We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be affected by trauma, and traumatic cataract carries an increased risk of PCR. We would welcome further discussion of this less recognised risk factor for PCR.
References:
1. Salowi MA, Chew FLM, Adnan TH, Ismail M, Goh PP: The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture. The British journal of ophthalmology 2017.
2. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Asaria RH, Galloway P, Sparrow JM: The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye (London, England) 2009, 23(1):31-37.
3. Shalchi Z, Okada M, Whiting C, Hamilton R: Risk of Posterior Capsule Rupture During Cataract Surgery in Eyes With Previous Intravitreal Injections. American journal of ophthalmology 2017, 177:77-80.
4. Chatziralli IP, Peponis V, Parikakis E, Maniatea A, Patsea E, Mitropoulos P: Risk factors for intraoperative floppy iris syndrome: a prospective study. Eye (London, England) 2016, 30(8):1039-1044.
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, f...
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, for example STROBE for observational studies, CONSORT for randomized trials, and PRISMA for systematic reviews and meta-analyses of intervention studies (see https://www.equator-network.org/reporting-guidelines/ for a full list of reporting standards).
Related to this project, CEV is examining the quality of published systematic review methods and maintains a database of systematic reviews in eyes and vision (http://cmr.cochrane.org/?CRGReportID=11343). We classify systematic reviews as “reliable” based on adherence to pre-specified criteria, (3) and send the “reliable” reviews to the American Academy of Ophthalmology for reference when issuing clinical practice guidelines. (4)
We urge all stakeholders to join our effort to ensure that vision science is recognized as evidence-based.
Literature cited
1. Joksimovic L, Koucheki R, Popovic M, Ahmed Y, Schlenker MB, Ahmed IIK. Risk of bias assessment of randomized controlled trials in high-impact ophthalmology journals and general medical journals: a systematic review. Br J Ophthalmol 2017;0:1–6. doi:10.1136/bjophthalmol-2017-310313
2. Institute of Medicine (IOM). Finding what works in health care: Standards for systematic reviews. Washington, DC: The National Academies Press; 2011
3. Lindsley K, Li T, Ssemanda E, Virgili G, Dickersin K. Interventions for age-related macular degeneration: Are practice guidelines based on systematic reviews? Ophthalmol. 2016;123(4):884-97. doi:10.1016/j.ophtha.2015.12.004.
4. Mayo-Wilson E, Ng SM, Chuck RS, Li T. The quality of systematic reviews about interventions for refractive error can be improved: a review of systematic reviews. BMC Ophthalmol.2017; 17:164 doi:10.1186/s12886-017-0561-9.
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These barriers exist from both a patient’s and clinician’s perspective. The most obvious hurdle is the disparity in subject knowledge between both parties and the potential for patients to feel isolated during discussion. Therefore, it is crucial that patient involvement is designed in a way that recognizes this, and provides adequate support either through training schemes or debriefing with expert members prior to meetings(3). There may be resistance from clinicians concerned that the need to accommodate patient understanding may restrict the scope of discussion. Other patient concerns include time commitment and logistical concerns such as travel reimbursements(3), both of which should be adequately addressed. Additionally, care must be taken when defining the patient recruitment criteria in order to ensure the volunteers are truly representative of the patient population concerned.
Ultimately, we applaud the efforts of this article in highlighting what is currently an inadequately tapped resource in the realm of ophthalmology, and we hope to see the ‘patient voice’ become an intrinsic part of future research.
References
1. Dean, S., Mathers, J., Calvert, M., Kyte, D., Conroy, D., Folkard, A., Southworth, S., Murray, P. and Denniston, A. (2017). "The patient is speaking": discovering the patient voice in ophthalmology. The British Journal of Ophthalmology, [online] 101(6), pp.700-708. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28455280 [Accessed 20 Sep. 2017].
2. Burns, K., Rizvi, L., Charteris, A., Laskey, S., Batty, S., Chokar, K. and Choong, K. (2017). Characterizing Citizens’ Preferences for Engagement in Patient Care and Research in Adult and Pediatric Intensive Care Units. Journal of Intensive Care, [online] Available at: http://journals.sagepub.com/doi/full/10.1177/0885066617729127[Accessed 20 Sep. 2017].
Chalmers, J., Timothy, A., Polverino, E., Almagro, M., Ruddy, T., Powell, P. and Boyd, J. (2017). Patient participation in ERS guidelines and research projects: the EMBARC experience. European Respiratory Journal, [online] 13(3), pp.194-207. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584721/ - C1[Accessed 20 Sep. 2017].
Kenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the li...
Kenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the literature with regard to how visual acuity relates to increased risk of MVC’s in glaucoma patients,3-5 we suggest that these findings be more clearly emphasized. Furthermore, we would appreciate any commentary from the authors regarding visual acuity as a significant risk parameter for MVCs. Specifically, we are interested to know if further analysis of the data would show a particular threshold for visual acuity to incite a significantly higher risk for simulated collision. Given our role to responsibly report the visual capacity of patients to safely operate a motor vehicle, this information may serve useful to further guide visual acuity parameters for motor vehicle licensing.
Author Affiliations:
1. Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, TX
2. Michael E. Debakey Veterans Affairs Medical Center, Houston, TX
References:
1. Ramulu PY, West SK, Munoz B, Jampel HD, Friedman DS. Driving cessation and driving limitation in glaucoma: the Salisbury Eye Evaluation Project. Ophthalmology. 2009;116(10):1846-1853.
2. Janz NK, Musch DC, Gillespie BW, Wren PA, Niziol LM, Collaborative Initial Glaucoma Treatment Study I. Evaluating clinical change and visual function concerns in drivers and nondrivers with glaucoma. Invest Ophthalmol Vis Sci. 2009;50(4):1718-1725.
3. Yuki K, Awano-Tanabe S, Ono T, et al. Risk Factors for Motor Vehicle Collisions in Patients with Primary Open-Angle Glaucoma: A Multicenter Prospective Cohort Study. PLoS One. 2016;11(11):e0166943.
4. Gracitelli CP, Tatham AJ, Boer ER, et al. Predicting Risk of Motor Vehicle Collisions in Patients with Glaucoma: A Longitudinal Study. PLoS One. 2015;10(10):e0138288.
5. Kwon M, Huisingh C, Rhodes LA, McGwin G, Jr., Wood JM, Owsley C. Association between Glaucoma and At-fault Motor Vehicle Collision Involvement among Older Drivers: A Population-based Study. Ophthalmology. 2016;123(1):109-116.
We noticed the article entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment" by Mulder and associates with interest.(1)
Several studies have been published concluding that elevated aqueous flare values seem to be associated with increased risk for PVR redetachment.(2-4) Schroeder et al reported that values >15 photon counts per milliseconds (pc/ms) increases the risk for PVR 16-fold.(4) Hoerster et al showed that the odds ratio for PVR development with preoperative flare values >15pc/ms was 30.7 (p=0.0001) with a sensitivity of 80% and specificity of 79%.(3) Conart et al verified these findings (OR 12.3, p<0.0001 for later PVR in flare values >15 pc/ms).(2)
In contrast Mulder et al concluded on their data compilation that laser flare measurements are inaccurate in predicting PVR.(1) Logistic regression analyses showed a significant increase in odds with increasing flare at least for the second centre (1) supporting the notion that high flare measurements herald PVR. However, the large variation precluded sufficient sensitivity and specificity to separate between groups. We assume the reason for the large variation is that high-level outliers were included. For center 2 only the highest and the lowest values were excluded, no information is provided for center 1. Values of 100pc/ms, here up to 312pc/ms, are uncommon for the low-level type of i...
We noticed the article entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment" by Mulder and associates with interest.(1)
Several studies have been published concluding that elevated aqueous flare values seem to be associated with increased risk for PVR redetachment.(2-4) Schroeder et al reported that values >15 photon counts per milliseconds (pc/ms) increases the risk for PVR 16-fold.(4) Hoerster et al showed that the odds ratio for PVR development with preoperative flare values >15pc/ms was 30.7 (p=0.0001) with a sensitivity of 80% and specificity of 79%.(3) Conart et al verified these findings (OR 12.3, p<0.0001 for later PVR in flare values >15 pc/ms).(2)
In contrast Mulder et al concluded on their data compilation that laser flare measurements are inaccurate in predicting PVR.(1) Logistic regression analyses showed a significant increase in odds with increasing flare at least for the second centre (1) supporting the notion that high flare measurements herald PVR. However, the large variation precluded sufficient sensitivity and specificity to separate between groups. We assume the reason for the large variation is that high-level outliers were included. For center 2 only the highest and the lowest values were excluded, no information is provided for center 1. Values of 100pc/ms, here up to 312pc/ms, are uncommon for the low-level type of inflammation in primary rhegmatogenous retinal detachment. Therefore, we challenge laser flare values beyond 100pc/ms. Measurements become easily disturbed by background lighting or cells leading to the necessity to exclude measurements falsified by artefacts.
