebs in our patients with drainage
failure after viscocanalostomy appears to suggest
that subconjunctival fibrosis is responsible'.
Clearly, if antimetabolites are being used in
trabeculectomies, it should be used in NPFS before
any reliable conclusions can be drawn.
Goniopunture was also only done after 18 months which
of course will not be of great help if the outflow
route after the trabeculodescemet's membrane has
scarred down. Thus to promote good filtration in
addition to intraoperative and postoperative use of
antimetabolites, goniopuncture can help in enhancing
and thus in maintaining a flow under the scleral flap.
Using lasers for suturelysis in trabeculectomies or
for goniopuncture in NPFS is part of the
armementarium we have in glaucoma surgery. The final
aim for the patient is not to know whether the
procedure is penetrating or not, but rather how
effective it is so that the discussion on whether or
not to use goniopunture is futile.
For ophthalmologists performing NPFS, the later is
compared to trabeculectomy what phacoemulsification
was to extracapsular cataract extraction. They will
never go back to it unless obliged to do so. However
it is clear that there is a learning curve to this
surgery and that it is not as forgiveful as is
trabeculectomy.
E. Ravinet, MD
A. Mermoud, MD
Reference
(1) Khaw PT, Wells AP, Lim KS. Surgery for glaucoma in the 21st
century. Br J Ophthalmol 2002;86:
710-711.
I read with interest Buono et al's paper [1]. They describe in detail
the value of anti-coagulant therapy in the management of giant cell arteritis. The role of anti-platelet agents however is not considered.
It
has been known for a number of years that thrombocytosis [2] and platelet
hyper-reactivity [3] are features of giant cell arteritis. Experimental
studies have shown that aspirin effectively sup...
I read with interest Buono et al's paper [1]. They describe in detail
the value of anti-coagulant therapy in the management of giant cell arteritis. The role of anti-platelet agents however is not considered.
It
has been known for a number of years that thrombocytosis [2] and platelet
hyper-reactivity [3] are features of giant cell arteritis. Experimental
studies have shown that aspirin effectively suppresses the production of
interferon-gamma, essential for the development of an inflammatory
infiltrate within the vessel wall [4]. Therefore in addition to an anti-
platelet effect, aspirin therapy may reduce this infiltrate, and the
consequent severe luminal narrowing that Buono et al. decribe in their
patient. Moreover, a recent retrospective study of 166 patients has
shown
that cranial ischemic complications developed in only 3% of the aspirin-
treated patients, compared with 13% of the patients treated with steroid
alone [5]. Given this early evidence it makes intuitive sense to treat
patients with giant cell arteritis using a combination of steroids and
aspirin in the first instance. Clearly heparin therapy may still have a
role to play in patients with severe complications but aspirin therapy
should be considered as part of the initial therapy following
diagnosis.
References
(1)Buono LM,
Foroozan R, de Virgiliis M, Savino PJ. Heparin
therapy in giant cell arteritis
Br. J. Ophthalmol., Feb 2004; 88: 298 - 301.
(2) Foroozan R, Danesh-Meyer H, Savino PJ, Gamble G, Mekari-Sabbagh
ON,
Sergott RC. Thrombocytosis in patients with biopsy-proven giant cell
arteritis. Ophthalmology. 2002 Jul;109:1267-71.
(3) Riddle JM, Bluhm GB, Pitchford WC et al. A comparative study of
platelet reactivity in arthritis. Ann N Y Acad Sci. 1981;370:22-9.
(4) Brack A, Rittner HL, Younge CK et al. Glucocorticoid-mediated
repression of cytokine gene transcription in human arteritis-SCID
chimeras. J. Clin Invest 1997;99:2842-2850.
(5) Nesher G, Berkun Y, Mates M, Baras M, Rubinow A, Sonnenblick M.
Low
-dose aspirin and prevention of cranial ischemic complications in giant
cell arteritis. Arthritis Rheum. 2004 Apr;50:1332-7.
Your article is very interesting and indeed very promising as far the management of lymphangiomas is concerned. Do the authors think this drug has any role in the management of capillary haemangiomas or other
vascular abnormalities of the eye?
We read with interest the case reports by Peponis et al. on the role of
corticosteroids in fungal keratitis. It is important to remember are that all
antifungal drugs used in clinical practice are fungistatic. Hence while an
abrupt cessation of steroid usage in recently diagnosed fungal keratitis may
cause increased inflammation, continuation of steroids may cause fungi to
p...