It would be interesting to know details on the protocol the authors followed to exclude artefacts. Furthermore, we would appreciate an explanation for the unusual variation of the values and the discrepant data towards previous reports.(2,4)
Reference List
1. Mulder VC, Tode J, van Dijk EH, Purtskhvanidze K, Roider J, Van Meurs JC et al. Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment. Br.J.Ophthalmol 2017. doi: 10.1136/bjophthalmol-2016-309134.
2. Conart JB, Kurun S, Ameloot F, Trechot F, Leroy B, Berrod JP. Validity of aqueous flare measurement in predicting proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment. Acta Ophthalmol 2016.
3. Hoerster R, Hermann MM, Rosentreter A, Muether PS, Kirchhof B, Fauser S. Profibrotic cytokines in aqueous humour correlate with aqueous flare in patients with rhegmatogenous retinal detachment. Br.J.Ophthalmol 2013;97:450-3.
4. Schroder S, Muether PS, Caramoy A, Hahn M, Abdel-Salam M, Diestelhorst M et al. Anterior chamber aqueous flare is a strong predictor for proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment. Retina 2012;32:38-42.
Thank you for your interest in our publication entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment".
As per request, we would like to provide more details on our protocol.
As described in our discussion, centre 1 used the mean of ten correct measurements making sure these measurements did not differ more than 2 standard deviations from each other. In centre 2, seven correct measurements were recorded of which the highest and lowest value were discarded leaving an average of five measurements. A correct measurement meant that the background readings did not differ more than 15% (indicated by the code ‘BG’ on the output) and that single “cell/C” measurements were replaced by an additional measurement. In addition, measurements with a small signal to noise ratio (indicated by the code ‘s/n’) were avoided as much as possible. However, with low flare values this was not always feasible. The flare meters were located in a room with blinds (centre 1) and a room without windows (centre 2); computer screens and lights were turned off during measurements. Both flare meters were calibrated monthly to assure correct readings. We therefore believe that the included mean values are artefact free.
Despite the exclusion of patients with additional conditions such as AMD, CRVO and preoperative PVR grade C or higher, we did end up with patients with a preopera...
Thank you for your interest in our publication entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment".
As per request, we would like to provide more details on our protocol.
As described in our discussion, centre 1 used the mean of ten correct measurements making sure these measurements did not differ more than 2 standard deviations from each other. In centre 2, seven correct measurements were recorded of which the highest and lowest value were discarded leaving an average of five measurements. A correct measurement meant that the background readings did not differ more than 15% (indicated by the code ‘BG’ on the output) and that single “cell/C” measurements were replaced by an additional measurement. In addition, measurements with a small signal to noise ratio (indicated by the code ‘s/n’) were avoided as much as possible. However, with low flare values this was not always feasible. The flare meters were located in a room with blinds (centre 1) and a room without windows (centre 2); computer screens and lights were turned off during measurements. Both flare meters were calibrated monthly to assure correct readings. We therefore believe that the included mean values are artefact free.
Despite the exclusion of patients with additional conditions such as AMD, CRVO and preoperative PVR grade C or higher, we did end up with patients with a preoperative flare value above 100 pc/ms. These measurements were accurate because they showed small SD’s (e.g. mean 263.8± SD 2.8; mean 196.5±SD 3.5; mean 162.0±SD 6.0) and flare was also visible upon slit lamp examination. Therefore, because these values do occur in patients with a rhegmatogenous retinal detachment we feel that inclusion of these measurements is mandatory.
However, excluding patients with a preoperative flare value above 100 pc/ms from our regression and ROC analyses – as is suggested by dr. Schaub and colleagues – did not significantly improve the results from either centre 1 or centre 2. Logistic regression centre 1: OR 1.013; p = 0.446, centre 2: OR 1.035; p = 0.028. Sensitivity and specificity at a cut-off of 15 pc/ms dropped to 78 and 39% in centre 1, and 36% and 77% in centre 2 (p = 0.051).
A possible explanation for the discrepancy with the previous reports is our low prevalence of postoperative PVR (7.5% and 6.2% respectively) compared to the previous reports. All previous reports included consecutive patients and found prevalences of 10.3%(1), 14.9%(2) and 20% (3). Both the positive predictive value (PPV) and the odds ratio (OR) are affected by the prevalence. This means that even with comparable sensitivity and specificity the PPV and the OR will be lower when the prevalence is lower. In addition, different reports used different definitions of postoperative PVR. We used reoperation due to epiretinal membranes and/or subretinal strands within six months of initial surgery, as did Schröder et al.(1) Hoerster et al. based their findings on PVR grade C at 3 months postoperatively. While ten patients developed PVR only four (6%) needed a reoperation.(2) It is unclear from the report whether all four patients had a flare value > 15 pc/ms but if this were the case this would give a PPV of 20% and OR of 8 instead of the reported 40% and 30. Conart et al. used PVR grade B and C at 6 months as the outcome. Moreover, they included 20% patients with preoperative PVR grade C which influenced the postoperative number of patients with PVR. Both studies included flare values > 100 pc/ms which confirms that high values are not uncommon.(2,3)
The predictive value of the flare value thus depends on the patient group that is targeted. Our results indicate that there is a large overlap in flare values which makes selecting those patient at high risk for developing postoperative PVR (according to our definition) inaccurate.(4) Dependent on the implications of a positive test result (flare value > 15pc/ms) we should decide whether a false discovery rate of 60-90% is acceptable.
We agree with dr. Schaub and collegues that identifying patients with an increased risk of PVR would be of great benefit in studies of the treatment of PVR by “enriching” the study population. Unfortunately, in our study, we have not been able to validate preoperative flare measurements for this purpose.
Recently, however, we have shown that postoperative flare measurements may have that potential (Mulder et al, non published data, presented at the NOG Maastricht, March 29 2017), and we encourage other groups to validate these findings.
References
1 Schroder S, Muether PS, Caramoy A, et al. Anterior chamber aqueous flare is a strong predictor for proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment. Retina 2012;32(1):38-42.
2 Hoerster R, Hermann MM, Rosentreter A, et al. Profibrotic cytokines in aqueous humour correlate with aqueous flare in patients with rhegmatogenous retinal detachment. Br.J.Ophthalmol. 2013;97(4):450-453.
3 Conart JB, Kurun S, Ameloot F, et al. Validity of aqueous flare measurement in predicting proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment. Acta Ophthalmol. 2016;.
4 Mulder VC, Kluft C, van Etten PG, et al. Higher vitreous concentrations of dabigatran after repeated oral administration. Acta Ophthalmol. 2017;.
Dear Sir,
We read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between t...
Dear Sir,
We read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between the different groups. Third group was basically with neovascularisation according to the author, but ishemia is the basic driving cause for neovascularisation. Also, it was not mentioned about type of neovascularisation that was considered in the third group, Neovascularisation of disc [NVD] OR Neovasculasiation elsewhere [NVE]. Since neovascularisation at disc would suggest that there is global ishemia. So we feel second and third group were not clearly defined by authors in the study.
According to the study, group 2 i.e. with peripheral ishemic group responded better to anti-VEGF than other groups. We wonder how would this grouping alter the management of DMO in any way, as it is already known that DMO treated with anti-VEGF would improve vision and reduce the macular odema.4, 5
Financial Support and Sponsorship
Nil
Conflicts of Interest
There are no conflicts of interest
References:
1. Xue K etal. Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy. Br J Ophthalmol 2017; 101:559-563.
2. Early treatment for diabetic retinopathy study [ETDRS] research group .ETDRS design and baseline patient characteristics. ETDRS report number 7 .Ophthalmology 1991; 98: 741 - 756.
3. Ronald KLIEN, MD, MPH, Michaiel D. Knudston, MS, etal. WISCONSON EPIDEMIOLOGICAL STUDY OF DIABETIC RETINOPATHY, the twenty five year incidence of macular odema in persons with type 1 diabetes .Ophthalmology 2009; 116 [3]: 497-503.
4. Paul Mitchell MD, PhD, Francesco Bandello, MD, FEBO; etal. RESTORE STUDY. Ranibizumab monotherapy or combined with laser versus monotherapy for diabetic macular odema. Ophthalmology 2011; 118 [4]: 615-25.
5. Pascale Massin, MD, PhD, Francesco Bandello ,MD ,FEBO etal Safety and efficacy of Ranibizumab in Diabetic Macular Edema [RESOLVE STUDY]. Diabetes care 2010; 33: 2399-2405.
Dear Sir
Thanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentio...
Dear Sir
Thanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentioned in the discussion section in the second paragraph of the last page.
Dear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
the location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations...
Dear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
the location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations
occured pre-operatively.
Was the visual acuity best corrected or uncorrected visual acuity.
I whole heartedly appreciate the work conducted by Chan Yun Kim et al in studying the treatment patterns and medication adherence of patients with glaucoma in South Korea.This study concluded that medication non adherence was seen more commonly in males , increased daily number of administration and increase in the number of eyedrops. We have also conducted a similar study at our centre in North India and would like to share our results .Our results are in agreement to the work conducted by Chan Yun Kim stating that increased number of instillation and increased number of eyedrops contribute significantly to medication non adherence. However, in our study we also found that medication adherence varies in different severity grades of glaucoma with severe stages being significantly more adherent than mild to moderate stages of glaucoma.Additionally, there was no difference found in medication adherence among males or females.