We read with interest the case reports by Peponis et al. on the role of
corticosteroids in fungal keratitis. It is important to remember are that all
antifungal drugs used in clinical practice are fungistatic. Hence while an
abrupt cessation of steroid usage in recently diagnosed fungal keratitis may
cause increased inflammation, continuation of steroids may cause fungi to
penetrate deeper into the cornea. The antifungal drugs rate poorly and are toxic
to the corneal epithelium [1]. Steroid usage even in tapering doses will reduce
corneal immunity.
We concur with the authors' view that sudden cessation of topical steroids
may cause increased inflammation which was hitherto kept under control by the
steroid usage. We have experienced such cases in our practice much of which is
for a rural population. We still advise caution in continuation of steroid usage
after the diagnosis of fungal keratitis is confirmed.
References
(1) Forster, R. K. The diagnosis and management of keratomycoses. Arch
Ophthalmol 1975; 93:1134.
I read with interest the editorial by Dr DF Chang on SBCS and find myself in agreement with many of his points raised.
A note of caution however. Several years ago when I had converted to topical clear cornea phako I started to perform SBCS on patients I felt required this and were suitable. As I saw the benefits for both the patients and the staff I decided to extend this to the majority of my patients....
I read with interest the editorial by Dr DF Chang on SBCS and find myself in agreement with many of his points raised.
A note of caution however. Several years ago when I had converted to topical clear cornea phako I started to perform SBCS on patients I felt required this and were suitable. As I saw the benefits for both the patients and the staff I decided to extend this to the majority of my patients. I was quickly stopped in my tracks when we discovered that
SBCS is classified and reimbursed to our NHS hospital as a single procedure.
This is even if the patients is listed as two separate procedures. Our hospital could obviously not afford to "reduce" my operating list from 10 cataracts to 5 and at the same time use 10 sets of equipment and 10 IOLs etc every list.
Therefore in the NHS one would have to very careful before embarking on
SBCS until the purchasers or PCGT or whatever they will become in
Foundation Status agree that it is more than a single procedure.
I know DF Chang is relating his practice in the USA but after all the
BJO
is mainly about the practice of Ophthalmology this side of the Pond!
We thank the BJO for publishing our Letter to the Editor regarding
appending authors' qualifications [1] and for inviting correspondence
from
its readership on the issue in the editorial "Who is Ivan Schwab?"[2].
The editors wisely remind us that medical authorities have
suppressed
important findings by lesser-known authors, using the notable example of
Semmelweis. Even today, critical new info...
We thank the BJO for publishing our Letter to the Editor regarding
appending authors' qualifications [1] and for inviting correspondence
from
its readership on the issue in the editorial "Who is Ivan Schwab?"[2].
The editors wisely remind us that medical authorities have
suppressed
important findings by lesser-known authors, using the notable example of
Semmelweis. Even today, critical new information remains vulnerable to
suppression by authorities, medical or otherwise. Perhaps the most
memorable rejection was that of Novotny and Alvis whose seminal work on
fluorescein angiography was rejected by the American Journal of
Ophthalmology in 1960 [3].
We agree with the editors that publication of an article should be
based on its scientific merit, not on its authors' qualifications or
eminence. We would emphasise that publication is an editorial
prerogative
based on advice from reviewers, who are a select group, rather than from
a
journal's readership. In our modern age, the editorial decision to
publish
an article in a Medline-indexed journal equates to enduring world-wide
dissemination. Therefore, we agree with the proposal that authors' names
and
qualifications should be masked from reviewers. We would go even further
to suggest that this information, and the authors' institutional
affiliations, should also be masked from the editorial board, until a
preliminary decision is made regarding publication. This would ensure
the
primacy of the article's scientific content, making it more likely that
first-rate articles from unfamiliar and little-known authors are
published
at the expense of second-rate articles from eminent authors.
In contrast to the function of a reviewer, the task of the reader
is, in our opinion, facilitated by a journal providing information about
the authors, including their qualifications. We, as readers, seek
information on the authors' educational background and professional
experience (using their qualifications as a proxy), and also previous
publications. We do this in order to understand their perspective, and
to help us put their interpretations of results into context. This
information is perhaps most important when the writing involves opinion
and speculation, which includes the discussion of results. In any event,
in the age of Internet search engines, the qualifications and background
of many authors are not hidden.
On another point, we do not begrudge the trolley boy's scholarly
aspirations. We agree with the Editors that he may be well-positioned to
write about his first-hand observations in the hospital. As readers, we
would prefer to know when it was the trolley boy's work, in order to
understand his perspective and the context of his writing. We may have
interpreted the same article differently had it been written by the
professor of infectious diseases, the senior lecturer in surgery, or the
newly graduated trainee in dermatology.
Finally, we commend Ivan Schwab for his fascinating BJO articles. We warmly
welcome him to our country, and we hope he enjoys studying our fauna.