We again express our gratitude to the researcher in enlightening our minds regarding medication adherence in South Korean population.
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
Show MoreDear Editors,
We are writing to express concerns about an article published recently in BJO. (1) While Joksimovic and colleagues claim to have conducted a systematic review, they did not. Rather, they describe a cross-sectional study of randomized trials in ophthalmology with two comparison (or “exposure”) groups: trials published in ophthalmology journals, and trials published in general medical journals. In contrast, a systematic review (also a cross sectional study) has been defined as "… a scientific investigation that focuses on a specific question and uses explicit, prespecified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies." (2)
To minimize mislabeling of systematic reviews, among other purposes, Cochrane Eyes and Vision (CEV) is partnering with individual ophthalmology and optometry journals to appoint a knowledgeable associate editor responsible for editorial functions related to systematic reviews at each journal (http://eyes.cochrane.org/associate-editors-eyes-and-vision-journals). Our research has indicated that many published eye and vision articles billed as “systematic reviews” do not adhere to accepted criteria, and are not reliable. (3)
In addition to adding associate editors for systematic reviews to their team, journal editors can insist that authors adhere to reporting standards, f...
Show MoreWe have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
Show MoreKenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1
Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the li...
Show MoreWe noticed the article entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment" by Mulder and associates with interest.(1)
Several studies have been published concluding that elevated aqueous flare values seem to be associated with increased risk for PVR redetachment.(2-4) Schroeder et al reported that values >15 photon counts per milliseconds (pc/ms) increases the risk for PVR 16-fold.(4) Hoerster et al showed that the odds ratio for PVR development with preoperative flare values >15pc/ms was 30.7 (p=0.0001) with a sensitivity of 80% and specificity of 79%.(3) Conart et al verified these findings (OR 12.3, p<0.0001 for later PVR in flare values >15 pc/ms).(2)
In contrast Mulder et al concluded on their data compilation that laser flare measurements are inaccurate in predicting PVR.(1) Logistic regression analyses showed a significant increase in odds with increasing flare at least for the second centre (1) supporting the notion that high flare measurements herald PVR. However, the large variation precluded sufficient sensitivity and specificity to separate between groups. We assume the reason for the large variation is that high-level outliers were included. For center 2 only the highest and the lowest values were excluded, no information is provided for center 1. Values of 100pc/ms, here up to 312pc/ms, are uncommon for the low-level type of i...
Show MoreThank you for your interest in our publication entitled "Preoperative aqueous humour flare values do not predict proliferative vitreoretinopathy in patients with rhegmatogenous retinal detachment".
As per request, we would like to provide more details on our protocol.
As described in our discussion, centre 1 used the mean of ten correct measurements making sure these measurements did not differ more than 2 standard deviations from each other. In centre 2, seven correct measurements were recorded of which the highest and lowest value were discarded leaving an average of five measurements. A correct measurement meant that the background readings did not differ more than 15% (indicated by the code ‘BG’ on the output) and that single “cell/C” measurements were replaced by an additional measurement. In addition, measurements with a small signal to noise ratio (indicated by the code ‘s/n’) were avoided as much as possible. However, with low flare values this was not always feasible. The flare meters were located in a room with blinds (centre 1) and a room without windows (centre 2); computer screens and lights were turned off during measurements. Both flare meters were calibrated monthly to assure correct readings. We therefore believe that the included mean values are artefact free.
Despite the exclusion of patients with additional conditions such as AMD, CRVO and preoperative PVR grade C or higher, we did end up with patients with a preopera...
Show MoreDear Sir,
Show MoreWe read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between t...
Dear Sir
Show MoreThanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentio...
Dear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
Show Morethe location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations...
Dear sir/maam
I whole heartedly appreciate the work conducted by Chan Yun Kim et al in studying the treatment patterns and medication adherence of patients with glaucoma in South Korea.This study concluded that medication non adherence was seen more commonly in males , increased daily number of administration and increase in the number of eyedrops. We have also conducted a similar study at our centre in North India and would like to share our results .Our results are in agreement to the work conducted by Chan Yun Kim stating that increased number of instillation and increased number of eyedrops contribute significantly to medication non adherence. However, in our study we also found that medication adherence varies in different severity grades of glaucoma with severe stages being significantly more adherent than mild to moderate stages of glaucoma.Additionally, there was no difference found in medication adherence among males or females.
We again express our gratitude to the researcher in enlightening our minds regarding medication adherence in South Korean population.
Pages