Editor,
We read Frau et al's report with interest and noted
that our article in Ophthalmology was not cited as
reference (Larkin G, Flaxel C, Leaver P. Phacoemulsification and silicone
oil removal through a single corneal incision.
Ophthalmology 1998;105:2023-7). In
this article, we reported our experience at Moorfields Eye Hospital with
34 eyes prospectively evaluated to l...
Editor,
We read Frau et al's report with interest and noted
that our article in Ophthalmology was not cited as
reference (Larkin G, Flaxel C, Leaver P. Phacoemulsification and silicone
oil removal through a single corneal incision.
Ophthalmology 1998;105:2023-7). In
this article, we reported our experience at Moorfields Eye Hospital with
34 eyes prospectively evaluated to look at the efficacy and potential
complications of combined cataract extraction and silicone oil removal
with posterior chamber lens implantation. We also reported the method of
Ms Maria Restori, BSc, MSc, MIPSM, Ophthalmic Ultrasound Specialist at
Moorfields Eye Hospital for calculating the IOL power in an oil filled eye
with correction for the specific gravity of silicone oil taken into
consideration.
Our findings were that the procedure was safe and effective for these eyes
that had often had many previous surgeries. The visual outcome in these
eyes was generally good with improvement in visual acuity, even with
recurrent retinal detachment or pre-existing macular pathology. We also
concluded that it was safer to place a rigid posterior chamber implant
after silicone oil removal due to potential contraction of the anterior
capsule limiting the view of the retina post-operatively. Our technique
was a passive technique but might easily be done with the I/A handpiece as
this group reported.
We feel that it would have been appropriate for them to make reference to
our study since it presents a much larger series with more detailed follow-up.
Dear Editor
A recent report stated it might be prudent to delay paediatric cataract surgery, at least for bilateral cases, until 4 weeks of age to lower the risk of later glaucoma,[1] and this suggestion was fully supported in an accompanying editorial [2]. Such a suggestion that could have an impact on the practice patterns of ophthalmologists and consequently the care of children with cataract should have stron...
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...
To The Editor,
In a recently published article by Chandra et al. the authors have stated that they conducted a "case-controlled" study to examine the anticoagulant effectiveness of warfarin in vitreoretinal surgery.(1) However, this study was conducted on a cohort of patients receiving pars plana vitrectomy (PPV); 60 patients who received warfarin (exposure) on the day of PPV were selected. These 'exposed' pati...
Dear Editor
Regarding the editorial by Khaw et al.[1] we are surprised that after quite a few years now non- penetrating filtering surgery (NPFS) remains only partly understood by many ophthalmologists. There are at present two main NPFS: viscocanalostomy as described by Stegmann, in which outflow filtration is at least in theory not subconjunctival, and deep sclerectomy with or without an implant or even wi...
Dear Editor
I read with interest Buono et al's paper [1]. They describe in detail the value of anti-coagulant therapy in the management of giant cell arteritis. The role of anti-platelet agents however is not considered. It has been known for a number of years that thrombocytosis [2] and platelet hyper-reactivity [3] are features of giant cell arteritis. Experimental studies have shown that aspirin effectively sup...
Your article is very interesting and indeed very promising as far the management of lymphangiomas is concerned. Do the authors think this drug has any role in the management of capillary haemangiomas or other vascular abnormalities of the eye?
Dear Editor
We read with interest the case reports by Peponis et al. on the role of corticosteroids in fungal keratitis. It is important to remember are that all antifungal drugs used in clinical practice are fungistatic. Hence while an abrupt cessation of steroid usage in recently diagnosed fungal keratitis may cause increased inflammation, continuation of steroids may cause fungi to p...
Dear Editor
I read with interest the editorial by Dr DF Chang on SBCS and find myself in agreement with many of his points raised. A note of caution however. Several years ago when I had converted to topical clear cornea phako I started to perform SBCS on patients I felt required this and were suitable. As I saw the benefits for both the patients and the staff I decided to extend this to the majority of my patients....
Dear Editor
We thank the BJO for publishing our Letter to the Editor regarding appending authors' qualifications [1] and for inviting correspondence from its readership on the issue in the editorial "Who is Ivan Schwab?"[2].
The editors wisely remind us that medical authorities have suppressed important findings by lesser-known authors, using the notable example of Semmelweis. Even today, critical new info...
Editor,
We read Frau et al's report with interest and noted that our article in Ophthalmology was not cited as reference (Larkin G, Flaxel C, Leaver P. Phacoemulsification and silicone oil removal through a single corneal incision. Ophthalmology 1998;105:2023-7). In this article, we reported our experience at Moorfields Eye Hospital with 34 eyes prospectively evaluated to l...
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